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Inquest - Corporal Jonathan Bayliss RAF

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Inquest - Corporal Jonathan Bayliss RAF

Old 5th Nov 2021, 00:01
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Front Seat Command Ejection waiting for money

...
TeeOne and CAEBr -
Thanks, that all makes sense. IIRC the ARLs came from the Kastelli mid-air in 2010.

The major medias seem to have lost interest, but from Wales on-line this arvo ...

https://www.walesonline.co.uk/news/w...ected-22072171

"An inquest in Caernarfon on Thursday was told 25 recommendations had been made following a Defence Safety Authority Service Inquiry into the crash.

Group Captain Jackson said a feasibility study had been carried out and confirmed the system could be changed so pilots in the front seat could eject a passenger.

He said: “The feasibility study was completed by Martin Baker and it was deemed, yes, it could be incorporated into the aircraft.”

He said the improvements were expected to take between two and three years once the business case was approved."

Manana ?? .... I don't think we have anything quite so urgent as that in our MoD dictionary.

I bet Jacko is wondering what sort of poisoned chalice he's been landed with. They were talking about this problem in the Hawk Risk Register back in 2012, when 'e'd 'ardly got 'is scraper. He's now Hawk DDH and CO Hawk Wing.

LFH
...
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Old 5th Nov 2021, 08:11
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Originally Posted by Lordflasheart View Post
[b]...
Group Captain Jackson said a feasibility study had been carried out and confirmed the system could be changed so pilots in the front seat could eject a passenger.

He said: “The feasibility study was completed by Martin Baker and it was deemed, yes, it could be incorporated into the aircraft. He said the improvements were expected to take between two and three years once the business case was approved.”
There's so much wrong with this statement I don't know where to begin.

Even if we ignore that fact he implies nobody recognised the risk until March 2018 (which would be untrue), why has a feasibility study taken over 3 years? Martin-Baker and BAeS will have known exactly what was needed, or else neither deserve their status as a Design Authority. Why has his office junior not self-tasked, identified funding, written the business case, and submitted it for approval within, at most, a few weeks? Instead, the witness is talking about 6 years and more from the accident to mitigation, by which time the T1 will be gone, except a few at the Reds which will presumably need a waiver as the timescale will start impingeing on the remaining useful life rule.

I'm afraid that, once again, an unfortunate MoD witness is reading from a script, probably written by those who are meant to have done the job, but don't actually realise this.

This all comes under 'maintaining the build standard', which is a prerequisite to a valid safety case, and permitting service regulated flying. It might be a good idea to start doing it again.
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Old 5th Nov 2021, 09:15
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IIRC the ARLs came from the Kastelli mid-air in 2010.
I think actually they first raised their head after XX186 in 1998.
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Old 5th Nov 2021, 11:46
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Originally Posted by CAEBr View Post
I think actually they first raised their head after XX186 in 1998.
And well before that, after the loss of XX298 in 1984.
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Old 5th Nov 2021, 12:26
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Broken arms and dislocated shoulders ?

Perhaps following from "Where are my arms after I pull the SPFH ?" as opposed to "Where are my arms after I pull the Face Blind handle ?"
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Old 5th Nov 2021, 15:26
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Hawk Risk Register - Fatigue Risk and mitigations

Hawk Risk Register - Fatigue Risk and mitigations

According to the multitude of media reports from the inquest, there has been a lot of generalised stuff about fatigue, referenced to Reds pilots.

SI - Page 1.4.70 (1.4.301.)

"The Sqn Chain of Command (CoC) maintained oversight of personnel fatigue .... The only time that a senior pilot had seen R3 fatigued was 2 weeks before the accident ..... . On that occasion R3 had removed himself from flying. "

SI XX204 Conclusions Page 1.4.102

"1.4.473. The Panel determined that when considered collectively it was very likely that R3 was, to a degree, fatigued, ... "

Contributory factors Page 1.1.103

g. ... "The pilot's working routine was detrimentally affecting his morale, not allowing him sufficient time for rest, consolidation and affecting his fatigue levels."

h. ... "Pilot fatigue."
****************************
...
According to an historic Hawk Risk Register, two fatigue risks had been identified, which required specific mitigation to become Low and Tolerable and ALARP.

I can find no mention in the SI of these specific risks or of the required mitigations.

They were referred to in 2012 as 'Cumulative fatigue' (RED/CFIT-PILINC/02) and 'Fatigue' (RED/STFBS/01. Those responsible were listed as the DDH and the Wg Cdr RAFAT.

Are these risks and mitigations still valid and in force ?
Are these issues included in the coroner's reference to 'breaches in duties' ?

