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-   -   Martin Baker to be prosecuted over death of Flt Lt. Sean Cunningham (https://www.pprune.org/military-aviation/584971-martin-baker-prosecuted-over-death-flt-lt-sean-cunningham.html)

Rigga 26th Jun 2018 20:21

Not too sure about how a book might be filled out sufficiently but a short (comedic flight safety) film might be more suitable.

pulse1 26th Jun 2018 21:03

Rigga, I suspect that tuc had tongue very much in cheek when he wrote

Someone should write a book.
In the Foreword to the book* which has been written, Tony Cable says it "will fascinate and anger you in equal measure". I am afraid that there is little room for humour.
* "Breaking of the Military Covenant" by David Hill. Proceeds to Help for Heroes I'm sure that a PM to tucumseh would provide more details of how to purchase it.

airsound 26th Jun 2018 21:28

Slight correction to that title, Pulse - it's 'Breaking the Military Covenant - Who Speaks for the Dead?'

Not sure if this is allowed, but I'll try, bearing in mind that the book is not for profit

https://cimg4.ibsrv.net/gimg/www.gmf...392894731c.jpg

Watch this space

airsound

Chugalug2 26th Jun 2018 22:28

Many here will be familiar with the MB series of ejector seats, even those as ancient as me. We all know that the scissor drogue shackle arrangement that tuc speaks of was common to all Marks from the Mk2 until the Mk10 in the Tornado (but not in the Hawk) introduced a different arrangement. Thus the MOD (and indeed the Air Ministry before it) was fully familiar with it, and RAF training has taught aircrew and ground engineers alike from the very first. For HSE to claim that the Mk10B drogue shackle arrangement in the Hawk was unique is bizarre. To further claim that evidence to the contrary in the form of a 1950's training video (from the original film) showing that very same arrangement and the sequence to be followed by servicing personnel is 'irrelevant' goes beyond bizarre and enters the dark world of MOD style tactics.

Sean Cunningham deserves better than this, we deserve better than this. The British Establishment seems to place its trust in sticking close to nurse for fear of finding something worse. It needs to know that nurse in this case is a killer and would do best to disown her and bring her to book before she kills yet more.

The book tuc mentions has indeed already been written, as disclosed by pulse1 and airsound. It is required reading for all who care about air safety, particularly UK Military Air Safety, which is in dire need of reform. At the moment it is a dysfunctional and broken system.

Chugalug2 25th Jun 2021 21:54

Well, here we are three years later (-1Hr) and in addition to the excellent book mentioned above by airsound is this one, again by David Hill :-


now in its 4th revision (June 2021) and available in Kindle form for a mere £2.99, as well as a paperback edition, another bargain at £6.99. As ever, all proceeds go to charity. David Hill adds this important revision to his other three books; Their Greatest Disgrace, Breaking The Military Covenant, and The Inconvenient Truth. No-one now can offer the excuse we were never told about that. We have been now, and as aviators it concerns us all....

https://cimg1.ibsrv.net/gimg/pprune....b2077d4230.jpg




DODGYOLDFART 28th Jun 2021 21:38

Red 5 - Got it today and must admit I am seriously impressed with the book and David Hill the author. Well researched and despite the various and somewhat complex technical issues involved it is presented in such a way that makes the facts jump off the page. Extremely well done David.

DOF

oldmansquipper 29th Jun 2021 18:51

An excellent book. Several ‘agencies’ should hang their heads in shame….(IMHO)

Is David still considered Mr Vexatious and on the Whitehall naughty step? Perhaps Tecumseh would know.

Jackonicko 29th Jun 2021 20:18


Originally Posted by langleybaston (Post 9521140)
Am I alone in being a little uneasy about this prosecution? Very difficult to put into words.

Here we have a magnificent world leading British company of undoubted excellence to go through the wringer. As I read the BBC, this is not manslaughter or criminal negligence. We are not talking about a dodgy operation running fun-fair rides, or operating unsafe ferries.

I suppose the most favourable outcome now would be for the fine detail of the problem/ cause to be understood and acted on [although we would hope that was done days after the tragedy], and that any fine was transferred without delay to the victim's family. Any senior employee seen to be negligent should be dealt with appropriately.

Please don't shoot the messenger, I have never sat in a bang seat, but I do grow weary of this liitigious society where every accident has a blame to be attached.

I have sat in bang seats, and share your unease, LB.

tucumseh 30th Jun 2021 05:59

Like most posts on this thread, LB's was made before it was known that MoD concealed the existence of at least twelve RAF training films, imparting the information Martin-Baker were accused of not providing. Nor was it widely appreciated that the Judge, Mrs Justice Carr, actually named in court one MoD recipient. But she had to accept Martin-Baker's guilty plea. (The book explains the process whereby he signed for the information, and it was disseminated within MoD).

