Sorry Dragartist . Fat finger syndrome wrong bloke !!!

Wot no Safety Case
 

Several screens back there was discussion about there not being a valid safety case for the seat in place at the time of the incident.
Has action been taken to put one in place now?
Surely the judge would have picked up on this.
I remember back in the early 2000s on the S&AD IPT we had recruited a Safety / Risk Manager. All very vogue and in keeping with what was going on at the time. Lots of pleasant noise over being pro active rather than re active. A number of HAZOPS had been ran involving all stakeholders.
That noise soon turned into hollow noise with the Safety Manager incumbent moving sideways to become the Business Manager. Another thing that becme vogue at the time! Almost like flavour of the month across the whole of the SMG early days of DE&S. Looking after Service Level Agreements and the like, rolling out many of the IT management systems such as Ballanced Scorcards, massaging Business Cases for Projects through the system.
So what happened after this. Was there ever a Safety Manager, did the Project Manager ever get round to preparing a Cassandra Hazard Log, did they ever hold a HAZOPS. The 2002 QinetiQ Report surely would have been referenced in this and probably also referenced in the RTS and supporting Certificates.
Perhaps the chap responsible at the time was busy trying to make himself look good in realising all the savings being demanded or lining himself up for a position in Industry when everything was contracted outlock stock and barrel.

Dragartist

The 2002 report references 39 other reports and documents. As of last month, MoD claims not to have any of them. And in 2014 MoD and Minister Philip Dunne claimed to have no knowledge of the 2002 report (and by extension, the 39 references). If there is a hazard log, safety case, etc, then MoD is admitting they are not referenced in it. Given the evidence relates to the Tolerable and ALARP statement, the Safety Case and RTS cannot therefore be valid in critical areas.

Readers may recall the basis of the charge against M-B was that it did not provide information to MoD in 1990 about the risk of over-tightening the Drogue Shackle Nut. Yesterday, the Health and Safety Executive confirmed, in writing, that it was well aware of witness evidence that MoD DID have the information, before 1990, and also that the modification to eliminate the risk was turned down by MoD in or around 1990. And on various occasions since. That, it did not think this exculpatory evidence 'relevant' enough to pass to the judge. This admission means perjury at the Inquest in 2014 is a distinct possibility, as it was claimed then that MoD had no knowledge whatsoever of the risk.

The Service Inquiry said the information could not be found, yet referenced various reports that set it out (stating they were 'non germane'). Where did it get that information, given MoD claimed not to have it? This is not the first time a Service Inquiry/BoI has cited documents that other parts of MoD have flatly denied the existence of. Chinook ZD576 and Sea King ASaC mid-air are the most obvious ones I can think of.

A brief summary of this case:
 

The bottom line is that the MoD/RAF got away with allowing one of their own to die.

Now it seems to be nobody's fault, and so, nobody is to be punished. The lessons to be learned, were already known.

MB get to pay a fine, not one person is in the frame.

The only guy to suffer is Flt. Lt. Cunningham.


Nothing to see here, move along.... until the next time.

Tuc, Others,

I might be able to shed some light on the MoD's inability to locate documents. I apologise in advance if this post has a flavour of 'the good old days' about it - it's not aimed at criticising the people now trying to do their best in the MoD. I also apologise for boring some of you.

A long time ago in a universe far away, the business of MoD departments (and commands) was conducted on paper using things called files, or in Navy parlance, 'packs'. If a letter (or signal, or other communication) came in, the registry would put it in the appropriate pack for you. They did this using a 'pack index', which everybody in the department used. They then sent you the pack, with the letter (or signal) highlighted as a numbered 'New Paper'. Here's a really important thing. The packs had a series of numbered 'minute sheets' in the front, in which you recorded EVERYTHING you did with that pack. If you just commented on a letter, you minuted it. If you wrote a Loose Minute, that was minuted. If you wrote a letter, you minuted it. If you made a decision, you minuted it. If you wanted the issue cross referenced to another pack, you minuted it. Registry minuted every addition to and withdrawal from the pack. Every minute was numbered and dated.

A final really important thing. If any pack dealt directly with airworthiness evidence or decisions, it was labelled as 'Airworthiness File' or 'Airworthiness Critical'. This applied extra controls on the packs, including secure stowages, more frequent reviews, more senior signatory levels, etc. The whole point of all this was to ensure that the decisions and instructions issued by the staffs were recorded in an auditable trail. It also also ensured that they could be found when required. It also made sure that papers weren't inadvertently destroyed.

