DV

I'm not an engineer and know nothing about ejection seats, but is the inquest comment by Neil Mackie at the bottom of the first quoted paragraph at post 85 what you are looking for?

dragartist

No problem. I agree with what you say and it is interesting that other areas saw the same approach by the CE. The entire process you speak of was disbanded by June 1993 in my area, and we had to seek other jobs because we had nothing to do. Or, we had plenty to do, but AMSO had pi##ed the money down the drain and stopped funding pubs, 765s, 760/1s, obsolescence, configuration control, mods, safety cases etc.

Co-incidence that this is the precise timeframe under discussion at the inquest? I don't believe in co-incidences; the same failures, at the same time, led to the "new" evidence on Chinook that MoD so arrogantly demanded for so long. Maybe that's why the MAA have withheld the SI report from the Inquest. Same old names cropping up.

Funnily enough, the HCDC has this week asked for evidence on this very subject. Interesting that they don't ask MoD..... One day the VSOs involved (AMSO/AMLs from 1985-96) will find their protection has disappeared! I notice one of them no longer posts here. Good riddance.

President of the inquiry at the inquest today:
Sean Cunningham inquest: snagged harness strap four days before tragedy led to ejection seat firing | Lincolnshire Echo

Further from today:
MoD was not told about key safety concern | Lincolnshire Echo

A stepped bolt will not make over-tightening a nut impossible, it simply prevents it from travelling any further thus retaining the correct spacing, you can tighten a nut until you strip the threads or snap the threaded portion off a bolt.

Nutty,
you are not wrong but we all know he knew what he meant.


I sit in amazement over how many column inches have been generated over a simple nut and bolt. (I was reluctant to join in to begin with)


the problem I have seen with shoulder bolts is that the thread gets undercut making them liable to sheer off if over tightened.


May be better to use a spacer tube. but I have not studied the assembly and constraints.


Let us hope what ever happens they get the books clear so there can be no scope for variation. In the Auto industry we used the term Poke Yoke to describe things being fool proof. I did a course at the Smallpeice Trust at Warwick a while back.


Drag

Call me a cynic but from what I read in the press the conclusions being drawn are that Flt Lt Cunningham f**ked up FOUR DAYS previously, in how he strapped in/unstrapped/safed the seat.

19 separate entries into the cockpit "missed" the unsafe seat.
Flt Lt Cunningham then missed it again on strapping back in and after pulling the pin he sat back and the seat fired.

I call bollocks on this, I am detecting a strong whiff of someone being scapegoated to save face of VSO, once again.

20 separate people do not miss the fundamental safety checks on seats....

Back when I learnt about seats as a humble liney I, like everybody else was taught that you are climbing on a bomb, one that wants to fire, one that wants to kill you and will do so if you do not give it 100% respect for every single second you are working near it.

when I had my backseat trip - the scariest part for me was removing that seat pan pin when the pilot commanded me to.

I do not believe Flt Lt Cunningham f**ked up - besides, whatever caused the seat to fire - the fact it malfunctioned which led directly to his untimely death needs to be fully investigated and made sure will never happen again.

this process needs to leave no stone unturned. Sadly it looks to me like the ole VSO wagon circling and MOD intransigence (sp) will win.

Again:ugh::ugh:

cornish, that is a bit harsh and does not fully reflect the facts.

Yes the technical investigation was in depth and extremely thorough,there is no need for any of this speculation - especially at this late stage in the proceedings !
This was always going to be a difficult one but surely worth sitting back and waiting for the report to be published before making sweeping statements on here !
As others have said - the findings will be published shortly.

rgds LR

Similar for me...It was a little strange removing the seat pan pin after all those years of ensuring it was firmly fitted ...
It got easier with subsequent flights : )

But MoD won't publish it. This removes the opportunity to ask informed questions at the inquest. To me, this means Cornish is spot on....


MoD have form here. They lie in court, and mislead by omission and commission. One day a Coroner will do his job and recommend charges be brought for perjury.

Excerpting from the post by Cornish and focusing on one element.

Looking back a zillion years ago to my days as a humble liney on Vulcans, Hunters and Frightnings I have to identify with the suggestion that "20 separate people" is a sufficiently large number to swallow. Granted there are differences in seat type, installation and generation (seats and people) but the fundamentals in training and awareness of hazards I feel pretty sure are still there, or certainly should be. Over the time I was active in line and ejection seat work I encountered a few hairy "there but for the grace of God" type personal lapses that are the inevitable consequence of requiring a human interface and such are always present but, it's the "20 separate people" bit that I find hard to swallow and should be a worrying number. Heavens above, one would have thought that at least one of those 20 would have identified that something was not quite right; another element in the mounting sequence of events perhaps ?

Both the Lincolnshire Echo and the BBC Look North had 7 individuals (including Sean Cunningham) entering the cockpit. The BBC also had the bit about 19 occasions. Would everyone of those 7 have been expected to check the safety of the seat?

