PPRuNe Forums

PPRuNe Forums (https://www.pprune.org/)
-   Military Aviation (https://www.pprune.org/military-aviation-57/)
-   -   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)

Exrigger 6th Mar 2018 12:07


Edited to add. After the accident, M-B issued SIL704, which said 'flush', not one or 1.5 thread pitches. As MoD (specifically the Service Inquiry/MAA according to the evidence) required this, why has RA4266 not been updated? Is this just applicable to Mk10B seats? To the RAF only? To all stiffnut applications? As the CAA promulgated this SIL, the world and his dog must now be thoroughly confused.
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.

Engines 6th Mar 2018 12:56

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

EAP86 6th Mar 2018 13:58


Originally Posted by tucumseh (Post 10074586)
As the CAA promulgated this SIL,

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

tucumseh 6th Mar 2018 14:22

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.

Slow Biker 6th Mar 2018 16:24

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.

NutLoose 6th Mar 2018 17:19


A safety critical system was being taken apart every 50 hours. By itself, that should have raised massive warning fla
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.

oldmansquipper 6th Mar 2018 18:06

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....

Slow Biker 6th Mar 2018 18:09

OMS - Sorry.

oldmansquipper 6th Mar 2018 18:58


Originally Posted by Slow Biker (Post 10074968)
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?

Engines 6th Mar 2018 20:13

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

Chugalug2 6th Mar 2018 21:44

OMS:-

was that the "golden era" of which Tuc et al speak?
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!

oldmansquipper 6th Mar 2018 22:14

Thanks Chug.

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

OMS

airpolice 6th Mar 2018 23:13


Originally Posted by Chugalug2 (Post 10075171)
The scoundrels in this scandal were RAF VSOs. Let us keep our eyes on that particular ball!



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?

glad rag 6th Mar 2018 23:32

"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!!

tucumseh 7th Mar 2018 00:08

airpolice


...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'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


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!!
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.

Chugalug2 7th Mar 2018 08:05

airpolice:-


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

oldmansquipper 7th Mar 2018 11:16


Originally Posted by Chugalug2 (Post 10075514)
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:-

https://www.amazon.co.uk/Their-Great...=UTF8&qid=&sr=


and, as he added, more on its way!

Copy on birthday wish list. 😊

dragartist 7th Mar 2018 12:37


Originally Posted by oldmansquipper (Post 10075724)
Copy on birthday wish list. 😊

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

dragartist 7th Mar 2018 12:51


Originally Posted by oldmansquipper (Post 10075010)
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?

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.

oldmansquipper 7th Mar 2018 14:06


Originally Posted by dragartist (Post 10075835)
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...


All times are GMT. The time now is 01:03.


Copyright © 2024 MH Sub I, LLC dba Internet Brands. All rights reserved. Use of this site indicates your consent to the Terms of Use.