Unlike the chicken and the egg, we know which came first here, but first doesn't necessarily mean cause. I agree with engines that the accident was the pilot's death, but the cause of that death was the failure of his parachute to deploy. The inadvertent ejection triggered the sequence that led to that cause, ie it contributed to it, but was not the cause of death.
Having said that, if any accidental ejection for whatever reason is now considered an accident per se, it rather muddies the waters. It also seems to conflict with the MAA definition of an accident, but no doubt discretion can be exercised, the question is by whom?
As others have said, this Report reads like a mangled schoolboy essay that the dog ate but then coughed up. It has revisionism written all over it. That is a problem shared with other BoI's and SI's featured in this forum. How can anyone take such a Report on trust? How do we know that the accident cause in the Report was even that found by the SI Panel? How can such a Report prevent future accidents if it can't be trusted? Do you trust it?

Thanks, airsound & tucumseh.

The technical investigation was carried out to an extremely high standard,the cause of the main chute not opening was found quickly...the cause of the ejection was always going to be trickier to find - but I can guarantee that the technical investigation into that was carried out to an extremely high standard as well.
Not sure why some are continuing to doubt the 'cause' and 'contributory' ... one could argue it either way but the end result is still a tragic death !
My personal view is that the cause of the accident was the ejection,the cause of death was the chute failure but as I posted previously - the 2 definitions are very different.

The wider airworthiness issues are separate to the technical investigation and I will not comment on that since others on here are far more knowledgeable !

Longer Ron


I agree.


I disagree, although see your point. Airworthiness is an engineering discipline and the engineer(s) on the SI panel should understand the impact systemic failings had on their findings. Duty of Care demands they report this.

I accept the SI's terms of reference do not seem to extend to underlying causes, so would place the onus on the MAA, who are seen to endorse and issue the report.

The aim is to prevent recurrence. As it stands, the SI's investigation and report may help prevent recurrence of that specific event at RAFAT, perhaps on Hawk. But most definitely NOT in the wider MoD.

That is because the root cause is, as you say, a wider malaise. There will be other avoidable accidents, and like many before them will be easily traced to the decision not to maintain build standards, safety cases or have a compliant RTS.

That this was a quite conscious DECISION in order to save money and hide waste, not an oversight or mistake, is what people cannot grasp, or in the case of MoD do not want to grasp.

tuc, as usual, makes the point better than I. The MAA as guardian of UK Military Airworthiness Provision needs to see what perhaps individual SI's might fail to, the correlation between all these fatal airworthiness linked accidents leading way back into Haddon Cave's 'Golden Period'. It doesn't do that of course because its very purpose, the reason that it exists, is to ensure that correlation never happens. It is greatly assisted in that by the fortuitous arrangement whereby all SI's are carried out under its auspices by its subsidiary, the MilAAIB.
This SI has indeed found out the technical problems with this seat that killed Sean Cunningham. Job done? No, because those problems were already known of by the RAF and the Seat Manufacturer respectively, yet the UK Military Airworthiness Authority claims to have had no knowledge of the latter whatsoever. Really? Why was that? It was the subject of urgent promulgation by MB, yet its major customer professes to have never been informed. That is where any Air Accident Investigator worth its salt would home in on and uncover the whole rotten mess that is UK Military Airworthiness. Does the MilAAIB do so? No, because this SI just went through the motions, like most other UK Military Air Accident Investigations.
The MilAAIB might well sit within the MAA for they are well suited to each other, the words chocolate fireguards come to mind. This is a tragedy of enormous proportions for UK Military Aviation. It has to be put right lest many more needless deaths are to follow.

Chug,

I think I have to gently differ from you in what is probably a minor matter.In any case, I post this only to attempt to help others through the issues.

First, I agree with other posts that getting into semantics over the various factors that led to this tragic accident aren't especially helpful. Like almost all such events, there was a chain of causes and events and the SI's job was to find all the links in that chain and set out recommendations to prevent re-occurrence.

I think the technical investigation into the seat aspects was well done, and it's good to see the capability of the old NAML (Naval Aircraft Materials Laboratory - now 1710 NAS) and the professionalism of the old RN AIU (the cornerstone of the new MilAAIB) still delivering good results. The fact that they got 'folded' into the MAA following Haddon Cave wasn't their fault - and I very much agree that having them there is a basic mistake. However, i would gently offer that calling them a 'chocolate fireguard' is just a bit strong. I'm sure that they are doing the best they can within the organisation that they were given to work with. In fact, I know they are.

