And here lies the issue that this and other similar threads keep highlighting: the constant changing of technical information, regulations, reducing training has culminated in a confusing and contradictory environment that is counter productive to its concept of safety/airworthiness and the protection of life.

Will changing the rules and regulations again, make any difference, is there a will from those at the top to admit the erosion of safety/airworthiness has been happening, if they did, do they have the will and knowledge to make those changes, or will more accidents/loss of life have to occur, and more importantly someone in the military management to actually be held culpable and dealt with appropriately to get the message through.

Perhaps I can help a little to clarify matters here.

Whenever any maintenance was carried out on RN aircraft, the supervisor for that work was required to ensure that the person carrying it out had the required qualifications, training and publications available to do the job. Units and departments also took care to ensure that any work on a safety critical item was carried out by an experienced tradesman. One of the basic requirements of any tradesman, as well as supervisors, was to understand the way in which the system they were working worked. If required to dismantle and reassemble a drogue shackle, they would have been required to understand that shackle's function, how it operated, and the key checks to be carried out after reassembly. These 'competences' were checked on a regular basis for all ratings, using a rolling 'performance check' system that was mandated on all FAA squadrons and departments. In essence, the RN pursued a 'competency based' system backed up by active local quality assurance.

Due to their particularly hazardous nature, any work on ejection seats was specifically authorised to a few personnel who had also done a special 'seat safety course'. If at all possible, work on ejection seats at first line was avoided by returning the seat to the bay and replacing it with a serviced item. One of the main reasons the RN did this was because we knew that, having dispensed with a specialist Weapons trade, the 'Weapons Electrical' ratings we had were less experienced than their forbears. hence the special precautions that were taken. Now contrast that approach with what the SI established happened on the RAFAT, where inexperienced tradesmen, with no authorised training, worked in pairs on the aircraft, supervising each others' work, using handy pre-printed forms.

Sorry if I'm repeating myself. We can all go on as much as we like about how many threads should have been showing, what sort of nut was used, and what APs were being used, and who issued what warnings. The core issues with this tragic accident are (in my view) staring us in the face.

An RTI that wasn't actually required to make the seat safe was issued by the engineering authority, possibly at the behest of the operating authority - and apparently nobody involved in the process kept a single record of how that happened.

A safety critical system was being taken apart every 50 hours. By itself, that should have raised massive warning flags. However, once again, no records seeem to exist on how that risk was supposed to be managed.

The RAF failed utterly to ensure that the people carrying out this safety critical task had the experience, training or supervision required to make it safe.

The poor s*d who actually overtightened the shackle on that day had, by the time he did it, been comprehensively failed by a number of people. Not by the system - by people not doing the jobs they were given to do.

The solution to this sort of problem is not, repeat not, more regulations and more instructions. It's this - do what we're already supposed to be doing.

Best Regards as ever to all those who are doing the work for real at the coal face today,

Engines

Tuc,

a SIL is a MBA 'instruction' to all their non-MOD customers. Where contracted to do so, a DO will redraft the SIL into the MOD's required format. The same happens for export customers but where there is no contract, the operator receives the SIL anyway.

Where a civil operated ex-military type has a live ejection seat, the CAA can require compliance with the SIL before the will allow a Permit To Fly to be issued. In line with usual civil practice, I believe the CAA would treat the SIL as approved data requiring operator compliance without being "promulgated" by the regulator. If its really important from an airworthiness perspective, they can designate the content as an Airworthiness Directive.

Unlike the UK MOD approach, 'approved data' is issued mostly by the Type Designer.

EAP

EAP

I tried to keep it succinct. On 16 November 2011, MoD promulgated SIL704 by means of Urgent Technical Instruction/Hawk/34. On 17 November 2011, the Civil Aviation Authority reflected it in Emergency Mandatory Permit Directive (EMPD 2011-008-E), which notified users other than the MoD. Two years later, SIL704A was issued - same again.