Sounds cumbersome, doesn't it? You'd expect this system to be slow and unable to react quickly. You'd also expect that it would involve hundreds of admin types shuffling paper. Dead wrong. A properly run Registry could get packs to you in minutes if required, on top of the daily 'drops' they carried out. Or you could go down there and sign the pack out. Emails were easy to control, if you just used the same numbering system for your computer files as the 'pack index' used.

Why have I bored you with this stuff? Because the MoD lost almost all of its control over airworthiness data as it entered the 'paperless' age. In my direct experience, few departments imposed a central numbering system over the new digital file folders being created by the thousand at hundreds of terminals. Again in my direct experience, one PT had no less than FOUR separate file folders, each purporting to be 'the' list of applicable Service Modifications. Simply put, the PTs no longer had an accurate record of where much of their airworthiness and technical data was. The Registries had been replaced with (larger) Business Management Teams and the task of file upkeep was transferred to the technical desk officers. Some did it diligently. Sadly, many didn't. Again, direct experience - I was asked to take over a complex avionics upgrade project - on calling for the files I was handed twelve inches of loose papers, which I was told represented the record of one year's work.

Paper files were now used to do no more than hold a copy of emails and letters - if the desk officers could be a***d to print the copies. Often, they couldn't. Minute sheets had fallen out of use, so reconstructing the history of a technical issue was now almost impossible. If you thought it couldn't get any worse, think again. In around 2009 new instructions were issued that henceforth, no 'weeding' or cross referencing of files was allowed, nor were papers to be moved from one file to another. The instruction explicitly said that the aim was to 'reduce time wasted in managing obsolete paper files'. Hundreds of files went off to 'archive', meaning that it was now impossible to find out what data was there.

I'm sorry, once again, for boring you with this, but it's germane to one of the most astonishing feature of this tragic accident. (to me, anyway). I continue to be amazed that anyone would have approved the issue of a Technical Instruction that called for the ejection seat drogue shackle to be dismantled every 50 flying hours, and then for this work to be carried out at first line. So, when I first read the SI report, I looked forward to an explanation. What I found astonished me. There was NO audit trail recording how the RTI came to be applied to the seat. NO entries in the 'Cassandra' hazard log. NO record of key decisions. NO explanation of why 22 Group decided to press for the adoption of an RTI that clearly posed a serious safety risk. NO record of who signed off the RTI without having checked it against the appropriate Safety Case. It's my considered view that had RTI/59D been properly staffed, recorded in the Hazard Log, reviewed by the right bunch of people (that would have been a Local Technical Committee, until they were disbanded), this accident might well have been avoided. Someone, somewhere would have stuck up their hand and asked whether RAFAT first line personnel were the right people to start taking ejection seats apart every 50 hours.

The SI report concludes with a series of recommendations, many of which say that PTs should 'ensure that they have a robust and audible method of tracking, reviewing and managing airworthiness decisons'. Tuc would say (correctly) that this is no more than 'comply with mandated instructions'. I'd have gone with a more direct approach, involving a number of Anglo-Saxon words.

If you fly a UK military aircraft right now you need to be concerned. If you're working in a PT and you can't lay your hands on airworthiness related data, you need to be worried. If you aren't recording what you are doing, and making sure that those records are being kept, you need to be REALLY worried. If you work in a PT and don't know what 'airworthiness related data' is, or where it's kept, you need to think about a career change.

Best Regards as ever to all those doing their best under difficult circumstances,

Engines

Engines, thank you for a comprehensive explanation of exactly where the wheel came off.

Can you explain why anyone, apart from the people sitting on the bang seats, should be worried?

Under what circumstances would anyone be in line for any kind of sanction or punishment?

I mean, really what would it take? People have died and still it's nobody's fault.

Why would you think they are going to get caught? Found out, yes, but caught? I don't see it.

Key passage. The people who chaired LTCs were Technical Agencies, one of the most carefully controlled appointments in the airworthiness world. The most senior TA in any discipline (let's say, avionics, a world I'm familiar with) chaired the HQ Radio Mods Committee. He always had a deputy, because as a TA himself he would be submitting modifications and was not permitted to self-certify. These committees were themselves served by central registries. In this case, in the Directorate of Military Aircraft Projects. It was closed down in early 1993, to coincide with disbanding of the HQMC. Its voluminous records, which the very competent ladies could, as Engines says, access immediately, for any part of the history of the equipment or aircraft, were mostly destroyed, and some randomly archived. Not one TA knew the registry was to close until we turned up one day and it was empty.