The company did not commit manslaughter or criminal negligence. But a prima facie case exists that MoD personnel did, by issuing instructions to technicians NOT to follow Martin-Baker's information, or the technical training provided by the RAF.

The fine detail of the problem was understood, and was dealt with twice in the training films. Also, in the technical publications and training provided by Martin-Baker (until MoD cancelled the contract in 1983). After the accident, MoD even issued a directive that Martin-Baker's information was STILL NOT to be implemented.

In 2018 Jonathan Bayliss was killed at RAF Valley. TWELVE factors in the Cunningham case were repeated. MoD had assured the Coroner in 2014 that they were being, or had been, acted upon. It lied. A recurring theme. And not forgetting that the Cunningham accident was itself a recurrence, repeating the failure that killed Simon Burgess - failure to conduct disturbed systems testing.

And yes OMS, you're regarded as vexatious if you ask questions about this! By both MoD and the legal establishment.

dctyke 30th Jun 2021 09:07

Sadly ironic that when we had unit seat bays anyone attempting similar sort of work on a installed seat would have most probably faced a tech charge. It most definitely would not be sanctioned. We had a harrier gr7 sat on the ground in the USA for nearly a week so a seat team could come out to change an item that was a much simpler task.

Would like to see the risk register for the removal of seat servicing and support at unit level.


RetiredBA/BY 30th Jun 2021 09:11

Got my copy yesterday, superb book, but what an incredible revelation of incompetence and downright dishonesty in both MOD and certain aspects of RAF training or lack of. On page 135 it reveals that only 2 aircrew of 40 questioned knew how to check the top latch was correctly engaged, unbelievable.. That , in my day certainly and should be now, , was one of the simplest but most vital checks on the seat, done carefully each time EVERY time.

Frightening, that training had fallen to this level.

My take is that the prosecution and conviction of MB was a miscarriage of justice.

Mandatory reading for anyone at all interested in this accident or ejection seats in general.

Bob Viking 30th Jun 2021 10:00

Retired BA/BY
 
Would it be possible for you to give us a bit more detail on the claim that so few aircrew knew how to correctly check the top latch?

That’s a hell of a claim and suggests that either I was the only one who used to teach it properly (which I know for a fact is not the case), that I myself was not teaching it properly (which I very much doubt is the case), that nobody pays any attention to ejection seat briefs (which I very much doubt) or that the author or reader is making incorrect assumptions.

I’m not suggesting that either you or the author are being slanderous in any way. I know you have a particular vested interest in ejection seat safety but I can assure you that in my 22 years of RAF service thus far, everyone I have ever met takes it as seriously as you do. So that claim seems a little off target to me.

The top latch in particular (I assume we are talking about the plunger) is one of the most vital checks and has always been stressed to pilots as such.

BV

longer ron 30th Jun 2021 10:12

Just to clarify though - that it was not the top latch in the XX177 accident.
On XX177 the scissors shackle had been overtightened which prevented the chute deploying.
The seat pan firing handle was suspected as not being pinned/checked/seated correctly which is what caused the seat to fire due to the SPFH being inadvertantly pulled out of its housing during after start checks.

Red Line Entry 30th Jun 2021 11:28

Bob,

Please - this is genuinely not an attempt to trip you up or embarrass you, but: would you mind, without looking it up, just articulating what you actually check for with the TLP?

tucumseh 30th Jun 2021 12:08

For those commenting before reading the book, the chapter in question is entitled 'A pattern of behaviour', and discusses the common factors between the Sean Cunningham, Mike Harland and Simon Burgess accidents.

The Top Latch Plunger issue relates to the Harland case, and the relevant extract is:

"The Top Latch Plunger, holding the seat in position until fired, had been incorrectly engaged. The assembly consists of a plunger element and a spring-loaded spigot running through its centre. (Figure 9). At the Inquest, on 19 October 2010, the pilot confirmed aircrew were expected to check this locking mechanism during pre-flight checks. But, he understood it was only necessary to ensure the spigot was correctly aligned. That, he and 40 other civilian and military Tornado aircrew he had canvassed did not know to also check the end of the plunger was flush with its housing. Only two people he asked knew this. But two is enough to indicate the correct instructions were provided by Martin-Baker. (In the same way groundcrew from Lossiemouth and Coningsby knew how to fit the Drogue Shackle nut correctly)".

So, if questioning the statement, might I suggest you speak to the pilot who gave evidence under oath.

The similarity with the Cunningham case is that MoD claimed a lack of information. The 'Figure 9' referred to reproduces a sectioned diagram of the assembly, provided by Martin Baker to MoD. It shows the "correct (plunger fully home)" plunger position, and an "incorrect (plunger not fully home)" position. BV, you may even have used it when training aircrew.

As with the Cunningham case, the book merely reproduces the information MoD says it does not have - sourced directly from MoD documents.

This repeats Chinook ZD576, Nimrod XV230, Hercules XV179, Sea Kings ASaC Mk7, and so on and on.

