Inquest - Corporal Jonathan Bayliss RAF
 

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The inquest into the death of Corporal Jonathan Bayliss will resume on 2nd November 2021 -

Council Offices - Shire Hall Street, Caernarfon.

Full Inquest scheduled for four days.

https://www.pprune.org/military-avia...e-inquiry.html

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Who speaks for the Dead ?
 

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Who speaks for the Dead ?

The inquest resumes next Tuesday, Nov 2nd - with four days scheduled.

The separate interest groups will likely include -

• MoD, who will not be keen for the inquest to consider the long list of repeat failures identified in various SIs and other inquiries, which despite frequent assurances at events like this, seem never to have been fixed. MoD will likely have instructed their barrister to steer everyone away from that sort of embarrassing stuff.
• The pilot, who appears to be legally represented.
• The family of Corporal Bayliss, who so far seem not to be legally represented, and who would be better served if this were an Article 2 Inquest - which might also have triggered legal aid.
• The Public Interest

One hopes the coroner will have summoned a suitably qualified and responsible witness, senior enough to answer questions and tell the truth about the Hawk Mk1 Safety Case etc, and senior enough not to feel threatened by a disciplinary.It will also include answering pointed questions about the relevant Risk Register and any possible more recent assessment of the Risk to Life and Duty of Care, both historical and post March 2018, in particular for the back seat carriage of ad hoc joy-riders and ground engineers who have been chosen to be trained as members of the Reds 'circus.'

That presupposes there will be anyone attending the inquest who will know the right questions to ask, and with enough clout to extract truthful answers.

Or will the coroner have to settle for well rehearsed assurances by some uniformed (or did I mean uninformed ?) lackey, that these accidents have already been fully investigated and lessons have been learned and she doesn't need to worry her PLH about technical details ?

That brings us to the question of Article 2 Inquests. It would seem from press reports of the pre-inquest hearing in May 2021, that the MoD barrister successfully argued against an Article 2 Inquest. He has probably been briefed to avoid anything more complicated. I think he said previously something simple like 'the aircraft stalled - that's it.' Well he would say that, wouldn't he ?

Is the inquest likely to become adversarial ?

If the MoD claims that the MoD, the procedures and the Risk Assessment are not to blame, who does that leave ? Fate ? Bad luck ? Corporal Bayliss ? The pilot ?

Whatever the outcome, Jon Bayliss didn't stand much of a chance on 20th March 2018.

LFH
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Between your post and comments elsewhere, you've pretty much nailed it Flashy. The Coroner's been misled, and MoD doesn't want their past form examined. I wasn't sure what "article 2" meant so had a look see. She must have been high. Is she really saying there is no possibility of MoD having breached their duty of care? Even the service inquiry report admits it.

Is there any possibility that a Barrister who understands the issues could be found to represent the family on a Pro Bono basis?

Seems like a case for 'crowd funding' a legal eagle. Where's Gilbert Blades and his clan when you need them? (I expect Blades senior is counsel to St Peter by now)

O-D

This, I think, is a key issue. Very few do, which has been all too evident at many a military Inquest, with them unable to pick up when MoD has lied under questioning. Hercules XV179 is the obvious example in England.

One of the deceased was Australian, where government policy is to fund legal representation for the bereaved. The family QC was superb. He had his experts on speed dial for advice during recesses. Even so, when the porkies came thick and fast it was difficult. It was only after the event that the evidence of one senior officer could be dissected, and proven entirely wrong. By then it's too late. And, of course, MoD arranged for one potential witness, a retired C-130 pilot, to be detained on the steps of the courthouse by security forces. Not dissimilar from the Cunningham case, when Mr C was physically dragged away when he tried to speak to those who were there to help. It's not just lack of representation that's the problem. It's the system tolerating this level of interference with due process.

Hopefully, Mr Bayliss and his family have expert help next week. One of the odd things (in my opinion) is that the well-known firm who usually provide a solicitor pro bono to the bereaved, are representing the pilot. That narrowed the family's options, but they were still initially represented. This abruptly ceased after the ruling that it was not to be an Article 2 Inquest, and they were not represented at the Pre-Inquest Hearing earlier this year.

