It is these words from the coroner which I believe have led to the HSE prosecution. I could be wrong but he was pretty clear in his assertion...

"Martin-Baker knew the parachute mechanism could jam if the nut and bolt were too tight as early as January 1990, the inquest was told.
The manufacturer warned some air forces but did not warn the MoD."

This comes from the BBC report of the coroner's inquest. Incidentally not too glowing praise for the RAF either...

http://www.bbc.co.uk/news/uk-england-lincolnshire-25943211

According to H-C the drawing up of a ‘Safety Case’, to identify, assess, and mitigate potentially catastrophic hazards before they could cause an accident, was mandated for military aircraft and other military platforms by regulations introduced in September 2002.

Quote:

---

I can recall confusion in PTs and it's perhaps not surprising that each ended up with a different SC approach and format.

---

I agree. Having seen the SCs for Nimrod and Tornado they are as different as chalk and cheese. With, in my opinion, the Nimrod SC having more substance and meaning.

DV

Customers were informed by MB Special Information Leaflet No. 704 in November 2011 and 704A in November 2013. Seeing as the accident happened on 8th November 2011 it is clear that the cause of the accident was known about, almost immediately.

DV

Thanks for the clarity, being pedantic, does anyone know what communication mechanism MB had previously used to inform the non MoD customers of the problems with the seat? Was there a previous SIL that went out but not to the MoD?

DV:-
House of Commons Hansard Written Answers for 10 Mar 2014 (pt 0002)


https://mail.google.com/mail/u/0/?ui...1&disp=safe&zw

https://mail.google.com/mail/u/0/?ui...2&disp=safe&zw

So working on that scenario, you could prosecute every manufacturer of any weapon system from Aircraft to a lowly bow and arrow, as you are putting persons in danger of getting shot, bombed, speared or generally killed, and I won't even mention the lead content of a round that far exceeds the legal limit for ingestion.

I believe all Mk10 equipped aircraft were grounded immediately after this accident, but soon after, the Tornado was cleared to fly. (different mechanism). The Hawks remained grounded.

In this case the duty of care "so far as is reasonably practicable" is discharged by ensuring that the customer/user to whom your product is sold has procedures and controls to mitigate that risk.

PDR

Key words - "contract deliverable". Key question - Was there a suitable and continuous contract in place? The funding for such contracts, as I've said many times, was chopped by 28% in three consecutive years, and the centralised management of this work stopped in June 1993. At the same time, the oversight committees were disbanded and the Agency contracts (paying specialist companies to collate and distribute such technical papers from Design Authorities) cancelled.

The admission the papers are "not held centrally" confirms what I've said. The question should be "Why not", because the regulations require them to be, and all procedures assume them to be.

edit: just removed an unnecessary bit.

The reality is that the RAF operated this aircraft/ejection seat combination for nearly 40 years before the accident occurred, and during that time there were successful ejections from RAF Hawks, so it seems unlikely that the failings were due to unfamiliarity or design flaws. Somewhere along those years personnel 'lost' their full understanding of operational and maintenance procedures. When, or if, changes were introduced processes should have been in place to review and understand revisions so that any re-training was effective and new requirements were safely applied.

Hi Engines, I disagree with your analysis at #26

I mentioned this on the original thread.

The Service Inquiry is into the "Accident involving Hawk XX177 on 8 Nov 11" that led to the death of Flt Lt Cunningham

The CAUSE must be the "inadvertent ejection due to displacement of the seat pan handle"

Why? Because the same event could have happened to a member of the ground crew earlier in the timeline. He would not have been strapped in
so the shackle would have had no bearing on his death or injury. Forgive my flippancy but Flt Lt Cunningham could have landed on the Families Day bouncy castle.

I'm on your side, and all the other who agreed with your analysis, but I believe the MAA got it right.

SirPeter....,


In this accident I am with ENGINES. If the sequence of events that you describe had taken place then the CAUSE of that 'accident' may well have been different. But it didn't so I don't believe you can ascribe a CAUSE based on something that didn't occur.


SS

SPHL,

Thanks for coming back and happy that you disagree - that's what a discussion thread is for. I think that in cases like this there will always be an element of policy and direction - often this is saying no more than 'this is how we are going to do things'. And this will be different across organisations.

In the case of MAA SI reports, I believe that the format currently adopted tends to make the reports less easily readable. This one was typical, with no list (that I could find) of the accident factors - you have to plough through the text to find them.