I'll be kind here. This is why the Service Inquiry couldn't find the Safety Case Report or the evidence that MoD knew in 1990 of the mod that would eliminate the shackle pinching risk. But what it was also saying was that no one in the seat PT or aircraft PTs using Mk10 seat had any clue either. That, I can't believe.

Even if I extend my kindness, as soon as the 2002 report was released last month, it was incumbent upon MoD to immediately inform both HSE and judiciary that it had now uncovered the evidence (a) proving the SI wrong, (b) proving the Inquest had been misled, and (c) casting considerable doubt of the safety of the allegations made against M-B.

And we get back to the question - so why did M-B plead guilty to an easily defended charge? Not wanting to upset MoD simply doesn't cut it. I wonder what the MAA are thinking. It must be patently obvious that this case has set their work back 20 years or more. And given they haven't made much progress in 8 years, that's pretty serious.

Airpolice,

Good questions. Perhaps I can offer a partial answer. In around 2010, the MoD issued new security regulations. I was working on a PT, and was required to undergo the 'on line' training. I was amazed to find out that the new guidance for classifying information included 'protecting the reputation of the Government or the Department from damage'. I queried this, thinking that perhaps the MoD had just bought some generic 'data security' training package which also covered civilian organisations. Nope, I was told in no uncertain terms that classification of data would now be driven (in part) by whether it might damage the PT's (or the Government's) reputation.

Of course, this actually meant the PT Leader's reputation, or that of his superiors, including VSOs. As a contractor, I had NO reputation to protect. Nor did the rank and file desk officers. So, when you talk about people actually being held to account, the system has closed ranks over the past few years. Not exactly 'open government' is it?

My approach to the issue is not always 'hang the swines' - unless they are the senior people who should d**n well carry the can. The best way is to make sure that the systems, processes and training of the people in the organisation are up to the job they've been given to do. In this case, know how important keeping full, organised and available records is, and making sure that they do their part to make sure it happens. To answer you directly, I was hoping that where people are discharging professional responsibilities, they will be worried if they find out that they're not doing their job properly. I admit to being an optimist here. The central problem is that the rank and file in the MoD are being managed and driven to 'just get the job done', not 'do the job properly'. By the way, 'doing the job properly' does not have to mean that it takes longer.

Best regards as ever to all those doing the job properly,

Engines

Engines, excellent posts, Sir! You describe in detail the extent of the dysfunctional mess that is present day UK Military Air Safety. Tuc has described before how files and records were "disappeared" overnight. That is why Sean Cunningham died, because that which would have kept his seat, his aircraft, and every other system and aircraft in the RAF, the FAA, and the AAC airworthy went through the shredder or was simply buried. Oh, and just to make certain that there would be no chance of saving the day, anyone who resisted this anarchy, who sort to enforce the regulations in defiance of orders to suborn the system, were summarily got rid of in place of unskilled, untrained, non-engineers.

That is what is being covered up. That is why the MAA is both unable and unwilling to expose that subversion, and why it cannot start out on the urgent reform that is necessary. That is why UK Military Air Regulation and Air Accident Investigation must be made independent of the MOD and of each other. As Engines says;

I couldn't agree more!

I am not an engineer by training, just a pilot, civil and ex military. I find it hard to believe that the shackle would need to be dismantled every 50 hours, (as “engines” stated) at any line stage. Just what might be the purpose of such a procedure, as the shackle is hardly subject to any wear or material degradation in normal use. M.B. or MOD initiated ? Or have I missed something?

Airpolice, Tuc, Chug, Others,

Sorry, my bad here - my sincere apologies. I missed out a key part of the problem that is also relevant to the issue of missing records of meetings.

It's now very rare for meetings within the MoD to be minuted, or otherwise recorded in any way. I spent around two years in a couple of MoD departments and in both areas, the only time meetings were minuted was when I stepped forward and did it. It was vanishingly rare for a desk officer or civil servant to take minutes. Lest casual readers think that this is a huge waste of time and effort that should be spent better on 'the real job', it's vital if you're going to record decisions that have an airworthiness impact. And it doesn't have to take long. It's easy to prepare a blank set of minutes built around the agenda, then concisely record the decisions and actions placed in the appropriate boxes. I usually aimed to get the 'RODs' (Record of Decisions) out within 48 hours of any meeting.

In one of the areas I worked in, I went so far as to prepare a Powerpoint brief on 'how to hold a meeting', with examples of what a set of RODs needed to look like. I found myself giving the brief to departmental deputy heads.