OMS and dragartist mention that the head of EA was a Wg Cdr stacker with no input to eng matters, these were raised to the Gp Capt. So, when the Gp Capt retired and was replaced by a CS with no eng LOD/LOA and no apparent interest, finance came first, higher level signatures were referred a Gp Capt in another PT. Then the Sqn Ldr head of AAES was posted and eventually replaced by another CS with no seat or indeed aircraft experience. Follow that up with the retirement of our PDS Officer, with his duties, LTC etc, handed over to the DOs. Add the distractions: preparing the case for seat maintenance remaining with the MoD rather than accepting a bid from MBA; constant efficiency and money saving drives and fending off the Army's bid to manage all explosive items, one can see where we are heading. I am not trying to justify anything, just adding to the plot.
Engines remarks that in his area a seat would be removed for any detailed work and swapped with a S item; surely that is the only way to do it. How on earth were RAFAT 1st line allowed to carry out a detailed RTI in situ.
Engines really hits the mark regarding knowledge and understanding of a safety critical system. A FJ sqn facing a summer of display detachments elected to 'train' an airframe snco to carry out Independent Checks on AAES, rather than send a wpns snco with the det. I have nothing against riggers, but a local training course would not imbue the individual with the depth of understanding needed to take on the responsibility of AAES Independent Checks. Our argument was dismissed. But on the same visit my faith in snco armourers was shaken. In discussion about independents with a wpns snco he ventured that to 'make sure it's done properly' he disconnects the PEC and reconnects it himself. He would not accept that by doing so he would invalidate the signatures of both the tradesman and the supervisor as well as his own. I could weep.
Phew, I've got that off my chest, it has been festering for a while. Now I can go back to working my way through the fascinating Pilots' Brevet thread.

Yes, I know of one aircraft that there were issues with the wing attachment bolts and it was deemed acceptable to pull and inspect them every 100 or so hours until sense prevailed and they realised the were doing more damage to the spars carrying out the inspection than the damage the inspection was raised to address.

Nutloose.

At one point in my EA career, I recall over rotation of Tucano and Harrier (whatever happened to them?) harness Quick Release Boxes (QRB) became a hot topic. Generated by an 'Air incident' signal the problem did not degrade the performance of the box when holding the pilot into the seat ...but, understandably, it was considered a bit disconcerting when a couple of pilots managed to do it whilst strapping in.

Against our specialist advice, the 'dark side' of the office decided to issue a PWI (a UTI in old money?) and follow up SI calling for a check of the QRBs on each BF. IIRC, the check involved the BF crew, probably the plumbers, carrying out several trial operations of the box to see if the QRB could be turned beyond the normal locked position.

From what was initially a couple of arisings, the office was suddenly faced with multiple failures and, of course, many lost sorties. The dark side swiftly handed the problem back to 'rubber and leatherware' where we established that the increase in incidents was directly related to overenthusiastic tradesmen working the box until it broke.

But we digress....

OMS - Sorry.

SB

I'm sure it wasn't just the Plumbers!!!

Nice honest post of yours earlier, BTW - and was that the "golden era" of which Tuc et al speak?

OMS,

Really good post, and you raise some very good points.

I was trained to be aware of the fact that the best way to really b****r up any system was to start disturbing it. Our servicing reviews in the 80s were always aimed at extending servicing intervals wherever possible. If you DID have to make a regular check on a system, you made sure that the check was as repeatable and non-intrusive as possible. I remember the QRB saga, and can add the RN's own saga with Sea King generator issues, where the damn things were coming out every 5 minutes as the problems mounted up.

One point I'd like to make, and I'm really sorry if my various blatherings have created the wrong impression. There never was a 'golden age', in my view. (I think this phrase first cropped up in the Haddon-Cave report). In my period going through from a callow youth to the giddy heights of a Commander, I saw plenty of errors, and made more than a few myself.

I lost good friends along the way, as well.

Luckily, I usually had bosses and subordinates who were not afraid to tell me I'd cocked up, and put me right. I was also fortunate to be in the Navy, where engineers were treated as an equal part of the team, and accorded respect by aircrew (once they'd earned it, of course).

I do think I was lucky in my timing, as we had the room to make decisions at a fairly junior rank, our concise RN engineering regulations were based on the principle of telling us what we couldn't do, not what we were allowed to do. We also had larger fleets of aircraft and more bases, which gave us all a better chance of getting the requisite experience as we moved through the system. We also had quite excellent technical Civil Servants (and contractors) working with and alongside us, sharing lessons and knowledge.