EDIT: Apologies, but I should make it clear that I think the senior officer at the XV179 Inquest was misled by briefings into misleading the court. The main lie was that, earlier in the proceedings, MoD denied ever knowing about Explosion Suppressant Foam, despite it being called up in mandated airworthiness regulations. Two MoD ESF specifications from 1971 were provided by a witness to the Coroner and Oz QC. Coroner David Masters accepted this evidence. tuc.

tuc :-
Indeed, tuc. Here we see all the safety nets that might assist in helping to search out the truth; various Service Charities, Article 2 Inquests, Informed Pro Bono lawyers, all seemingly unavailable to the family of Cpl Bayliss. They are left at the mercy of the RAF/MOD, which will be merciless unless checked in its tracks by the Coroner (who confirmed that Article 2 would not feature, I understand). This situation could be repeated ad infinitum unless the attitude of the Establishment changes.

In short, your loved ones could be treated with the same lofty contempt if you are currently serving.

The Enemy IS the State
 

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The Enemy IS the State ......

Corporal Bayliss should not have died. His death was wholly avoidable. Under the circumstances, he didn't stand a chance.

MoD through their barrister, persuaded the relatively inexperienced coroner that it should NOT be an Article 2 Inquest. One aspect of that decision seems to be that the coroner is thereby limited to the bare facts of the death and unable to apportion blame or civil or criminal liability .... though a narrative verdict can be delivered.

In the case of an Article 2 inquest, the coroner can consider 'system neglect.' This is sometimes referred to as a 'Middleton Inquest.' That is where we should be at.

Is the inquest likely to become adversarial ?

Regardless of any procedural limits on the coroner, I feel sure that won't prevent the MoD barrister pointing fingers - and you can be sure he won't be pointing fingers at the MoD who pay him.

MoD will know that if it were an Article 2 inquest, it would be MoD under scrutiny.

A 'defendent' who hoped to be found not guilty, would be unwise to admit guilt even to their defence counsel. Thus MoD has probably made great effort to limit what their own barrister knows about the case.

Jon Bayliss paid the ultimate price, which cannot be refunded. Whether or not MoD has paid, or will pay anything to the 'family' possibly under NDA, that can't replace their loss.

It would be difficult, but in the feverish atmosphere of the coroner's court, not impossible, to point a non-aviation no-holds-barred finger at Jon, sowing only tiny seeds of suggestion that 'he might have realised ....' You only have to consider what rubbish can appear in the national press about aviation matters. If the family are not represented, that would only leave the coroner to speak up.

So if MoD has it's way, that really only leaves the pilot. It might even be to the benefit of the pilot for this to be an Article 2 Inquest. He may be just as much a victim - of the rotten system that rules his flying, if the MoD barrister has been instructed that in extremis, he is to do a hatchet job. I think he said previously something simple like 'the aircraft stalled - that's it.' He would then ask 'Who stalled the aircraft ?' You can see where this might lead.

Article 2(1) of the ECHR states: “everyone’s right to life shall be protected by law”. That places two substantive duties on member states:

1. A negative obligation to refrain from taking life

2. A positive obligation to take appropriate measures to safeguard life.

It seems in this case that substantive duties under Article 2 (point 2 above) have been breached. That is why it should be an Article 2 Inquest. It is not too late.

However, switching to Article 2 would require a substantial adjournment to be declared next Tuesday, Nov 2nd. That would be terribly inconvenient for some of the parties who want this out of the way, before it gets any worse. .... The coroner has been quoted as saying she would keep it under review. It is within her power. It is not too late.

LFH
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Risk Assessment and Duty of Care
 

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Risk Assessment and Duty of Care - Big Cheese Holes and the Big Cheese

Corporal Bayliss should not have died. His death was wholly avoidable. Under the circumstances, he didn't stand a chance.

From the SI - He did not receive some of the listed training expected for newly selected circus members which elevated the risk. Such that the SI recommended the DDH should mandate a formal training syllabus. Under the circumstances, that issue probably made little or no difference to the fatal outcome.

From the SI - The pilot was distracted by certain issues beyond his control, including a simulator ride at Valley between flights, being required to carry out flight manoeuvres that arguably were incompatible with a shakedown flight for a prospective circus member, misjudging the flight path, losing control and ejecting. Under the circumstances, those 'overwork' issues probably made no practical difference to the fatal outcome.

