I fear that what has been learned is that VSOs can hide their wilful and fatal misconduct, with the collusion of all concerned. I would dearly like to be wrong.

I think we need to be confident that there isn't other latent issues hiding in the MB design and safety management.

Years ago a friend was logging his first proper seat time; after contemplating the rather violent change of scenery he started wondering when the parachute would make its appearance. He even had the presence of mind to remember he had a high level barostat fitted to the seat so the chute should have made a relatively quick appearance. When he tried to move his hand to the manual separation release he found the the sleeves of his LSJ were bound so tightly between his legs and so much material had been stretched by the force of the restraints (with the restraint fabric pulled through to the metal clips) there was no way he could move his hand over his thigh, let alone across his kneepad to operate the handle. He then spent time trying to work his way free of the Houdini straight jacket.

The chute did deployed before he got to the manual handle. MB's response to this issue was initially dismissive of an issue before deciding that the seat eventually worked so why should he moan.

Quite a few of us revisited the seat rig to contemplate what would happen when the restraint cords were pulled beyond the stitching (not possible on the training rig) and contemplated how much LSJ material would be pulled tight around the shoulders by the power of the arm restraints. Those of us with knowledge of the accident opted for a shorter LSJ sleeve length but outside of this circle the issue was treated with derision.

In the years since the arm restraint design has spread across multiple types and judging by the number of long LSJ sleeves I see one hopes that the issue has been resolved rather than forgotten.

Before this accident my sleeve length looked like this; I do not know if Typhoon mitigates the issue in a different way or if the issue has carried over:

http://i.dailymail.co.uk/i/pix/2013/...81_964x638.jpg

If anyone needs their blood boiling, Jeremy Vine is covering this shortly on BBC Radio 2...

With the greatest respect, MoD/MAA constantly putting to bed accidents with the same root cause is what has caused recurrence and even more deaths. As I said before, 56/60 recommendations to implement mandated policy. 17 main factors, all MoD's liability. Three years before this accident there was a report concerning poor practice when fitting fasteners on Nimrod. Nimrod cancelled, report put to one side, as if it could only be a Nimrod problem, not (e.g.) one of general training, supervision and culture. Then, the XX177 SI rips into - training, supervision and culture.

Bob Viking, can you please tell us WHY zero-zero seat pins (MDC too?) are replaced on the move these days?

Surely it would be better to do so only when stationary and before unstrapping?

MB are quoted in today's Times "This was an isolated failure relating to the tightening of a nut during maintenance procedures conducted by RAF Aerobatic Team mechanics."
Is that a 'Yeah but it's still the RAF's fault' kind of comment?
Going back to page 1 of this thread, did 'some liney', 6 years ago, find their career come to an abrupt halt or have the RAF had to wait, without prejudice, for the HSE case to conclude before initiating any internal action?

Integration of AEA
 

Hi JTO,
I do know that the RAFCAM integration team at Henlow did used to put a great deal of effort into the things you describe. Use of various crash test instrumented dummies and test rigs to simulate g etc. They also carry out detailed forensic examination of AEA that has been subject to actual use in events. Their top man has given a number of lectures to the RAeS on the subject. I understand that most recently their efforts have been focused on fire retardant gear and also body armour.
Not sure what will become when they move from Henlow. I would have thought the sensible thing to do was to merge with the QinetiQ gang at Farnborough. However there was always a willy waving contest between the two organisations which at one time, Pre privatisation of Q2 were more joined up.

dragartist/JTO

I fully agree. The 2002 QQ report, which informed MoD of the shackle problem (again), is a model example of a joint effort by M-B, BAeS, QQ and MoD. The vast majority in these organisations do a superb job.

But it is this report which renders the claim M-B didn't provide a bulletin a complete red herring. Had the SI seen it, they would have had to caveat their report 'the 1990 bulletin can't be found, but we got shed loads of subsequent notifications and did nothing'. The 'quality of design charge' was dropped by the HSE (who reported that?), which makes the Coroner look foolish (not reported either). But it looks like M-B took a hit on the administrative oversight charge just to get it out of the way, not realising MoD had withheld evidence that revealed MoD's greater offences.

