Martin Baker to be prosecuted over death of Flt Lt. Sean Cunningham

[FJ2ME]

It is these words from the coroner which I believe have led to the HSE prosecution. I could be wrong but he was pretty clear in his assertion...

"Martin-Baker knew the parachute mechanism could jam if the nut and bolt were too tight as early as January 1990, the inquest was told.
The manufacturer warned some air forces but did not warn the MoD."

This comes from the BBC report of the coroner's inquest. Incidentally not too glowing praise for the RAF either...

http://www.bbc.co.uk/news/uk-england-lincolnshire-25943211

[Distant Voice]

According to H-C the drawing up of a ‘Safety Case’, to identify, assess, and mitigate potentially catastrophic hazards before they could cause an accident, was mandated for military aircraft and other military platforms by regulations introduced in September 2002.

I can recall confusion in PTs and it's perhaps not surprising that each ended up with a different SC approach and format.

I agree. Having seen the SCs for Nimrod and Tornado they are as different as chalk and cheese. With, in my opinion, the Nimrod SC having more substance and meaning.

DV

[Distant Voice]

I would find it difficult to believe that the HSE after investigating MB and "finding a smoking gun" did not require MB to inform their customers, or indeed inform the customers themselves.

Customers were informed by MB Special Information Leaflet No. 704 in November 2011 and 704A in November 2013. Seeing as the accident happened on 8th November 2011 it is clear that the cause of the accident was known about, almost immediately.

DV

[PhilipG]

Originally Posted by Distant Voice

Customers were informed by MB Special Information Leaflet No. 704 in November 2011 and 704A in November 2013. Seeing as the accident happened on 8th November 2011 it is clear that the cause of the accident was known about, almost immediately.

DV

Thanks for the clarity, being pedantic, does anyone know what communication mechanism MB had previously used to inform the non MoD customers of the problems with the seat? Was there a previous SIL that went out but not to the MoD?

[Chugalug2]

DV:-

Customers were informed by MB Special Information Leaflet No. 704 in November 2011 and 704A in November 2013.

House of Commons Hansard Written Answers for 10 Mar 2014 (pt 0002)

Military Aircraft

Angus Robertson: To ask the Secretary of State for Defence when his Department received copies of Martin-Baker's Special Information Leaflets, SIL 704 and SIL 704A; and what steps it has taken to incorporate the revised checks into the appropriate maintenance publications. [190344]

Mr Dunne: Special Information Leaflet (SIL) 704 was received on 15 November 2011 and SIL 704A on 18 November 2013. Corresponding Ministry of Defence (MOD) Technical Instructions were issued on 16 November 2011 and 5 December 2013 respectively to ejection seat maintenance units. Both Technical Instructions mandated checks of the ejection seat drogue shackle that were more stringent than those laid down in the SILs. In both cases, amendment action to the appropriate MOD maintenance publications commenced soon after issue of the Technical Instruction.

Angus Robertson: To ask the Secretary of State for Defence if he will place in the Library a list of Martin-Baker's Special Information Leaflets, with contents summary, issued between 1990 and 1996. [190345]

Mr Dunne: Martin-Baker Aircraft issues Special Information Leaflets (SIL) to the Ministry of Defence as a contract deliverable for each aircraft type. The Department does not therefore necessarily receive a copy of every SIL issued by the company. Information on SILs relating solely to aircraft types and equipment that are no longer in-service is not held centrally and could be provided only at disproportionate cost. A list of those SILs that are known to have been received by the Department between 1990 and 1996, with contents summaries, will be placed in the Library of the House.

https://mail.google.com/mail/u/0/?ui...1&disp=safe&zw

https://mail.google.com/mail/u/0/?ui...2&disp=safe&zw

[NutLoose]

"It shall be the duty of every employer to conduct his undertaking in such a way as to ensure, so far as is reasonably practicable, that persons not in his employment who may be affected thereby are not thereby exposed to risks to their health or safety."