The path leading to Jon Bayliss' death was laid down many years earlier. Someone would eventually come to grief.

The foundation was the systemic, blind belief that the risk involved in routine and frequent carriage of any non-aircrew in the back seat of a Hawk T1 (especially with the elevated risk associated with certain flight activities) could be passed off as Low and Tolerable and ALARP.

In principle, it's a little bit like building V-Bombers, where only certain crew members were provided with ejection seats. Was the risk deemed to be Tolerable and ALARP or whatever it was called in those days ? Or was it passed off as "Rien ne peut être fait. C'est la guerre froide" ?

Many relatively minor shortcomings in technical and training records, administration and oversight were listed in the XX 204 SI. More serious shortcomings were identified in the SI for XX177 (like absence of a valid Safety Case and the length of time taken to locate and obtain important documents from the multitude of agencies with fingers in the Hawk Pie. Similar issues for other Hawk crashes. And as regularly mentioned and warned, even to the NW Wales Coroner, a long list of serially ignored recommendations, while lying to successive inquests, inquiries, courts etc., that 'lessons have been learned and all recommendations have been implemented.'

Among all the fancy risk assessment data, including as shown in the risk register at the time of XX177 ten years ago, and doubtless up to XX204 in 2018, I could find nothing that discussed or questioned the fundamental issue of why any passenger or supernumerary crew member must be seated in the back (as opposed to anywhere else.) Nothing even to suggest that the seat-specific risk had been considered or had achieved the magic words 'Low and Tolerable and ALARP.'

Everyone in the Hawk and Red Arrows world should know about the command ejection system as fitted to the Hawk T1. Hawk T1 was designed as a trainer, where the command pilot ie the Instructor, would be the GiB, and command ejection could only be initiated 'from the back.' If the command pilot is in the front (as for most Hawk T1s these days, command ejection must be switched off. You can't currently switch 'command' from back to front. Neither can you allow an unqualified back seater the ability to initiate ejection for both seats.

That leaves the back seater to make his/her own 'in extremis' decision to eject, whether ordered or not. What happens when the front seat command pilot of a doomed Hawk T1 shouts "Eject ! Eject ! Eject !" and the back seater doesn't go ? .... How long would you give it ?......................................................
Why did this specific risk assessment (if any) apparently stop where it did ?

With XX204, the SI begins to open up that discussion at last.

Recommendation 1.5.6 Page 1.5 - 2

f ) "RAFAT DDH should ensure that Circus are only employed as Supernumerary Crew on sorties that are directly associated with their primary role and not exposed to potentially hazardous flight profiles .... "

Analysis conclusion 1.4.477. Page 103

"... "Simulations indicated that if a front seat-initiated command eject system had been in place then both individuals might have vacated the aircraft before ground impact."

1.4.482. Two Aggravating Factors. (page 103)

a. The engineer's lack of experience to independently initiate his own ejection.

b. The lack of a front seat-initiated Command Ejection system.

1.5.2 Recommendations - "AOC 22 Gp should ....

e. Assess the feasibility of the incorporation of a command eject capability into the Hawk T Mk1 that would allow aircraft commanders to initiate the ejection for occupants from either cockpit seat."

And from the Convening Authority Comments - dated April 2019

NB The Convening Authority DG DSA post holder in March 2018 was Maj Gen Felton. Since March 2019, DG DSA is AM Gray. I have no knowledge of which DG wrote the comments to SI XX204. Bear in mind the comments were written when it was believed Hawk Mk 1 would be in service until 2030. You can see how the landscape might be changing ...

1.6.11. " ... The rationale for engineers to be Supernumerary Crew and deliver engineering support away from RAF Scampton is clear. Nevertheless, their employment in such a capacity should only be on sorties that are directly related to their primary role."

1.6.12. "... With aircraft commanders in all 3 main Hawk T Mk1 squadrons predominately occupying the front cockpit seat, it is appropriate to assess the feasibility of a command eject capability that could also be initiated from that position. Alternatively, Defence may have to assess if the risks associated with carrying passengers in the rear cockpit of the Hawk T Mk1 are tolerable.

