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Martin Baker faces prosecution re Red Arrows ejection death.

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    #41
    Further BBC report about the prosecution

    http://www.bbc.co.uk/news/uk-england...shire-43031833

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      #42
      Not really sure what the QC is talking about in relation to the shackles. The person who assembled it would have been fully aware of its purpose and how is should feel. The Mod should be in court facing charges .

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        #43
        Anyone with a deep interest in this case needs to read and re-read the PPRUNE thread.
        There are posters there who know exactly what has gone on.
        MB should NOT be in the dock...

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          #44
          Had an interesting pub conversation last night with an ex- packer at MB ( left company in less than ideal circumstances not too long ago ) who is adamant that the machines that 'squash' the fabric into the pack on the seats were poorly maintained, not correctly calibrated, and prone to compress the chute at a higher pressure than was specified, thereby giving the canopy less chance to deploy in a ground-level actuation.

          Beer talk, complete bolleaux, a guy with a grudge,..... or a credible whistle-blower. It is hard to know.

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            #45
            Propstrike - According to the accident report though, 'compression' of the packed chute was neither the reason that the chute failed to deploy nor a contributory factor.

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              #46
              Originally posted by Nige
              Anyone with a deep interest in this case needs to read and re-read the PPRUNE thread.
              There are posters there who know exactly what has gone on.
              MB should NOT be in the dock...
              That was the impression I got. With those "In the know", failing to understand why MB have stood up and taken the blame.
              Then again, we only know what has been reported in court.
              Engine Failure:.... A condition which occurs when all fuel tanks mysteriously become filled with air.

              Comment


                #47
                I'm sorry, and although it pains me to say it, I believe the right people have been in the dock. Having read the report and drawing on my own aircraft design experience the MB shackle design is shockingly bad. It should never have been released from the drawing office as it's so obviously not fit for purpose within a safety critical system. The basis that something is safe solely because of the angle a spanner is turned is completely at odds with the overarching design requirement that "no single failure shall result in a catastrophic consequence" in Def Stan 00-970. It's the design authority (MB) fundamental responsibility to deliver a safe product and safety must not be policed in afterwards. For once the accountable manager in the design authority has been brought to book and, much to his credit done the right thing.

                Now should there be another person in the dock from the MOD certification authority, who knew of this, and did nothing for years (tolerated the intolerable), without question yes.
                Last edited by Vega ECM; 16th February 2018, 17:17.

                Comment


                  #48
                  What would be interesting to know would be the failure rate of the Mk.10 seat and how many unintended ejections have occured in the lifetime of the Mk.10.

                  After reading the report a number if times - there was a chain of events happening that day that should not have
                  happened.

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                    #49
                    Simple question: Is not the shackle a common part used on all MB seats from year dot?

                    Comment


                      #50
                      From posts on the dark side...
                      There are people on that thread with deep and intimate knowledge of the seats, the MOD, MB and other players.
                      Please read it - it's shocking...

                      I met MB's vice-preident of engineering at a lecture 2 nights ago.
                      You could not find a more inteligent, passionate, and safety concious engineer if you tried...

                      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.
                      The Red Arrow Case in a Nut Shell
                      What do we know ?

                      (1) Early 1980s, Martin Baker recommend shrouds over firing handles, MoD decide not to fit them.
                      (2) 1983 MoD offered a retrospective shroud on the Hawk which was refused.
                      (3) Drogue/Scissor jamming can be caused by a least two events (a) over tightening of the bolt, (b) geometrical lock.
                      (4) In 1990 gas shackle was being fitted (Court evidence)
                      (5) Mod offered for Hawk was offered all round the world, none has taken it up. (Court evidence)
                      (6) MoD regarded risk as being 1 in 115 years (Court evidence)