This is another area where I don't see a malicious 'cover up' so much as a basic failure to manage and record the work required to safely procure and/or support complex air equipment. Again, I blame the bosses - they are the people who can set the standards, explain clearly what they want and see that it gets done. Honestly, these days, many of them have never attended a minuted meeting.

The more I think of it, the more I see this as the reason that the Cunningham SI were unable to find any records of the meetings associated with the RTI. It's probable that the meetings were simply never recorded. As Tuc so ably points out, this is a problem that never arose with LTCs. These were formal, highly structured meetings that would never have dreamed of not issuing minutes, Indeed, most department heads I worked with would have played merry hell if they hadn't seen the regular LTC minutes coming across their desks.

The MAA should not have to tell people to minute their meetings. This should be 'ops normal' for any organisation dealing with airworthiness issues. It's absolutely basic, standard, uncontroversial stuff that should be happening, but isn't.

Best Regards as ever to those taking the minutes,

Engines

When the great ones depart at last for their dinner,
The secretary stays, getting thinner and thinner,
Wracking his brains to record and report
What he thinks they will think they ought to have thought.

from The Manual of Service Writing, JSP 101, if I remember correctly (quite a long time ago....)

airsound

RetiredBA/BY

The dismantling was deemed necessary by the Hawk Support Authority, to do some NDT crack detecting. It was NOT thought necessary by MoD's own Subject Matter Experts (1710 Sqn). The instruction was issued via RTI/Hawk/059. The regulations forbade an RTI if the Design Authorities (Martin-Baker and, in this case, especially BAeS) needed to be involved. As it was an RTI, the chances decreased considerably of the mandatory up-issue of the Safety Case. The Service Inquiry commented on the first bit, and lack of a valid Safety Case; but not the rogue RTI. It confirmed Martin-Baker were not involved in the RTI, which contains a number of basic errors/omissions which would have been picked up had the process described above, by Engines and myself, been in place. That is, MoD no longer lets Agency Contracts to have an independent party check and double-check such instructions. Pre-1993, this would have snagged the RTI straight away. (I'd like to think the TA would spot it, and snag it internally in the first place). You could write a book about this case.

Engines

Quite right. Next day was normal, 48 hours tops. A Local Technical Committee is, by definition, a safety meeting. Ex-committee decisions were routine. In fact, if run properly the LTC itself was just a summary of events over the past period, some signing of papers, the odd bit of new business that had cropped up in the last 24 hours, etc. The company had financial delegation to commit MoD funding without the TA's approval - to get things moving on a safety issue. This is a unique delegation, and because of it the company man was a company nominee, but an MoD appointment. Again, unique.

RetiredBA/BY,

I'd like to add a couple of points to Tuc's (customary) excellent reply.

As the SI report makes clear, the RTI (RTI/59) was developed in response to discovering a crack in an ejection seat top cross beam in July 2010. With assistance from MB and 1710 Naval Air Squadron (the latest incarnation of what was once the Naval Aircraft Materials Laboratory , the MoD's only dedicated material testing and NDT laboratory) it was determined that a visual inspection for cracking every 14 days was appropriate, and that the seat could safely be operated with a cracked beam. This was recommended to the Hawk Support Authority.

Things now get hazy due to the lack of meeting minutes , and indeed of almost any records of the decision trail. In early August, the Hawk SA, with the AES PT, produced RTI/59, which called up a full NDT inspection of the beam, requiring disassembly of the drogue shackle. From the SI report, it appears that a meeting took place later in August chaired by 22 Group, acting as the Aircraft Operating Authority (AOA). The SI report says that the AOA was 'not content to operate the aircraft with a cracked cross beam as the visual effect might undermine aircrew confidence in the system'. Four further iterations of RTI/59 took place between August and October 2010 (unusual), leading to a 50 hourly check with associated disturbance of the shackle. The SI report notes that this 50 hourly NDT check was kept in place even after 1710 NAS had provided assurance to the PT that a visual (non-dismantling) examination was adequate.

In my view, the PTs (Hawk and AES) didn't have to impose the full RTI/59 on the seat. 1710 and MB had told them a visual inspection was OK. It appears that it was 22 Group who demanded the full NDT inspection so as not to 'undermine aircrew confidence'. Even after further assurance from 1710, the full RTI was kept in place. So why did 22 Group get to call the shots? Why did the PTs go for a full NDT inspection and shackle dismantling? Did the PTs get 'told' what to do by their aircrew? We just don't know. No minutes or records. The MAA saw all this as an 'other' factor. I respectfully disagree, and consider the failure to properly consider all the safety implications of this RTI to be a 'contributory' factor. But that's just my view as retired engineer. Doesn't really change the price of fish.