I say again. MoD lied.

RetiredBA/BY 30th Jun 2021 12:25


Originally Posted by Bob Viking (Post 11070889)
Would it be possible for you to give us a bit more detail on the claim that so few aircrew knew how to correctly check the top latch?

That’s a hell of a claim and suggests that either I was the only one who used to teach it properly (which I know for a fact is not the case), that I myself was not teaching it properly (which I very much doubt is the case), that nobody pays any attention to ejection seat briefs (which I very much doubt) or that the author or reader is making incorrect assumptions.

I’m not suggesting that either you or the author are being slanderous in any way. I know you have a particular vested interest in ejection seat safety but I can assure you that in my 22 years of RAF service thus far, everyone I have ever met takes it as seriously as you do. So that claim seems a little off target to me.

The top latch in particular (I assume we are talking about the plunger) is one of the most vital checks and has always been stressed to pilots as such.

BV

BV If you properly read what I wrote you would not need to ask the question.

As I said, has been repeated here by Tecumseh , I was quoting what was written on p 135 of the book and I was quite astounded at that statement as I thought EVERY pilot who used ejection seats would correctly check the latch.

I suggest you read it.

Please note the comments on p33 re making the seat safe, pins being replaced AFTER the jet has come to a halt on chocks, engine shutdown, NOT as part of the after landing checks whilst the aircraft is moving.

The book states, not me, that the unsafe seat was not identified by no fewer than 7 individuals on 19 checks !

I seem to remember you were critical of me. advocating this procedure, as was done in my time on 2,3 and 4 seats, in an earlier post.

tucumseh 30th Jun 2021 15:23

Further to RetiredBA/BY's post, the other statements he correctly mentions (pins, unsafe seat not identified) were taken from MoD reports.

Bob, I do not doubt that the pilots you taught were attentive and took ejection seat safety seriously. But some very senior officers (and Civilians) demonstrably did not. See dctyke's post, above. If the regulations and instructions had been followed, this accident would not have happened. Who withdrew the wherewithal to satisfy those regulations and instructions? Again, dctyke nails it. What does the risk register (or hazard log, or impact assessment, or Safety Case) say about the decision to withdraw that capability? A rhetorical question - there was no Safety Case. Again, as admitted by MoD. Been there before.

Bob Viking 30th Jun 2021 19:54

Questions, questions.
 
RLE.

It would appear to be cheating now but I could tell you even when drunk that it is ‘spigot in line with the plunger, plunger in line with (or slightly recessed) the housing’. I also fully understand why that is important and I knew it before Mike Harland’s accident.

I would be genuinely shocked if 38/40 of my FJ colleagues honestly did not know that when questioned.

BA/BY

With regards to the pin in whilst taxying thing (I haven’t read the book and I’m not likely to, so quoting page numbers won’t help) I’ve never had a problem with it. Clearly some people have and the latest modification to the ejection seat firing handle housing has taken care of that.

Remember that lots of things went wrong for Sean and I’m not going to get drawn into any public conversations about the incident.

Please don’t think for one second that ejection seat safety is not taken very seriously nowadays. I can assure you it always has been on every unit that I have served on in three different Air Forces.

BV

dctyke 30th Jun 2021 20:17

When I was a sqn wpns tm I went through mandatory cockpit ejection seat safety certification check individually with all the aircrew once a year. One of the most emphasised of those checks was the top latch plunger.

Bob Viking 30th Jun 2021 20:24

Dctyke
 
That is still done which is why I am a little sceptical about such a claim.

BV

tucumseh 1st Jul 2021 06:06

Bob Viking / dctyke

What you're actually highlighting and confirming is that, despite correct information and training being provided, initially by Martin-Baker and then MoD/RAF, poor practices were allowed to develop, and were perpetuated by savings at the expense of safety. (The Nimrod Review in a nutshell). Thank you for that support.

I cannot speak for Bob's case, except to reiterate what was claimed at the Inquest. But the excellent training dctyke was obviously given became impossible to implement due to these cuts. In this case, the demise of seat bays combined with Engineering Authorities issuing illegal Routine Technical Instructions. Who met their legal and moral obligations by reporting these violations? To whom, and what was their reaction?

For example, few, if any, at Scampton or Valley would understand that an RTI was strictly prohibited in this case. But they would all know, intuitively, that something was very wrong. Any trained fitter, of any trade, would know not to torque the drogue shackle nut. (Quite apart from the fact Martin-Baker's instructions said DO NOT TORQUE). So why the hell instruct maintainers to do it? And why (apparently) did no-one go back to the Issuing Authority and say THIS IS BOLLOCKS, DID YOU MISS YOUR FIRST DAY'S TRAINING? As the book says, this is akin to a prospective pilot's first lecture on lift.