Last point. Whatever the system they have to work within, 'the youth of today' are absolutely excellent. The young engineers and aircrew I encounter are simply outstanding, and deserve our respect and support as they serve their country.

Best regards as ever to all our service personnel,

Engines

OMS:-
The "Golden Period", refers to the Haddon-Cave Report in which he bizarrely labelled the early 90s thus, when they were in fact the very years that the UK Military Air Safety System was being plundered, sabotaged, and rendered utterly dysfunctional by certain RAF VSOs. He then misleadingly shifted the deterioration of airworthiness provision to later years. Now how might he have got hold of that idea, when he had evidence before him as to the chronological sequence of this scandal? That the MAA uses the Haddon-Cave Report as its foundation says it all. Isn't there a parable about houses and sand?

Engines, I acknowledge the woeful behaviour of the RAF from top to bottom as highlighted by the SI and yourself in this fatal tragedy. Your pride in your own Service is understandable and commendable, but might I gently point out that the crisis in UK Military Airworthiness involves all UK Military Aircraft of whatever Service?

One of the threads on this very forum concerns the loss of seven RN aircrew in a mid-air collision between two Sea King "baggers" in poor visibility. They were fitted improperly with HISLs which had simply replaced the existing ACLs without trial, contrary to regulations. In the very conditions they were flying in the forward HISLs caused pilot glare and it was the practice therefore to switch them off, contrary to regulations. I only instance this as yet another example of when the lower orders are faced with a fait accompli from above then they have to make do as best they might. The scoundrels are those who place them in that position. The scoundrels in this scandal were RAF VSOs. Let us keep our eyes on that particular ball!

Thanks Chug.

From what slow biker was saying, the run down he so graphically describes was roughly the same period (90s).

OMS

I make an observation, no more:

I am not in any way, subtle or disguised, trying to incite anyone to do anything. I say that, not with a view to avoiding a prosecution, but simply to highlight the open nature of my question.

From my reading of this, and many other posts on similar topics, I feel there might well be a desire, indeed some benefit to be had, from..... us... as a community... as it were... moving away from discussing VSOs and the MoD as faceless entities, and actually naming the people, not the positions they held, when this series of (scandalous / treasonable / careless / reckless) acts were carried out, and indeed, commanded.

I say again, I am not suggesting that we name them on here, I am simply asking, am I the only person who thinks that we should?

"In discussion about independents with a wpns snco he ventured that to 'make sure it's done properly' he disconnects the PEC and reconnects it himself. He would not accept that by doing so he would invalidate the signatures of both the tradesman and the supervisor as well as his own."

Oh yes, there was me thinking that little dit was the property of the (ex) REME supervisor....how do you check the flying control electrical connectors for correct assembly, connection, and auto locking? You take them orf and on again yourself, Sah!!

airpolice

I'd say they have been, repeatedly, on the Mull of Kintyre and Nimrod threads. Haddon-Cave praised some of them. They've been named elsewhere in print, and shortly will be again. Had he published the evidence Chug talks of, H-C would have had to name and shame them, instead of those he did.


Glad Rag

See Chinook FADEC connectors! In-flight servicing to check their security, instead of selecting the correct type/locking in the first place. Barking.


Engines. Sea King generators. Only time I've seen 24kVA generators run at 23.96; and that was with a 3rd fitted. And they complained they couldn't get more EW kit. Perhaps a 40W bulb.

airpolice:-

It all depends on your imperatives. Mine, as well as others who post here, is the very urgent reform of UK Military Airworthiness and Air Accident Investigation in order to avoid future avoidable accidents and deaths. Even if that is achieved the UK will still be left with the mess that is the MOD, and from which this scandal erupted. That is up to the UK to resolve in its own time. Personally, I won't be holding my breath.

As tuc says, a lot of what you seek is already in (e)print. Here is a link for starters:-



and, as he added, more on its way!

Copy on birthday wish list. 😊

And all the profits go to charities not in to Mr Hills pocket.

