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Hawk XX204 Service Inquiry

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Hawk XX204 Service Inquiry

Old 15th Oct 2019, 19:18
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This incident appears to bear some striking resemblance to that which occurred to Hawk T1A XX334 on 19(R) Sqn at 2TWU in September 1992.
https://aviation-safety.net/wikibase/wiki.php?id=55475
In this instance, the person that died was I believe, an experienced Hawk QFI, participating in a QWI course. He was in the rear cockpit, with the Captain in the front cockpit.
This incident still haunts me to this day and I wonder were the lessons learned adequately promulgated around the Hawk community of today?

I speak only as an armourer on the squadron that was 'back-seat qualified' and on shift at the time of the crash. I/we flew many times in the rear cockpit, sometimes to deploy to Coningsby or Leuchars for a small '2-ship' Det. and on occasion, just for fun in the weather ship or a target tug. The practice was actively encouraged by our aircrew and the guys and girls the squadron loved it. But let's be clear, we were passengers, not supernumerary crew.
To the best of my knowledge, EFATO was never practiced when ground crew were being carried in the rear cockpit. We were however always meticulously briefed, each trip, on the possibility and procedure for ejection. Always challenged to confirm that the Command Selector Valve in the rear cockpit was 'down and off' during taxi, even though the pilot would have checked it when we got to the aircraft.

Fair to say that I had a very good understanding of the ejection seat, but I'm not sure that I would have ever initiated ejecting without being instructed to do so; maybe if I knew that the pilot had been incapacitated by something like a birdstrike, but highly unlikely. If an engine failure had ever occurred on take-off (and I don't recall any during my six years on the Hawk), the only thing I would have done is sit tight, keep quiet and wait for instructions!
For us ground crew minions, we place our trust in our pilots and accept the risk.

I'm sure that Cpl Bayliss was like I, was just pinching himself at how lucky he was to be able to have such an experience. RIP mate....
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Old 16th Oct 2019, 03:57
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K3k3 and DV

It does you both credit that you were able to accept my message in the spirit it was intended. No hard feelings on my part.
My message was also a wider one to anyone reading this.

I believe all of us should be wary of commenting on subjects where our knowledge is either lacking or out of date. Especially instances such as this.

As an example I have flown the Tucano (135 hours as a student), but not since 2001. If we were to be discussing a Tucano incident I would refrain from getting involved with any technical aspects of the conversation since I accept that my offerings could not be guaranteed to be correct.

Sorry to get all ‘preachy’.

BV
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Old 16th Oct 2019, 06:56
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Cpl Bayliss should not have been in the back as the pilot intended to do a practice engine failure esp with no command eject available. He did not have the training or knowledge when confronted with this situation.
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Old 16th Oct 2019, 09:08
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Originally Posted by LincsFM
Cpl Bayliss should not have been in the back as the pilot intended to do a practice engine failure esp with no command eject available. He did not have the training or knowledge when confronted with this situation.
Good post LFM. There is the nub of it, and the chamber pachyderm then is how come he was?
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Old 16th Oct 2019, 09:33
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LincsFM

Cpl Bayliss should not have been in the back as the pilot intended to do a practice engine failure esp with no command eject available. He did not have the training or knowledge when confronted with this situation.
Based on my experience with inquest and Fatal Accident Inquiries, I believe that this is a conclusion that could be reached by the coroner, whose main task it is to determine the cause of death not the accident.

I note that one contributing factor that is common to this accident, the one involving XX179 (Aug 2011) and the one involving XX233/XX253 (March 2010) is an inadequate risk register. The SI refers to 'Bow Tie' analysis, this does not replace the risk register. As someone who is familiar with this 'tool' I can say that if the newly developed Bow Tie for the Red Arrows is similar to that developed for Tornado MAC then it is of little use.

Despite all this the ODH was happy to sign off to say that risks associated with the operation of RAFAT Mk1 Hawk aircraft were Tolerable and ALARP. This is the statement that he should be called on to justify at the inquest.

DV
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Old 16th Oct 2019, 09:52
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Despite all this the ODH was happy to sign off to say that risks associated with the operation of RAFAT Mk1 Hawk aircraft were Tolerable and ALARP. This is the statement that he should be called on to justify at the inquest.
Agreed. And the ODH is (?) AOC 22 Gp? Or does it go all the way to C-in-C or CAS?
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Old 16th Oct 2019, 10:06
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Originally Posted by Distant Voice
Based on my experience with inquest and Fatal Accident Inquiries, I believe that this is a conclusion that could be reached by the coroner, whose main task it is to determine the cause of death not the accident.