The Service Inquiry made the ludicrous claim that no basic engineering principle had been breached. Here's one... The effect of friction. That one claim should, in my opinion, prompt the Chief Engineer to launch a review of engineering training, and for the Convening Authority to reconvene the SI, under a trained engineer. Not to mention it is even more exculpatory evidence in the persecution of Martin-Baker.

Despite your reluctance to read the book it Bob, it is the only place you'll find details of how to avoid recurrence, which is something that anyone in the Services and MoD should, I believe, be keen to learn. However, I know the MAA and legal establishment disagree. But I also know from your posts I'm not a lone voice, another claim MoD has made!

Chugalug2 1st Jul 2021 07:21

BV :-

I haven’t read the book and I’m not likely to, so quoting page numbers won’t help
Bob, I find your rather dismissive attitude to David Hill's book Red 5 surprising and very much out of character. Presumably it isn't the cost of buying either the Kindle or Paperback editions as both are at a minimal price, and whatever proceeds there are go to charity. I would not have expected a closing of mind from someone who has always been a voice of moderation and authority on this forum. David Hill writes from the knowledge of how the system is supposed to work, how it used to work, but how it stopped working and why. He has been at pain to emphasise that it was deliberately subverted from the very top and, despite the professionalism of those like yourself who strive to maintain standards behind the Station Gates, once dealt the savage cuts in finance and experienced manpower the inevitable spread of unairworthiness throughout the fleets led to the numerous airworthiness related fatal accidents featured in this forum, including of course Sean Cunningham's.

This revised edition is simply the latest offering from him, but all his books are authoritative and based on evidence. He is not about attacking the RAF, or rather what I would call the "real" RAF, ie that which operates from behind those same Station Gates, but against those VSOs that perpetrated this crisis in Air Safety and those who have attempted to cover it up ever since. It cost us the Air Cadet gliders, now reduced to a shadow of their former selves, and our Maritime Patrol capability, again only now being rebuilt at long last. It has cost us losses in life, material, and Air Power. Those like you who serve in the RAF are naturally reluctant to accept that, but all the more reason to read what David Hill says with an open mind. Then decry him if you must, but in all fairness read this book first!

dervish 1st Jul 2021 07:57

Some excellent posts here. I share chug's view and that of others. This book is required reading.
I hope the author doesn't mind, but this passage from page 70 stands out....

"Why was MoD signing a report arising from a British Aerospace query? Because Martin-Baker had correctly notified MoD. This is precisely the kind of empirical evidence required by investigators, and again indicative of the lack of depth of all investigations. Martin-Baker were accused of not advising MoD of the issues addressed by this investigation. MoD signed the report. Q.E.D."

That leaves me utterly speechless at the prosecution's gall and Martin-Baker's guilty plea, and despite producing the evidence proving them innocent of the charge, the author doesn't hold back from criticizing them. Their plea, to avoid upsetting MoD (the author directly quotes their lawyers), defeats justice and encourages recurrence. But the really interesting part is towards the end, The HSE investigator should be in the dock. I can't understand why the judge was happy being lied to.

This is a work of major importance. BZ Mr Hill.

Martin

RetiredBA/BY 1st Jul 2021 08:55

[QUOTE=Bob Viking;11071126]RLE.



BA/BY

With regards to the pin in whilst taxying thing (I haven’t read the book and I’m not likely to, so quoting page numbers won’t help) I’ve never had a problem with it. Clearly some people have and the latest modification to the ejection seat firing handle housing has taken care of that.

Absolutely incredible that someone like yourself is not reading every word of this excellent book. You might just, might, learn something to your advantage, particularly as you are flying the same type, seat.

So you have no problem inserting pins whilst taxi-ing. Yet. BA never had a gear pin problem till their 787 incident at LHR two weeks ago, very expensive but very fortunately without injury. Their procedures WILL no doubt change after the AAIB conclude their investigations.

I am still at a total loss as to why you guys are installing pins whilst taxiing when such a procedure was an absolute no no, for obvious reasons in the interest of safety as described on p33 of the book, in the MUCH bigger RAF during my time. We were not amateurs and I would argue to any court etc. anywhere, that if our procedures had been practiced there is very good chance that this accident would not have occurred

Apart from essential actions for after landing the only place for eyes is outside the cockpit, particularly if taxiing in a formation. Leave the seat pins til shutdown, when you can give it your full and complete attention and a careful visual check, each time every time.

Buying the book may just be one of your best purchases !

( and just to be clear, I was a. RAF standards QFI and an ejectee, so have a close interest in and some knowledge and experience of these matters)

Bob Viking 1st Jul 2021 10:51

BA/BY
 
I know and respect your experience and I’m not trying to pick a fight.

If we’re going to play the willy waving game though I am a CURRENT Hawk QFI with very nearly 3000 hours on Hawks (T1/T2/115/165/166) and have at various times been a standards QFI as well in three different Air Forces so I am hardly an amateur. I do not have direct experience of ejecting though so you definitely trump me there.