As I've posted, my own opinion is that the format adopted by the MAA for reports makes it harder for them to be clearly understood and acted upon. In this case, the technical factors were reasonably clear, but the organisational aspects were less clearly established. And that brings up to the issue of how far up the chain the SI can go in looking at the 'organisational' stuff. I agree with Tuc that the SI should have found out why the aircraft's Safety Case was so badly compromised. It should also have established why the airworthiness trail for the RTI (which is supposed to be auditable) was so thin.

But I don't think that any SI is going to be able to go back tens of years and look at funding and policy decisions by VSOs that contributed to the present situation. My own view is that the MoD has to be responsible, at all levels, for managing and preserving 'Air Safety', which includes airworthiness. That means people have to do their job. The basics haven't changed. What does bother me is that a number of managers within the system no longer have a clear idea of what 'the basics' involve.

Best Regards as ever to all those working the issues,

Engines

Engines, I take your gentle differing in the spirit with which it is offered and certainly take the point that the personnel of the MilAAIB did as good a job as they could in the circumstances. It is those circumstances with which I take issue.


If the AAIB were a part of the CAA and there were airworthiness related accidents occurring one after the other in the civil air fleets because of systemic failures that rendered airworthiness provision dysfunctional under the CAA (the civil airworthiness authority), then the AAIB would be placed in the impossible position of finding Gross Negligence in its parent organisation. It wouldn't of course, because it is independent of the CAA for that very reason.


Here we have the whole incestuous relationship of UK Military Airworthiness Provision and Air Accident Investigation laid bare. The formation of the MAA has if anything worsened the situation that preceded Haddon Cave. There at least was the possibility that a well informed BoI President, prepared to go out on a limb in defiance of his superiors might just start asking the questions that I have suggested. The remote possibility of such a loose cannon has now been resolved by nesting the MilAAIB within the MAA, the very organisation that has inherited the Mare's Nest that is UK Military Airworthiness Provision. The VSO's can rest easy!


It is all very well for SI's to say, "not my job, mate!" when I suggest that they should delve deeper, but if they don't then they are part of the same problem that is the MAA, the Nimrod Report, and the MOD, ie the great cover up of the deliberate destruction of UK Military Airworthiness Provision. That is why 63 people died in the various airworthiness related air accident threads in the PPRuNe Military Forum. You'd think that would concern Air Accident Investigators, wouldn't you?

I entirely agree with this, not least because, with the passage of time, it is very unlikely that an SI panel will have the individual or collective experience or knowledge to ask the question. In my experience, your typical BoI or SI engineering member has never served in a post that would expose him to the detail of airworthiness assurance; and that is where the Devil lies. And aircrew would simply not be expected to know, in the same way I would never expect to be asked about piloty stuff.



This is where MAA oversight comes in. They most definitely DO know of these problems from tens of years ago; because they remain current, they have been told this in the form of formal reports, submissions to Haddon-Cave and Lord Philip and during meetings with Ministers. Yet, they (MAA) are willing party to recent DE&S and Ministerial rulings, upholding the rulings of Alcock's crowd 21 years ago (Baker, December 1992), that refusing to make "savings at the expense of safety" is an offence. (What is it about Bakers? It was another Baker who upheld the same ruling in MoD(PE) on 9.9.02, a ruling still cited by DE&S, Ministers and the Head of the Civil Service and provided under FoI).


Please consider that fact. Then ask why the MAA was established. Because Haddon-Cave condemned this long standing policy of "savings at the expense of safety". (Only he conveniently omitted to say it was policy since 1988). That is, the MAA and DE&S are on record as disagreeing with the very premise upon which the MAA was formed. You couldn't make it up.


Most in MAA would, I hope, be astonished at what is being said in their name. But the fact remains, and is fully documented, that their senior staffs are fully aware of these continuing systemic failings, routinely condone them and flatly refuse to officially recognise them. That refusal and gross dereliction of duty can be seen in what is omitted from the RAFAT SI report. Perhaps, in private, they are fuming. But demonstrably they vent their spleen on those, like me, who tell the truth, while actively protecting those responsible for so many deaths. Do us all a favour and resign now.