The Army Air dispatchers were just the same. Rag Packers at AFPSU would sign off and stamp up the old 28fts.
Depending on SPM (Supplies Proceeding Men) the Despatchers would ope the pack add a week link between the static line and Apex and recluse the pack without signing anything.

Dragartist made himself unpopular when he found out, insisting that the Despacther signed for the maintenance. Of course they were not Authorised to do this. Years ago they even packed the supply drop parachutes. We had several maldrops where the finger was pointed at the rag packer.

Imagine if you will, a Jaguar Sqn in Germany at the height of the Cold War. A scarlet safety thread break tie on the parachute flap closure pin has been found broken on AF. It is shift change and anyway probably too difficult to call out the duty squipper to rectify it (and complete the necessary paperwork on those lovely pressure sensitive forms of course) The simple solution was to get the armourers to do it (after all they work on seats, don't they?) No problem ...until armourer detailed realises he had no scarlet thread. Still No problem 'cos he had some locking wire in his pocket....

Luckily, a bright FLM (yes there were plenty of them!..bright ones I mean) prepping the jet for flight next day, queried the shiny wire where red thread should be.....

Caused a bit of a flutter in the dove coot, that one...

Imagine if you will, a Jaguar Sqn in Germany at the height of the Cold War, Wing Commander checking out his jet finds the drogue chute disconnected behind the flaps in the headrest.... Queue the bloody SIB questioning everyone, never did get to the bottom of the how, why or sadly, possibly who!

Tuc,
I know that you know, but just to clarify to some that may not know...The M-B SIL is "Approved Data" and is written by the OEM giving particular information and/or instructions for a specific issue on a specified item. As such, the SIL takes precedence over any general standards and practices laid down in documents like MODs RA's or, for civil aircraft, AMM Standard Practices.

The Official Transcript of the Judges remarks when passing sentence are now posted on the Judicial website and found on this link.

https://www.judiciary.gov.uk/wp-cont...t-23022018.pdf

Interesting that the Lady chose not to even read the unsolicited evidence submitted.
How can this be right?

The judiciary must consider and decide using all evidence presented by both prosecution and defence. Any information not presented by prosecution or defence is not evidential and must not be considered without exceptional reason.

If people wish information to be considered, it must be given to either the prosecutor or defender (who will share it if relevant).

Correct - I was on Jury Duty once and we asked the Judge why no-one had produced notes of a telephone call to the Police - he said pretty much what Crab said - if it isn't put forward as evidence you are to assume it doesn't exist and/or is not thought to be relevant

The 'unsolicited evidence' (proving MoD knew of the risk of over-tightening before 1990, and of the mitigation that eliminated it altogether), was provided to the judge, HSE and Lincolnshire Police. MoD had denied knowing of this at any time to 2011. The charge and judgement were based on this false premise.

As she said, the judge chose not to read it, but passed it to the HSE for comment - specifically asking about disclosure of evidence. (MoD had denied the existence of the QinetiQ report that formed the bulk of this 'unsolicited evidence', and had even briefed Philip Dunne MP to say in Parliament that MoD knew nothing of the alleged content).

The HSE replied (and this is in writing) that the evidence (of innocence) was irrelevant, although of course they didn't say 'of innocence'.

Thus, the judge was seriously misled (by omission), and many of her remarks are tainted by not having read, or been advised by HSE of, this exculpatory evidence.

In furtherance of their stated strategy of not upsetting MoD, it would appear (again, HSE's statement) that Martin-Baker concurred. Plainly, the company didn't think it irrelevant, but chose not to use it in their defence. That is, they took the hit.

The judge's remarks make if clear (at least to me) that she understood something was very wrong here, and she makes a point of criticising the fact that vital evidence was not put to her, due to the guilty plea. However, it was, but she didn't read it.

There is a process for evidence to be presented to the court. That process was not followed.

I'm sure you're right, airpolice, when you sayBut where expert opinion not directly connected to the presentation of the case holds factual evidence, how should they get that process followed? It seems that the principle actors, prosecution and defence, were able to class that evidence as irrelevant without any possibility of redress, even from the judge.

airsound

airpolice

What process was not followed? The police were told, and they (I believe) are obliged to pass evidence to the prosecution. They didn't. The prosecution were advised. The slightly unconventional direct approach (to the judge's clerk) was forced by the late plea, and the knowledge that vital evidence would remain concealed. The judge did not complain, perhaps content that it had been sent to the prosecution; which she did anyway.

