Inquest - Corporal Jonathan Bayliss RAF
The Service Inquiry recommended 'AOC 22 Group investigate the incorporation of an artificial stall warning capability'. (para 1.4.253)
From the Coroner's remarks, and her written decision, it would seem she was displeased that the same recommendation had been made after an incident in 2007, with nothing done. She is not trying to dictate a solution, but repeating her point that known risks are not tolerable and ALARP, and that this constitutes negligence (but not gross negligence).
Some would say negligence is negligence.
Would I be wrong here to see a parallel between this inquest and that for the Nimrod? Criticism of the MoD by a coroner eventually led to the end of the Nimrod. Is it possibe that a similar outcome will bring a complete end to the Hawk Mk1 and, therefore, the Red Arrows? I can't imagine that MoD will be too pleased to set up a test project for such a limited application.
Doesn`t the USN T-45 Goshawk have an AAI plus audio....?
Would I be wrong here to see a parallel between this inquest and that for the Nimrod? Criticism of the MoD by a coroner eventually led to the end of the Nimrod. Is it possibe that a similar outcome will bring a complete end to the Hawk Mk1 and, therefore, the Red Arrows? I can't imagine that MoD will be too pleased to set up a test project for such a limited application.
The family did cite the Nimrod Review, saying in a submission to the Coroner that the same systemic failings were recorded by Mr Haddon-Cave. But, as noted earlier, while she took past breaches into account when ruling on Article 2, she did not when considering the admitted breaches.
I suppose the main difference is that there was a Nimrod safety case, albeit not fit for purpose. Here, there wasn't one. Haddon-Cave considered the former worthy of legal action (but named the wrong people), while Ms Sutherland completely ignored it.
The Coroner's letter to Secy of State Ben Wallace setting out her 'matters of concern' makes interesting reading.
Her role is to establish cause of death. Her two matters of concern relate to cause of accident, an entirely different thing. It is seemingly of no concern that the pilot lived yet Jonathan died. Which is actually MoD's formal position.
Her stance seems to have changed once the issues raised at the Inquest were collated and sent up to the Chief Coroner. A political direction imposed upon her? She cannot help but notice the contradictions between her words of November and those of December.
Her role is to establish cause of death. Her two matters of concern relate to cause of accident, an entirely different thing. It is seemingly of no concern that the pilot lived yet Jonathan died. Which is actually MoD's formal position.
Her stance seems to have changed once the issues raised at the Inquest were collated and sent up to the Chief Coroner. A political direction imposed upon her? She cannot help but notice the contradictions between her words of November and those of December.
Coroner's PFD Letter
...
Bayliss Inquest - Prevention of Future Deaths letter
The Defence Minister's reply dated 7th March 2022 is here - https://www.judiciary.uk/publication...deaths-report/ along with the Coroner's PFD letter.
With respect - They all seem to have completely missed the point.
The historic risk assessment and mitigation for back-seater carriage was shot to pieces by the death of Corporal Bayliss. A risk re-assessment seems to have been done since 2018, but whatever its conclusions, it clearly missed the point and has done nothing for back-seat safety.
Back-seaters, including Circus are still being carried and the only changes made so far are administrative. If MoD thinks that future 'promised' changes are enough to make continued current carriage ALARP and Tolerable, they need to think again. Alternately, they may think the paper changes and 'promises' are enough to hoodwink us.
The Coroner put up two half-hearted Matters of Concern 'in order to prevent further death' but missed the obvious elephant. She did not ask why it was considered necessary to carry Circus members on certain (or any) Hawk flights. She did not ask how the new risk-assessment of continuing to carry Circus members could be considered ALARP and Tolerable in view of the fatality and when safer alternatives were available.
The Minister replied in the same vague vein, though he did, to my surprise (because I don't remember that being promised at the Inquest) suggest - " the development of a Command Ejection capability, and ... are already in train."
The principal reason Jon Bayliss died was because he was unlucky enough to be sitting in the back of a perfectly serviceable aircraft when it happened to crash. More warning and he might have ejected when so ordered. Command Eject and he might have been successfully command-ejected by the pilot.
Why was he in the aircraft in the first place ? He was not a required member of the operating crew, thus his presence was arguably optional. He was in the aircraft because it suited some long-standing and so far unquestioned organisational agenda, as a convenient and cheap way of transporting ground crews. Also, up to now - it was probably considered great fun and a bit of a reward for hard-working and trusting ground crew who presumably did not have to be ordered to fly, or forced to join the Circus.
No matter what shuffling of paper or tweaking of simulators, the next time a pilot screws up, the back seater will still be at the same serious risk as Jon Bayliss, while there is no front to back Command Eject.
