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Martin Baker faces prosecution re Red Arrows ejection death.

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    Originally posted by Mick F View Post
    The RAAF Museum's Ca-27 Avon Sabre has been grounded since March '15. Cartridges life expired, MB had notified of withdrawal of support a few months prior. Operated by Temora Aviation Museum on the RAAF Museum's behalf, the two museums and MB Australia recently trialled three models of current seats for retro fitment. A decision on whether to proceed is pending.
    And remember that the Temora Sabre already uses a retrofit seat: the original NAA seat (with mods) was standard equipment on RAAF Sabres and the current seat was a recent expedient to overcome similar issues with non-availability of an NAA seat cartridge. I dare say the abrupt ejection characteristics of the single-charge NAA seat catapult may also have had a bearing.

    Modern seats may be the way to go for many warbirds, but if one bears in mind the lack of 'zero-zero' capability on those early seats, plus their habit of crippling pilots, it's not necessarily a bad thing.


      It may be that the HSE investigation only began after the inquest.


        Originally posted by bazv View Post
        As far as I am aware - the family settled compensation with MOD a couple of years ago -
        The MOD insurers will be looking to recover any payment they have made from the person/organisation that they feel are responsible. It is not clear to me what actual evidence has been available. Do the MAIB work on the same basis as the AAIB?

        HSE can possibly bring a case under "due diligence" if proper records have not been kept or a fit and proper record system is not in place.


          3.1 of the HASAW.

          3 General duties of employers and self-employed to persons other than their employees.

          (1)It shall be the duty of every employer to conduct his undertaking in such a way as to ensure, so far as is reasonably practicable, that persons not in his employment who may be affected thereby are not thereby exposed to risks to their health or safety.

          MB are a company that manufacture an ejector seat. If they were to maintain that seat then this regulation would be in my view the correct one to serve on them. But, if the RAF maintained the seat then they would be in breach of this regulation if they were not immune from prosecution.

          Crown Immunity from Criminal Liability
          Action in the criminal courts is taken 'on behalf of the Crown'. Statute law is approved by the Crown (Royal Assent).
          It would, it is said, be strange for the Crown to prosecute itself and this is the basis for the Crown being 'immune' from prosecution for criminal liability.
          Tact is the knack of making a point without making an enemy.


            So who actually maintains the seats ? RAF, BAE or others ?
            Doesn't it also follow that the pilot must share some of the responsibility for seeing that the seat was safe ?

            When contractor Mike Harland fell out of a Tornado in 2007, the Crown Prosecution Service decided that there was
            insufficient evidence to charge anyone with manslaughter due to gross negligence, and that it was an accident.
            Engine Failure:.... A condition which occurs when all fuel tanks mysteriously become filled with air.


              Two issues. One the handle appearing to be "locked" but not actually locked, and the failure of the chute due to "over" tightened shackle bolt.
              The coroner reported that there had been 19 opportunities by 7 RAF personnel including the pilot to check the handle was in safe position.

              The coroner's view was that none of the engineers who worked on the seat could be criticized.

              This is why I feel that the case will be about "due diligence" and recorded keeping which includes the dissemination of important information. MB knew about the shackle tightness problem some time ago but appear to have no paper chain to the RAF. The coroner reported that the RAF had not given adequate training to its engineers so this possibly implies that MB had informed the RAF of the problem with the handle but that the RAF had not passed that information on to the personnel coming into contact with the seat. All record keeping and due diligence.

              "Due diligence" and the recording thereof is all important when the sh$% hits the fan and explains the proliferation of the warning signs stuck on everything these days. Usually the first n pages of instruction manuals now contains instructions of what not to do with your new gadget. "Slippery when wet".


                respectfully refer back to post #7


                  I see nothing in post #7 that would change anything in my last post which related purely to the announcement that the HSE is bringing a case and the conjecture about which mechanism within the HSE remit will be used. My post also quotes "facts" that have been reported attributable to the coroner. I make no comment on any "facts" other than to see how they could lead to a prosecution by the HSE.

                  I am not discussing the rights and wrongs of the case purely the mechanisms being used, so far, to bring a prosecution as I am not aware of all the relevant facts. I am happy to let the due processes of law take its course and hopefully come to a conclusion.

                  Whether the manner this is done meets with your approval would seem to be what is concerning you and I make no comment on that.

                  Al Capone comes to mind.


                    The MOD report can be read here. It consists of several pdfs, and makes sober reading.



                      Martin Baker pleads guilty



                        No such thing as an accident these days apparently ?, there always has to be someone to take the blame.
                        I wonder what the outcome would have been, had this happened 30 or 40 yrs ago ?
                        Engine Failure:.... A condition which occurs when all fuel tanks mysteriously become filled with air.


                          The death was caused by the tight shackle not the firing of the seat. This was a known problem and as such could have been prevented. When push comes to shove, insurance wise, this is all important. As I have said all along it is all going to rest on the paper chain and the demonstration of due diligence. How was this known problem disseminated down the chain and if the chain is broken who broke it? Are we not past the age where "workers" are expendable?