I note that one contributing factor that is common to this accident, the one involving XX179 (Aug 2011) and the one involving XX233/XX253 (March 2010) is an inadequate risk register. The SI refers to 'Bow Tie' analysis, this does not replace the risk register. As someone who is familiar with this 'tool' I can say that if the newly developed Bow Tie for the Red Arrows is similar to that developed for Tornado MAC then it is of little use.

Despite all this the ODH was happy to sign off to say that risks associated with the operation of RAFAT Mk1 Hawk aircraft were Tolerable and ALARP. This is the statement that he should be called on to justify at the inquest.

DV
Good post. I imagine the Reds carrying of groundcrew as Supernumerary crew will also be looked at . As RA2340 quotes "The Supernumerary Crew Certificate of Competence will provide auditable evidence that the individual has achieved the level of competency required by ADH/AM(MF) orders to operate/be employed on the Air System"

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Old 16th Oct 2019, 10:23
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Agreed. And the ODH is (?) AOC 22 Gp? Or does it go all the way to C-in-C or CAS?
The ODH is AOC 22 Gp. He is the one who makes the ALARP (Safety) statement.

DV
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Old 16th Oct 2019, 11:53
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Reading para 1.4.106 and the paras leading up to it - the case for Circus to be carried was strong; the case to be considered as SC was in my opinion weak, and the means by which they achieved SC and were endorsed was not - to me - thorough.
I also note that the lack of the 2017 simulator sorties was not elevated to DDH, let alone ODH.

Is it not the case that the ODH could reasonably expect his aircrew to operate the Hawk T1 in a manner that didn’t involve straying into the parameters noted in the report, whilst conducting simulated low level emergencies, on a sortie with a rear seat occupant whose training was, as had already been said, inappropriate for the situation he faced?

I acknowledge the panel’s finding that a comprehensive command eject system may (with the caveats as published) have saved both aircrew.


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Old 16th Oct 2019, 12:27
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On a different tack...

I am curious as to how the Hawk Simulator fitted into all this. The pilot flew the emergency in the simulator a couple of times less than 2 hours before the accident. The simulator staff didn't find any noteable faults with his exercises though presumeably they hadn't pick up the new changes to the PEFATO profile. In the absence of any recordings of the exercises, the accident investigators didn't appear to check that the simulator could have given any false cues or perceptions in this kind of manoeuvre.

I'm not having a go at the simulator, I actually worked on it's development, and thought it would be a great training aid and have uses in accident investigations as well but that doesn't seem to be so in this instance.
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Old 16th Oct 2019, 13:20
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Rear seat occupant or not it seems to me that a more stringent approach to this form of training is required.

I would suggest that it should be a requirement that if low key cannot be made at the required minimum height or greater with reasonable spacing then it IS to be discontinued.

For example, many years ago, several transport aircraft crashed in low vis ops when going right down to minimums or below even when vis or rvr was BELOW that required.

The rules were changed so that descent below minimums plus 500 feet ( IIRCC) was prohibited when rvr/ vis was below that required.

I would suggest that the above could very easily and quickly implemented with no operational detriment and far easier than implementation of command ejection.
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Old 16th Oct 2019, 14:38
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Originally Posted by Mortmeister
This incident appears to bear some striking resemblance to that which occurred to Hawk T1A XX334 on 19(R) Sqn at 2TWU in September 1992.
https://aviation-safety.net/wikibase/wiki.php?id=55475
In this instance, the person that died was I believe, an experienced Hawk QFI, participating in a QWI course. He was in the rear cockpit, with the Captain in the front cockpit.
This incident still haunts me to this day and I wonder were the lessons learned adequately promulgated around the Hawk community of today?