Two years later the Defence Command Paper announced the surprise premature retirement of C-130, BAe146, Typhoon Tranche 1, E-3D Sentry and Hawk T1. In the latter three cases a clear about face from fairly recent positive statements on out-of-service dates and arguably, for all five types, resulting in an unwelcome capability gap. Perhaps Hawk T1 is going early because MoD refuses to pay for any general mitigation. Has RAFAT managed to head off any big changes to current Circus procedures ?,,,......................................................... ....
I seems to me entirely possible that the new DG DSA has had time to review a number of safety matters and has found them wanting. Furthermore it is entirely possible she has done what her predecessors seem to have avoided, grasped the nettle and tried to rope the sacred cow. .... Consider this -

"... Alternatively, [ without front seat command ejection] Defence may have to assess if the risks associated with carrying passengers in the rear cockpit of the Hawk T Mk1 are tolerable."

As it stands, a proper assessment of risk to life and duty of care for Hawk T1 rear seat passengers, could not possibly justify a claim of Low and Tolerable and ALARP. ... Jon Bayliss' death seems to support that argument. You would have to look further for an acceptable safety assurance.

If Circus has to travel, why not in the front seat ? If that is unacceptable to RAFAT, rather than pandering to the sacred cow, declare that it is equally unacceptable to continue with the current arrangements and another safer mode of travel will have to be found. Perhaps that discussion has already taken place. If so, what was the outcome ?

Other notable national aerobatic teams use support air transport as a matter of course, albeit many because their aircraft are single seaters. MoD knows this well because last year they sold a spare C-130J to the US Navy for their Blue Angels, (to be flown by the USMC in pretty Blue Angels colours and Marine Corps markings.

MoD has several C-130s and BAe146s for disposal. Re-cycling one or two of these might be cheaper in the long run than having a more expensive repeat of XX204.

However, there is no public indication (since 2018 and even now) that anything has actually changed (or is about to change) in terms of Red Arrows Circus seating or command ejection or alternative travel arrangements.

If no change is envisaged, that would be to publicly abandon any pretence of safety concern for this particular issue. That might suggest that DG DSA has either followed the laissez-faire or lost the battle.

If I were the NW Wales Coroner, in the Public Interest I would declare the Bayliss inquest to be Article 2. I would also summon the DG DSA, the Big Cheese herself, who might even welcome the opportunity to spill the beans in public, though it might put a damper on her career.

Jon Bayliss should not have died. His death was wholly avoidable. Under the circumstances, he didn't stand a chance.

Immediate Action to prevent a repeat would deliver a measure of justice for his family and for his memory, and would clearly be in The Public Interest.

Who Speaks for the Dead ?

LFH
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Not possible in a Hawk T1.
Although the rear cockpit has enough controls to land a Hawk,only the front cockpit has the LP Fuel C0ck,Parking Brake and other stuff such as the Main Flap controls,electrical switches and some Radio (?) controls.

​​​​​​That's not the reason not to, all that can be fixed with modifications, some very extreme; such as correcting the command eject, so the rear goes with the front. I suspect a very small modification, uncostly for 13 aircraft though.

I sense it's all down to £££.

Not a small modification for the cockpit controls Moi,changing the command eject system would possibly have been more viable.

Did BAe offer MoD a Hawk Command Ejection Mod ?
 

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Thanks Ron and Moi -

That would make sense - similar for the Gnat before. It really limits the options to command eject Mod or not at all.

I wonder if British Aerospace ever offered MoD the option to modify Hawk T1 for command ejection from either seat ? ... If not, why not ?

Did MoD refuse what would have been a sensible offer, using the same pathetic excuse that they used to refuse Martin Baker's proposal for fitting the Gas Shackle to Hawk ejection seats ? ... While taking it for Tornado ?

Deaths inevitably follow every case of inappropriate or plain daft decisions (like so many others) made in the safety of the office.

LFH
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Bayliss Inquest now Article 2
 

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From North Wales Live - Amelia Shaw - this evening

https://www.dailypost.co.uk/news/nor...thing-22038712

"At the pre-inquest hearing earlier this year Ms Sutherland came to the decision that article two of the European Convention on Human Rights - the right to life - had not been engaged.