Please remember that the report is discussing the Hawk T1 and its ejection seat. The Hawk I currently fly has a much updated seat that does not use the mechanical scissor shackle. The seat pan handle modification also makes it impossible to install the pin in the wrong place.

I know you feel very strongly about installing a pin whilst taxying because of the procedures that were in place when you were flying on bang seats. However, vacating the runway and stopping (that is the current recommended procedure) to install the pin is not inherently unsafe. In fact I would argue that the sooner you can make the seat safe, the better.

I know we can dream up scenarios where a ground ejection during taxy back to dispersal is necessary but personally I would rather take my chances with vacating the aircraft manually once I am at safe taxy speed.

I know we will never agree on this but the current procedures were not dreamed up on a whim and have been subject to extraordinary levels of scrutiny by people with a lot of experience and approved by individuals who would be required to represent themselves in court.

BV

tucumseh 1st Jul 2021 14:08


Originally Posted by Bob Viking (Post 11071467)

The Hawk I currently fly has a much updated seat that does not use the mechanical scissor shackle. The seat pan handle modification also makes it impossible to install the pin in the wrong place.

BV


I assume you realise that the existence of the gas shackle is one of the many pieces of evidence that demonstrated MoD and the Health and Safety Executive lied to the court? The HSE claimed Martin-Baker had no understanding of the risk, yet they had designed it out with the gas shackle. We're still waiting to hear from MoD precisely how the risk could remain tolerable and ALARP after 1983, when the decision was made not to fit the gas shackle in Hawk, but put it in (e.g.) Tornado.

Also, we await news of why MoD refused so many times to embody the firing handle shroud.

It is indeed gratifying to see a current pilot so willing to counter MoD and HSE's evidence to the Judge that these two issues were irrelevant, as they were completely divorced from the risks of incorrect strap routing and an over-tight shackle nut and bolt. You would have made an excellent Defence witness, as I suspect you would also have been able to counter the HSE's claim to the Judge that the Mk10 seat was the ONLY one to ever have a scissor shackle. MoD did not demur. But I suspect your career would have suffered!

RetiredBA/BY 2nd Jul 2021 10:16


Originally Posted by Bob Viking (Post 11071467)
I know and respect your experience and I’m not trying to pick a fight.

If we’re going to play the willy waving game though I am a CURRENT Hawk QFI with very nearly 3000 hours on Hawks (T1/T2/115/165/166) and have at various times been a standards QFI as well in three different Air Forces so I am hardly an amateur. I do not have direct experience of ejecting though so you definitely trump me there.

Please remember that the report is discussing the Hawk T1 and its ejection seat. The Hawk I currently fly has a much updated seat that does not use the mechanical scissor shackle. The seat pan handle modification also makes it impossible to install the pin in the wrong place.

I know you feel very strongly about installing a pin whilst taxying because of the procedures that were in place when you were flying on bang seats. However, vacating the runway and stopping (that is the current recommended procedure) to install the pin is not inherently unsafe. In fact I would argue that the sooner you can make the seat safe, the better.

I know we can dream up scenarios where a ground ejection during taxy back to dispersal is necessary but personally I would rather take my chances with vacating the aircraft manually once I am at safe taxy speed.

I know we will never agree on this but the current procedures were not dreamed up on a whim and have been subject to extraordinary levels of scrutiny by people with a lot of experience and approved by individuals who would be required to represent themselves in court.

BV

No willy waving on my part. The point I was making is that I am not an “ armchair quarter back”. You may know, others may not.

If the current SOP is to clear the runway, STOP, and then replace the pins I see no issue there at all, seems perfectly safe and reasonable.

However, if the likely procedure ( inserting pin by feel at 50 Knots on a formation roll out) as suggested in 1.4.2.22 in the service enquiry WAS done, that is totally different and I can think of NO reason for such premature action.I have my views on that based on what was practiced, totally different, during my 12 years of ejection seat occupancy and during which I was the refresher course instructor of several very influential and senior pilots including commandant ( des) of CFS.

None did anything remotely like that.

I rest my case.

pulse1 2nd Jul 2021 11:22


I know we will never agree on this but the current procedures were not dreamed up on a whim and have been subject to extraordinary levels of scrutiny by people with a lot of experience and approved by individuals who would be required to represent themselves in court.
I am nearly through this excellent book and one of the main points of it seems to be that, above a certain rank, the responsible individuals do not have to represent themselves in court. Their involvement is frequently covered up by omissions and lies. The farce of a trial of Martin Baker is a classic example.

The book also exposes the truth that many safety issues are not "subject to extraordinary levels of scrutiny by people with s lot of experience. It appears that we cannot afford them any more.

biscuit74 2nd Jul 2021 12:29


Originally Posted by pulse1 (Post 11072044)
I am nearly through this excellent book and one of the main points of it seems to be that, above a certain rank, the responsible individuals do not have to represent themselves in court. Their involvement is frequently covered up by omissions and lies. The farce of a trial of Martin Baker is a classic example.