LFH
...
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Old 9th Nov 2021, 12:28
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Forgive my intrusion to this thread, but something has crossed my mind that may be pertinent to the discussion.

I was stationed at Scampton when Sgt Inman ejected from a Red Arrows Hawk (XX227?) during a transit flight from Macrihanish to Kinloss. ISTR, during a discussion with a member of the Red's 2nd line team not long after the incident, the question was asked why the pilot wasn't also ejected when Sgt Inman left the aircraft and he replied that the Red Arrows aircraft differed from the rest of the Hawks in the fleet in that the command ejection was initiated from the front seat.

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Old 9th Nov 2021, 13:33
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Originally Posted by 4mastacker View Post
... and he replied that the Red Arrows aircraft differed from the rest of the Hawks in the fleet in that the command ejection was initiated from the front seat.
All wrong I'm afraid. They are all the same and the rear can (selectably) command eject the front seater but not the other way round. Originally on the premise that the main role would be pilot training with the instructor (aircraft commander) in the back seat. The aircraft role has expanded somewhat and there is little if any student instruction left. That is (one of) the points of this argument.
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Old 9th Nov 2021, 13:55
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To paraphrase the Red Arrows' risk register. If command eject is on, and the passenger ejects both inadvertently, then the risk is of injury (not death according to MoD) to both. The 'tolerable and ALARP' mitigation is to have command eject off, so that only the passenger is injured.

But, as admitted at the Inquest last week, it's not ALARP, and I'm sure the Bayliss family don't think it tolerable.

This admission by MoD is, presumably, one reason why the Coroner adjourned. Another might be that a senior officer stated quite categorically that Bayliss should NOT have been in the aircraft.
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Old 9th Nov 2021, 14:06
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Old 9th Nov 2021, 14:08
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Daily Telegraph letters yesterday:

Too risky a manoeuvre

SIR – An inquest has been considering the death of a Red Arrows engineer, Corporal Jonathan Bayliss, at RAF Valley in 2018.

When I saw the footage and read the report of the crash, my reaction was that the pilot was practising a “turn back”. This manoeuvre is questionable in its efficacy and carries a high risk; the aircraft is on the cusp of the stall throughout and, given the aerodynamics of the Hawk wing, once it goes wrong, there is no way out.

As Officer Commanding Flying at RAF Chivenor in 1992, I was involved in the board of inquiry into an identical accident in which a young weapons instructor student died because he, too, failed to eject – why we’ll never know.

The inquiry was thorough, but the outcome was clear: the aircraft stalled and recovery was impossible, given its height, so the crash was inevitable.

At the conclusion of the inquiry, I wrote that, given the risks, and as a turn back had never been done for real, I recommended that practising the manoeuvre be discontinued.

I was, however, overruled by the powers that be, who stated that “it was a good judgment exercise” and should remain in the syllabus.

Three months later, a Hawk was written off at Valley following a practice turn back, although both pilots walked away from it. Twenty-six years later, sadly, Corporal Bayliss lost his life, and it could have been avoided.

Wg Cdr Jeremy Parr RAF (retd)
Suckley, Worcestershire
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Old 9th Nov 2021, 15:20
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ROC man
When I saw the footage and read the report of the crash, my reaction was that the pilot was practising a “turn back”. This manoeuvre is questionable in its efficacy and carries a high risk; the aircraft is on the cusp of the stall throughout and, given the aerodynamics of the Hawk wing, once it goes wrong, there is no way out.

As Officer Commanding Flying at RAF Chivenor in 1992, I was involved in the board of inquiry into an identical accident in which a young weapons instructor student died because he, too, failed to eject – why we’ll never know.

The inquiry was thorough, but the outcome was clear: the aircraft stalled and recovery was impossible, given its height, so the crash was inevitable.

At the conclusion of the inquiry, I wrote that, given the risks, and as a turn back had never been done for real, I recommended that practising the manoeuvre be discontinued.

I was, however, overruled by the powers that be, who stated that “it was a good judgment exercise” and should remain in the syllabus.

Three months later, a Hawk was written off at Valley following a practice turn back, although both pilots walked away from it. Twenty-six years later, sadly, Corporal Bayliss lost his life, and it could have been avoided.