So working on that scenario, you could prosecute every manufacturer of any weapon system from Aircraft to a lowly bow and arrow, as you are putting persons in danger of getting shot, bombed, speared or generally killed, and I won't even mention the lead content of a round that far exceeds the legal limit for ingestion.

[overstress]

it is clear that the cause of the accident was known about, almost immediately.

I believe all Mk10 equipped aircraft were grounded immediately after this accident, but soon after, the Tornado was cleared to fly. (different mechanism). The Hawks remained grounded.

[PDR1]

Originally Posted by NutLoose

So working on that scenario, you could prosecute every manufacturer of any weapon system from Aircraft to a lowly bow and arrow, as you are putting persons in danger of getting shot, bombed, speared or generally killed, and I won't even mention the lead content of a round that far exceeds the legal limit for ingestion.

In this case the duty of care "so far as is reasonably practicable" is discharged by ensuring that the customer/user to whom your product is sold has procedures and controls to mitigate that risk.

PDR

[tucumseh]

Martin-Baker Aircraft issues Special Information Leaflets (SIL) to the Ministry of Defence as a contract deliverable for each aircraft type. The Department does not therefore necessarily receive a copy of every SIL issued by the company. Information on SILs relating solely to aircraft types and equipment that are no longer in-service is not held centrally and could be provided only at disproportionate cost. A list of those SILs that are known to have been received by the Department between 1990 and 1996, with contents summaries, will be placed in the Library of the House.

Key words - "contract deliverable". Key question - Was there a suitable and continuous contract in place? The funding for such contracts, as I've said many times, was chopped by 28% in three consecutive years, and the centralised management of this work stopped in June 1993. At the same time, the oversight committees were disbanded and the Agency contracts (paying specialist companies to collate and distribute such technical papers from Design Authorities) cancelled.

The admission the papers are "not held centrally" confirms what I've said. The question should be "Why not", because the regulations require them to be, and all procedures assume them to be.

edit: just removed an unnecessary bit.

[zerofivezero]

The reality is that the RAF operated this aircraft/ejection seat combination for nearly 40 years before the accident occurred, and during that time there were successful ejections from RAF Hawks, so it seems unlikely that the failings were due to unfamiliarity or design flaws. Somewhere along those years personnel 'lost' their full understanding of operational and maintenance procedures. When, or if, changes were introduced processes should have been in place to review and understand revisions so that any re-training was effective and new requirements were safely applied.

[SirPeterHardingsLovechild]

Hi Engines, I disagree with your analysis at #26

1. The MAA found that the CAUSE of the accident was the inadvertent ejection due to displacement of the seat pan handle. Various CONTRIBUTORY factors were identified around the SPH design and use in service, also strap positions.

I honestly don't buy the MAA's analysis. Here's my stab:

1. If the shackle had worked, this would have (very probably) been an incident, with the pilot surviving. It became an accident because he died. He died because his parachute didn't deploy. It failed to do so because the drogue shackle had been disassembled and on reassembly overtightened to such a degree that it jammed. The jammed shackle was, in my view, the CAUSE. The inadvertent operation of the SPH was a CONTRIBUTORY factor.

I mentioned this on the original thread.

The Service Inquiry is into the "Accident involving Hawk XX177 on 8 Nov 11" that led to the death of Flt Lt Cunningham

The CAUSE must be the "inadvertent ejection due to displacement of the seat pan handle"

Why? Because the same event could have happened to a member of the ground crew earlier in the timeline. He would not have been strapped in
so the shackle would have had no bearing on his death or injury. Forgive my flippancy but Flt Lt Cunningham could have landed on the Families Day bouncy castle.

I'm on your side, and all the other who agreed with your analysis, but I believe the MAA got it right.

[Single Spey]

SirPeter....,


In this accident I am with ENGINES. If the sequence of events that you describe had taken place then the CAUSE of that 'accident' may well have been different. But it didn't so I don't believe you can ascribe a CAUSE based on something that didn't occur.