Some posters accepted and praised this SI as thorough and entirely credible when it was first published. The real airworthiness experts on this forum have subsequently highlighted serious and indefensible shortcomings in the conduct and conclusions of this SI and in the way the MAA, who are responsible for it, continues to carry out its business. The very thorough and scientific investigation into the seat aspects by 1710 NAS is one of the few positive elements of what is, in my opinion, a sloppy, misleading and incomplete piece of work.

On a more human level, please do not overlook the SI's deliberate targeting of the RAFAT's culture and ethos in their report. Based loosely on psychometric theory, stereotype preconceptions, unsubstantiated assertions presented as fact and some dubious interpretation of training records, most of which have subsequently been challenged and disproved, the integrity and professionalism of the pilots was publicly questioned and declared a contributory factor in this tragic accident. This unprofessional, disgraceful and indefensible personal blame game must have caused considerable anguish and anger within the team, who were themselves victims in the tragedy.

As an outsider but with some knowledge of the true facts of this case, I find the MAA's endorsement of this aspect of the SI absolutely outrageous.

Tecumseh and Engines
I was being specific in that the technical investigation was part of the SI,not the complete SI per se.
I know it is a subtle point,and I do realise the wider responsibility of airworthiness,I was merely (again) praising the technical side of the investigation.

LR,

Thanks for the reminder and yes, I think you are right - the technical side of the SI report was, in my view, a sound piece of work.

Best Regards

Engines

LR

Thank you and yes, I agree. What was published was technically sound. Like others, I wonder what wasn't published!

My view comes from regarding airworthiness as an engineering discipline and thus expecting a section in every such report that makes a positive statement that they have assessed the currency and validity of, at least, the Aircraft Document Set. Few SIs, or BOIs before them do this. This one went further than most, stating that the Safety Case report doesn't exist. Then, nothing, despite the next logical step being the Whole Aircraft Safety Case. I simply cannot believe any engineer would fail to dig deeper. Especially, post-Haddon-Cave.

I wonder at the restrictive boundaries they have to work to. It is crystal clear to me that the MAA audits of 2010/11-ish have highlighted the long standing policy and practice of regarding Safety as a complete waste of money. How can the SI/MAA/MoD meet its obligation to try to prevent recurrence if it doesn't address such an obvious root cause?

That is why I suspect the MAA have omitted much, allowing attention to be diverted to the other allegations mentioned by Genstabler. Whoever has failed in this Duty diminishes themselves by their refusal to acknowledge the truth. We desperately need a BoI/SI President or Coroner with the balls to recommend a reconvening on the grounds they have been lied to, or misled by omission or commission.

Engines and Tecumseh.
Sorry I had written a longer post but decided to delete most of it (esp cos I was at work at the time ; ) !) .
As another forumite posted earlier...any investigation will pick up procedural shortcomings in almost any organisation ....so perhaps to a certain extent - there but for the grace of big G go all of us.

rgds LR

I'm interested in something you said earlier tuc. The RTI didn't meet the criteria for an RTI. That's been said before on other accidents. A Servicing Instruction on the Mull of Kintyre Chinook that shouldn't have been. A Service Mod on the ASaCs that broke every rule. Same on the Tornado shot down by the US. Bad that none of the SI or BOI mentioned these. :(

dervish

Correct. And each directly related to a casual factor noted by the BoI, yet they missed the fact the implementation broke the regulations. The detail I mentioned earlier. And in each case the Safety Case was not updated when the SI(T) or SEM was issued, which breached ..........

If you've never done it, you'd never notice. But it was spotted and included in evidence to Lord Philip, seen by the MAA. Yet, the same happens again on Hawk.


Edited to add that my comment obviously applies less so to the Chinook, because the fact the aircraft was not permitted to fly was withheld from the BoI by Bagnall and Spiers, so they totally ignored airworthiness issues!!

What I find strange is that Martin Baker SIL 407 was issued just a few days after the accident, but it does not get mentioned in the SI report. And yet, testing was carried out using the criteria set out in the document (para 1.4.3.9) which suggested that the new approach was OK. Yes, I know there are those who will say that SIL 407 came after the accident, but this was the immediate mitigation in order to prevent other accidents. In the same way Nimrod fuel loads were reduced after the XV230 accident. That fact got mentioned by the BOI and the Coroner.

However, we now know that the "new approach" was not OK; hence the introduction of the feeler gauge in SIL 407A two years later. This too fails to get a metion at the Inquest.

It does appear to me that every effort has been made to steer the "cause", and blame away from seat failure to inadvertent pulling of the firing handle.