Riskman - Yes, because it was!

Thanks for the headsup.
Actually, wasn't as bad as I expected.
He'd John Nichol on for a user comment.

I think I posted about this point once before. HMG cannot be prosecuted for alleged offences of the HSE, because the law does not apply to the Crown.

Ergo although MOD may have commited sins, it has not committed any offences.

roving, we are all only too well aware of Crown Immunity. Even if that were not the case, the problem here is that Sean Cunningham's aircraft was unairworthy because the UK Military Air Regulator, the MAA aka the MOD, had failed in its duty to ensure otherwise. The apologists as ever want to ram a stovepipe onto this tragedy, just as they did with the Mull Chinook, the Iraq Hercules, the Afghanistan Nimrod, and every other airworthiness related fatal air accident that have accounted for some 75 lives in such accident threads in this forum alone. Rather than wanting to set heads on spikes, be they JO pilots, SOs and 1* VSOs, or Company CEOs, we need to wrest Regulation and Investigation from the maw of the MOD, and make them independent of it and of each other. Unless and until that happens the urgent reform of both processes will be stillborn. More people will then die needlessly in unairworthy UK Military aircraft. Let the Crown be immune, just stop the cover up, admit the actions that led to this scandal, and allow proper reform to start. Time is of the essence (as no doubt you would be prone to say), for the longer this mess continues the longer that UK Air Power is fatally compromised.

Hear, hear, :ok::ok::ok:

Chugalug2, I am with you on all of that.

I was not simply being pedantic but underlining, once again, the fact that the Crown's immunity absolves it from penal consequences for its sins of commission and omission whilst others without immunity are hung out to dry.

Hear, hear to that. Sorry, Viking, it's not time to put it to bed until we have the reason for the change to long tried and tested procedures . Who, CFS, 4 FTS, HS, MB, Boscombe, or REDS, and why?

I would argue , to any forum, that replacing a seat pin without a visual checK of correct insertion, is dreadful practice, even more so if the aircraft is moving and in close proximity to other moving aircraft.

Let's hope the RAF has changed this basically unsafe procedure.

I would ask too, does RAF engineering not require an independent inspector to sign off critical work such as the was done on the shackle before releasing it to fly?

"...and just for the record, I flew ejection seats for 12 years, ejected once, hence my close interest in this accident, and was senior standards QFI in my last unit, so not exactly an uninformed amateur in this matter.

You're wasting your time expecting Bob Viking to stop asking you to move along as there's nothing to see here.

Just like the incident a few months ago where a Hawk went completely dark, and quiet above cloud, Bob thinks we should just play nice and not make waves.

Obviously our lords and masters know better than us, that's why they are our lords and masters. So... when the VSOs tell us to face the front and shut up, we ought to do just that.

No good is going to come of looking for the truth, we already know what it is, and it has to remain a secret to protect the guilty.

Lots to answer...
 

Tucumseh.

When I said “give it a rest” I was not referring to the broader discussion of airworthiness. I was referring to the “it wouldn’t have happened in my day” brigade. I have no problem with your discussion.

BEagle.

I have been flying on MB seats constantly since 2001. Since day one I have been taught to insert the seat pan and internal canopy handle pins during taxi back (stopping if necessary especially as an inexperienced pilot) and visually check them. The MDC unit pin is inserted after egress.

Newer aircraft also have a PINS caption on the CWP to indicate if the pin is inserted with the canopy closed.

Until recently (coincidence) we would also unstrap whilst taxiing. That practice has now ceased (which I disagree with).

Also remember that newer Hawks are able to taxi with the canopy open.

Retired BA/BY

I respect your experience but we did this to death a few pages ago.

I cannot tell you who made the change to procedures but somewhere between you retiring from the RAF and me joining, it happened.

It would not have been done on a whim and the same CFS that you and BEagle remember would have carefully reviewed the procedures.