Best regards as ever to all those doing the work,

Engines

Just wondering how these sample 1000 series Regulatory articles fit in with the references to process/procedures/responsibilities within the thread, although it is to be noted that there is a lot of use of the word should, which is defined in MAA-002 as:

https://www.gov.uk/government/upload...13_Issue_3.pdf

https://www.gov.uk/government/upload...14_Issue_5.pdf

https://www.gov.uk/government/upload...15_Issue_7.pdf

https://www.gov.uk/government/upload...16_Issue_2.pdf

https://www.gov.uk/government/upload...21_Issue_3.pdf

https://www.gov.uk/government/upload...23_Issue_4.pdf

https://www.gov.uk/government/upload...24_Issue_6.pdf

https://www.gov.uk/government/upload...30_Issue_3.pdf

Side issue I know but in the RA's linked to by Exrigger, Why do they use the American spelling "Organization" rather than the English language "Organisation"?

Probably because, just like one of my Wing Commanders who, when asked the same question, was adamant that it was the "correct" spelling. He didn't have the functioning brain cell to notice that his version of documents produced on Word said "English - United States" in the bottom left-hand corner, and further had no idea you could actually change the default language to "English - United Kingdom".

Yet another reason that made me wonder how he ever attained such a rank .....

Vendee a further aside includes the use of authorize/authorization & Cannibalize/cannibalization to name some more and omegaV6's explanation is not far from the truth.

Cross beam
 

As I have no 'informed' knowledge of where the ejection seat cross beam is and why it should crack perhaps someone can educate me.
This whole sorry episode is so full of 'bean counter' servicing cost savings affecting what is a very technical piece of safety equipment, that the 'man in the street' would be astounded that the company (MOD RAF) have allowed the capability of such equipment to be affected by a person working on such equipment not to realise the purpose of a 'shackle' or how this 'simple' device should be assembled. This situation only confirms that the 'standards' required for working on such equipment are not fit for purpose or that the (MOD/RAF) see that this is a problem. As an ATC Staff Cadet on a Gliding School I used shackles all the time and have done so for many decades since. In certain cases it is quite possible to 'pinch' the open end and usually a spacer bar or precision bolt is used in cases where this would cause an 'ongoing' problem. A shackle is normally used where 'movement' of the connection is required, and I knew that as a Cadet. It is quite obvious that something that is 'dismantled' many more times than originally planned becomes a 'consumable' and therefore in a very special case such as an ejection seat the cost of a new connection seems paltry. That the RAF have allowed standards to be reduced to such a level is a national disgrace and its VSO's have done the service no favours by allowing this for many years. I would not have dreamt this could be the case years ago, but have just seen my old Air Cadet Gliding organisation destroyed by such a lamentable state of affairs. MB have dedicated their business to saving lives and produce a first rate product that is so much more than a 'bang seat'; however their customers must realise that this special piece of complex safety equipment needs proper care and servicing from suitably trained staff and anything less is negligent. The RAF have been negligent and no amount of carpet shuffling or letting MB take a hit can hide that.

Exrigger,

A quick scan of these RAs shows (at least to me) the limitations of trying to ensure (ore assure) airworthiness via regulation. This, of course, has been the MAA's main mission - to regulate absolutely everything so that all people have to do is 'comply with the regulations' to assure air safety'.

Unfortunately, at least in my experience, the level of 'air safety' or indeed airworthiness, an organisation achieves is not at all related to the amount of regulations it tries to obey. I once chaired a meeting where we aimed to take a 'first pass' at comparing RN and RAF aircraft operating and maintenance regulations. The RN guys came in with four or five books. I am not making the next bit up. The doors swung open, and our RAF colleagues pushed in a large four wheeled trolley loaded up with many tens of volumes. Note - these were the non aircraft specific regulations.

I don't want to belittle my light blue colleagues here. They worked to good standards, were keen and professional engineers. But, as we quickly found out, there were numerous examples of regulations in their own books that they didn't even know existed. many were pure dross, and could be easily ditched. (To their considerable credit, a very smart Gp Capt engineer did just that a couple of years later - I cherish a hope that the sight of the RN's slimline stack of books might have helped start that process).