DV

Returning to the absence of a safety case for the seat it is worth re-reading this BoI (another tragic loss of a top bloke) in a fresh light:

https://www.gov.uk/government/upload...ornado_rpt.pdf

Seat Modification
 

I note that a modification was introduced to the MK10 ejection seat in Tornado aircraft which replaced the scissor shackle with a gas shackle. Does anyone know what advantages the later has over the former?

DV

The mod as a whole was advertised as improving low altitude performance, although it also included a new parachute and a gas bladder to push the parachute pack out of the headbox more quickly. I couldn't say what the advantage of the gas shackle in isolation is supposed to be. What I do know is that the shackle link and the offending bolt are still present, and can be "wiggled" if desired to check that the link hasn't been clamped onto the shackle.

Many thanks for that information. However, I do note that MB Special Information Leaflet 704 and 704A (brought out after the accident) make it clear that no freedom of movement checks are required for seats with a gas shackle.

DV

I can see where this is going! Has MoD claimed the two are unrelated as the seats are different?

What I see is that the gas shackle operates differently to the scissor shackle, to such a degree that the problems encounter with the Hawk seat are mitigated by the modification. A modification that was embodied on Tornado seats only. Why?

You can not get much lower than Flt Lt Cunningham's zero level ejection.

DV

DV,

I wasn't party to any of the work that underpinned this mod, but some interesting observations on platform out-of-service dates might go some way to explain how it came to be embodied on Tornado but not Hawk. The mod was introduced in the mid-2000s, so would have been staffed in the early 2000s, when Tornado OSD was still 2025. I don't know what the Hawk T1 OSD was meant to be back in the early 2000s, but I do know that it has been put back (I think as a combination of MFTS shenanigans, provision of international defence training, and undoubtedly with a nod towards RAFAT preservation) and now falls after Tornado OSD, which has been brought forward to 2019.

The following is all my postulation: perhaps the cost-benefit part of the ALARP calculation back in the early 2000s decided that the "long" remaining life of Tornado made it worthwhile to fit the mod, while there was insufficient benefit gained from the "short" remaining life of Hawk T1. And by the early 2010s, when the OSDs were changed, the Hawk still had insufficient life remaining to make embodiment worthwhile.

At any rate, that would be a procedurally-correct and justfiable reason for having 2 different mod states of seat. It's almost certain to be the case that, in reality, the Tornado and Hawk cap sponsors, PTs and operators were operating in totally separate 'pillars of excellence' and didn't notice what each other was doing...

Easy Street; Jusy what I thought.

DV

ES, I follow your logic re OSD of two platforms at the time the mod was proposed [The weight growth mod]. I may have missed something as I understood from the SI that a Safety Case [for the Hawk seat] did not exist. It is therefore a big assumption that anyone ever did any ALARP detriment calculations. I would wish to be wrong about this.


I am sure there will be an audit trail for the decisions recorded on the F714/715 Cost and brief Sheets we operated at the time.


I love the term "Pillars of Excellence" you introduced. unfortunately I saw all the pillars crumble and pleased to be away from it all these days!

" A modification that was embodied on Tornado seats only. Why?"
 

ISTR this was part of a package of several seat mods (known in some quarters as the "six pack") which were intended to address the problem of Tornado ejected mass growth over time. Part of the mass growth was due to hardware growth (including AEA) and part was due to aircrew mass growth – quite a few exceeded the 99%ile assumed during system design. The latter was partly managed by dietary means but not in all cases; some pilots were reassigned. A more modern 'chute was included to improve seat performance and the strops were strengthened. In the interim while the mods were cleared and embodied, a series of a/c speed limits were introduced to limit strop loads.

Its a long time ago so I couldn't guarantee all of the details.

A big factor in the AEA mass growth was the persistent use of the Tornado on desert operations. At one point I think the standard load of water in the combat survival waistcoat grew to over 3 litres, with another 5 in the survival pack! Factor in pistol, ammo and PRC112 CSAR radio, and it's perhaps even clearer why Tornado would get a modified seat, but not the Hawk.

Even in peacetime, though, the AEA keeps getting heavier as redesigns increase the amount of fabric for fire-retardency purposes, because someone decided it would be a good idea to insist on RW and FJ crews all wearing similar kit (so the FJ kit has to meet RW fire escape criteria, even though this is not necessary with an ejection seat). Typhoon decided to ditch the UK standard flying kit a long time ago, and since then FJ AEA has not been done in a very integrated way... perhaps another symptom of the IPTs becoming PTs?