SS

[Engines]

SPHL,

Thanks for coming back and happy that you disagree - that's what a discussion thread is for. I think that in cases like this there will always be an element of policy and direction - often this is saying no more than 'this is how we are going to do things'. And this will be different across organisations.

In the case of MAA SI reports, I believe that the format currently adopted tends to make the reports less easily readable. This one was typical, with no list (that I could find) of the accident factors - you have to plough through the text to find them.

Hoever, I will try to justify my view of the factors. My reasoning goes like this:

1. The MAA definition of 'Cause' is "the event that led directly to the accident".
2. In my view, the 'accident' was the death of the pilot. He should have survived this ejection - the MAA report says so. Had he survived, this would not have been an accident, probably only an incident.
3. In my view, the 'event' that led directly to the pilot's death was the failure of the drogue shackle to operate correctly. Not, in my view, the inadvertent operation of the seat pan handle.

The reason I have contributed to this thread is the way the report treats the content and application of RTI/Hawk/59. It's my view that had this RTI not been issued in the form it was, the pilot would have survived. Despite the MoD having no safety case for the seat (required to validate the RTI), despite there apparently being no records of how 2 PTs, 22 Gp, 1710 NAS, MB and others discussed and decided on the RTI, the MAA assessed all this as merely an 'other factor'. From my own experience, i cannot understand how anyone would not recognise the significant safety risks posed by dismantling a vital part of the ejection seat every 50 flying hours. I honestly fail to understand why the MAA did not pick up on this as a major contributory factor.

However, the case is now going to proceed, and for my part, I intend to make this my final post on this thread until the verdict is in. Thank you to all those who have replied to my posts with such thoughtfulness and honesty.

I would finish by expressing my sincerest condolences to Flt Lt's Cunningham's family and friends.

Best Regards as ever to all those who serve their country,

Engines

[NutLoose]

i cannot understand how anyone would not recognise the significant safety risks posed by dismantling a vital part of the ejection seat every 50 flying hours. I honestly fail to understand why the MAA did not pick up on this as a major contributory factor.

Totally agree with you, it reminds me of the Pipers that had a Spar failure, they then decided you would need to inspect the bolt holes every I think 100 hours, it was found they were doing more damage to the spars of the fleet pulling bolts out that would normally never be removed, than the odd case of failure. So it was cancelled.

[oldmansquipper]

Nutloose. In a lighter vein - Very similar to the Tucano QRB cover plate over rotation issue late 90s?. Because the Quick Release Box was fitted `to the seat`as part of the SCH when in the aircraft, Weapons Techs (the plumbers) developed an `Instruction` (SI?) to check for over rotation on AF/BF. This consisted of instructions to "Try to turn the cover plate beyond the stop point...." Results? from 1 or 2 arising the failure rate (and u/s QRBs/Aircraft) increased rapidly until someone called off the gorillas!

"A I`m an armourer, B I`m an armourer...C etc. "

[PDR1]

...the difference between armourers and bombs being that you can actually get *smart* bombs...



PDR

[superplum]

Originally Posted by oldmansquipper

Nutloose. In a lighter vein - Very similar to the Tucano QRB cover plate over rotation issue late 90s?. Because the Quick Release Box was fitted `to the seat`as part of the SCH when in the aircraft, Weapons Techs (the plumbers) developed an `Instruction` (SI?) to check for over rotation on AF/BF. This consisted of instructions to "Try to turn the cover plate beyond the stop point...." Results? from 1 or 2 arising the failure rate (and u/s QRBs/Aircraft) increased rapidly until someone called off the gorillas!