The book also exposes the truth that many safety issues are not "subject to extraordinary levels of scrutiny by people with s lot of experience. It appears that we cannot afford them any more.

The idea that the VSOs responsible do not willingly come to court to explain their policies and actions seems extraordinary. Surely if they are truly leaders they should be be proud of what they do and what they stand for, happy to defend their behaviours. To do otherwise lets the whole organisation down, doesn't it? Certainly not much of a match with the blurbs on their website.

'Cannot afford them' (experience safety people.) Really? That is back to the old saying " If you think safety is expensive, try having an accident."

Double Hush 2nd Jul 2021 12:32

tucemseh,

"Also, we await news of why MoD refused so many times to embody the firing handle shroud."

Back in the day, as an 'end user' I was involved with some trials for potential MODs to the seat after the Sean Cunningham accident. The revised SPFH 'faceplate' was a no-brainer. The shroud was more nuanced. On the Hawk T2, the SPFH is angled forward quite markedy and the proposed shroud denied visual confirmation of the SPFH safety pin status. The only way to check the pin and therefore seat status with the shroud fitted, either sat in the seat or looking in from outside, was to leverage the handle back, quite forcibly. Not a good move if the seat wasn't safe. That problem prevented the immediate fitting of the shroud to the seat in the T2. Whether that is still the case, I cannot say.

BTW, I have ordered the book. I just need Covid restrictions to be relaxed so I can return to Blighty and collect!

tucumseh 2nd Jul 2021 13:19

Double Hush

Many thanks. Apologies if I didn't make it clear, but the 'many times' I mentioned were in the 1980s, at the same time the gas shackle mod was rejected. After the accident, MoD and the HSE claimed that MoD initiated the mod/design as result of Sean 's death. Nothing could be further from the truth.

In 2016, the HSE then argued in court that if it could be shown a modification to the handle could have prevented ejection, then Martin-Baker were guilty of negligence for not having taken such action. This overlooked that Martin-Baker HAD taken action. This wasn't the first or last time the HSE claimed the company could set about modifying aircraft without a by your leave. At no time did MoD demur, so these outright lies became accepted fact, and were later repeated by the BBC in an episode of 'Defenders UK', in which the HSE lied again. The HSE and BBC (and Judge) were in possession of the facts before any of these claims were made. They weren't errors, they were blatant lies.

tucumseh 2nd Jul 2021 13:32


Originally Posted by biscuit74 (Post 11072065)
The idea that the VSOs responsible do not willingly come to court to explain their policies and actions seems extraordinary. Surely if they are truly leaders they should be be proud of what they do and what they stand for, happy to defend their behaviours. To do otherwise lets the whole organisation down, doesn't it? Certainly not much of a match with the blurbs on their website.

Those familiar with the Mull of Kintyre case will recall that MoD successfully argued a legal point that if the authors of 'evidence' or claims were not in court, then their work could not be discussed. MoD then prohibited the very senior officers involved (Wratten, Day, Graydon, etc.) from appearing at the Fatal Accident Inquiry. Some years later, Wratten claimed to Jeremy Paxman on Newsnight that Sheriff Sir Stephen Young 'rejected the option of calling my colleagues and I to give evidence. One has to ask why (he) pursued such a course of action'.

POBJOY 2nd Jul 2021 16:31

Shackle use
 
Having been a user of shackles since my ATC gliding days (and subsequent marine use) I awaited the 'book' with keen interest to see how this simple 'connecter' fitted in with a high tech escape system.
The answer was simple there was a requirement to connect a rope type end to a metal fitting.(in gliding usually to a weak link assembly) (in marine use a rope to a chain). In both cases the 'pin' is load bearing and the nut stops the pin working loose and falling out. Frequently the pins have 'eyes' which can be wire locked rather than a nut. In both cases shackle deformity can occur when overtightened (mainly due to thread wear). In a case where a shackle gets used on to a more technical fitting and a constant gap must be retained it is common practice to use a internal pin sleeve or spacer that prevents inadvertent gap closure. Was / is there a reason this is not common practice on the seat application or was the requirement for a new pin and nut deemed a reasonable alternative. On the basis of cost and the low number of times this was required it seems incredible that anything else was even considered for such an important component.

tucumseh 2nd Jul 2021 17:58

Pobjoy

Your question was asked and debated here when the SI report became available. As Martin-Baker chose not to defend themselves (in order to protect MoD) there was no opportunity to ask. I’m sure it would have come up in court during what was to have been a six-week trial.

So, all that can be said (unless someone involved decades ago wants to come forward) is that the shackle bolt and nut arrangement was deemed to be the engineering design solution, and this was accepted by MoD. The type of bolt changed in the Mk9 seat, but the fitting instruction to MoD remained the same. ‘Tighten the nut until contact is made with the Drogue Shackle. Do not torque’.