And a big factor in the aircrew mass growth was life at Bruggen. Especially on Fridays. Happy times...

Literally no. But in seat terms yes. The subject accident had zero AoB and zero RoD, both of which are highly significant in terms of successful ejection envelopes. Many have died at greater altitude (by definition) than the subject accident but out of seat limits i.e. there is scope to improve on "literal zero-zero".

The Mk12 in the GR5/7 is an example:NoD

Yes, but how is the gas shackle element of the modification programme related to the weight problem? This appears to be more about improving the release of the drogue chute from the seat, and deploying the main chute.

It is true, as Easy Street states, that the "offending" bolt and shackle remain and can be "wiggled", but they are no longer the point of release as they are with the scissor shackle. From the drawngs associated with SIL704 it seems that a lug is permanently attached to the drogue shackle by the bolt and the other end is attached to the gas piston assembly. This becomes the point of release.

On the face of it, it would appear that if Flt. Lt. Cunninghan's seat had been fiitted with a gas shackle, rather than a scissor shackle, he would have survived. Perhaps the SI team and the Coroner were encouraged to wear "Hawk" blinkers rather than the Mk10 modification programme as a whole.

DV

DV,

I don't think this is an RAF seat, but it looks similar enough to illustrate how the drogue shackle sits on a modified seat:

http://www.ejectionsite.com/updates/MK10Amod-2.jpg

I see what you mean about the 'lug' not being affected by the tightness of the bolt - it doesn't appear to be a collar-type affair. I agree that it's difficult to see how the shackle might improve low altitude performance - about the best speculation I can offer is that it might have come as an essential part of the gas bladder improvement. Other than that, it would appear to be somewhat distinct from the boarding mass issue.

OK, for "lug" read "plunger". The point being is that at release the drogue shackle bolt no longer has to pass through the jaws of the scissor shackle, it is released by the plunger. I believe that if over-tightening was a problem then it would have been mentioned in the SIL.

DV

Our postings cross.

That is the point I was making.

DV

Am I alone in wondering if Distant Voice hasn't unearthed the real reason that the SPH triggering the inadvertent (but normal zero/zero) ejection was found to be the main cause of Sean Cunningham's death, rather than the drogue bolt jammed within the original scissor shackle jaws that actually sealed his fate?

On 25th Feb, in a written answer to a question put by Angus Robertson, Mr Dunne stated;

This is a misleading statement and only applies to those Mk10 ejection seats fitted to Tornado aircraft. If all seats had been modified, which included the replacement of the scissor shackle with a gas shackle, then it is highly unlikely that Flt. Lt. Cunningham would have died. The "bolt" isssue is a red herring.

The real failure lies in MoD's inability to read across from one platform to another. I came across the same problem with hot air pipes in Nimrod. The same pipe "lagging" had caused a fire on a Tornado (ZA599, 17 May 02), but no one had told the Nimrod office; result 14 dead.


DV

This systemic failure was notified within the Chief Engineer’s organisation (AMSO) in late 1992 when it was announced the necessary, mandated procedures would no longer be implemented, in order to save money. Shut down was in June 1993. No compensatory provision was made, and instead of a central authority existing to ensure such notifications were made, project offices were forcibly stove-piped.



In 1999 Director General Air Systems 2 was advised to order a fleet inspection of Tornado (in the first instance) because of this precise problem; this time on IFF. This was brought about by another project office and Boscombe Down discovering that the IFF office routinely failed to integrate warning systems, rendering aircraft vulnerable to friendly fire. They had stated “It works on the bench, so it’ll work in the aircraft”, thus at a stroke ignoring every principle of systems integration and functional safety. He (Fauset) refused, ruling it quite acceptable to knowingly deliver a functionally unsafe aircraft to the Services. The Chief of Defence Procurement (Walmsley) later upheld this ruling; which DE&S upheld no less than 3 times last year. In 2002 another 2 Star, XD5 (Porter), was similarly advised. He, too, refused.



In 2003 ZG710 was shot down, which the senior Reviewing Officer (Burridge) confirmed would have been avoided had the safety work been carried out. (It was actually cheaper to do it properly first time around. DGAS2 dug his heels in as to admit the aircraft was unsafe would have upset those who committed fraud).



All the above was presented to Haddon-Cave and Lord Philip.

We’ve been here before and the lessons are being ignored.