Personally, I don’t want to be strapped into a live seat after landing. I can count several instances where crew (including myself) have had to perform an emergency egress where having the seat safe made for a quicker and safer exit.

FRCs will state during the emergency egress drills as item 1:

Seat pin...insert

I would argue that the chances of screwing that up are far higher when you are trying to exit in a hurry than they are during the taxi back.

Our opinions clearly differ but they are both based on what we were taught. A touch of confirmation bias for both of us perhaps?

I can assure you and BEagle that pins discipline has always been rigorously enforced and always will be.

Airpolice.

I have no beef with you but, please, grow up.

BGG.

Thankyou!

Did I miss anyone?!

BV

Bob Viking - Thank you.

Roving - I think you know that the persistent offences I mention are breaches of the Air Force Act (and its successors?). Making false record attracts a maximum 2-year sentence. I'm not just talking about the aircrew training records in this case, but the more serious and serial offences committed by those who knowingly signed to say they had personally ensured a valid safety case existed, when a succession of Service Inquiries have revealed they did not. That is a legally binding declaration, and the false declarations resulted in numerous deaths in aircraft that had no legal Release to Service. Chinook. Tornado. Nimrod. Sea King (albeit, it was very nearly right). C-130. Hawk. That is not an isolated instance. Those cases alone span 17 years. In my opinion, that indicates a very serious organisational failure, which MoD seems completely ambivalent towards. Not 'seems'. Confirmed, in writing.

Public interest. 'Safety of public whom the aircraft overflies'.

Not always. See previous post! The policy is good. The implementation is lacking. Nimrod Review in a nutshell.

That there would be a dangerous precedent, because the minute you start to ignore the written instructions / manuals, the whole lot for the aircraft might as well be slung in the bin... just because it tells you in the written instructions that you can lift off in 1000 metres with a maximum of XYZ fuel onboard, do you double that fuel load and ignore the book on a 1000 metre runway?

BigGreenGilbert - tuc is of course right when he points out the safety of the public as one reason for us all having a right to know about the Dark Hawk. I certainly don’t want to find myself wearing a Hawk of any kind when I’m just walking along minding my own business.

But there’s surely a moral reason as well. That Dark Hawk is public property - our taxes paid for it. There are probably only three reasons why we shouldn’t be allowed to know the details - confidentiality involving either personal privacy or commercial sensitivity, and national security. As far as I know, none of those applies here.

Does it not occur to you that yourdisplays the kind of arrogance that still expects unquestioning deference for superiors (of which perhaps you may be one)? I believe those attitudes should have disappeared years ago.

airsound (who's sorry for the thread drift)

I worded that rather badly I'm afraid. I should have said "If the instructions are clearly dangerous, refuse to carry out the job & report the matter to higher authority.

JTO the phrase same but different applies. IIRC the Typhoon Flight Jacket (LSJ/LP) uses Kevlar reinforced Arm Restraint Extension Lines attached to the jacket sleeves (these plug into the seat QRB - QRF in old money), unlike Tornado, where the arm restraint lugs are attached to the jacket arm and the restraint lines were part of the seat (?).

I'd like to say that what happened to you friend wouldn't happen today, from experience the kit is tested to the nth degree via high speed wind-blast testing, live ejections, 'wet drills', burn tests, etc.

Flight Idle,

Again that can be a dodgy course, say you think it is overtightened and XYZ chief tells you ignore the book and XYZ is wrong, you are carrying the can for your actions in not following the laid down procedures. I know, it seems wrong, but thats how it is, also look at the other thing, if the aircraft is needed how long does it take to pass this up the chain and assuming it does not get stopped on route, to get a reply from the manufacturer and a response back down that chain.
Civi Wise I can contact my Manufacturers rep who will contact the Company design team and I can have an answer emailed to me in a couple of days.

Though sadly the CAA of late have allowed parts of the maintainence manuals to be ignored, that in my eyes is a disaster waiting to happen, as a piecemeal approach leaves what to do and what to ignore up to the individual as opposed to you having to follow it all.