This is the information Martin-Baker were fined £1.1M for not providing. MoD’s APs and Martin-Baker manuals from the 50s - 90s containing it were provided to the court and HSE. So too the RAF training films clearly showing the final test that was omitted. So too witness evidence from the head of Tech Pubs in MoD. The HSE simply told the Judge the films were ‘irrelevant’, and flatly denied the existence of the APs and manuals that were provided to both it and the Judge.

Following these instructions would prevent over-tightening and deformity of the shackle. Instead, the nut was over-tightened to such a degree the bolt was bent and new thread cut.

The question then is why, after the accident, did MoD re-issue its instruction to torque the nut to 50 lbf-in; yet again completely ignoring the instructions from Martin-Baker.

Of course, the main question is why in situ servicing was being carried out when the manuals and APs unambiguously said ‘Remove seat from aircraft’. This meant a false declaration was made that the seat was serviceable, because its serviceability could not be verified. Someone gambled when issuing the order not to follow Martin-Baker’s instructions. He lost, and Sean Cunningham died. As dctyke said earlier, we'd all love to see the risk assessment and justification.

Bob Viking 2nd Jul 2021 19:17

The Book
 
I have obviously been too dismissive of the book in question. That was not actually my intention.

I just meant I’m not in a position to read it right now. I’m sure it is a good read and a valuable tome.

I should also point out I haven’t flown the Hawk T1 for over ten years so I am not so concerned by T1 procedures.

The Hawk T2, with the SPFH shroud and the pins caption along with the gas system, addresses most of the issues being discussed here.

It is also worth remembering I am an operator not a policy man and in-depth discussions of airworthiness are not my area of expertise. I can assure you though that if I was concerned about the safety of my aircraft I would not strap into it. Thus far that has not been a problem.

BV

POBJOY 2nd Jul 2021 19:46

TUC Thanks for that, I assume that 'normal' or good practice would require a new nut and bolt fitted as directed and then checked for free movement. hardly a difficult operation and seemingly in the general scheme of things not expensive for what it does. I can see that in place seat servicing would be a real loss of good practice, and also a loss of a good opportunity for a loose article check at the same time. Considering the location of the only operating handle being low down in a restrictive place that itself makes a cogent inspection difficult in situ. With that mind set running the show it beggars belief that no one saw a big red light and flagged up what was quite obviously a dangerous practice for such a complex piece of safety equipment. No wonder they b..... up the glider fleet.

Chugalug2 2nd Jul 2021 20:56

BV :-

It is also worth remembering I am an operator not a policy man and in-depth discussions of airworthiness are not my area of expertise. I can assure you though that if I was concerned about the safety of my aircraft I would not strap into it. Thus far that has not been a problem.
And there in a nutshell is the problem. Let me add immediately that I shared that same attitude back when. The difference is that I was fortunate to have served when airworthiness was run by the experts that have since been replaced by placemen, and under an RAF leadership that respected those experts and took their advice. I would further add that it was only after I retired that I learned about airworthiness and how the lack of it in UK Military Aviation has caused very many deaths and goes on doing so. I learned about it here, in this very forum. I learned about it from tucumseh and other experienced engineers who have testified here about the monstrous attack on UK Military Air Safety by RAF VSOs and of the cover up of their actions since by other RAF VSOs. So you are not alone by any means Bob.

However, the difference is that my good fortune meant that airworthiness related accidents were few and when they happened immediate remedial action was taken. The best example I can think of was the grounding of the Hastings fleet (some 80 aircraft around the world) following the crash of Hastings TG577 after take off from Abingdon that killed all 41 on board. The failure was discovered by the BoI, and subsequent checks made immediately resulted in the fleet grounded wherever they were. Because proper records had been kept airworthiness was regained slowly as rectification teams completed a complex repair including of course the two bolts that had failed (yes bolts again!). Still the penny didn't drop and I thought of it in terms of serviceability with no inkling of the difference with airworthiness. Civil aviation is no different, I spent more years with the airlines than with the RAF and still blissfully ignorant. If anyone thought about it at all, airworthiness was for the boffins and 'policy makers' as you call them. Fine if they are up to the job and not undermining it to make savings at the cost of safety!

I would respectfully suggest that you start worrying now about the safety of the aircraft you strap into and read Red5 ASAP!

tucumseh 3rd Jul 2021 05:44


Originally Posted by POBJOY (Post 11072253)
TUC Thanks for that, I assume that 'normal' or good practice would require a new nut and bolt fitted as directed and then checked for free movement. hardly a difficult operation and seemingly in the general scheme of things not expensive for what it does. I can see that in place seat servicing would be a real loss of good practice, and also a loss of a good opportunity for a loose article check at the same time. Considering the location of the only operating handle being low down in a restrictive place that itself makes a cogent inspection difficult in situ. With that mind set running the show it beggars belief that no one saw a big red light and flagged up what was quite obviously a dangerous practice for such a complex piece of safety equipment. No wonder they b..... up the glider fleet.