Hoever, I will try to justify my view of the factors. My reasoning goes like this:

1. The MAA definition of 'Cause' is "the event that led directly to the accident".
2. In my view, the 'accident' was the death of the pilot. He should have survived this ejection - the MAA report says so. Had he survived, this would not have been an accident, probably only an incident.
3. In my view, the 'event' that led directly to the pilot's death was the failure of the drogue shackle to operate correctly. Not, in my view, the inadvertent operation of the seat pan handle.

The reason I have contributed to this thread is the way the report treats the content and application of RTI/Hawk/59. It's my view that had this RTI not been issued in the form it was, the pilot would have survived. Despite the MoD having no safety case for the seat (required to validate the RTI), despite there apparently being no records of how 2 PTs, 22 Gp, 1710 NAS, MB and others discussed and decided on the RTI, the MAA assessed all this as merely an 'other factor'. From my own experience, i cannot understand how anyone would not recognise the significant safety risks posed by dismantling a vital part of the ejection seat every 50 flying hours. I honestly fail to understand why the MAA did not pick up on this as a major contributory factor.

However, the case is now going to proceed, and for my part, I intend to make this my final post on this thread until the verdict is in. Thank you to all those who have replied to my posts with such thoughtfulness and honesty.

I would finish by expressing my sincerest condolences to Flt Lt's Cunningham's family and friends.

Best Regards as ever to all those who serve their country,

Engines

Totally agree with you, it reminds me of the Pipers that had a Spar failure, they then decided you would need to inspect the bolt holes every I think 100 hours, it was found they were doing more damage to the spars of the fleet pulling bolts out that would normally never be removed, than the odd case of failure. So it was cancelled.

Nutloose. In a lighter vein - Very similar to the Tucano QRB cover plate over rotation issue late 90s?. Because the Quick Release Box was fitted `to the seat`as part of the SCH when in the aircraft, Weapons Techs (the plumbers) developed an `Instruction` (SI?) to check for over rotation on AF/BF. This consisted of instructions to "Try to turn the cover plate beyond the stop point...." Results? from 1 or 2 arising the failure rate (and u/s QRBs/Aircraft) increased rapidly until someone called off the gorillas!

"A I`m an armourer, B I`m an armourer...C etc. "

...the difference between armourers and bombs being that you can actually get *smart* bombs...

:E

PDR

I could get to "E"

Before I comment, I must declare an interest. Tomorrow, on 30 September, I will celebrate the 52nd anniversary of becoming the 664th pilot to save their life using a Martin Baker ejection seat. A year or so later, I attended a gala dinner at The Dorchester after Martin-Baker notched up their 1000th success. Not a single ejection, within the design limits of the seat had been unsuccessful. Subsequently, several thousand more, 7506 precisely, are here today because of the brilliance of Martin-Baker engineering. Writing to me in October 1964, Sir James Martin, Managing Director and Chief Designer said “as the person responsible for the design of all our various ejection seats, it naturally causes me great pleasure (to hear about your escape).” At the same time, Sir James extended a “hearty” invitation to have lunch and visit the works. It took me until the 50th anniversary year, 2014, to accept the invitation. Meantime, for the rest of my flying career, I happily entrusted my survival to Martin Baker seats. It is vital not to underestimate the psychological effect of knowing that you were flying with the world’s best and most reliable escape apparatus. Put simply, Martin Baker was a benchmark for engineering excellence and reliability. Visiting the factory in September 2014, it was impossible not to be impressed by the sheer dedication and attention to detail in every aspect of their Denham factory.

During my RAF career of nearly 35 years, I had the duty to investigate 2 high-profile aircraft accidents, one of which resulted in the death of 9 crew members, so I am fairly well acquainted with the investigation process and most of the other human consequences that such investigations inevitably yield. The aim of the accident investigation is to determine the cause and much mental effort is devoted to isolating the root cause of the accident from other factors which merely contributed to the accident. I expect that this inquiry team, together with its convening authority, would have been presented with a similar challenge. The trouble with aircraft accidents is that they often result from a sequence of events, none of which, in isolation would necessarily have caused the accident. The day that “Murphy’s Law” strikes the sequence of events, design failure, technical failure, maintenance error, human error etc, has been allowed to continue to a conclusion. It follows that, quite often, humans can spot things before they go wrong, interrupting the fatal chain before catastrophe strikes. Often, humans are unaware of the dangerous turn of events and so they do nothing. Very rarely, humans disregard the warning signs that their expertise and training should have equipped them to see. In this case, the inquiry will determine whether any personnel had been “negligent” and whether they should be held to blame for their action or inaction. Proving negligence is not straightforward for the living and, at least in my day, almost impossible for the deceased. Often, in the absence of categorical proof, sleeping dogs must be left to lie. This doesn’t, however, prevent lessons from being learned and procedures to prevent recurrence being enforced. Hopefully, before all this occurs, risk assessments will have identified most, but crucially never “all,” of what could go wrong.