Quite right N. MoD did have such a (mandated) process, but we were told to cease it in June 1993. It's still used, entirely unwittingly(!), by a flagship Infantry programme. But I've seen a recent Aircrew Survival Equipment contract that doesn't call it up. Presumably nobody in the IPT realises the contract is a crock as they posted it on the internet. The process is simple. Named engineer at Air Station in contract (it was a C/T at Wyton, for example, on Nimrod R SRE). Design Authority could accept a phone call from him, and intermediately start work without further approval; up to a specified limit which equated to man-hours. This gave the Technical Agency time to formalise. Commercial or Finance not involved at any point. On R, there was sliding scale as an incentive. Big bucks if you cracked it that day. Less if 24/48 hours, and so on. SFA if you screwed up.

Easy to say.

As nutty and others have alluded to, the problems are still with us even now and nothing is being done to ensure issues like these are PREVENTED in the first place.
First port of call?
Skill of hand. Followed by an enquiring mind.
Basic, basic stuff.
Is it too much to ask?

Here is the threat. Childish as my views may seem to Bob, this is not about my right to know, it's about everyone's right to have everyone know. Telling the world why that Hawk went dark is not a threat to national security, however it might well be a threat to commercial opportunities for the people at Warton.

Despite the clear rules, people eventually do things in a different manner, and for a while it's all good. Then someone dies, and in the aftermath, we learn (again) the lessons of years ago.

We all know about the foam in the C130 fuel tanks, so there is little or no chance of a C130 going into a combat zone without that and nobody being aware.

The situation with the Hawk T2 however.... Imagine the scene in 15 years from now, and three contractors later, nobody still on the flight line at Valley from last summer.

Because it has been kept quiet, nobody talks about it, so it never gets passed down the line, and the same bad practice creeps in, for the same reason that it crept in last time.

A solo student is caught out, this time at night, and he (understandably) collides with an airliner.

Who are the MoD going to blame that on?



Back to the thread topic.....

I might have misunderstood, but I thought that, and I'm happy to be corrected here, MB have declared that the seat failed because the RAFAT mechanics failed to service the seat properly,

yet the report said the last work on the seat was carried out at Valley on 24th October.


On the basis that I'm right there, am I also right to say the RAFAT mechanics are in blue suits (literally) and the Valley people are civilian contractors? I'm genuinely asking, I've not been to Scampton, or Valley, for years.


As for the SI report, I found the bit at 1.4.5.23a & b quite interesting.

Section 1.4.5.24 directly contradicts Gilbert's assertion that good practice always evolves.


The term used is "incorrectly authorized deviation" when discussing the fact that the Reds had rules, that were not compliant with what had been agreed and written down, by the people responsible for agreeing and writing down the rules.

Why is it so hard for the RAF to find **** like that before someone dies? What on earth is going through the heads of people making changes to procedures, and not getting approval? How can anyone give approval without having checked the impact of the changes.

As for.......

"The positive picture of flight safety and the state of publications and pilot log books appears to be contrary to the findings in this Section.

It is the Panel's view that the Formal Staff Visit may not have provided the AOC with an accurate picture of the RAFAT upon which to base his report."

Sometimes you need to say it very clearly. Either the RAFAT suddenly went off the rails, big time, just after the AOC's inspection, or there wasn't much real inspecting getting done.

I’m astonished at M-B’s guilty plea. Even assuming the company couldn’t prove that it had informed MoD of the risk of over-tightening in 1990 (along with all the other users), its lawyers must surely have been aware of the 2002 QinetiQ report? The latter date rings true to me for another reason: undergoing a course on a Mk10-equipped aircraft around that time, I distinctly remember the ground school instructor advising us to give the drogue shackle link a ‘wiggle’ to check it wasn’t pinched. Unless this had always been part of Mk10 groundschool patter (can’t remember that far back!) then intra-MoD awareness of the 2002 report would explain why the potential fault was highlighted.

Easy Street

Well said.