But today she said that, following further disclosure from the Ministry of Defence, the "low threshold has been met for article two" to be engaged due to "breaches in duties".

Excellent start. I wonder what she will turn up next ?

LFH
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Telegraph article

https://www.msn.com/en-gb/news/uknew...out&li=AAnZ9Ug

"Katie Sutherland, the coroner, said the inquest - which is expected to last four days - would look .... what recommendations were made following other air crashes involving the Red Arrows in 2011."

Seen that link to the Flt Lt Cunningham case posted here on pprune a few times over the past 2 or so years. BZ

Did BAe offer MoD a Hawk Mk 1 'switchable' Command Ejection Mod ?
 

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Did BAe offer MoD a Hawk Mk 1 'switchable' Command Ejection Mod ?

According to the multitude of media reports from the inquest yesterday, there was lot of stuff about the lack of command ejection from the front seat.

But nothing to say if MoD had been offered and rejected the 'switchable' command ejection mod for Hawk Mk 1 ? I imagine if it was the other way round, we would have been told LaC by now. So far, silence.

The issue was commented on by the DG DSA herself in Part 6 of the XX204 SI, so I would be disappointed if the question had not arisen.

Will anyone at the inquest ask ?

LFH
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How about the Hawk T2? We’re any changes to Command Ejection made to that version?

As I understand it, Martin Baker are the DO for the seats on the TMk.1 under contract from the MoD, so BAE Systems are not directly involved in any mods until they get actioned and the installation changes (wiring/switches) need to be designed. The TMk.2 seats are under a different contract arrangement.

The command ejection system on the T2 (which remains an MBA system) is unchanged from other Hawks. The only seat change was the introduction of arm restraints at the MoD's specific request and cost (having been assessed as unnecessary by both MBA and BAES). The use of arm restraints were raised in a much older T1 Service Inquiry with the RAF never showing an appetite to fit them on the T1 fleet preferring to then highlight the discrepancy by fitting them to the T2.

CAEBr

Front Seat Command Ejection waiting for money
 

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TeeOne and CAEBr - Thanks, that all makes sense. IIRC the ARLs came from the Kastelli mid-air in 2010.

The major medias seem to have lost interest, but from Wales on-line this arvo ...

https://www.walesonline.co.uk/news/w...ected-22072171

"An inquest in Caernarfon on Thursday was told 25 recommendations had been made following a Defence Safety Authority Service Inquiry into the crash.

Group Captain Jackson said a feasibility study had been carried out and confirmed the system could be changed so pilots in the front seat could eject a passenger.

He said: “The feasibility study was completed by Martin Baker and it was deemed, yes, it could be incorporated into the aircraft.”

He said the improvements were expected to take between two and three years once the business case was approved."

Manana ?? .... I don't think we have anything quite so urgent as that in our MoD dictionary.

I bet Jacko is wondering what sort of poisoned chalice he's been landed with. They were talking about this problem in the Hawk Risk Register back in 2012, when 'e'd 'ardly got 'is scraper. He's now Hawk DDH and CO Hawk Wing.

LFH
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There's so much wrong with this statement I don't know where to begin.

Even if we ignore that fact he implies nobody recognised the risk until March 2018 (which would be untrue), why has a feasibility study taken over 3 years? Martin-Baker and BAeS will have known exactly what was needed, or else neither deserve their status as a Design Authority. Why has his office junior not self-tasked, identified funding, written the business case, and submitted it for approval within, at most, a few weeks? Instead, the witness is talking about 6 years and more from the accident to mitigation, by which time the T1 will be gone, except a few at the Reds which will presumably need a waiver as the timescale will start impingeing on the remaining useful life rule.

I'm afraid that, once again, an unfortunate MoD witness is reading from a script, probably written by those who are meant to have done the job, but don't actually realise this.

This all comes under 'maintaining the build standard', which is a prerequisite to a valid safety case, and permitting service regulated flying. It might be a good idea to start doing it again.

I think actually they first raised their head after XX186 in 1998.

And well before that, after the loss of XX298 in 1984.

Broken arms and dislocated shoulders ?

Perhaps following from "Where are my arms after I pull the SPFH ?" as opposed to "Where are my arms after I pull the Face Blind handle ?"