Yes, you would first glance at the stowage in the cockpit to ensure it was empty, then check the seat to ensure all the pins were in before entering the cockpit., it is drilled into you, they can and do kill people.

RAF Germany was slightly different as the main gun sear was not installed on the ground on the Jags, something to be honest I could never understand, because it takes seconds to fit and remove, so in that case there would be one pin in the stowage.

When strapping in you would do a final check to ensure all the pins were in the stowage then hold up 5 fingers to show all 5 pins were stowed and wait for an acknowledgement.

Many moons ago they were moving an old gate guardian off the gate to refurbish it in the USA and the seat fired killing to guy on brakes, there was a worldwide alert and all gate guards were checked, several were found to still have live seats fitted!

I've seen a photo which recreates the condition that Sean's seat handle and pin were believed to be in when he climbed into the cockpit on that fateful day. Based on what I've seen, I woul believe it if you told me that 100 people had missed the unsafe condition. Viewed from the front of the seat, the condition is obvious, but cockpit access checks are always carried out from above, from where the condition is not obvious at all. There are subtle visual clues and I'm told these have now been widely promulgated to the user community. VSO conspiracy theories are probably wide of the mark on this occasion.

I gotta confess, I'm totally bamboozled as to why anybody is seeing cover ups and conspiracy here :confused::confused::confused:

As someone who has spent all of 1 hour 30 mins on a bang seat (pax in Jaguar circa 1980) and is not an engineer, the unfolding sequence of events seems perfectly clear and the inquest testimonies completely revealing.

The coroner will deliver the verdict, which has FA to do with the RAF/MOD, and what happens after that is, at this point, conjecture. From where I'm sitting, I can't see how anything is being held back.

Agreed, but that is a design flaw that needs correcting, no way should you be able to fit a pin with the handle out of position.

They will publish...after the inquest is completed !

So far I have seen no desire to cover up,any important information relevant to cockpit safety has been passed on to the operators,it just has not thus far been published into the public domain!
The CAA put the shackle bolt information into the public domain very quickly after the accident !

Yes it is the responsibility of every person entering or working in the cockpit to ensure that the relevant safety devices are fitted,one needs a competency to do so - which is renewed every 6 months.

I'm not sure everyone is listening. The seat appeared to be safe with the pins in the correct places. I too have seen what the pin and seat pan handle looked like when set in this condition - it looked safe, but tragically it wasn't.

I have no reason to doubt that the 7 people that checked the seat (including Sean) carried out their checks diligently and believed the seat to be safe. Quite honestly if I had checked it the list would have just increased to 8. To me (and the SI) the seat has a design flaw that allows the pin to be inserted when not safe. When I flew this seat type (Hawk & Tornado) I had no idea that this was possible.

The SI did not bury this bad news - as soon as this became known to them all users of the seat were alerted with photos and instructions on what to look for. They did not wait for the conclusion of the SI or the Inquest.

Seat pan handles on previous Mks of seat have been modified before when it was found that the pin could be wrongly fitted. I'd be amazed that this problem was not known to MB. As for ths Mk 10 seat shackle, I would be asking the German Airforce why they spent a lot of money completely re-designing theirs.

From Lincolnshire Echo


Oh for goodness sake. Not again.

That alone tells you MoD is fully embroiled in covering up. Was the Safety Case updated to reflect the above changes to the baseline?

The initial SI members, in all probability, did a very good job. But why did the MAA/MoD (same thing) withhold the report until after the inquest. Easy. MAA/MoD do not want informed questions. The Coroner should have jumped on them straight away, citing precedent.

I think you will find that the SI report is available to the Coroner. It forms part of the evidence. The witnesses are there to expand on the evidence. It is only publication to the wider public that is withheld until the inquest is complete.

Tuc,

I agree wholeheartedly.

- in AVM Green's own words.

In all my 28 years in the RAF if ever the question of dilution of skills and training in engineering manpower was raised, which it was many times, it was invariably in the context of a potential impact on flight safety.

Still, AVM Green managed to get in some words of management bolleaux to support his case. I'm sure the Reds groundcrew were looking forward to being "uplifted"!

WTF?
 

So, the pin can be in place while the seat is armed, but that's not a design fault?

Slight thread drift but a quick q for the seat experts out there - if it was the lap strap that was routed through the handle, had the sequence subsequently worked normally, would full man-seat separation have occurred? Clearly the deceleration forces of main chute deployment (which aids the man/seat sep if I recall correctly) may cause component failure but would it have been the cable between handle and seat that failed or the harness?

Yes, it is available to the Coroner. But not to people who would actually know what questions to ask. Please note, that in all the similar cases of attempted cover-up discussed here (Nimrod, Chinook, Tornado, C130, Sea King etc) it is members of the public, not MoD staff, who have revealed the truth.

The witnesses are required to state the truth, the whole truth and nothing but the truth. That means they are not to mislead, by omission or commission - which is on a par with perjury. In all the above cases, MoD did. You've got to admire their consistency.