The HSE charges were 'catch all', and specifics were not revealed until very late in the day; probably why M-B pleaded not guilty last year. It emerged in October that the two charges related to (a) quality of design, and (b) failure to send out a technical bulletin in 1990. The legal strategy dreamed up by their solicitors was 'don't upset MoD'. The quality of product charge, for obvious reasons, was the one to concentrate on.

The company statement (posted by airsound the other day) implies the quality of product charge was dropped. Those in court confirm this, although the way it was presented was apparently vague. If true, and even if guilty, the paperwork one would be a minor administrative error. (The allegation relates to 1990, but even the SI report admits the information was known by the correct people in 1991). The problem the company created for themselves was that media and public opinion was already tainted by the Coroner's inaccuracies and ill-informed comment - caused in part by MoD concealing relevant evidence, including the 2002 report. M-B and their solicitors have a copy obviously, but the strategy meant it wasn't used. I think this poor, because it would have cleared them of both charges.

(Remember, the SI report was not published until after the Inquest, and the MAA issued a written statement five days after evidence had finished that the family had only just been given a copy. Nobody could possibly prepare a case in time against MoD's version).

This report is actually a catch-up exercise by QQ, as MoD required independent safety assurance for Mk10A seat mods that had been developed and trialled in 1998, as a result of the 1996 Tornado Airworthiness Review Team report (TART). The mods were approved in 1999, but lacked an audit trail. One mod negated the risk of over-tightening the nut. This report closed the loop. The TART report is also what clears M-B on the paperwork, the Director of Flight Safety repeating his 1992 criticism that dissemination of safety information by the RAF was poor. (MoD denied the existence of TART for many years; and in this Hawk case MoD claimed no knowledge whatsoever of when the mods were developed or why. This lie was repeated in the House. You always follow the lie).

All this was too late for M-B, and it is plain the senior Director made an executive decision to plead, and get it over with. This was made very recently, because even a few days before the court appearance former MoD employees were standing by to give evidence, having been sought out by the solicitors (not come forward themselves).

Hope this helps. It will be interesting to hear what's said in court next month, if reported. Regardless, the truth will be published!

tuc, thank you for the insightful reply.

‘Don’t upset MoD’ seems to me a disastrously misguided strategy. What would MoD do if upset? Buy American or Russian? Mount a disinformation campaign to scupper M-B’s overseas sales? With the idea of a UK industrial strategy being in fashion that’s politically unthinkable. It’s probably legally impossible too. On the other hand, the damage inflicted on the company’s reputation by the guilty plea is very real. Unless I’m missing something crucial this is a woeful misjudgment by M-B.

Easy Street Fully agree.

There is a view in some circles that if the HSE elect to bring a charge in court under the HASAWA, it is extremely unlikely that the charged party would be found not guilty despite the cogency of the evidence. These views are often associated with a story where this has been the case of guilt being found despite strong mitigating evidence. I've heard some of these stories but I must confess I've never researched their accuracy. Ultimately it is MBA's insurers who will have the strongest influence on whether to plead guilty or not and cost/success is an issue.

As regards the product design quality charge, I suspect that it may have been dropped because of a difficulty in determining, after many years in service, how much of the design could truly be assigned to MBA's responsibility. I can think of many instances of designers' preferences for in-service fixes being 'discouraged' by PTs etc. Warnings, procedures, instructions, training etc. being cheaper are often preferred over proper modifications. In the safety world they have a desirability order of priority for fixing safety problems and 'elimination' of the hazard always comes first in the order.

BTW this isn't to say that PTs don't need to have a strong influence on matters. Unfortunately the HASAWA contains separate duties for designers/manufacturers and operators and this wasn't well recognised in MAA regs. Industry did make representations on this to the MAA on several aspects of the regs but from memory (warning: may be faulty these days) the only outcome was some words in Def Stan 00-56 to the effect that compliance with the Def Stan does not necessarily mean that parties' legal duties are satisfied. This lack of clarity was a driver for a certain engine company issuing so-called 'duty of care' letters to try and mitigate their own liability situation. Unfortunately, many believe that such letters can actually make it worse.