Hawk Risk Register - Fatigue Risk and mitigations
 

Hawk Risk Register - Fatigue Risk and mitigations

According to the multitude of media reports from the inquest, there has been a lot of generalised stuff about fatigue, referenced to Reds pilots.

SI - Page 1.4.70 (1.4.301.)

"The Sqn Chain of Command (CoC) maintained oversight of personnel fatigue .... The only time that a senior pilot had seen R3 fatigued was 2 weeks before the accident ..... . On that occasion R3 had removed himself from flying. "

SI XX204 Conclusions Page 1.4.102

"1.4.473. The Panel determined that when considered collectively it was very likely that R3 was, to a degree, fatigued, ... "

Contributory factors Page 1.1.103

g. ... "The pilot's working routine was detrimentally affecting his morale, not allowing him sufficient time for rest, consolidation and affecting his fatigue levels."

h. ... "Pilot fatigue." According to an historic Hawk Risk Register, two fatigue risks had been identified, which required specific mitigation to become Low and Tolerable and ALARP.

I can find no mention in the SI of these specific risks or of the required mitigations.

They were referred to in 2012 as 'Cumulative fatigue' (RED/CFIT-PILINC/02) and 'Fatigue' (RED/STFBS/01. Those responsible were listed as the DDH and the Wg Cdr RAFAT.

Are these risks and mitigations still valid and in force ?
Are these issues included in the coroner's reference to 'breaches in duties' ?

LFH
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Forgive my intrusion to this thread, but something has crossed my mind that may be pertinent to the discussion.

I was stationed at Scampton when Sgt Inman ejected from a Red Arrows Hawk (XX227?) during a transit flight from Macrihanish to Kinloss. ISTR, during a discussion with a member of the Red's 2nd line team not long after the incident, the question was asked why the pilot wasn't also ejected when Sgt Inman left the aircraft and he replied that the Red Arrows aircraft differed from the rest of the Hawks in the fleet in that the command ejection was initiated from the front seat.

All wrong I'm afraid. They are all the same and the rear can (selectably) command eject the front seater but not the other way round. Originally on the premise that the main role would be pilot training with the instructor (aircraft commander) in the back seat. The aircraft role has expanded somewhat and there is little if any student instruction left. That is (one of) the points of this argument.

To paraphrase the Red Arrows' risk register. If command eject is on, and the passenger ejects both inadvertently, then the risk is of injury (not death according to MoD) to both. The 'tolerable and ALARP' mitigation is to have command eject off, so that only the passenger is injured.

But, as admitted at the Inquest last week, it's not ALARP, and I'm sure the Bayliss family don't think it tolerable.

This admission by MoD is, presumably, one reason why the Coroner adjourned. Another might be that a senior officer stated quite categorically that Bayliss should NOT have been in the aircraft.

https://cimg7.ibsrv.net/gimg/pprune....2cbb548212.jpg

Daily Telegraph letters yesterday:

Too risky a manoeuvre

SIR – An inquest has been considering the death of a Red Arrows engineer, Corporal Jonathan Bayliss, at RAF Valley in 2018.

When I saw the footage and read the report of the crash, my reaction was that the pilot was practising a “turn back”. This manoeuvre is questionable in its efficacy and carries a high risk; the aircraft is on the cusp of the stall throughout and, given the aerodynamics of the Hawk wing, once it goes wrong, there is no way out.

As Officer Commanding Flying at RAF Chivenor in 1992, I was involved in the board of inquiry into an identical accident in which a young weapons instructor student died because he, too, failed to eject – why we’ll never know.

The inquiry was thorough, but the outcome was clear: the aircraft stalled and recovery was impossible, given its height, so the crash was inevitable.

At the conclusion of the inquiry, I wrote that, given the risks, and as a turn back had never been done for real, I recommended that practising the manoeuvre be discontinued.

I was, however, overruled by the powers that be, who stated that “it was a good judgment exercise” and should remain in the syllabus.

Three months later, a Hawk was written off at Valley following a practice turn back, although both pilots walked away from it. Twenty-six years later, sadly, Corporal Bayliss lost his life, and it could have been avoided.