Wg Cdr Jeremy Parr RAF (retd)
Suckley, Worcestershire
I think that maybe Jerry is wrong?
My understanding is that the Practice Engine Failure was initiated with "apparently" enough height and speed to get to Low Key. Once the pilot had failed to achieve that Gate the Practice should have been "Knocked Off".
The poor decision to continue put the aircraft into a continually worsening situation. Even at half way round finals the aircraft could have been flown away quite safely.
The fact that the Hawk T1 does not had an AoA Gauge, Stall Warner or Command Eject Front to Rear only made the outcome more inevitable.
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Old 9th Nov 2021, 15:27
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Originally Posted by Background Noise View Post
All wrong I'm afraid. They are all the same and the rear can (selectably) command eject the front seater but not the other way round. Originally on the premise that the main role would be pilot training with the instructor (aircraft commander) in the back seat. The aircraft role has expanded somewhat and there is little if any student instruction left. That is (one of) the points of this argument.
Thank you for that reply. I must say that I'm surprised that someone who worked on the Red's aircraft appears to have given out inaccurate information - I wasn't in a position to contradict what he said.
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Old 9th Nov 2021, 18:47
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Originally Posted by Dominator2 View Post
ROC man

I think that maybe Jerry is wrong?
My understanding is that the Practice Engine Failure was initiated with "apparently" enough height and speed to get to Low Key. Once the pilot had failed to achieve that Gate the Practice should have been "Knocked Off".
The poor decision to continue put the aircraft into a continually worsening situation. Even at half way round finals the aircraft could have been flown away quite safely.
The fact that the Hawk T1 does not had an AoA Gauge, Stall Warner or Command Eject Front to Rear only made the outcome more inevitable.
Sort of. A (practice) turn back (to the reciprocal runway in the examples above) is also initiated with enough energy to get back to the runway. Both however, can go wrong quite quickly and it is then down to the pilot to recognise (or not) that situation. Neither manoeuvre gets to a classic Low Key so it is impractical to use that as a gate.
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Old 10th Nov 2021, 11:02
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Hawk Risk Register abandoned ?

...
Hawk (Red Arrows) Risk Register - PEFATO - Turnbacks

'Exhibit No 67 - Risk Register' - from the Scampton XX177 accident in 2011, includes some sixty separate risks and where necessary, the required mitigation.

Although the spreadsheet style register is not specifically titled, it seems reasonable to presume it is specific to the Red Arrows, because every one of the risk file names begins with 'RED/.' Each risk is required to be reviewed periodically - six months or a year, though a few are conditional.

One of the identified risks - Risk No. RED/LOCI-HAN/04 - refers to 'turnbacks.'

This risk was described as -

.... "Effect - Loss of Control during the manoeuvre ..."

.... "Worst credible outcome - loss of pilot and supervising pilot"

.... "Liklihood - remote."

.... "Severity - critical.

... "Risk level - Medium."

.... "Risk owner - DDH. .... Risk Manager - OC RAFAT.

The required mitigation to reduce the risk to 'Low and Tolerable and ALARP was in three parts -

.... i) "Bespoke turnback training by HQ CFS Exam Wing."

.... ii) "60 day currency" ... [That's one practice every two months.]

.... iii) "Requal by QFI if ... [60 day currency] ... lapsed."

I can find no mention of a Hawk or RAFAT Risk Register, nor of the specific risk, nor of the mandated mitigation, anywhere in the XX204 SI. ...... A lot of contradictory mishmash, like for instance, the table on Page 1.4 - 7. - PEFATO recency - 30 days for 100 Sqn, 60 days for 736 NAS and, unbelievably, 'Not mandated' for RAFAT.

You'd think that issue alone would have invited comment from the XX204 Board, if only to deplore the change from the mandated '60 days' only six years earlier, and given the record of accidents resulting from practicing EFATOs and Turnbacks, and including the presumption that passengers should not be carried while practicing 'dodgy' manoeuvres.

Nothing in Part 1 to say if the Risk Register was included as an exhibit or had been considered. The closest I got was this cryptic comment -

..... Page 1.4.105 Observations

...... j. ... "The DDH's Air Safety register appeared to be more of a personal record rather than a formal decision register."

Four specific problem areas listed in the Risk Register at the time of XX177 at Scampton were discussed in great detail in the XX204 SI (only six years later) but without any reference to the Risk Register or to the Risk Codes or to the required mitigations.

The specific risk codes are -

RED/OTHR-1/05 - Command Ejection. ... RED/STFBS/01 - Fatigue

RED/CFIT-PILINC/02 - Cumulative Fatigue and ... RED/LOCI-HAN/04 - Turnbacks

Was the XX204 Board unaware of the Risk Register or of the importance of (ignoring) the mandated mitigations that referred specifically to Red Arrows, whose fatal crash they were investigating ? .... Or were they told 'not to go there' ?

Or has the entire Hawk Risk Register been abandoned ?

Someone must know.

LFH
....
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Old 10th Nov 2021, 11:37
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LFH

I’m sure your intentions are pure and honourable but I’m afraid your posts are a tough read.