                          Just in general with air and train accidents it never ceases to amaze me how accidents are almost always a collection of events, each one of which is minor, that align to cause an incident.

                          What a difference a comma makes in the BBC News title.

                          "Red Arrows death firm admits failings."

                          "Red Arrows death, firm admits failings."


                            Its not a matter of workers being expendable -its the chain of events that lead to the ejection. Reading the results of the board of enquiry gives a stark reading of how many potentials for error there were that day.



                              While it is possible Martin-Baker erred in some way, the RAF's offences are admitted.

                              The Routine Technical Instruction the maintainer was working to was illegal. An RTI or UTI is only permitted if the Design Authorities (M-B and BAeS) are NOT involved. On a safety critical escape system, they must be. The crucial issue is that an RTI/UTI does not ensure a safety case update. This is why they are not Special Instructions (Technical), and aren't even mentioned in the authoritative Def Stan. Had the correct route been taken (an SI) then the lack of a safety case would have been flagged. Oversight was lacking, as it had been removed as a savings at the expense of safety. Plainly, no one with the remotest understanding of the regulations scrutinised this entire process - which had nothing to do with M-B.

                              Regardless of whether the 1990 bulletin was issued to MoD (and the only office it was required to be sent to ceased to exist in 1993, so how can one prove it either way?), MoD has released the 2002 report in which the warning about the possibility of the shackle jamming is crystal clear. This renders the alleged offence entirely academic, as MoD admits that it knew nine years before the accident.

                              The maintainer cut new thread on a bolt. The nut and bolt were therefore immediately scrap, but were not replaced. We don't know why, as his evidence has not been released. My own experience - you feel it.

                              The Service Inquiry made much of the 1.5 threads issue, ignoring a contradiction in MoD training that says one thread. Had it been one thread, the parachute would have deployed. I can't speak for the RAF, but an RN maintainer would follow NAMMS and his trade training - one thread. Also, out of interest, the FAA says one.

                              There's a lot more to this, and I'm afraid I must disagree that the only common factor is Martin-Baker. One crucial common factor between this and other cases is that 56 of the 60 recommendations in the SI report can be summarised - do what the regulations tell you to do. NONE of them are Martin-Baker failures.

                              Agreed. Importantly, because the SI report was not released until after the Inquest, the court only heard MoD's highly edited version of events. His words were unwise, and he should have at least added balance by pointing out MoD's offences, but he was serially misled. It looks like this issue of quality of design is what has been dropped by the HSE after discussions 'narrowed the issues' (i.e. being allowed to present independent evidence for the first time).

                              But I'd still have liked to have heard the head of Tech Pubs tear into the claim MB didn't send out the bulletin in 1990. He's been waiting since 27 October for the solicitors to take evidence. Having tracked him down, but gone no further, this was the indication something was going on.
                              says it all really
                              Last edited by TonyT; 22nd January 2018, 17:36.


                                Further report



                                  I think reading the BOI is a more valid .


                                    I wasn't suggesting it was David. The point I was making, in response to post #31, is that employers and manufacturers now have to show "due diligence" in preventing work place accidents, which was not the case in the past and that is right and proper. We should no longer have statistics like how many workers died building this or that bridge or tunnel.


                                      Problem with this accident is that people are focusing on the final part of incident.
                                      There are far too many factors in this and I am a bit disturbed that the person who assembled the shackle didnt realise that as a part of its function it should readilly move.


                                        A sad and tragic occurance to which MB has taken the blame. Spin the coin and think of the number of lives saved by this company over the years. Not excusing this situation and the death of this pilot though which should not have happened.
                                        I have kleptomania,But when it gets bad
                                        I take something for it.


                                          Yes indeed David, that is exactly what it is all about and is what MB and MOD have admitted. The procedures were in place that would have prevented this incident, the death but probably not the ejection, but were not followed. In my view it is almost always a management failure, they do not ensure that the correct procedures are being followed. This is totally unacceptable within the armed forces and it was made very clear that the ground level people were not to blame. As I have repeatedly said the HSE prosecutions are just that, H & S, and relate to "due diligence" in that information was not properly disseminated.

                                          I felt that the coroners comment that the safety system on the pull handle was "entirely useless" somewhat missed the point. The system worked satisfactorily if correctly used, however, with hindsight, is was of poor design as it was not fail safe. SOP required the insertion of the safety pin whilst rolling out from landing, necessitating it was done by feel. It would appear that there was no documentation on how the pin was to be used correctly and checked. The MAA report states that "it was not widely known" that the pin could be inserted incorrectly. This was the failure and although there were many opportunities to inspect that the handle was locked if you do not know what you are looking for you will not necessarily find a problem. Instructions on how to inspect satisfactorily that the pin is correctly installed would seem essential. It would appear that for very many years many aircraft were probably in an unsafe configuration whilst on the ground having followed the roll out procedure on landing.

                                          As David has said reading the MAA report is essential to understand why the HSE prosecutions are taking place, a link was posted early in this thread and is repeated here.