Wg Cdr Jeremy Parr RAF (retd)
Suckley, Worcestershire

ROC man
I think that maybe Jerry is wrong?
My understanding is that the Practice Engine Failure was initiated with "apparently" enough height and speed to get to Low Key. Once the pilot had failed to achieve that Gate the Practice should have been "Knocked Off".
The poor decision to continue put the aircraft into a continually worsening situation. Even at half way round finals the aircraft could have been flown away quite safely.
The fact that the Hawk T1 does not had an AoA Gauge, Stall Warner or Command Eject Front to Rear only made the outcome more inevitable.

Thank you for that reply. I must say that I'm surprised that someone who worked on the Red's aircraft appears to have given out inaccurate information - I wasn't in a position to contradict what he said.

Sort of. A (practice) turn back (to the reciprocal runway in the examples above) is also initiated with enough energy to get back to the runway. Both however, can go wrong quite quickly and it is then down to the pilot to recognise (or not) that situation. Neither manoeuvre gets to a classic Low Key so it is impractical to use that as a gate.

Hawk Risk Register abandoned ?
 

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Hawk (Red Arrows) Risk Register - PEFATO - Turnbacks

'Exhibit No 67 - Risk Register' - from the Scampton XX177 accident in 2011, includes some sixty separate risks and where necessary, the required mitigation.

Although the spreadsheet style register is not specifically titled, it seems reasonable to presume it is specific to the Red Arrows, because every one of the risk file names begins with 'RED/.' Each risk is required to be reviewed periodically - six months or a year, though a few are conditional.

One of the identified risks - Risk No. RED/LOCI-HAN/04 - refers to 'turnbacks.'

This risk was described as -

.... "Effect - Loss of Control during the manoeuvre ..."

.... "Worst credible outcome - loss of pilot and supervising pilot"

.... "Liklihood - remote."

.... "Severity - critical.

... "Risk level - Medium."

.... "Risk owner - DDH. .... Risk Manager - OC RAFAT.

The required mitigation to reduce the risk to 'Low and Tolerable and ALARP was in three parts -

.... i) "Bespoke turnback training by HQ CFS Exam Wing."

.... ii) "60 day currency" ... [That's one practice every two months.]

.... iii) "Requal by QFI if ... [60 day currency] ... lapsed."

I can find no mention of a Hawk or RAFAT Risk Register, nor of the specific risk, nor of the mandated mitigation, anywhere in the XX204 SI. ...... A lot of contradictory mishmash, like for instance, the table on Page 1.4 - 7. - PEFATO recency - 30 days for 100 Sqn, 60 days for 736 NAS and, unbelievably, 'Not mandated' for RAFAT.

You'd think that issue alone would have invited comment from the XX204 Board, if only to deplore the change from the mandated '60 days' only six years earlier, and given the record of accidents resulting from practicing EFATOs and Turnbacks, and including the presumption that passengers should not be carried while practicing 'dodgy' manoeuvres.

Nothing in Part 1 to say if the Risk Register was included as an exhibit or had been considered. The closest I got was this cryptic comment -

..... Page 1.4.105 Observations

...... j. ... "The DDH's Air Safety register appeared to be more of a personal record rather than a formal decision register."

Four specific problem areas listed in the Risk Register at the time of XX177 at Scampton were discussed in great detail in the XX204 SI (only six years later) but without any reference to the Risk Register or to the Risk Codes or to the required mitigations.

The specific risk codes are -

RED/OTHR-1/05 - Command Ejection. ... RED/STFBS/01 - Fatigue

RED/CFIT-PILINC/02 - Cumulative Fatigue and ... RED/LOCI-HAN/04 - Turnbacks

Was the XX204 Board unaware of the Risk Register or of the importance of (ignoring) the mandated mitigations that referred specifically to Red Arrows, whose fatal crash they were investigating ? .... Or were they told 'not to go there' ?

Or has the entire Hawk Risk Register been abandoned ?

Someone must know.

LFH
....

LFH
 

I’m sure your intentions are pure and honourable but I’m afraid your posts are a tough read.

They are not especially well structured and it is often hard to understand what you are after.

In my view, a coroner is far more likely to obtain the relevant information and get to the bottom of things than a rambling poster on Pprune.

Maybe just let the lady get on with it and publish her findings in due course?