I do not know very much about the “Military Aviation Authority” since this tri-service organisation replaced the Inspectorate of Flight Safety which used to be responsible for accident investigations in my day but I do not suppose that the principles of investigation are very much different. I am certain there will have been a meticulous inquiry in this case.

It is therefore somewhat surprising that the Health and Safety Executive should consider that military business falls within their judicial terms of reference. More fundamentally, I wonder what possible public interest there could be in rehearsing a very expensive inquiry and then failing to get a conviction (for fail they surely will for the reasons I have outlined above)? Quite what washing dirty laundry in public will do for morale is very hard to see and undermining the perceived integrity of life-saving systems in such a public way is surely not a sensible thing to do. If it is Flight Lieutenant Cunningham’s kin who are driving the prosecution, I hope they get what they want but I have to say, as one who is married to the widow of a victim of a notorious bit of flying and engineering negligence, I would have advised differently.

The court case will be expensive, time consuming and will, regardless of the result, undermine confidence in the good order and discipline of the service. It is unlikely to expose anything more of relevance that has not already been uncovered by the Inquiry.
For those of us who are dismayed (and very frightened) by the remorseless erosion of defence capability in recent years, it beggars belief that scarce human and financial resources should be diverted from our fighting posture.

More useful than smart4rses!

:)

Oh absolutely, no offence intended - just a target of opportunity as they say.

:E

PDR

With or without referring to the AP...?

:E

PDR

Further reflection on the drogue shackle bolt issue leads me to ask this of the airworthiness and safety experts here. Was it sufficient for MB to deal with the known potential for shackle pinching by issuing maintenance guidance alone, and not doing anything more fundamental (such as introducing a shouldered bolt, reshaping the components, or even issuing a torque setting) to mitigate the issue? If it could be shown that a comparatively simple physical modification would have removed the accident mechanism, then would MB be open to a charge of negligence for not having taken such action in the 20-odd years between the risk becoming known and Sean's death?

TW50, agree it's odd to see the HSE becoming so prominent at military aircraft accident sites, not that they have a perfect right to be there, but they do seem to turn up quite often these days. I think that Scampton turned out to be a bit of a perfect storm with the MAIB, Police and HSE all appearing (with the Coroner pulling some of the strings too). Does it need all of them? Does it really help the efficiency of the process especially when other aircrew could also be at risk from a technical fault?

I know that the AAIB have negotiated a national agreement with the 43 UK Police forces on protocols for aircraft accidents, surely something similar could be sorted out for military accidents? Whatever happens, it's still a bit odd that the HSE feel they need equal billing in all circumstances. Maybe this is part of their motivation?

EAP

Shirley that should be "F" ?

Easy Street

I’m afraid the answer is not simple. The contractual relationship, if any, between MoD and Martin Baker needs to be known. MoD is obliged to put in place a continuous contract to maintain the build standard (which is what you’re talking about). This hasn’t been policy since at least June 1993 and it was fragmented for a few years before that. A key part of that contract is the delegation of financial powers to a named individual at the company, authorising him to self-task safety tasks, in the certain knowledge the company will be paid. The aim, of course, is to get crucial information out there as soon as possible. If there is no contract, there will be no task, and today 99.999% of MoD staff will give you a blank look when you mention this.

I’m not convinced MB did not provide the technical information/advice to MoD. This aspect has not been investigated at all and a key event was MoD shutting down its central registry and agency contracts that dealt with all such documentation. At a stroke, it meant that the process was no longer managed as a full-time job by a few, but as a 5 minutes, once a month task by hundreds. Without training. We got a few days notice of these changes and a party of us descended on the old registry to retrieve files before they were destroyed, only to find no sign of life, or filing cabinets. And no instruction was issued to companies telling them of any new department or address.