There's a few separate issues there.

Yes, a new nut and bolt is required every time the Drogue Shackle assembly is dismantled. MoD's report did not address this, and the Routine Technical Instruction being followed at the time does not mention it. The proper assembly instructions (not the illegal RTI) say it is to be assembled in the parachute bay as part of the duplex drogue assembly, which is later fitted to the seat in the seat bay. At that point any jamming or resistance would be obvious, as two checks are required to ensure the shackles can freely disengage. AND THEN ARE NOT TO BE DISTURBED. If they are, then you start again. Yep, it's hassle, but its an escape system that is only required to work once. If you get it wrong, someone dies. But it appears someone spotted an opportunity to save money by eliminating that hassle, without thinking through the impact. I cannot speak for Martin-Baker, but I understand they expressed grave concern at this not-so-cunning plan. So too did MoD armourers. But there's a certain type of person in MoD who sees this as the company being bolshie and awkward, that MoD knows best. Nope, they're satisfying legal obligations.

A free movement check is carried out by pilots, but it gives false confidence. The shackle lugs can be pinched by over-tightening which (as illustrated by the SI in an image of the XX177 shackle), but when this happens the lug faces are no longer parallel. This can allow free movement at the bolt, but not at the ends of the lugs. The effect is variable, and in this case the SI calculated a speed of 50kts would be required to overcome this resistance. It follows that it is likely the problem had occurred before, but only manifested itself when the seat was required at the extreme of its design envelope. (Zero-Zero). Hence, the instruction that the nut just touches the shackle when attached. That eliminates any problems caused by slight tolerance differences in bolt lengths and lug gap.

The handle issue was addressed very well by the SI, who confirmed that the seat height mechanism was required to be motored to the top after use, to allow easier visibility of the handle/pin. However, it reported that the Red Arrows maintainers had been instructed to leave it as is; the implication being this was to shave seconds off a start-up regime, which the Panel said was shorter than normal for other Hawks. I know nothing about Hawk operations, so cannot comment.

My last comment actually highlights one of the main errors made by the HSE and Judge (and MoD in general). I've never been in or worked on a Hawk. But that doesn't stop me understanding basic fitting practices taught when a sprog. Or prevent me from reading and understanding the manuals and APs (which are both excellent). The Judge rejected expert evidence from a highly qualified mechanical engineer on the basis he was not an aviation engineer. As you rightly said Pobjoy, the basics apply to other domains, such as marine engineering. Similarly, the HSE denied that the scissor shackle assembly was in any other seat, because these other seats pre-dated Hawk. A 2 year old can destroy that logic, but.... Similarly, it said information relating to previous Marks of seat was irrelevant, because they were not Mk10s. The fact that the many parts of the design remained the same was also irrelevant - although in this case the HSE went further and denied the scissor shackle was in any other seat. The Judge confirmed it WAS, since 1952, but the HSE just ignored her and continued with its claims even after the trial. What am I saying? The HSE was incompetent, and actively misled the courts and family. MoD was complicit, as it knew this and said nothing.

Chugalug2 3rd Sep 2021 11:59

A fully revised Kindle version of Red 5 is now out containing new evidence dutifully ignored by those responsible for Military Air Safety. I can do no better than quote the blurb on the Amazon site :-


Revised and updated, September 2021. Includes and discusses new images and information from the investigation, which MoD and HSE withheld from the courts and family.
This is a story of unrelenting misconduct and injustice. Martin-Baker, designers of the world’s best escape system, were prosecuted for not providing information they had already supplied many times, but the Ministry of Defence instructed its engineers not to use. Bizarrely, the Judge named an MoD recipient in court. Applying this information would have saved Sean Cunningham’s life.
The Health and Safety Executive and Lincolnshire Police did not evaluate verbal, written and video evidence proving the allegation false. The Judge and Coroner were misled. This subversion of the judicial system has placed military aircrew, passengers and the public at greater risk.
Also discussed is post-trial misconduct by the HSE and BBC; linkages to the Shoreham Air Display accident, in which the Air Accidents Investigation Branch confirmed MoD had the information necessary to avoid the death of Sean Cunningham; and an analysis of the Service Inquiry report into the death of Corporal Jonathan Bayliss, passenger in a Red Arrows Hawk which crashed in March 2018; revealing twelve common factors with the death of Sean Cunningham.
All proceeds to charity.

Note, if you don't own a Kindle reader, you can still read Kindle books on your PC (other OS provided for also) by downloading the free Amazon App :-


Haraka 7th Sep 2021 17:50

Just now read the update on this on my Kindle.
I submit that it is worth reading as a part of this author's ongoing campaign over several years.
I would savour any qualified opinion on these cases cited..


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