I speak only as an armourer on the squadron that was 'back-seat qualified' and on shift at the time of the crash. I/we flew many times in the rear cockpit, sometimes to deploy to Coningsby or Leuchars for a small '2-ship' Det. and on occasion, just for fun in the weather ship or a target tug. The practice was actively encouraged by our aircrew and the guys and girls the squadron loved it. But let's be clear, we were passengers, not supernumerary crew.
To the best of my knowledge, EFATO was never practiced when ground crew were being carried in the rear cockpit. We were however always meticulously briefed, each trip, on the possibility and procedure for ejection. Always challenged to confirm that the Command Selector Valve in the rear cockpit was 'down and off' during taxi, even though the pilot would have checked it when we got to the aircraft.

Fair to say that I had a very good understanding of the ejection seat, but I'm not sure that I would have ever initiated ejecting without being instructed to do so; maybe if I knew that the pilot had been incapacitated by something like a birdstrike, but highly unlikely. If an engine failure had ever occurred on take-off (and I don't recall any during my six years on the Hawk), the only thing I would have done is sit tight, keep quiet and wait for instructions!
For us ground crew minions, we place our trust in our pilots and accept the risk.

I'm sure that Cpl Bayliss was like I, was just pinching himself at how lucky he was to be able to have such an experience. RIP mate....
You have written a post describing my thoughts far better than I could have done, using a valid accident to illustrate them.
I too have been in your situation and almost certainly would not have recognised that a PFL exercise had gone awry, until far too late.
Indeed, hearing the engine start to spool-up may have reassured me that we were overshooting?
Like you, I felt I did have enough knowledge to deal with an obvious situation, if presented.

There are times when we are totally reliant on the skills of others - thus sensible rules are written for our protection.
As an example, over the years, the rules on carrying ATC Cadets on helicopters were made more stringent, much limiting the exercises cleared with them on board.
They may have enjoyed being there, but they did not need to be and almost certainly had no balanced view of the associated risks.

Having "contracts" is not a phrase I am familiar with, I learn.
However, it does seem to have many parameters to satisfy - looks good on paper, but is it clear enough in a dynamic situation?
A simple gate might be easier?

lsh

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Old 16th Oct 2019, 15:34
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Posted By Orca
I also note that the lack of the 2017 simulator sorties was not elevated to DDH, let alone ODH.
I understand that it is the responsibility of the AOC to sign off, following a flying demonstration, that all aspects of pre-season operations are safe and ready. I respectfully suggest that this is not limited to how smart the crews and aircraft are, or whether smoke comes on at the right time, but all round training and associated paperwork. In the XX 149 SI report, dated 29th April 2012, it is recommended that the AOC 22 Group should, amongst several other things,

(1) Develop an effective Unified Risk Register in accordance with RA 1210.
(2) Conduct a risk assessment to ensure any work load associated risks from RAFAT tasking and flying rate, for all personnel, are suitably mitigated such that they are Tolerable and ALARP.

What did AOC 22 Gp do to comply with those recommendations, and how was it monitored? No need to have the risk elevated to him, the XX 149 had done that. Was his answer to simply arrange for 'risk register transition to BowTie analysis' (para 1.4.413). Well the effectiveness of such an action can be seem at para 1.3.8.

'In examining the RAFAT BowTies that were active at the time of the accident, the Panel could find no evidence of where the flying of SC or Circus had been considered, and consequently there was no evidence of the SC training syllabus having been used as a barrier within a threat line.'

DV
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Old 16th Oct 2019, 19:22
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I may have misunderstood but wouldn’t the sign off to which you refer in your first para be conducted after the display flying work up was complete?

I don’t disagree with your other points but wrt SC status and training - can an ODH not rely upon the assurance given by nominating Commandant CFS as ‘awarding authority’ for SC status?
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Old 16th Oct 2019, 22:59
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Having flown in the Hawk back seat as a civilian out of Valley - I wonder how many non-pilots might just freeze when presented with a time critical ejection decision.
The handle is there - but there'd be ground rush - a tremendous surge of Adrenalin and no doubt and instinctive reaction to brace for impact.
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Old 17th Oct 2019, 12:31
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Originally Posted by tartare
Having flown in the Hawk back seat as a civilian out of Valley - I wonder how many non-pilots might just freeze when presented with a time critical ejection decision.
The handle is there - but there'd be ground rush - a tremendous surge of Adrenalin and no doubt and instinctive reaction to brace for impact.
I had a couple of back seat fast jet trips back in the 80's including on a post major servicing Jaguar airtest. I know for certain that I would have done the same as the unfortunate Cpl Bayliss. I would have reacted to a call from the pilot to eject but only experienced aircrew could appreciate that the aircraft was heading rapidly towards the ground and initiated ejection independently of the pilot within the limited timescale.
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Old 17th Oct 2019, 13:35
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orca:-
can an ODH not rely upon the assurance given by nominating Commandant CFS as ‘awarding authority’ for SC status?
Well clearly not. The MAA seems to believe that by printing out reams of bumf like Regulatory Article 1020,