EAP

EAP86

Excellent observations. Had the case proceeded on the quality of product charge, and if M-B had chosen to defend themselves, there would have been much commonality in the defence to both charges. One being that the seat was serviced to an illegal / rogue Routine Technical Instruction, devised and issued by MoD and in breach of every know regulation. The fact is, by its own admission MoD was well aware of the information it claims M-B did not provide, and did not incorporate it in the RTI or, it seems, training.

I think (IMHO, sadly) MB have taken a pragmatic commercial decision to take the hit and get on with life. However, I am saddened that MoD has not taken responsibility for obvious failings on their part and fessed up. It is obvious that responsibility has to be taken for this unnecessary death, but it would appear that more blame attaches to MOD than MB, whose excellent product has saved very many lives.

Although the HSE cannot prosecute the MoD, even in the event of a fatal accident, it is very surprising to me that they have not censured them, which they are at liberty to do. I agree with many of the posters in this thread, it seems much more of the liability for this tragic accident lies with MoD, rather than Martin Baker.

From a vendor aspect, the situation with regard to service bulletins on Hawk equipment could be confusing. Every export Hawk instruction would normally go through BAe Systems to the customer. However since the UK MoD dealt directly with Martin Baker on all aspects of the T Mk 1 seat design and mod standard, BAe Systems would not try to read across the export instructions to the T Mk 1 and advise MoD as they would assume MoD had been sent an equivalent instruction directly from Martin Baker. Whether Martin Baker did that and it went missing in MoD I have no idea.

I have to confess I cannot remember seeing the equivalent export service bulletin but someone in Flight Systems or Airworthiness at Brough could probably find a copy with my signature on the covering form.

Walbut

Martin Baker seats
 

Does anyone know what the current situation is regarding the type of shackle fitted to the Red Arrow Mk10 B ejection seats. Is it gas or scissor?

DV

The RAF Hawk TMk1 fleet still have the original standard Mk10 seats with the scissor shackle. The broadly similar seats in the Tornado fleet were modified a few years ago to incorporate the gas shackle. The Hawk TMk2 fleet have the newer lightweight seats with the gas shackle.

CAEBr

Sentencing on 23rd Feb
 

For those who missed it - Lincoln Crown Court, 12 and 13th Feb.

A bit of to and fro during the two days pre-sentencing hearing. Speeches for the prosecution and defence as reported by the Beeb 12th -

Red Arrows death: Ejection seat firm 'put lives at risk' - BBC News

and 13th - Red Arrows death: Ejection seat failure a 'once every 115 years' event - BBC News

and rather more luridly in the Daily Express.

M-B has already agreed to pay £550,000 prosecution costs.

Adjourned to 23 February for sentencing.

..................

It appears the 'quality of design' charge wasn't dropped, per se, but HSE conceded (for some extraordinary reason) that CAD wasn't available to Martin-Baker in 1947. Better to say HSE agreed the level of severity was lower than at first implied.

This doesn't detract from the fact that the offending design, and the resultant risk of the Scissor Shackle/Drogue Shackle jamming due to nut over-tightening, was designed out in 1990, but MoD declined to adopt the modification in Hawk. The 1 in 115 years calculation was not adjusted when poor training and engineering practices developed. In any case, the existence of a minor mod that eliminated the risk altogether, meant MoD bore a risk in Hawk that was not ALARP.

I understand the judge expressed uncertainty as to what to do. Hence, the 10 days to think. She was less than pleased at M-B's last minute change of plea. A few days previously, having been informed of evidence concealed by MoD, she had the sense to call it forward. But she didn't ask why HSE had proceeded in the face of this evidence, which raised considerable doubt over the safety of the prosecution. Perhaps she's just got to accept they pleaded.

It will be interesting to see what she does. I keep thinking of this...

1. 56 of the SI's 60 recommendations were mandated policy.
2. All 17 contributory factors were MoD liabilities.
3. Of the 3 aggravating factors, 2 were MoD liabilities, and one shared with M-B.
4. Of the 6 other factors, 5 were MoD liabilities, and one shared with M-B.
5. All 13 observations were MoD liabilities.