The sort of problems I've been pointing out on this thread won't be solved by writing more regs. It will need a more basic appreciation of WHY things need to be done in certain ways, not WHAT the regs tell you. I don't think I ever referred to the RN or JSP regs for running files and packs, or holding meetings. I applied the principles I'd been taught, observed my superiors (good and bad), learned from them, and when I was ready, brought my own ideas into play.

Just my opinion (warning - opinions here) one of the best ways to help achieve airworthiness/air safety would be for MoD PT projects to be subjected to the sort of 'phase reviews' that BAE started doing a while back. Very experienced engineers would come in and subject your project to really close scrutiny over a period of some days. Your project could NOT proceed until you had the phase review pass certificate. It was people like this who knew what to look for.

Best regards as ever to the fine young engineers who are now doing the business for real,

Engines

Pobjoy,

Take a look at the SI report on the standards of servicing that were happening on the RAFAT ejections seats. Key issues found:

1. There was no 'Q' course to qualify RAFAT airmen to work on the Hawk. Babcock personnel did a 5 week course - the RAF declined to use this course.
2. The Hawk TMK1 Support policy Statement said that there was no requirement for pre-employment training for airmen before they worked on the RAFAT. The Support Authority were 'unsure' as to why this was the case.
3. Then gaps were made up by OJT carried out by SNCOs. Many of these had no qualifications as instructors, nor was there an approved syllabus.
4. As a result of the above, RAFAT engineers were maintaining Hawk aircraft without any compliant training.
5. RAFAT armourers had no access to a central training cell. They had to rely on OJT to be trained to work on the ejection seats. A number of the RAFAT armourers had no recent experience of working on ejection seat equipped aircraft. One had had no seat experience in the 6 years since his basic training.
6. The SI found evidence of signatory and supervisory malpractice.

I struggle to find reasonable words to express my thoughts on this lot, without appearing to be a permanently grumpy old retired engineer, I really do. Ejection seats can, will, and have killed, and in the RN they were always treated with severe respect. Armourers working on seats were properly trained, qualified, certified, checked, and and there was any dismantling of seat sub -assemblies required, the whole seat came out and went back to the seat shop. Taking seat shackles apart every 50 hours using as setup like this was just asking for trouble. The SI correctly notes it as a contributory factor.

In sum, I simply don't recognise what the SI report sets out as any form of professionally run fast jet maintenance operation. The tragedy is that NONE of this lot is now going to come out, MB having pled guilty.

This is one area where 'hang the guilty b******s' works for me.

Best regards as ever to those doing the best with what they have,

Engines

Well said Engines!

Thanks Engines, I agree, but having taken the origanal CAA regulations and converted them, removed non miltary relevant parts, or amended to fit in with the new way forward for the MAA, applied the regulations to civilan companies working within the military environment, that they did not follow themselves, or understand what it was all about, made for rather confusing and interesting times.

There are a lot in the MAA who are trying to do things right these days, but they are, as has been pointed out on numerous threads like this, sometimes overridden by the hierarchy. It also did not help when they initially filled posts with people who were not compliant with the requirements for those posts, again that just means things got lost in the noise, including safety issues, which this and other threads have illustrated.

The ASIM system using DASOR's only works when people know what should be reported in the first place, then report it if they are not bothered about career progression, and then have people who can investigate, analyse and ultimately put actions in place to stop it happening again, unfortunately it is stovepiped into individual platforms with not much thought to safety issues that could be applicable to others.

A phrase I heard regularly after Haddon Cave report came out was 'nothing to do with us, that is Nimrod only', and we all know that is not correct.

Engines,

You have made some excellent post and identified a number of very valid points.
Having spent most of my 24 years as an armourer working on Mk.10 seats (6 on Hawk) I just need to clear up one thing.
The removal of the Scissor Shackle Bolt is something a properly trained and authorised tradesman would be very familiar with, it has to be disconnected in order to remove the primary cartridge in the top of the ejection gun, part of the dis-arming process that is carried out on every single seat removal.
In my time on Hawk (at 2 TWU 88-94) we had a training cell that monitored our qualifications, with all training carried out locally on the squadron (there never was a Q course for Hawk only an X-annotation). With that many aircraft and student pilots, we pulled seats that often that it became second nature (I could still remove one now from memory).
Back then, most of the guys on RAFAT were ex-Hawk guys from Valley, Brawdy or Chivenor, so they knew the jet well. I understand for some time now, there have been 1st tourist engineers on RAFAT, probably because there is no 'pool' of experience to draw from other Hawk units, as they have been civilianised. However, they should have had to demonstrate their competence in carrying out seat work, prior to being authorised to carry out that work and have a training record to substantiate that.
I have posted previously on this incident, but have not felt comfortable about this for some time due to comments made by certain individuals.
Certainly, on the squadron that I worked on, we were all aware of ensuring the freedom of movement of the parachute withdrawal shackle in 1988. I can only conclude that the general 'dumbing down' of training over the years and a lack of experience have contributed here.
But bear in mind, are talking about the tradesman that did the job, the NCO who carried out the Vital checks and the SNCO who did the Independent checks all missing this one critical failure of a basic task.
Why? Someone should be desperate to answer that question....