https://assets.publishing.service.go...20_Issue_9.pdf

it can avoid avoidable accidents. The problem is the infamous Swiss Cheese model. Anyone, all or some, of those holding the many acronym denominated posts described therein can subvert the aim and hence enable the avoidable accidents to happen. No Air Safety system is 100% reliable, but one that has been drafted from scratch, because the previous one was put through the shredder and its proponents hounded from office, is doomed to failure.

What is needed is a Regulatory Authority with teeth which can and will bring to book those in the highest echelons that renege on their responsibilities. What is needed is an Air Accident Investigator that can find those causes identified and forecast years prior to the accident but not acted upon. In other words a Regulator and an Investigator independent of the MOD and of each other.
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Old 18th Oct 2019, 08:40
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can an ODH not rely upon the assurance given by nominating Commandant CFS as ‘awarding authority’ for SC status?
"If we had a fatality in the military tomorrow, I could give you the four names for any part of military defence who have accepted personal accountability for that. Perhaps I could refer to one of our Duty Holder letters from the Chief of the Air Staff, Sir Andrew Pulford to Air Vice Marshal Turner,[AOC 22 Group] who is an Operating Duty Holder. Line 4 of the letter says: “You are personally legally responsible and accountable through the Secretary of State for air safety, the air systems and functional safety in your area of responsibility.” We are now crystal clear in the military about where that accountability lies and it is not at lower levels, but at pretty senior levels: Lieutenant Colonel up to Chief of the Air Staff in this instance, and above to the Secretary of State"- Air Marshal Richard Garwood (DG Defence Safety Authority) in oral evidence given to Defence Sub Committee on 26th Nov 2016.

It is the Operating Duty Holder who signs the ALARP safety statement.

At the time that Richard Garwood made that statement, and since the introduction of the Duty Holder concept, there had been the Tornado collision in 2012, Lynx - controlled flight into terrain in 2014, and Puma – wire strike in 2015, with a total loss of life of 12 in four years. No Duty Holder was held accountable; no Duty Holder has was called into a court to validate his ALARP case. Just words.

DV

Last edited by Distant Voice; 18th Oct 2019 at 09:00.
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Old 18th Oct 2019, 13:15
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JTO

What an excellent post. I recognise every word.

The common denominators between this XX204 report and that of XX177 (Flt Lt Cunningham, issued in 2012) will be blindingly obvious. The final act differs, but the underlying failures remain the same. Given MoD claimed the recommendations from 2012 were being implemented, one is entitled to ask why so little progress was made before March 2018.

Various office holders/DHs are the subject of recommendations. For example, AOC 22 Gp has eight. To implement them requires resources and trained staff. He (and others) will have staff who know what they want, but not necessarily how to go about it. He might even ask why those recommendations that are mandated policy have been ignored. He might get a sympathetic hearing from DE&S, but be told (a) no endorsed requirement, but in any case (b) we no longer employ sufficiently junior civil servants to do this stuff.

(If you’re interested, these were ‘special tasks’ handed out to staff who sat one below the MoD(PE) minima. Among other things, they identified the funding, or staffed the bid if it was a bit costly - say, over £20M - and generally managed the task. I say £20M, because it is formal policy in MoD that it is a ‘routine expectation’ of any technical grade to be able to identify up to that sum for such use, without degrading operational capability. Not that it’s enforced these days, but perhaps it should be. People should be given the opportunity to learn their limitations).

Straight away, the AOC is up against it, and I sympathise. Almost by definition, the current AOC will be long gone before anything is done, and his successor will say he has other ‘new’ problems; not realising that most are the same old problems. He generally finds out after the next accident. Meanwhile, if they’ve read these reports, aircrew and groundcrew are wondering WTF is going on. And, as we know, the typical Air Staff response is to dismiss feedback as ‘ …uninformed, crewroom level, emotive comment lacking substantive evidence and focus’. (Nimrod Review, p360). This, in reply to the RAF Director of Flight Safety (Air Cdre E.J. Black), who had fully supported the crewroom. That was in 1998, and the XX204 and XX177 reports are just two examples full of precisely the same ‘emotive comment’.

