LFH, a real tour de force, sir! If ever I ask myself again how to best explain the stranglehold the MOD has had over exposing the scandal that is UK Military Air Safety then the answer is simple, "like wot he said!". Of course this is an arcane and complicated subject and one wouldn't reasonably expect anyone who isn't a fully trained and experienced airworthiness engineer to have a complete understanding of it. I certainly don't, but I now know far more than I ever did before, having read through the airworthiness related fatal accident threads here or, more conveniently, the various books by David Hill. If an old has been like me can do it then much younger serving aircrew can, and should! As LFH says, it is in the interests of every aviator, military or civil, to do so.

A quick trip down a tropical river is all that is necessary to understand how things should be, and how they most glaringly are not!

Inquest to be resumed 3rd December
 

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From the NW Wales Coroner's Office 19 Nov.

"Inquest resumption 3 December 2021, 9:30am"

LFH
...

The stupid thing is if you subvert the outcome, then your safety regime is not fit for purpose, the reason you carry out a follow up to an accident is to find the root cause and prevent it from killing some other unfortunate
If someone prevents that happening or covers it up, and someone else pays the ultimate price then they should be prosecuted for involuntary manslaughter., and until that happens nothing will change.

Pity the MOD wiggle out of being charged with Corporate Manslaughter:

https://www.cps.gov.uk/legal-guidanc...e-manslaughter

Government Departments

Section 11(1) and Schedule 1 of the Act provide that specified government bodies can be prosecuted for Corporate Manslaughter. The statute provides an exception to the general rule that a crown body cannot be prosecuted for a criminal offence (see section 40 of the Crown Proceedings Act 1947).

Schedule 1 lists the government bodies to which the offence applies. It includes the major departments of central government such as the Department of Health, Department for Education, DEFRA, Ministry of Defence and the Home Office, as well as the Welsh Government.

Section 16 contains provisions which identify the relevant body to prosecute where functions have been transferred from one public body to another since the date of the offence.

Can an individual be charged? after all the NI trials show service personnel can indeed be charged.

Past precedent would seem to indicate that if that were to be the case it would be someone of 1* or below.

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Nutloose -
Thank you. ... I wish more folks realised this basic tenet.

Exrigger Useful link that.... Last I heard, it was called 'Crown Immunity' which officially got you off almost everything that was officially crooked.

Known risk of being 'done' for corporate manslaughter would easily explain MoD's determination to lie about multiple Service fatalities (as rambled about regularly on PPRuNe) and in the book "Breaking the Military Covenant - Who Speaks for the Dead ?"

The problem seems to be that corporate subversion and corporate wiggling have been going on for at least twenty seven years (Mull Chinook in 1994) so it would now take a miracle to cut out the collective institutional infection.

'Wiggling' does not even come close. If you can control the entire system you don't need to wiggle. Corporate Mutual Insurance Company - of Whitehall, London.

Let's see how brave Madam Acting Senior Coroner feels on Friday 3rd December .... If she wants to be confirmed in post ?

Dare I wonder if this might be an opportunity for a turning point, towards a bit of old fashioned honesty ?

LFH ....

NB - Chugalug - I am reliably guessing that the "VSO Risk Register" is still in force (unamended since 1994) but is only made available to Two * and above who qualify for life membership of CoMIC (of Whitehall.)
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I used to religiously read the accident reports when in the service to learn and further my knowledge in the hope I would avoid such pitfalls, every wall in the building was plastered with flight safety information, had I known then what I was reading was a great work of fiction with half truths and blatant lies by those that should have known better, I think I might have thought why do I bother..

What was it the poster used to say,

“Flight Safety is Everyone’s Responsibility”

I obviously missed the small print at the bottom stating

“Senior Officers are exempt from the above statement.”

Briefly, the Inquest concluded today.

MoD got a kicking. Known risks not tolerable and ALARP. Failure of duty of care. Repeated failure to implement recommendations from previous accidents (even when instructed to by government).

But, these violations are not gross breaches. She did not define 'gross'.

However, she did make a point of confirming what we already know. The DSA/MAA is not independent, despite claiming it is. All things being equal, this should have far-reaching implications.

This criticism is infinitely worse than that made by any other Coroner, with the exception of Mr Walker in the Nimrod XV230 case.