Perhaps it is a design DEFECT! If it turns out to be so, they can claim they didn't lie.

Tuc, you may be right. We can expect a new design to be an evolution rather than a fix.

That way they can say the design has matured into the new style rather than having needed to be fixed.

I would like a coroner to state that in the interest of obtaining the WHOLE truth, SI reports should be placed in the public domain well in advance of the inquest; in fact well in advance of the pre-inquest hearing. In the case of the Super Puma Fatal Accident Investigation, currently taking place in Aberdeen, the AAIB published their 209 page report over two years ago. If they can do it, so can MoD/MAA.

DV

Any word of a fleet inspection of the offending assembly?

On 10th November 2005, in reply to an MP's question about trend failures (on Chinook) Adam Ingram replied that trend failures only apply to that tail number. If a similar failure is found on another aircraft, that is another, separate case and not considered part of a trend. MoD/MAA has consistently supported this statement. Routine monitoring of trend failures was cancelled by the Chief Engineer in 1991. (That timeframe again).

Assuming an inspection HAS been ordered by someone sensible, I won't hold my breath waiting for an admission Ingram was deliberately misled. But all here should be concerned that this is the level of advice given to Ministers (and courts) and an indication of how MoD will lie. And concerned that "colleagues" in MoD are prepared to lie to Ministers in order to hide "savings at the expense of safety"; and the reasons why the "savings" were thought necessary.

The Old Fat One: Many thanks for that information, but the witness only states that the indications were that the bolt was "Vastly over-tightened". We are assuming that that means more than one and a half threads showing. But surely someone must have checked the bolt after the accident. If only one and a half turns are showing, and the bolt vastly over tightened, there is something wrong with the instruction. It has already been stated by one witness that instructions were vague.

Has there been any evidence presented to the court by the person who fitted the nut and bolt? Were approved nuts and bolts used?

DV

If you read the previous posts, sometimes a lot of torque was needed to achieve the 1.5 threads showing, not all nuts are equal in size, nor are bolts, have a bolt a fraction to short and a nut a fraction to deep and you struggle... you erm, don't just throw any nut and bolt in there and hope for the best.

I still remember the Westland Split pin holes, that must have been drilled from both sides or offset as they would line up one side, but not the other.

Wrathmonk,
I think I would want to see exactly which strap was routed where before making a judgement on that. I am struggling to picture it in my mind.

WRT the strength of Harness v Handle Linkage question, the Harness is very strong, designed to take massive loads and it is a mechanical linkage to the Handle. It is fair to say that may well have had a significant effect on man/seat separation.

Begs the question so what context were they raised in then

So whilst 1.5 threads may be ok with one type of nut and bolt it may not be with another.

I suppose my questions are simple. From the material evidence after the crash has MB confirmed that (1) the approved nut and bolt type was fitted, and (b) the specified number of threads were shown. If the answer to both questions is "Yes", then the wrong criteria is being used to determine correct fitment.

DV

A zero/zero ejection puts great demands on the 5' drogue to withdraw the main chute from the headbox. There is no momentum (speed) to provide the drag required to work at maximum efficiency. However- they do work and have done many times in zero/zero conditions. But if the scissor shackle was vastly over tightened then that is just one more difficulty for the designed sequence of events to overcome. Without the drogues being released there would be no complete man / seat separation as the main parachute cannot deploy despite the harness being released from the seat anchor points by the barometric time release unit operating.
I find it inconceivable that a pilot of his experience had wrongly routed the harness through the ejection handle.
I'm also not able to see on the Mk10b how the safety pin can be inserted and not lock the handle in its proper place- just doesn't work- if the handle is not in housing properly the pin doesn't fit.

So Flt Lt Cunningham twice routed a strap thru the handle??
pull the other one,
If this is possible then it is not a design flaw, or defect it is fundamentally unsafe.

Now forgive my lack of type specific knowledge here but how different is the strap arrangement in a hawk to an F3 ? Circa 98 onwards.

Because when I had my backseat there were only two tongues that when into the QRF.

They came down over the shoulders, the crotch straps came up and thru the square ends of the lap straps then the tongues came thru the crotch straps and into the QRF.

You then tightened the laps before the shoulders and your liney adjusted the slack out behind you.

I can see a possible way that a crotch strap could be routed thru the handle but not a lap.

Regards

Cornish- That's how it's done on the Hawk too.
I cant see how a routing issue arose either.

Jimgriff

There are a couple of incidents from RAF Valley recently of this happening plus it happened on the Sea Harrier with an exchange officer so there's a few I'm aware of - how many live ejection seats have you strapped into?

Jimgriff, mistakes happen irrespective of how experienced you are, indeed I think it's around 1000 hours is often quoted as the most dangerous time. I knew the chap that LJ101 mentions and the incident - he was hugely experienced. As for the pin - if it can go wrong , it will.