Before I face the wrath of the assembled kangaroo court I can state categorically that I have no dog in the fight.

BV

Lordflasheart - Thanks for your posts. In summary then, relevant risks weren't ALARP, the risk register was pants, and MoD didn't disclose this. That sums up a lot of threads here.

Bob Viking - Having taken MoD's side the coroner was persuaded to change her mind. The successful argument was posted on pprune. It's even in a book. I don't think she worked it out by herself.
If you are aircrew you have a big dog in the fight.

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Dear Bob Viking,

Thank you. ... If I may, I'll start from the bottom and begin with Kangaroo Courts.

Among these I would include the disgraceful and inexplicable overturning of the Mull Chinook SI by two RAF gentlemen, which resulted in the families of your colleagues being denied compo for many years - until a bit of public rambling on PPRuNe uncovered the deep rooted technical and institutional lies that had been supported by the state for so many years.

I would follow with the Kangaroo Crown Court at Lincoln, in which MBA were unjustifiably prosecuted by the HSE, where despite MBA, the Judge and the HSE being shown the exculpatory evidence, the court was happy to accept the technical lies and MBA's spineless and inexplicable guilty plea. The subject being principally the scissors shackle/gas shackle issue which put you and your colleagues at risk for many years.

Then I would look at the Sea King collision inquest where the coroner showed no interest in the truth and the MoD lied to the families about the case. Or the C-130 inquest where MoD security officials prevented an RAF officer entering the Coroners Court where he intended to give evidence of MoD lies about ESS. It took a brave coroner - there are some - to compete with the state on that one, and probably helped with the establishment of a cadre of 'specially trained' coroners to deal with active service deaths overseas, probably encouraged by MoD who hoped to prevent more unseemly verdicts publicly blaming MoD for their secret shortcomings relating to service deaths.

Madam Acting Senior Coroner's Caernarfon predecessor, in post for fifty years, is on record as having told some PPRuNe ramblers he was not able to take account of their real evidence because they were not 'interested parties.' It was he who should have held a local inquest into a service death in Scotland, where, as I am sure you will know, it was discovered that service personnel are not considered to be employees, thus doing them out of certain rights.

One hopes Madam Coroner may have felt able to consider certain rambling information that has been submitted to her and to her predecessors, or even that she may surreptitiously read those ramblings on PPRuNe after lights out.

I hope that her about face on Article 2 will have some beneficial result for Jon Bayliss' family and for future service deaths, but I worry that it is more likely to result in her not being confirmed in post, pour encourager les autres à suivre la ligne.

So what am I after ? Relevant to the current thread, I would like to know if the Hawk (RAFAT) Risk Register still exists. If so, why was it not mentioned in the SI ? If it doesn't, what has replaced it ? As I tried to explain, there are several very relevant issues which were glossed over or plain ignored by the XX204 Board, that would not be known about without access to the (historic) Risk Register. Someone will surely know the answer.

I would also like the MoD and the State to stop trying to conceal the truth about the next few service fatalities, or even to take preventative action. I gather from your posts that you are an experienced Hawk and service pilot yourself. It might be your mates or mine next, and (who knows ?) a bit of rambling on PPRuNe might just tip the balance.

You're right - the entire subject is a tough and highly technical read. Many readers (but not boards of inquiry, coroners, barristers or interested parties who want to know the truth) might be forgiven for dozing off after the first page. Finding the truth is always complicated but fortunately, it is now well helped by modern communications, when all sorts of previously concealed evidence can pop up to confound those who would conceal. Learning the truth would be particularly unpalatable when the enemy turns out to be the state that employs you to protect it.

I'm sorry my posts seem not well structured and hard to understand - and long winded again. I didn't have the benefit of the Short Service Writing Course. There are several well written good books by an author named David Hill. I can't remember if you previously said you'd read any of his stuff, or that you couldn't be bothered to do so. I'm sure you know where to find them.

Yours sincerely, LFH.

PS. I'm not sure I do 'pure and honourable' but I appreciate your thinking I might ;)

...

LFH

A wonderful response.

Keep posting.

LFH
 

That is a great response.

I clearly didn’t articulate myself very well previously.

I wasn’t questioning your motives but just pointing out that your earlier posts were not very clear.

BV