The comment quoted from the coroner explains why the MOD avoided a corporate manslaughter charge again, in isolation that is probably correct, but add all the other failures of duty of care in the not to distant past there must be a case to take some more serious action against the MOD as they do seem to avoid actually doing anything to prevent incidences repeating themselves.

Is a Coroner not allowed to consider previous offences? Is the reason because this evidence wasn't given to the Coroner in court? I read that the family didn't have a lawyer.

Exrigger/Dervish

You both raise good points. Perhaps I can shed light…

The reason why Ms Sutherland, the Coroner, overruled her predecessor on Article 2 was the submission to her by the family that there were 12 common factors between the 2011 death of Sean Cunningham, and that of Jonathan Bayliss. She accepted the evidence that MoD had assured the Cunningham Coroner that all these issues had been, or were being, dealt with. She put this to MoD, and it admitted the ongoing breaches. Additionally, she cited another case, at RAF Mona in 2007, criticising MoD again for not reducing risks to tolerable and ALARP.

But, when considering the question of corporate manslaughter, she did not take these prior breaches into consideration, only looking at them as they applied to the Bayliss case. She ruled that these breaches (and the lies) ‘did not fall far below what can reasonably be expected of the organisation in the circumstances’. She also said that ‘there was not a sufficiency of evidence’ of MoD’s breaches (despite it admitting them).

Nor did she take not account that the same underlying breaches – refusal to implement mandated regulations, accompanied by a series of false declarations that they had been implemented – had led to scores of avoidable deaths in accidents where the root cause had been notified in advance to senior officials, officers and Ministers.
Like me you will find this strange, and I’m sure there is a proper legal explanation, or a legal nicety that I’m unaware of.

Dervish, in reply to your question about the evidence, in addition to written submissions the family raised all the above in court, and the Coroner accepted it all as true.
It is worth noting that the family did not ask the Coroner to consider gross negligence manslaughter against the pilot. Quite the opposite; they noted ‘he was as much a victim of MoD’s negligence’. It was corporate manslaughter she was asked to consider, because that is where the evidence lay. Inexplicably, in her written decision the Coroner said the family had asked her to consider manslaughter against the pilot.

Vey interesting thread; such a frustrating and unfortunate case. Amidst much wisdom, I'm pleased to read some discussion around the appropriateness of the PEFATO. Notwithstanding the luxury of armchair hindsight, an operating culture which allows a fatigued pilot to fly PEFATO with ground crew in the back is going to be challenging to defend...

Thanks for the explanation tuc. :ok:

Have I missed it, or has the media response to the MoD admitting it has lied / misled assorted coroners been subdued at best? I realise they are very busy with No 10 Christmas parties past and present, but admissions such as this are very rare, and have huge import.

I suppose the risks associated with stall warning and command ejection will now be declared ALARP (Temporal) because some sort of modification programme is under consideration, and we will just fly on. The collision risk associated with Tornado GR4 was declared ALARP (Temporal) and we know what happened there. ALARP (Temporal) is a fudge conjured up by the hierarchy to avoid the consequences associated with an RA that states that if a risk is not ALARP then all routine flying must cease.

DV

Falcon900

No, I'm afraid you didn't miss anything. More or less complete silence, especially from the broadsheets. Even the local media in NW Wales pulled the plug.

It is perhaps worth noting that during the Sean Cunningham case in 2018, MoD demanded that the BBC confirm its (inconveniently accurate) line of inquiry would be dropped. They also demanded that a BBC journalist hand over all her notes on the case. The first was satisfied by senior management simply taking journalists off the story, but to her credit the young journalist refused to hand over her notes.

Which is a pity in a way. That was the day an MoD witness blurted out that safety cases are unrelated to airworthiness. The journalist's notes would have taught him a few things.

Last Saturday's Telegraph offered the headline "MoD 'must act to prevent more RAF crashes". It went on to say that the MoD considered fitting stall warning to the Hawk following a previous accident in 2007 but decided not to invest in the system. Ms Sutherland said "This does give rise to concerns that future deaths will occur and action should be taken". The article said that she would recommend to MoD that stall warnings should be installed in the aircraft and better simulator training developed.

Note to SofS
 

https://www.judiciary.uk/publication...deaths-report/

Does anybody have links to other records?

I am at a loss as to why it is recommended to fit a Stall Warning System when an Angle of Attack Indicator with Audio Warning would achieve so much more?

Is it just that the Coroner was not adequately briefed to enable her to fully understand the problem?