DGDSA says at the end of the report that he ‘agrees’ with all the recommendations. What does that mean? It isn’t a formal endorsement, so the DHs are no further forward, 19 months after the accident. If DGDSA has, as we’re told, the ear of Secy of State, what the DHs want to read is ‘I’ve briefed the Secy on what we need, he’s agreed and given his endorsement, I’ve briefed the personnel responsible for delivery and given them timescales, they’re cracking on and must report progress to the DHs every Friday’. Now, it’s a long time since I’ve done this and visited MB every Friday morning (that new-fangled e-mail thing might suffice these days) but, believe me, doors open when you have such a task. Of course, many of the recommendations can be satisfied by self-tasking. Or just doing what the regs say. Unfortunately, both are anathema to many.

The DHs have every right to ask why the common Causes, Factors, Observations and Recommendations from previous accidents haven’t been addressed. But that doesn’t absolve them of what JTO mentions - the ‘I didn’t know’ defence. Whatever happened to the old system of the 2 Stars’ primary task being a monthly assessment of the Top 10 risks in ‘his’ risk register(s)?
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Old 18th Oct 2019, 13:27
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All very depressing, but it would seem to be an integral part of human nature when it comes to the blame game. By the same token, we should recognise that there does not always need to be someone to blame when something bad happens.Unforeseen and unimagined things do happen. People do not always observe and adhere to rules and procedures, Errors of judgement can be made innocently and in good faith,

As the name suggests, Duty holders have a duty , which includes, inter alia, the duty to act diligently and professionally, to exercise their professional judgement to the best of their ability, and to pay due care and attention to the matters in their charge. You can pick different words if you wish, but there is no getting away from the fact that they cannot be expected to be perfect in every respect at every moment. It should also be recognised that decisions are rarely taken against the standard of achieving zero risk. ALARP is much bandied about, but stop and think what it means ; As Low As Reasonably Practicable.Clearly there is a degree of subjectivity involved, and reasonable people could easily differ as to what is reasonably practicable without acting unprofessionally or dishonestly.


Taking as an example the decision to require Hawk Pilots to perform PEFATO training on a regular basis. How might a reasonable duty holder have gone about reaching this decision? Obviously, as a single engined aircraft, loss of engine power at takeoff is a serious problem, and whilst with modern equipment far from an everyday occurrence, still a measurable risk of it happening. What are the consequences when the risk occurs? Best case, pilot manages to land safely, next best crew eject safely aircraft crashes into an empty field, worst case, aircraft crashes into a built up area with crew aboard. Clearly the last of these is catastrophic, whilst the first is but a minor drama, and an outcome whose probability can be dramatically increased by pilot training. The Duty holder diligently and properly arrives at the conclusion that pilot training is warranted, and next sets out to determine the form this might take.
Simulator training is attractive, as it can be undertaken without exposing the pilot or the aircraft to the real risks associated with reducing power in an airborne aircraft for a PEFATO drill, so simulator training is mandated.
The duty holder is however concerned that this is not enough, and agonises over whether "real" PEFATO drills should be mandated. Deeply mindful of the Meteor asymetric landing fiasco, they are faced with trying to evaluate whether the risks from the training are greater than the risks they are trying to mitigate. Any attempt at such an evaluation requires the duty holder to make an estimate of the likely number of engine failures at take off and compare it with the likely number of casualties from PEFATO training. Given the size of the Hawk fleet, its length of service, the frequency with which PEFATO drills would be flown, and the number of things which could go wrong, it is inconceivable that the duty holder could have concluded that there would be no casualties from the introduction of mandatory PEFATO training.
The fact that we are now dealing with just such a casualty does not automatically mean that there is a duty holder to blame. Rather, we may be looking at an accident which was anticipated when the decision was made to implement PEFATO training, and however tragic, it does not negate the validity of the original calculation.

As it happens, there is much about this particular incident which in my view calls the duty holders into question, but I did want to offset some of what I felt was a drift in this thread towards the position that there was always and automatically a duty holder to blame.
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