It may well be that the current Minister honestly intends to install 'front to back' Command Eject - but for a mere couple of dozen Hawk Mk 1s - what would you believe ? If the modification work is easy or inexpensive, why wasn't it done years ago ?
There are (or were) plenty of 'spare' transport aircraft which might fit the bill for routine RAFAT support. Many other national aerobatic teams fly single seaters. They don't have a problem with provision of support aircraft. The Blue Angels bought one of our 'surplus' C-130Js. Time to put up or shut up ?
Historically, for many aircraft types, practising the failure killed more folk than any actual failure. Civvy-wise, it is no longer permitted to practise engine failure on a real (air transport) aeroplane. It can only be done in a simulator. Bear in mind that a civvy aeroplane may be carrying hundreds of pax who don't have the benefit of ejector seats or parachutes and who might not use them even if ordered.
Question 1. Why is it still considered necessary to practice 'engine failure after takeoff ' in terms of what is demonstrably a challenging flight regime ? Horsing a Hawk round in the weeds with not a lot of knots has contributed to some nine crashes and four deaths since 1982. What is wrong with 'zoom and eject in comfort' ?
And in the mean time, the only way to ensure that RAFAT back-seater risk is ALARP and Tolerable - is regrettably to ban back-seat rides for all but required pilot training and assessment, at least until front to back Command Eject is in service.
Question 2. Why does MoD believe it is still safe to continue carrying non-pilot back-seaters, without front to back Command Eject ?
LFH
...
Bayliss Inquest - Prevention of Future Deaths letter
The Defence Minister's reply dated 7th March 2022 is here - https://www.judiciary.uk/publication...deaths-report/ along with the Coroner's PFD letter.
With respect - They all seem to have completely missed the point.
The historic risk assessment and mitigation for back-seater carriage was shot to pieces by the death of Corporal Bayliss. A risk re-assessment seems to have been done since 2018, but whatever its conclusions, it clearly missed the point and has done nothing for back-seat safety.
Back-seaters, including Circus are still being carried and the only changes made so far are administrative. If MoD thinks that future 'promised' changes are enough to make continued current carriage ALARP and Tolerable, they need to think again. Alternately, they may think the paper changes and 'promises' are enough to hoodwink us.
The Coroner put up two half-hearted Matters of Concern 'in order to prevent further death' but missed the obvious elephant. She did not ask why it was considered necessary to carry Circus members on certain (or any) Hawk flights. She did not ask how the new risk-assessment of continuing to carry Circus members could be considered ALARP and Tolerable in view of the fatality and when safer alternatives were available.
The Minister replied in the same vague vein, though he did, to my surprise (because I don't remember that being promised at the Inquest) suggest - " the development of a Command Ejection capability, and ... are already in train."
The principal reason Jon Bayliss died was because he was unlucky enough to be sitting in the back of a perfectly serviceable aircraft when it happened to crash. More warning and he might have ejected when so ordered. Command Eject and he might have been successfully command-ejected by the pilot.
Why was he in the aircraft in the first place ? He was not a required member of the operating crew, thus his presence was arguably optional. He was in the aircraft because it suited some long-standing and so far unquestioned organisational agenda, as a convenient and cheap way of transporting ground crews. Also, up to now - it was probably considered great fun and a bit of a reward for hard-working and trusting ground crew who presumably did not have to be ordered to fly, or forced to join the Circus.
No matter what shuffling of paper or tweaking of simulators, the next time a pilot screws up, the back seater will still be at the same serious risk as Jon Bayliss, while there is no front to back Command Eject.
It may well be that the current Minister honestly intends to install 'front to back' Command Eject - but for a mere couple of dozen Hawk Mk 1s - what would you believe ? If the modification work is easy or inexpensive, why wasn't it done years ago ?
There are (or were) plenty of 'spare' transport aircraft which might fit the bill for routine RAFAT support. Many other national aerobatic teams fly single seaters. They don't have a problem with provision of support aircraft. The Blue Angels bought one of our 'surplus' C-130Js. Time to put up or shut up ?
Historically, for many aircraft types, practising the failure killed more folk than any actual failure. Civvy-wise, it is no longer permitted to practise engine failure on a real (air transport) aeroplane. It can only be done in a simulator. Bear in mind that a civvy aeroplane may be carrying hundreds of pax who don't have the benefit of ejector seats or parachutes and who might not use them even if ordered.
Question 1. Why is it still considered necessary to practice 'engine failure after takeoff ' in terms of what is demonstrably a challenging flight regime ? Horsing a Hawk round in the weeds with not a lot of knots has contributed to some nine crashes and four deaths since 1982. What is wrong with 'zoom and eject in comfort' ?