In practical terms, the parties involved have got away with it.

A simple fine, paid for by the company from their massive reserves, and the ability of their sales people to openly tell existing and future clients, that MB took one on the chin to spare the client.

Where, as in this case, the crown decides not to present evidence to the court, the court must not go looking for it. Every player has their part, and each must do their own. Shortcomings (to be kind to them) on the part of the Police & Prosecution, are not matters for the public to resolve. Tragic isn't it?


They all get to sweep this under the carpet. I suggest that anyone who is really concerned about this should subscribe to Private Eye and read, every two weeks, about the eye watering waste of public funds, and abuses of process happening all the time.

I know that in this particular case, we are talking about the death of a fellow pilot, but the same scandals that keep that from being addressed, keep everything else under wraps as well.


If you don't like the fact that the Judge was not able to consder the evidence, then complain to your MP, that's how the system is supposed to allay your fears. An independent judiciary however, must (they say) be protected from political interference. So your MP can't change what a Judge decides to do or not do. You don't get to vote for Judges, only Judges do.


On a local level, even if everyone in your village, town, county, decided that they wanted stronger sentencing for offenders, you can't get that. The courts are independent of the elected representatives of the people. Remember the people? Those who suffer at the hands of criminals. Those people who know what they want to see happen to the bad guys.

You can lobby your local Councillor or MP, (who can't do anything about it) but whatever you do, don't try to lobby a Magistrate, Sheriff or JP. That's a different offence entirely.

The independent (there's that word again) judiciary, are protected from your interference, by law.

On the other side of the Atlantic, there is a big country with plenty problems of it's own, but they do get some things right. Particularly the process of voting for Judges. Where a court is not dishing out the sentences that a community wants to see, the voters have a chance to make their displeasure felt.

With the passage of time, this event will be consigned to a false history, like many others.

He died because his parachute failed to open.
The police helicopter in Glasgow crashed because it ran out of fuel.
ZD576 hit the ground because the were flying too low.
XV230 crashed because it caught fire.
Titanic sank because it hit an Iceberg.
The American civil war was about slavery.

Time passes, most people forget, more people die.

That's just the way it is.


Tucumseh, the process is that the Prosecution lay out their case before the court, and the Defence do their best to refute the allegations. We simply cannot allow the public to be shouting from the sidelines.

The irrefutable truth of what they are shouting, is not, legally, relevant.

· Cost cutting at the expense of safety
· Deliberate concealment of the illegal nature of an activity
· Poor health and safety record
· Falsification of documentation

But yet, the crown has not put anyone from Mod in the firing line.

A blind man, running for a bus, could see that there are people, not jobs, who need to be on trial here. It's never going to happen.

Everyone seems content to blame the MoD, as if the building was making the decisions, when in fact they were made by people who are now living the good life, on serious pensions.

Just think of the legacy this leaves us with. Why bother doing it right? They never come after you anyway.

Air Police:-
The "parties" were just the bit players to the elephant in the room, the MOD. It is the MOD that has got away with it, yet again.

Its apologists will once again be congratulating themselves on a hand well played, and thus perpetuating the cover up.

As long as the cover up continues Military Airworthiness remains broken.

As long as it is broken avoidable accidents continue.

The more they continue then the needless deaths go on happening.

And all because of a hand well played...

airpolice

You made this point last week, and you are correct. It was also pointed out that those who initiated the quite conscious rundown of airworthiness management have been identified. That publication asks the question 'Who or what is MoD?' and a decision was taken to avoid naming anyone below 2 Star, for stated reasons. I think that correct, given the available evidence and imperative.

To name individuals, publishers tend to require written, irrefutable evidence (and I think it only right to apply this to pprune). Accompanied, ideally, by these people putting themselves on record in the media and, if possible, recordings of this. On Mull of Kintyre we had all of this evidence, so no problem.