Careful study of this extract from the BoI Report provides many of the answers.

https://www.gov.uk/government/upload...3_analysis.pdf

Mortmeister

Excellent post.

I simply note that (a) MoD flatly deny this, and (b) the HSE considered it 'irrelevant' when offered in evidence, and did not think it affected their case against M-B for not reminding MoD of this in 1990. I've never worked on ejection seats, but the individual elements are basic fitting, and without hesitation believe you.

Exrigger

This is now applied to aspects that were hitherto mandated. I first saw this in about 1999 when a non-engineer line manager had a pop, saying 'Def Stans are not mandatory'. Well, they are, if called up in the contract. And a small series of them are mandated in every aviation contract. Not hundreds - just 4 or 5; and only one that any project manager should know by heart. It is THE Bible. Had it been followed, this accident would not have happened. Many of the recommendations in the SI report, and those in other reports, amount to - implement this Def Stan. Much of the content of these Standards is now 'should' instead of 'shall'. But I wonder if the MAA have actually rescinded the overarching directive that they are mandated? Very confusing for those who have to implement them.

Tucumseh, with regard Def Stans you are correct, however the RA's in one specific area were amended to remove certain information that caused problems for the contractors, the Def Stan still retained the information and was extant within the contracts, but the RA took precedence despite that.

I don't think I will but thanks for your input.

But the SI says, in section 1.4.3.9 'Drogue and Scissor Shackle from XX177'

So waggling the shackle during preflight checks may not have picked up the overtightened bolt anyway...

After a fair few years in industry dealing with such matters, I can advise that the recognised order of precedence is that the Contract terms come first, the contractual technical specification next, followed by the RAs etc. The RAs have direct relevance when it comes to the firm being awarded DAOS (or other) approval. This situation arises because there is no statutory basis for UK military airworthiness. The various arrangements are only 'legal' due to the SoS for Defence use of the Crown Perogative to mandate them. While the SoS' orders are binding on the CS and Military, they must be confirmed by contract for industry.

As an aside on the use of "Organization" within the MAA, this arose because of a minor obsession by one of the first Directors of the MAA. While this usage appears in the OED, it is regarded as archaic. A friend in the MAA once told me that the two main internal issues were the use of the 'z' in such spellings and ensuring that the interests of horse riders were given proper attention when it came to low flying and so on.

EAP

EAP86:

As you say that is the correct order of precedence, however, having been involved in MRP 145 approvals since they were introduced for civilian maintenance contractors, this point was argued that the quoted contracted Def Stans took precedence over the RA's that were amended to remove pertinent information, the argument was lost and the companies have to submit a Alternative Acceptable Means of Compliance to work to the Def Stan and not the RA, attempts to amend the RA to re-align with the Def Stan were unsuccesful.

Quote from MAA-03:

And then one wonders why we keep having these threads on here, when the critical safety sytems are full of mis-understandings and confusion, or are simply not followed.

Tecumseh and engines, thank you, gentlemen, for your detailed reply.

Having read the SI it still sticks in my craw that M.B. were fined for not protecting the RAF
from itself ( at least that is how it appears to me) as there is a list of 14 contributory factors in that SI.

The one item, of several, which really disturbs me is that there was a practice of inserting the. SFH pin WITHOUT visual reference, hard to believe that such a safety critical item was so (mis) managed.

Another thing which I do not understand, and to which no one has yet given a reasonable answer:

If the pin was removed before engine start it follows that taxi OUT was conducted with a live seat.

Why, then, was the SFH pin replacement not left in place during the taxi IN and carefully replaced, with visual observation and confirmation of correct replacement, on reaching the pan and the engine shut down ?

It’s a long time since I was a QFI, (and my own ejection) but I just cannot begin to understand why such an unsafe practice was allowed, tolerated, let alone became an SOP.

Has that practice been changed following this tragic death ?