They are not especially well structured and it is often hard to understand what you are after.

In my view, a coroner is far more likely to obtain the relevant information and get to the bottom of things than a rambling poster on PPRuNe.

Maybe just let the lady get on with it and publish her findings in due course?

Before I face the wrath of the assembled kangaroo court I can state categorically that I have no dog in the fight.

BV
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Old 10th Nov 2021, 16:09
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Lordflasheart - Thanks for your posts. In summary then, relevant risks weren't ALARP, the risk register was pants, and MoD didn't disclose this. That sums up a lot of threads here.

Bob Viking - Having taken MoD's side the coroner was persuaded to change her mind. The successful argument was posted on PPRuNe. It's even in a book. I don't think she worked it out by herself.
If you are aircrew you have a big dog in the fight.
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Old 11th Nov 2021, 09:25
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Dear Bob Viking,

Thank you. ... If I may, I'll start from the bottom and begin with Kangaroo Courts.

Among these I would include the disgraceful and inexplicable overturning of the Mull Chinook SI by two RAF gentlemen, which resulted in the families of your colleagues being denied compo for many years - until a bit of public rambling on PPRuNe uncovered the deep rooted technical and institutional lies that had been supported by the state for so many years.

I would follow with the Kangaroo Crown Court at Lincoln, in which MBA were unjustifiably prosecuted by the HSE, where despite MBA, the Judge and the HSE being shown the exculpatory evidence, the court was happy to accept the technical lies and MBA's spineless and inexplicable guilty plea. The subject being principally the scissors shackle/gas shackle issue which put you and your colleagues at risk for many years.

Then I would look at the Sea King collision inquest where the coroner showed no interest in the truth and the MoD lied to the families about the case. Or the C-130 inquest where MoD security officials prevented an RAF officer entering the Coroners Court where he intended to give evidence of MoD lies about ESS. It took a brave coroner - there are some - to compete with the state on that one, and probably helped with the establishment of a cadre of 'specially trained' coroners to deal with active service deaths overseas, probably encouraged by MoD who hoped to prevent more unseemly verdicts publicly blaming MoD for their secret shortcomings relating to service deaths.

Madam Acting Senior Coroner's Caernarfon predecessor, in post for fifty years, is on record as having told some PPRuNe ramblers he was not able to take account of their real evidence because they were not 'interested parties.' It was he who should have held a local inquest into a service death in Scotland, where, as I am sure you will know, it was discovered that service personnel are not considered to be employees, thus doing them out of certain rights.

One hopes Madam Coroner may have felt able to consider certain rambling information that has been submitted to her and to her predecessors, or even that she may surreptitiously read those ramblings on PPRuNe after lights out.

I hope that her about face on Article 2 will have some beneficial result for Jon Bayliss' family and for future service deaths, but I worry that it is more likely to result in her not being confirmed in post, pour encourager les autres à suivre la ligne.

So what am I after ? Relevant to the current thread, I would like to know if the Hawk (RAFAT) Risk Register still exists. If so, why was it not mentioned in the SI ? If it doesn't, what has replaced it ? As I tried to explain, there are several very relevant issues which were glossed over or plain ignored by the XX204 Board, that would not be known about without access to the (historic) Risk Register. Someone will surely know the answer.

I would also like the MoD and the State to stop trying to conceal the truth about the next few service fatalities, or even to take preventative action. I gather from your posts that you are an experienced Hawk and service pilot yourself. It might be your mates or mine next, and (who knows ?) a bit of rambling on PPRuNe might just tip the balance.

You're right - the entire subject is a tough and highly technical read. Many readers (but not boards of inquiry, coroners, barristers or interested parties who want to know the truth) might be forgiven for dozing off after the first page. Finding the truth is always complicated but fortunately, it is now well helped by modern communications, when all sorts of previously concealed evidence can pop up to confound those who would conceal. Learning the truth would be particularly unpalatable when the enemy turns out to be the state that employs you to protect it.

I'm sorry my posts seem not well structured and hard to understand - and long winded again. I didn't have the benefit of the Short Service Writing Course. There are several well written good books by an author named David Hill. I can't remember if you previously said you'd read any of his stuff, or that you couldn't be bothered to do so. I'm sure you know where to find them.

Yours sincerely, LFH.

PS. I'm not sure I do 'pure and honourable' but I appreciate your thinking I might

...
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Old 11th Nov 2021, 11:34
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LFH

A wonderful response.

Keep posting.


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Old 11th Nov 2021, 12:46
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LFH

That is a great response.

I clearly didn’t articulate myself very well previously.

I wasn’t questioning your motives but just pointing out that your earlier posts were not very clear.

BV
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