And in the mean time, the only way to ensure that RAFAT back-seater risk is ALARP and Tolerable - is regrettably to ban back-seat rides for all but required pilot training and assessment, at least until front to back Command Eject is in service.
Question 2. Why does MoD believe it is still safe to continue carrying non-pilot back-seaters, without front to back Command Eject ?
LFH
...
Last edited by Lordflasheart; 19th Mar 2022 at 01:25.
If I may add a couple of points to what LFH has posted and what is in the linked documents. I flew the Hawk T1 for over 40 years, instructed on it for 30 years and flew quite a few non-aircrew in the rear seat. I also authorised many others for the same activities.
My first point is with respect to PEFATOs. We flew these fairly regularly adhering to very specific minimum airspeeds and energy states (combinations of airspeed and height). Often, we recognised that we had insufficient energy such that we flew a go-around (and for real would have ejected). There was never any pressure to continue and if it was an instructional sortie or checkride then the required standard related to correct decision making and not actually touching down on the runway. Overall, if the SOPs were followed then I did not consider these to be particularly high risk manoeuvres and stall prevention was achieved by strictly adhering to minimum speeds and maximum bank angles. The speeds flown and the energy states during the accident manoeuvre were significantly lower than what I had ever known to be taught or promulgated. In addition, 'low key' for a low energy pattern such as this needed to be an energy state and not a geographical position with respect to the touchdown point as was usually considered for a full forced landing pattern. For continued safe operation of the RAFAT aircraft prior to any of the suggested modifications being incorporated, have the SOPs been reinforced and/or amended to take into consideration energy states and minimum speeds when engine out, for practise or for real? I am sure that they have but I have not seen any mention of this reported.
With respect to using flight simulators for PEFATO training, the pilot needs to maintain a visual sightline to the runway at all times during the pattern, and the visual systems of many simulators do not allow this (vision being limited to forward of the '3-9 line'). Therefore, if on-aircraft training were not permitted any simulator used would have to have an adequate visual system to allow the pilot to use the same visual cues as for real.
There was a significant ambiguity in the Aircrew Manual of which there has been little mention. It stated that the minimum airspeed once the gear and flaps were down was, at the accident weight, 155 KIAS (170 KIAS being the nominal airspeed). However, what it should have said was that this was the minimum speed at which to commence the flare to touchdown (in order not to stall) but some interpreted this as the minimum airspeed in the finals turn also. I consider that this ambiguous wording was one of the greatest potential risks for stalling during forced landing patterns and I always reinforced this clarification very strongly in all training that I delivered.
I do not believe that the decision as to whether non-aircrew can fly rear seat in aircraft such as the Hawk T1 is necessarily just a simple yes/no. It may be an overall no (with a potential for reducing morale and motivation for groups such as 'The Circus') but there is also the consideration that it could be a 'yes' but only for lower risk activities such as transit flights. I have certainly operated such that we would not fly any forced landing patterns, or one engine inoperative patterns if multi-engined, with passengers on board. Similarly, in later years low flying, and low level aerobatics/display flying (under civilian regulation), were not permitted with passengers on board.
This was such a tragic accident and however much Jon may have understood and accepted the risks it is his family and friends who will continue to be affected. This is the one aspect that must never be forgotten when considering the future.
My first point is with respect to PEFATOs. We flew these fairly regularly adhering to very specific minimum airspeeds and energy states (combinations of airspeed and height). Often, we recognised that we had insufficient energy such that we flew a go-around (and for real would have ejected). There was never any pressure to continue and if it was an instructional sortie or checkride then the required standard related to correct decision making and not actually touching down on the runway. Overall, if the SOPs were followed then I did not consider these to be particularly high risk manoeuvres and stall prevention was achieved by strictly adhering to minimum speeds and maximum bank angles. The speeds flown and the energy states during the accident manoeuvre were significantly lower than what I had ever known to be taught or promulgated. In addition, 'low key' for a low energy pattern such as this needed to be an energy state and not a geographical position with respect to the touchdown point as was usually considered for a full forced landing pattern. For continued safe operation of the RAFAT aircraft prior to any of the suggested modifications being incorporated, have the SOPs been reinforced and/or amended to take into consideration energy states and minimum speeds when engine out, for practise or for real? I am sure that they have but I have not seen any mention of this reported.
With respect to using flight simulators for PEFATO training, the pilot needs to maintain a visual sightline to the runway at all times during the pattern, and the visual systems of many simulators do not allow this (vision being limited to forward of the '3-9 line'). Therefore, if on-aircraft training were not permitted any simulator used would have to have an adequate visual system to allow the pilot to use the same visual cues as for real.