There was a 'Q' course in the early days of the Hawk Mort - I did mine at Hawker Squiddelly Dunsfold june/july 1977 whilst on my way to Brawdy for the introduction of Hawks for the TWU.I do not know how many 'Q' courses were actually carried out - not that many I guess.My docs were annotated (something like) Q-AHK-A as I was a rigger.


Same in 1978 - the shackle rattle was always carried out by the aircrew during pre strap in checks.

Exrigger:

I feel your pain. I was involved with 'MAOS' when ADRP held it's original 'Ad Hoc Sub-Committee' on the subject, the discussions on the original Def Stan 05-130 with ADRP and EngPol, and the subsequent drafting of the relevant RAs.

It was frustrating, to say the least, to discuss issues in the meetings and achieve a degree of mutual understanding only to find that later discussions within the MAA (or with the senior officer levels) left the text unchanged or changed to something even more unacceptable. There seemed to be a view that industry could agree and accept anything and very few realised the strict legal and commercial constraints under which we operated. To be fair, this view wasn't universally held but over the years I observed many shrugs signifying "...I know, but what can I do?"

The maintenance regs were originally drafted as Def Stans because only industry was expected to work to them. Industry has always been discouraged from contracting to MOD internal regs such as JAP100, JSPs, RAs etc because they can change without any involvement from industry; thats why Def Stans existed. Many of these documents were actually caveated to say they were not to be used for contracting purposes but I'm aware that this rule was often disregarded, possibly less so in the Air domain than Land or Sea.

EAP

Thanks EAP86, I went to RAF Wyton for the original meetings on what became MAOS, and it was comical listening to what was being put forward and the surprise when industry pointed out that some of their ideas would not work. With regard MAP-01 & 02, JAP 02 & 02 as was, were included in the maintenace contracts as there was RAF personnel as part of the workforce and we had to use military paperwork, F700 etc, on that score civilian companies had issues with that as they were wanting to run things independantly from the military, but with MRP-145 approvals and reality kicked in it was realised that this approach would be impractical.

It was also pointed out that RA AMC's quite often link to the MAP-01, so despite trying to deny the link and ignore the MAP-01, to maintain approval the companies have to comply.

Again, it does make one wonder if all this confusion is partly responsible for having the opposite effect on safety than it is designed to safe guard and improve.

I read with interest the BOI analysis. I don't know when the requirement for OJT to be carried out by trained Instructors, or personnel having received sufficient training on instructing was introduced. Certainly it was not practice in the 1960s, when I both received and carried out OJT. On the 2 occasions when I gave evidence to a BOI, my technical ability and use and availability of documentation was queried, and the BOI satisfied, but formal training qualifications were never raised as an issue or contributory factor.

Standards
 

Thank you those who are more up to date than I.

There is a formal 'Order of Preference or Hierarchy for the Selection of Standards for MoD Acquisition'. My copy pre-dates the MAA, but Defence Standards sit above UK MoD Departmental Standards and Specifications. I don't have a copy which says where the MAA documents sit.

In aviation, this was complemented by Controller Aircraft Instructions, mandated upon every member of Air Systems Controllerate. The 05-Series of Procedural Defence Standards were mandated in every aviation contract. This was the one area where Def Stans sat above 'Recognised Industry Standards'. Which is just another way of saying what others have confirmed.

What was immediately obvious to me when the MAA started producing all this 'regulatory set' was, in key areas (e.g. maintaining the build standard, which is what would have avoided so many deaths) their words reflected, almost word for word, the aborted Chief of Defence Procurement Instructions (CDPIs) from 1993. The MAA made precisely the same mistake in its definition, and immediately went off at a tangent. As far as I know, this is still the case (based on a word search of key words). The problem was, the money had already been withdrawn to maintain the perfectly good 05-Series Def Stan, and eventually it was scrapped. So, today there are no laid down procedures that industry agree with. It might accept a contract lacking it, but I'll lay money its engineers have a copy of the Standard in their top drawers. Both Parts. I'd lay more money on MoD not being able to produce Part 2 at all, and only having an old version of Part 1, at best. That Standard was not written or issued by ADRP. It was written and maintained by the Technical Agencies I mentioned earlier. My old boss's name is still in my copy, promulgating the last update - which we had written to reflect changes in legislation.

This all may sound faffy, but it is the foundations upon which the safety aircrew take for granted are laid. Its money in the bank and costs peanuts to implement, because the work is not volume-related. You know within a very small margin how much the annual cost is. Getting it wrong costs an awful lot more, and not just after an accident.