"A I`m an armourer, B I`m an armourer...C etc. "

I could get to "E"

[Top West 50]

Before I comment, I must declare an interest. Tomorrow, on 30 September, I will celebrate the 52nd anniversary of becoming the 664th pilot to save their life using a Martin Baker ejection seat. A year or so later, I attended a gala dinner at The Dorchester after Martin-Baker notched up their 1000th success. Not a single ejection, within the design limits of the seat had been unsuccessful. Subsequently, several thousand more, 7506 precisely, are here today because of the brilliance of Martin-Baker engineering. Writing to me in October 1964, Sir James Martin, Managing Director and Chief Designer said “as the person responsible for the design of all our various ejection seats, it naturally causes me great pleasure (to hear about your escape).” At the same time, Sir James extended a “hearty” invitation to have lunch and visit the works. It took me until the 50th anniversary year, 2014, to accept the invitation. Meantime, for the rest of my flying career, I happily entrusted my survival to Martin Baker seats. It is vital not to underestimate the psychological effect of knowing that you were flying with the world’s best and most reliable escape apparatus. Put simply, Martin Baker was a benchmark for engineering excellence and reliability. Visiting the factory in September 2014, it was impossible not to be impressed by the sheer dedication and attention to detail in every aspect of their Denham factory.

During my RAF career of nearly 35 years, I had the duty to investigate 2 high-profile aircraft accidents, one of which resulted in the death of 9 crew members, so I am fairly well acquainted with the investigation process and most of the other human consequences that such investigations inevitably yield. The aim of the accident investigation is to determine the cause and much mental effort is devoted to isolating the root cause of the accident from other factors which merely contributed to the accident. I expect that this inquiry team, together with its convening authority, would have been presented with a similar challenge. The trouble with aircraft accidents is that they often result from a sequence of events, none of which, in isolation would necessarily have caused the accident. The day that “Murphy’s Law” strikes the sequence of events, design failure, technical failure, maintenance error, human error etc, has been allowed to continue to a conclusion. It follows that, quite often, humans can spot things before they go wrong, interrupting the fatal chain before catastrophe strikes. Often, humans are unaware of the dangerous turn of events and so they do nothing. Very rarely, humans disregard the warning signs that their expertise and training should have equipped them to see. In this case, the inquiry will determine whether any personnel had been “negligent” and whether they should be held to blame for their action or inaction. Proving negligence is not straightforward for the living and, at least in my day, almost impossible for the deceased. Often, in the absence of categorical proof, sleeping dogs must be left to lie. This doesn’t, however, prevent lessons from being learned and procedures to prevent recurrence being enforced. Hopefully, before all this occurs, risk assessments will have identified most, but crucially never “all,” of what could go wrong.

I do not know very much about the “Military Aviation Authority” since this tri-service organisation replaced the Inspectorate of Flight Safety which used to be responsible for accident investigations in my day but I do not suppose that the principles of investigation are very much different. I am certain there will have been a meticulous inquiry in this case.

It is therefore somewhat surprising that the Health and Safety Executive should consider that military business falls within their judicial terms of reference. More fundamentally, I wonder what possible public interest there could be in rehearsing a very expensive inquiry and then failing to get a conviction (for fail they surely will for the reasons I have outlined above)? Quite what washing dirty laundry in public will do for morale is very hard to see and undermining the perceived integrity of life-saving systems in such a public way is surely not a sensible thing to do. If it is Flight Lieutenant Cunningham’s kin who are driving the prosecution, I hope they get what they want but I have to say, as one who is married to the widow of a victim of a notorious bit of flying and engineering negligence, I would have advised differently.

The court case will be expensive, time consuming and will, regardless of the result, undermine confidence in the good order and discipline of the service. It is unlikely to expose anything more of relevance that has not already been uncovered by the Inquiry.
For those of us who are dismayed (and very frightened) by the remorseless erosion of defence capability in recent years, it beggars belief that scarce human and financial resources should be diverted from our fighting posture.

[superplum]

Originally Posted by PDR1

...the difference between armourers and bombs being that you can actually get *smart* bombs...



PDR

More useful than smart4rses!

[PDR1]

Oh absolutely, no offence intended - just a target of opportunity as they say.



PDR