                      Now let's join the dots together

                      (1) Around 1990 the possibility of jamming because of bolt over tightening became known about, so the gas shackle was introduced.
                      (2) The gas shackle was fitted to all seats leaving the factory from that time. This explains Canadian Hawks and Mirage III fits
                      (3) Martin Baker offered up a modification to all users for in-use seats; it was not taken up; probably because of costs.
                      (4) Mitigation was to ensure no over tightening.
                      (5) Around 1997 it was decided to upgrade the parachute on Tornado seat (Mod 2198). This required re-qualification trial by MB
                      (6) During the course of these trials (1998) a shackle jam occurred, but this time due to a geometric lock.
                      (7) This could not be ignored, so gas shackle modification became part of Mod 2198
                      (8) Gas shackle modification eliminated the two known causes of scissor shackle jamming on RAF Tornado.
                      (9) 2002, review of the trials programme for Mod 2198 issued by QinetiQ. Customer Ref No. suggests that tasking was made in 1997.
                      (10) Gas shackle modification not read across to RAF Hawk T1s flown by Red Arrows ( suspect cost and low risk; 1 in 115 years)
                      (11) All RAF Tornado a/c modified (Mod 2198) between late 2007 and early 2012 (latest). No mention of gas shackle just parachute upgrade.
                      (12) 8th Nov 2011, Flt Lt Cunninghan initiates ejection sequence after strap misrouted through firing handle.
                      (13) Flt Lt Cunningham died when parachute failed to deploy because of one of the jamming causes (over tightening of bolt)
                      (14) November 2011 (after accident) MB issue SIL 704, making it clear that there was not an issue with gas shackle seats.
                      (15) SI panel examines evidence including references to Tornado zero/zero ejection problems and gas shackle.
                      (16) Final SI report, supervised by MilAAIB, makes no reference to Tornado ejection problems and gas shackle.
                      (17) No mention of Tornado ejection problems and gas shackle at inquest.

                      Bottom Line

                      Had Flt Lt Cunningham's seat been fitted with a firing handle shroud the ejection sequence would not have been initiated. Had his seat been fitted with a gas shackle he would have survived the ejection, perhaps with two broken legs, but he would have survived.

                      What has Martin Baker done wrong? Martin Baker hold the Ace, King and Queen of trumps, so why did their Defence QC not play them on 13th Feb 2018? Was someone holding a gun under the table. Sincerely hope that the Judge sees through this farce.

                      Comment


                        #51
                        What has MB done wrong?

                        As the design authority MB is responsible for the safety of the product;- i.e. The safety case, the hardware and all proceedures required to maintain it.

                        If the design authority finds a deficiency by which the safety can no longer be assured it's thier legal responsibility to declare this to the user. This normally means any modification costs will be paid for by the supplier. MB offered a modification and expected the customer to pay but they also offered an assembly process (failure rate calculated @ 1 in 115 years*) which they claimed would maintain the safety case. The MOD accepted the latter, but this incident proved the procedure was hopeless so MB should have sorted their unsafe design at their expense, after all they recognised it was unsuitable for everyone else.

                        No company should deliver equipment which is unsafe and then expect the customer to pay extra to make it safe.

                        The really sad thing in the case was that for MB the fix for the shackle bolt was very little cost.

                        * see the Rogers commission report for the problems with these kind of probability estimates.
                        Last edited by Vega ECM; 18th February 2018, 00:56.

                        Comment


                          #52
                          Ouch.

                          I saw this on the BBC and thought you should see it:

                          Red Arrows death: Ejection seat firm fined 1.1m - http://www.bbc.co.uk/news/uk-england...shire-43171049

                          Comment


                            #53
                            Tornado with the MK.10 seat was not grounded for a month -the narative on the shackles is completely baffling . It was one overtightened shackle not done by MB and whoever did it would have been aware of its function. Rather than just concentrating on MB -they should have looked at all aspects including procedures with the Red Arrows .

                            Comment


                              #54
                              David
                              Let me try again, apologies but when you work with this every day it's difficult to put my mind in the right place to explain it.