The same contract is the vehicle for maintaining the Safety Case. The Mk10 ejection seat didn’t have one, which points to a breakdown in this contractual relationship, as well as serial offences by MoD staff, who MUST have made false declarations in airworthiness documentation. (The HSE knows this, and says there is nothing wrong with it. I disagree).

One could say there is a moral obligation on the company, but an oft-asked, and never answered question was – how long must they be expected to work without payment? For example, MoD is obliged to provide Sample (or “Hack”) equipment, and often specialist test equipment, to companies under the above contract; and pay for their maintenance. As a matter of policy, AMSO started to run this down in 1990. I well recall that on the day Maggie Thatcher stepped down, I was at one company (Thorn-EMI Varian) and they handed an AMSO supply officer a letter asking which car park the MoD wanted over £2M worth of its test equipment dumped in. (Environmental Test Chambers, which had been rotting for over 2 years without maintenance). They were fed up subsidising MoD, and paying rent for storage. That TE was urgently required for Merlin development.

As to this specific case, I cannot say if the actions you suggest should have been a modification (or a Change), but your are right – either way one would expect Martin Baker to make a proposal to MoD. Who is to say they didn’t? Again, it became routine in 1990/1 for such suggestions to be ignored, because AMSO were just beginning to implement the policy of running down airworthiness management. One of the first instructions was not to amend APs. Alternatively, Martin Baker may have noticed the potential problem, but decided it was a procedural or maintenance oversight. After all, a maintainer should be expected to realise something is wrong if he’s tightening a nut and starts cutting thread on the shank of a bolt. Also, if trained on the mechanism, he should know it has to be free to move/swivel when assembled, and that a simple check of this is required. Martin Baker could, legitimately, claim that only an idiot would cut new thread and tighten it so much as to render it unfit for purpose. Part of the process is training and proper application. It is not for Martin Baker to stand over the maintainer and check his work. And, in any case, Martin Baker should be immediately absolved of any liability because of the illegal 50 hour RTI. The very fact this was implemented indicates either (a) there was no contract, or (b) specialist advice was ignored. Those familiar with the Mull of Kintyre case will see the resonance here. Odiham issued an illegal Servicing Instruction, probably because a request to have the design made safe was turned down. MoD has form here – Martin Baker does not.

tuc:-
Then HSE will learn a very valuable lesson if they discover their mistake in court. In which case might we then expect them to issue a Crown Censure against the MOD? We live in interesting times...

"authorising him to self-task safety tasks"

I'm aware of at least one example where a PT officer seeing this scrubbed the item out of the contract saying that only a crown servant could authorise expenditure no matter how small the limit of liability. In effect the amount was just enough to decide whether any more effort would be required for further investigation.

Was it Def Stan 05-125 which contained this? I'm also aware of a discussion at NETMA about monitoring safety and airworthiness where the PT said "...but we do this". I can't help thinking that vague or misleading regulations contributed to the confusion. Possibly a mitigating factor in MBA's case?

EAP

I have no idea of the procurement process but as a long time, 12 year, occupier of MB seats, and an ejectee myself. ( Mk 4 seat) I read most of the MAA report with more than passing interest.

The thing that struck me as very strange indeed is that installing the safety pin was part of the after landing checks and it was sometimes, often, done by feel !

In my day we did not install the pins until the aircraft was parked on the line, dispersal, and the the pins, seats and canopy, very carefully replaced.

Was there some reason why the RAF changed, or even allowed, these procedures as the report said?

Getting a bit more into the technical aspect of the shackle and bolt. I agree that, as stated early, It's very surprising that MB didn't design a bolt with a shoulder that the nut was tightened up against. I've been a dreadful aviation hoarder/scavenger for years and have played with plenty of MB products. The innovative design and build quality is staggeringly impressive. So the use of a 'normal' off the shelf bolt is very surprising. (I know MB probably made the bolt specifically.

I am slightly puzzled about the torquing up of a locknut & bolt where you don't want the nut to bottom-out on the thread or even against a fitting the bolt goes through. In other words you are purely relying on the resistance to the 'locking' ability of the nut. A brand new nut is invariably going to be stiffer than a well worn one. How do you calculate a torque that caters for both cases? Clearly, if a normal nut were used you could only achieve a tightening torque when the nut is up against the fitting! If the specified tightening torque is less than the resistance of a worn nut screwed along a continuous thread, then you can only achieve that value when the nut impinges on something else.