There was a significant ambiguity in the Aircrew Manual of which there has been little mention. It stated that the minimum airspeed once the gear and flaps were down was, at the accident weight, 155 KIAS (170 KIAS being the nominal airspeed). However, what it should have said was that this was the minimum speed at which to commence the flare to touchdown (in order not to stall) but some interpreted this as the minimum airspeed in the finals turn also. I consider that this ambiguous wording was one of the greatest potential risks for stalling during forced landing patterns and I always reinforced this clarification very strongly in all training that I delivered.
I do not believe that the decision as to whether non-aircrew can fly rear seat in aircraft such as the Hawk T1 is necessarily just a simple yes/no. It may be an overall no (with a potential for reducing morale and motivation for groups such as 'The Circus') but there is also the consideration that it could be a 'yes' but only for lower risk activities such as transit flights. I have certainly operated such that we would not fly any forced landing patterns, or one engine inoperative patterns if multi-engined, with passengers on board. Similarly, in later years low flying, and low level aerobatics/display flying (under civilian regulation), were not permitted with passengers on board.
This was such a tragic accident and however much Jon may have understood and accepted the risks it is his family and friends who will continue to be affected. This is the one aspect that must never be forgotten when considering the future.
With regard to practice turnbacks (or indeed any simulated emergency), I remain unconvinced of the value of the exercise if the handling pilot instigates the situation. Be it an engine failure in a single engine airplane, chopping one throttle in a multi or simply pulling the cable release in a sailplane on a winch launch or aerotow, if the handling pilot closes the throttle/pulls the release etc then their mind is already in front of the situation. This is not the case in the real thing, which is why the instructor should always instigate the simulated emergency.
With regard to practice turnbacks (or indeed any simulated emergency), I remain unconvinced of the value of the exercise if the handling pilot instigates the situation. Be it an engine failure in a single engine airplane, chopping one throttle in a multi or simply pulling the cable release in a sailplane on a winch launch or aerotow, if the handling pilot closes the throttle/pulls the release etc then their mind is already in front of the situation. This is not the case in the real thing, which is why the instructor should always instigate the simulated emergency.
Entirely agree; there is a huge difference. (Which makes the accident behind this enquiry so puzzling; why not just throw it away early when you realise you have made it too hard for yourself? We all have bad days, poorer judgment days. Another reason for doing these exercises without unnecessary folk aboard.)
Sean Cunningham's BoI stated that there was no Safety Case for the ejection seat he died in. That meant by extension that his aircraft was unairworthy. Thus all Hawks were also unairworthy then. Subsequently the T1's were to be grounded but the Reds' T1A's are to continue flying. Of course, the MOD avoids mention of the A word at all times, so is the Hawk still unairworthy? By the same token the Nimrod was officially airworthy until the MOD grounded them all and then said that it wasn't. I don't query that this fatal accident happened with the aircraft in an irrecoverable stall on short finals leading to the death of its rear seat passenger, but was it airworthy?
Sean Cunningham's BoI stated that there was no Safety Case for the ejection seat he died in. That meant by extension that his aircraft was unairworthy. Thus all Hawks were also unairworthy then. Subsequently the T1's were to be grounded but the Reds' T1A's are to continue flying. Of course, the MOD avoids mention of the A word at all times, so is the Hawk still unairworthy? By the same token the Nimrod was officially airworthy until the MOD grounded them all and then said that it wasn't. I don't query that this fatal accident happened with the aircraft in an irrecoverable stall on short finals leading to the death of its rear seat passenger, but was it airworthy?
Safe to Operate and Operated Safely are different questions.
It was not a technical failure that lead to loss of the aircraft.
Performing high risk manoeuvres with pax in the aircraft was prohibited for many activities such as LL flying, where the situation could degrade too rapidly for pax to observe, assimilate and act to a deteriorating situation.
The absence of command eject was a known issue and an aggravating factor.
Why was this activity allowed?
XX204 was not being operated safely.
It was unairworthy and had no safety case?
It was airworthy but had no safety case?
It was unairworthy but had a safety case?
Which one please?
David Hill has now published his latest book, A Noble Anger, which is available from your favourite South American bookseller in paperback at £5.99, or Kindle version at £2.49. It joins his other titles that relate to the sorry saga of the attack on airworthiness by RAF VSOs from which UK Military Aviation has never recovered, thanks to the continuing cover up of this scandal by the MOD. I would point out that A Noble Anger has been endorsed by Jon Bayliss's family and, as always, all net proceeds go to charity :-
A tip for those who are non-Prime customers, at Check-Out select a nearby Amazon Pick-Up location (lockers or shop) and delivery to there will be free, as this is an Amazon and not a Merchant sale
A tip for those who are non-Prime customers, at Check-Out select a nearby Amazon Pick-Up location (lockers or shop) and delivery to there will be free, as this is an Amazon and not a Merchant sale
Last edited by Chugalug2; 27th Jul 2022 at 16:02.