In this case, some names have been released - read the Inquest reporting from 2014. But I would certainly never repeat them, because everyone knows MoD would never allow someone in the witness stand who actually knew anything. Yes, we heard from one chap who insisted - probably truthfully - he'd never been told not to over-tighten the Drogue Nut. But he was a diversion. We never heard from his seniors as to why he wasn't trained; not just in how to fit a nut, but in how the device worked in the first place. Or their seniors, who decided to change the seat maintenance policy without ensuring training and pubs were updated. Or their seniors, who issued a directive that pubs and training were not to updated, as it was a waste of money. Or their boss (suddenly, singular) who issued the policy to waste the money, that made paying for this work difficult. Very quickly you get back to the same people who were named first time around; and whose policies begat Nimrod, C-130, Sea King, Tornado and all the other avoidable deaths. These are not sh*t happens deaths. Their root causes were predictable, predicted, notified (often years in advance) and ignored. The names of those who ignored these direct, face-to-face warnings, backed up by written warnings, are very well known and already in the public domain.

To me, the original legal failure in this case was that of the CPS, who decided that MoD's admission was not sufficient grounds for prosecution. When it admitted serious offences in the SI report; repeated from previous cases? The prosecution of M-B was a diversionary side-show. Expect a few names from the HSE in a future Honours List!

Given MB have plead guilty, might there be scope for civil proceedings by the victims family?
A further ordeal on top of an already terrible ordeal for them, for sure, but no scope for the two sided in the trial being "hand in glove" .....

There would only be proceedings if the claim was contested. MBA's insurers will have factored this into their considerations.

EAP

Falcon900

An interesting proposition. I wonder if some legal minded contributors could say if this could go ahead given MoD admitted liability and settled with the family before the Inquest? My opinion of this is that MoD knew what was in the SI report and wanted it settled, before anyone realised the extent of the offences committed. I also think, at that time, MoD didn't believe for one minute that someone else would be blamed. Their guilt was so obvious and openly admitted, and the judge made it clear she was completely baffled by M-B's guilty plea.

Edit - EAP got in first, but it doesn't change my post.

Addressing the question of compensation, it is in England & Wales governed by legislation.

https://www.legislation.gov.uk/ukpga/1976/30/section/1A

Where a claim arises consequent upon a fatal accident caused by the fault of a third party or parties, there are three elements:

(1) Damages for "Bereavement" fixed by law. It is currently £12980 -- it may have been a lower sum in 2011.

(2) Funeral Expenses.

(3) Damages awarded to those financially dependent on the deceased at the date of his death. That is a slide rule exercise. A percentage of the diseased annual earnings is assumed to reflect the diseased's contribution to maintain those financially dependent upon him. Widows not in employment and children being obvious examples. The rule of thumb when I dealt with such cases, was two-thirds of the diseased's net income. That sum is then multiplied by a number set out in a table reflecting the diseased age, the dependent's age and the current yield on 10 year Gilts.

The hard and fast rule in England and Wales, is that fatal accidents are far cheaper for the insurers of the third party held negligently responsible than, for example, causing serious and permanent disability.

In a fatal accident case where any of the dependents are children, i.e. aged under 18, any settlement, including the sums apportioned for the children, has to be approved by the Court.

There can be only one settlement!

A settlement may not preclude the third party who has paid out, later seeking to recover a contribution from another party also considered responsible. There may, however be costs implications for bringing any separate claim. An added complication is that there are strict time limits for claiming a contribution. I may be wrong but I have a vague feeling it is (or was) 2 years.

Roving, the problem with this tragedy is that it represents merely the tip of an iceberg which has accounted for 74 deaths in military airworthiness related fatal accidents featured in this forum alone. Airworthiness for which the MOD by itself or via its subsidiary authority is responsible. The real death toll is probably many times higher. By presiding over this farrago of a trial, the judge allows the iceberg to carry on the carnage unencumbered. Given the renowned independence of the judiciary, frowned upon by airpolice (though I am not so convinced), surely she could have ordered a mistrial if she were beset by the doubts her remarks seem to imply?

Having read her remarks, as a professional do you find they raise more questions than they answer?