It makes you wonder what the MOD support contract was that was in place, for the aircraft I maintain you pay for the manuals and all updates, service bulletins etc, the only things you do not need to pay for are Airworthiness Directives which come from the CAA, FAA etc.
I do wonder if the contract was all embracing, that could account for the RAF not getting some of the documentation other forces appear to have received.

Civi street wise we always replace lock nuts with new, RAF wise we used to check for run down torque resistance, you can measure that on a torque wrench..

As for a shouldered bolt, there might have been good reasons, such as the reduced diameter threaded portion if the bolt was shouldered not being of sufficient strength so as to not fail in the case of an ejection, and the main shank of the bolt not having sufficient clearance in the shackle for its diameter to be increased.

.

Umm, possibly, but there must be a better design! If not, why not use an appropriate 'feeler gauge' type tool to place between the inside of the shackle and the scissor linkage to tighten the nut against that is removed once the nut has been correctly torqued.


Having spent many hours sat on both Mk3 and Mk 4 seats, the face-screen pin was always inserted 'blind'. Quite a test of dexterity, flexible limbs and a long reach! I recall in the JP when dual we did each other's pin.

The seat pin was also fitted blind, but then both pins visually checked upon leaving the aircraft.

That was it - I knew I was close!

:O!

Nope. the shouldered bolt design had been in use for decades. My first encounter was in 1963 on JP Mk4 seats. Their use continued at least to Mk 9. Ejection forces would have negligible (if any) effect on the bolt which only serves to hold the drogues (same sizes) attached until the aircrew/seat separate.

Just a thought, is this case now sub judice?

But the seat is designed for various types, perhaps the shouldered bolt previously used had reached its design limits on the later seats, seat weight, crew weight, ejection envelopes etc all will play their part. There could be a myriad of reasons to redesign it, and there must have been some, otherwise they wouldn't have gone to the expense and trouble of doing so, and by removing the waisted portion, one would have thought strength of the bolt was possibly one of them..

There are two things that come to my mind here: -

We are informed that other users had been informed many years previously about this problem. What was the process for informing them? Was SIL 704 a reissue of a previous communication, that the MOD/RAF had not noticed that it had not got?

What was the advice to the other users of the Mk10 seat and if this advice had been implemented by the RAF would this event have occurred? The other side of this question is did the advice to users required new parts to be put into the seats? If so, from a corporate governance point of view, how is it that MB did not notice that the MOD/RAF had not ordered any of these kits..

There's a third point to add - it's apparent that a number of people in the UK knew/know of the issues and I'd guess that more than one person who works/has worked on those seats, knows of the issues - why wasn't this alerted/raised back through a process to make safe the design?

Although I have said it already I'll say again. That bolt was never meant to be fastened/unfastened all the time. For the Ist half (or more) of that seats life it's possible it was never undone. Work would only have been ever done in the seat bay and opening the shackle was done by releasing the BTRU. I would be interested to know who authorised 1st line rectification of ejection seats after the demise of seat bays. I would like to think this would have been discussed at MB and recorded decisions made.

Edit, a distant memory but I'm sure at servicing we tested the opening of the shackle we a spring balance measurement, had to be under a certain pull weight.

EAP86

The PT officer obviously didn't know that the Def Stan was mandated in every aviation related contract. This delegation to Post Design Services Officers at Design Authorities is unique, and it was why MoD Technical Agencies (uniquely) are named in contracts, whereas otherwise it is simply the post title. The PT officer you mention almost certainly wasn't a properly authorised or qualified TA. He may have been "Suitably Qualified and Experienced" as defined by the MAA, but I can assure you this comes nowhere near the criteria for a TA, who (typically) will have worked on similar kit as a fitter/technician/ diag/supervisor, then been a design draughtsman or similar, engineering staff officer in an HQ branch, promoted into MoD(PE) and been manager of scores of projects. Only then would you be considered. However, I concede this has probably been diluted since my day!

Locknuts - 100% replacement. Given there are arguments for and against re-use, it is better to be safe than sorry, for the sake of a few pence. As a young planner/examiner, I'd have been crucified if I didn't specify new nuts every time. But at front line, I accept a concession might be occasionally necessary. I always thought of this in the same way as in-line splices, being a simple greenie.

Lock nuts in the RAF while I was serving were not mandatory to replace, you checked their run down torque, and were trained to do that, however I always did replace them and have ever since, I once had a cost conscious owner question me over it, I said I was replacing them end off, he then brought in a magazine article a few weeks later that had a rudder bar that came adrift because of it and the penny finally dropped.