Thanks Chug
I bought the Kindle version and read it in one sitting. A well written in-depth investigation.
Not a harsh word about either the Reds or the pilot, the author spelling out why each were badly let down.
He identifies the failings that weren't mentioned in the RAF report. Among a series of revelations the biggest one is MoD lying to the court and family about previous occurrences. That meant the coroner ruled negligence but that it wasn't gross. I can't recall that being mentioned in the press.
The sub-title is 'The manslaughter of Jonathan Bayliss', which seems at first a bit presumptuous. But he sets out his case and by the end you're left thinking he might just be wrong. It's far worse.
A handbook for everyone involved in military aviation. £2.49 and proceeds to a worthy charity. BZ
I bought the Kindle version and read it in one sitting. A well written in-depth investigation.
Not a harsh word about either the Reds or the pilot, the author spelling out why each were badly let down.
He identifies the failings that weren't mentioned in the RAF report. Among a series of revelations the biggest one is MoD lying to the court and family about previous occurrences. That meant the coroner ruled negligence but that it wasn't gross. I can't recall that being mentioned in the press.
The sub-title is 'The manslaughter of Jonathan Bayliss', which seems at first a bit presumptuous. But he sets out his case and by the end you're left thinking he might just be wrong. It's far worse.
A handbook for everyone involved in military aviation. £2.49 and proceeds to a worthy charity. BZ
Manslaughter - Police investigation ?
...
I've just received one of those advertising emails suggesting, based on my previous readings, that I purchase a book entitled - "A Noble Anger: The manslaughter of Corporal Jonathan Bayliss."
Made it seem like an opportune moment to ask -
Is it true that North Wales Police are or have been investigating the Bayliss case from a manslaughter and/or 'lying to the Coroner' pov ?
LFH
I've just received one of those advertising emails suggesting, based on my previous readings, that I purchase a book entitled - "A Noble Anger: The manslaughter of Corporal Jonathan Bayliss."
Made it seem like an opportune moment to ask -
Is it true that North Wales Police are or have been investigating the Bayliss case from a manslaughter and/or 'lying to the Coroner' pov ?
LFH
...
I've just received one of those advertising emails suggesting, based on my previous readings, that I purchase a book entitled - "A Noble Anger: The manslaughter of Corporal Jonathan Bayliss."
Made it seem like an opportune moment to ask -
Is it true that North Wales Police are or have been investigating the Bayliss case from a manslaughter and/or 'lying to the Coroner' pov ?
LFH
I've just received one of those advertising emails suggesting, based on my previous readings, that I purchase a book entitled - "A Noble Anger: The manslaughter of Corporal Jonathan Bayliss."
Made it seem like an opportune moment to ask -
Is it true that North Wales Police are or have been investigating the Bayliss case from a manslaughter and/or 'lying to the Coroner' pov ?
LFH
Affirmative. Since just before Xmas 2022. Following a formal complaint by the family, and a retired Air Marshall coming forward to confirm that a senior officer's evidence under oath was 'wrong'. MoD denied this but the evidence, in the form of a DFS report, was produced by a well-known company. His 'wrong' evidence, it is suggested, made the difference between the Coroner's finding of negligence, and one of gross negligence.
They also asked that Lincs Police be involved given the 12 or so common factors between Bayliss and Cunningham, as MoD had assured the Lincs Coroner in 2014 that the recommendations were being implemented. You may recall that Lincs Police conducted an investigation in 2011/12, but later distanced themselves from it; and will not release any information on their work, nor even acknowledge any form of report was written. When asked to look at this, the Independent Police complaints people ruled that Lincs Police were correct to say that one is 'not entitled' to make a complaint, unless one is an affected party. They upheld this a further twice.
North Wales Police then disagreed with Lincs and the Complaints people, accepted the Bayliss family's complaint, and appointed a Detective Chief Inspector; whose progress seems rather slow, perhaps because of......
The Coroner's actions are included in the complaint, as she told the family only to ask questions, about the time of the accident, of said senior officer. When he took the stand, as the final witness, he announced he would NOT be answering these questions, and she allowed this. The Inquest closed about 2 minutes after her ruling, leaving the family nowhere to go.
Hope this helps. All in the public domain.
The following users liked this post: