From the BBC :

http://www.bbc.co.uk/news/uk-42773834
I wonder how much this buffoon understands about ejector seats, or mechanical engineering in general, and how it can be that it took 20 years (at least) before this issue came to light. And how many successful deployments came in that time.

WHBM

Agreed. Importantly, because the SI report was not released until after the Inquest, the court only heard MoD's highly edited version of events. His words were unwise, and he should have at least added balance by pointing out MoD's offences, but he was serially misled. It looks like this issue of quality of design is what has been dropped by the HSE after discussions 'narrowed the issues' (i.e. being allowed to present independent evidence for the first time).

But I'd still have liked to have heard the head of Tech Pubs tear into the claim MB didn't send out the bulletin in 1990. He's been waiting since 27 October for the solicitors to take evidence. Having tracked him down, but gone no further, this was the indication something was going on.

For sure something is going on. The charges were watered down in order to prevent MoD being brought into the dock and quizzed on things such as safety cases.

DV

American stuff always has been 1 thread in safety, but in the RAF I was taught it was 1 1/2 theads, and it was hard changing over in my mind to the lesser standard when I had too.

Wow, I’ve become an apologist now.

This series of seats had numerous design issues. Some of these were communicated to some customers, but others were not.

I give no slack to the MoD when justified, MB deserve the same. Airworthiness directives and notifications are not something that can be lost due to MoD reorganisation. They are formally issued and tracked by the company with regulator oversight. The reason MB didn’t produce a copy was down to the fact it never existed then or any subsequent year. Worryingly, when evidence of damage was noted by MB during numerous post-accident ejection seat inspections they still didn’t warn the customers or issue an airworthiness note or directive. One must now question the use of MB to support accident investigations as they are neither honest or independent.

Feel free to throw as many stones at the MoD as you like as they have presented many rich targets. But in this case the Inquest, Coroner and prosecutors didn’t find a neatly bound and airworthy design, supported by carefully honed documents communicated to all with a robust feedback loop with a single guilty-looking end user ignoring all concerns and design changes. They found a company with a cavalier attitude with flawed internal safety management and a seat design the coroner called ‘utterly useless’. That company has now admitted its guilt at the eleventh hour, so why should we consider them innocent?

Did we get to learn about the Coroner's engineering and/or flying qualifications, or was he/she just another excitable heckler?

PDR

The trouble with ejection seats is one cannot demonstrate the required System Integration Readiness Level as quickly as most other parts of an aircraft design; not least because one hopes that in-use experience is rare. The design evolution is not a normal iterative process. And one iteration does not necessarily lead directly to the next.

This means the reporting a feedback loop of the Safety Management System must be robustly implemented. MoD more or less stopped this in June 1993. It had already issued instructions to curtail Fault Investigations and Technical Publication amendments in 1991-2. That is a significant timeframe here.

M-B stand accused of not sending a single Camera Ready Copy of a Technical Bulletin to the Seat Engineering Authority. In 1990, that was small office, probably one man and his dog. But at least it was a single point of contact. But with successive re-organisations, such centralised functions were shut down (reiterated by Haddon-Cave). So, which new stove-pipe did the 1990 seat EA bring his single CRC to? Probably not Hawk. Tornado perhaps? If only because it was the single biggest user. The claim by the SI was that MoD could not find the bulletin. Did they track down the 1990 EA and ask him? At the Inquest this somehow morphed into M-B did not provide it, but it seems this was more a misunderstanding and clumsy wording than an accusation. In fact, M-B's solicitors were so unconcerned they paid little heed to this aspect - which I don't think served their client very well.

Place your self in the seat EA's shoes. He gets a bulletin saying 'don't over-tighten the nut'. He perhaps speaks to CSDE, who laugh at him. 'Teaching armourers to suck eggs, no way we're sponsoring a tech pubs amendment, ATP would laugh at us. And the money's been chopped anyway'. So, the seat EA does not need to take the next step, informing the aircraft EA. RAFHS at Boscombe don't get a sniff. It's marked 'no further action', and stuck in an anonymous file.

Then ask when we stopped employing Technical Authors for the Topic 4s. Around 500 posts chopped, and it was contracted out - at precisely this time. Allied to that, we heard of poorly trained MoD maintainers. When those changes (cuts) were being made, the Training Needs Analysis should have been updated, to recognise the new, lower levels of expertise. In turn, the Pubs Authority (ATP) would say 'Pubs need to be updated to reflect the more detailed instructions needed for non-specialists who are now maintaining seats'. It wasn't just M-B who had to find a new way of conveying technical information to a dumbed-down MoD. The 'trainers of the trainers' had this precise problem in 1992-3 when seeking to work out how to have Chinook FADEC maintained. And the Director of Flight Safety let rip at the Chief Engineer and ACAS over it:
‘There is a gap in the present orders and procedures concerning the amendment of Air Publications. The problem lies with the question of what the tradesmen do in the meantime. Do they to work to and sign for an activity which is known to be wrong, or do they work outside the content of the maintenance document and thus be hostage to fortune should a problem occur?’

None of this has anything to do with Martin-Baker.


Yes they are. When D/MAP registry closed down, following the announcement that HQ Mods Committees were being disbanded, thousands of files were never seen again. This was right in the middle of a 5-year 'freeze', when only the most critical projects were allowed to proceed. (In November 1994 I took over the top priority Support Helicopter programme, which had been endorsed in January 1990, but absolutely no progress had been made due to this freeze. As soon as the freeze was lifted, it was under contract in 48 hours. The first thing was a 4-phase risk reduction exercise to stabilize the airworthiness baseline, as it had lapsed in that time). Now, did this happen on seats? Probably. And it was nothing to do with M-B.

Remind me someone please, what was the cause of the accident?

The failure in 2000, by MoD, to have the scissor shackle replaced by the gas operated type, when they knew there was a problem.

DV

A technician over-tightened a nut.

PDR

There is speculation here that the Red Arrows will in due course switch from the Hawk to the T-6C.

New aircraft for Red Arrows ? what are the options? | Combat Aircraft

The seat went off


SPHLC

Well, I'm glad mine did !

Top West, you ask a serious question.
Root cause?
The sequence of events:
The seat pan handle was operated - no one knows how or why. Speculation that the safety pin was not properly engaged and a strap had been passed through the yellow and black loop as young Cunningham moved about to settle into his seat and conduct his checks.
The seat fired.
The parachute failed to deploy. The cause being a bolt had been overtightened by an RAF technician. The bolt was quite critical. It should have not pinched the legs of the shackle together allowing it to swivel. The bolt was tightened such to show at least one and a half threads protruding from the nut. It had been tightened so tight to achieve this that it had cut a thread into the bolt. Poor design in that it was critical and should perhaps have been made fool proof. (A shoulder bolt or spacer tube to ensure the arms of the shackle were not pinched together.)
A simple check to ensure the shackle rotated about the bolt should probably have been wise. As this was essential to parachute deployment.
MB knew of the issue and had told other operators but apparently could find no evidence of having told their most “intelligent” customer.

Avoidable ? Yes. By design, by having appropriate training in place, by having appropriate documentation in place for maintenance, perhaps explaining the consequences of overtightening the bolt and knowledge of operation of the parachute deployment mechanism.

Oh and there being a Safety Case in place. The safety case would support the reasoned argument that the system posed no hazards to those involved in the maintenance or operation of the equipment. It would normally begin that the Designer is competent to design that type of equipment. It has been independently tested to ensure it meets the requirements specification. It has been maintained by competent people in line with a set of documented procedures. All to sub components are manufactured and sourced appropriately. Any hazards and incidents that come to light during use are properly investigated and addressed with lessons learned being promulgated.
So if it was known that overtightenng the bolt would prevent the parachute deploying that fact would be made known to the operators.

Yes, that's what I thought when I skimmed through the report - well, thought of spacer.
(Bas - ex marine eng)

Just a simple 'Feeler gauge' check for enough gap to ensure freedom of movement, if the bolts the wrong size then change it. Just don't clamp things together because the instructions tell you to.

How simple is it to have a properly engineered 'Gap' by feeler gauge, not all this 'Torque loading a bolt' so it's in 'Safety?' Just 'winding it up until the thread, or thread & a half shows through & clamping parts together as a result.

As I said much earlier, pilots used to 'Rackle the shackle in my day, to ensure that the shackle was really free.

Very recently (days, and too late), a report came to light showing MoD knew of various issues in 1999. This was concealed/withheld from Service Inquiry, Coroner, CPS, HSE and Police. The penny probably dropped that one MoD office had inadvertently released evidence that another sought to conceal, so the associated reports giving finer detail have not been released. (This has happened before, and is what sunk MoD on Mull of Kintyre). FoI requests are now rejected.

It is known that even if the shackle was free to move by hand, it could occasionally jam when under load. The design worked to the original aircrew weight spec, but not when it was changed to take account of heavier (male) and lighter (female) crew. This resulted in a modification to one seat variant, but not that fitted to Hawk. The question is why that mod was not adopted in Hawk. It is not as simple as a design flaw. It is more a case of an adequate design becoming less so when the spec is changed. This is routine, every day stuff to EAs and TAs in MoD; and industry.

This does not exonerate M-B over the claim not to have sent information to MoD in 1990 (demonstrably they informed BAeS, and it becomes a case of who was responsible then for initiating aircraft tech pubs amendments), but it does prove conclusively that MoD was wrong to claim it did not know in 2011. Legal authorities were misled by omission. Perjury is a possibility.

Why did M-B not use this report as evidence that MoD knew? We know the answer. Their solicitor's stated strategy of 'not upsetting MoD'. In my opinion, this makes all concerned complicit in future accidents that share this root cause (systemic airworthiness failings). We've been here before, too often.

Thank you. I found, through harrowing experience in one case and arguing in a political minefield in another, that defining the concise cause of the accident is the most demanding element of the inquiry. It's all very sad but it seems that the seat fired and everything else that happened only made matters worse.

On a personal note, I am exceptionally sad about the whole affair. I am the 664th of many thousands who now owe their lives to Martin Baker and I remember, as yesterday, the expression on the face of the Armourer who had serviced my seat as he presented me with the face blind handle as a souvenir.

Having previously been trained on the Gnat and Hunter, when I returned to Valley for a refresher course on the Hawk, I was taught ALWAYS to check visually that the seat firing handle was fully down when inserting the safety pin and that the seat and MDC pins shouldn't be re-inserted until the aircraft was stationary with the engine shut down on chocks - "It's a zero-zero bang seat and you might need it as a last resort on the ground".

But I read that people are re-inserting pins as part of the after landing checks - why? Particularly an inexperienced passenger fumbling about. I can't see how a pilot can visually check that the pin has been correctly inserted if he/she is looking where the aircraft is going whilst taxying.

Although the SOP I was taught might have prevented the seat firing handle being pulled inadvertently, the over-tightened scissor shackle would still have proved fatal for a zero-zero ejection with no time to use the manual separation procedure.

BEagle
 

We covered this several pages ago. Rightly or wrongly procedures have changed over the years.

Saying that “it was much better in my day and I would never have made that mistake” are fruitless.

What I can say is that after Sean’s untimely death it is far less likely to happen to anyone else.

Can we put it to bed now?!

BV