                              Right if a person is trusting thier life to the functioning of a complex system, in the eyes of law, the organisation that designed it are seen as the rightful place to declare it safe for use in service, not the operator, MOD, Red Arrows, etc

                              When a design organisation supplies a complex safety critical aero system they do so against a technical specification called Def Stan 00-970 which explicitly demands that no single failure shall lead to loss of life. So it's not acceptable for one man with a spanner to make one mistake which could kill someone;- as happened here. The shackle bolt should have had a shoulder against which the nut would be torqued and hence would never clamp the shackle on to the ring. This is really basic simple design precautions.

                              In the early 90's when this design deficiency was discovered, MB quite shamefully tried to charge the MOD for modification to fix it. The MOD quite rightly declined to pay so MB declared that safety could be maintained with a operator proceedure with a safety analysis that this would go wrong once in every 115 years. These analysis are only as good as the data input in to them which is normally speculative and their limitations are well known in the industry;- Note the Space Shuttle Challenger disaster where the safety case was negated completely by launching it with seals below the lowest temperature they'd ever been tested at. Likewise here we had a fitter who was convinced that one and a half threads in safety was normal.

                              Hence it was quite wrong to put the operators into a position where such a simple single error could kill someone.

                              Most people don't understand the role of the certification authority either. They audit the design authority purely to verify they have done what they committed to do.

                              Although there are people on prune determine to make up a conspiracy, they simply don't understand how safety critical systems are designed, declared safe and where the legal responsibility lie.

                              I hope this helps. Move on there's nothing to see.
                              Last edited by Vega ECM; 23rd February 2018, 18:26.

                              Comment


                                #55
                                .............they should have looked at all aspects including procedures with the Red Arrows .

                                I do apologise, David, for getting your name wrong!

                                They did David, right down to the pilot taking a phone call on his mobile as he walked to the plane and that the CO had been appointed direct from display flying and therefore already had a relationship with the display pilots. SOP was for COs to be brought in from outside so that there were no such relationships. As in all these inquiries, rail, air and maritime, absolutely every aspect is investigated and assessed to see if it contributed in any way to the event and the outcome of the event. These inquiries do not, of themselves, produce prosecutions, nor can the evidence collected be used by a third party, such as the police, to bring a prosecution, Shoreham highlighted this very clearly.

                                This prosecution was brought by the HSE and there may be more to follow.

                                From the inquiry, and as Vega has said, it was clear that the MOD was aware of the issue even if there was no actual paper trail as such, whether that could be proved in a court of law is another matter.
                                Last edited by paul1867; 23rd February 2018, 19:18. Reason: apology added.

                                Comment


                                  #56
                                  Vega -it would be nice to move on however as with a lot of cases there are clear examples of how not wanting to spend has resulted in deaths -Tornado TCAS being a prime example of something that was long overdue . In this case human error meant that a new thread was cut on the bolt -undoubtedly the torque would have been beyond what was
                                  the design spec for the bolt . However whoever did that thought he had done a good job -in reality when you mention that MB had already a design improvement -the talk should have been what are the consequences of not carrying it out . Clearly that didnt happen and cost seems to have been the overiding factor .

                                  If the shackle had worked to specification - there would have been a lot of questions to answer on exactly what was happening that day .

                                  Comment


                                    #57
                                    Interesting development

                                    https://www.pprune.org/military-avia...ingham-31.html

                                    This case drags on. The Health and Safety Executive's legal department have found it necessary to forward exculpatory evidence to Martin-Baker's solicitors, proving MoD knew of the risks from Day 1 (introduction of Scissor/Drogue Shackle release mechanism). This was denied in court, and the HSE's charge was based on MoD's claim NEVER to have known the Drogue Nut should not be over-tightened.

                                    Also, and despite reminders after the accident NOT to torque load the nut (also reflected by the CAA in Emergency Mandatory Permit Directives), the MoD chose to ignore this and still insists on it being torqued to 50 lbf in.

                                    If MoD is permitted to ignore such directives, and destroy its corporate knowledge, at what point does providing warnings or advice to MoD become utterly futile? It was HSE's case that, had Martin-Baker provided (reiterated) a warning in February 1990, then MoD would have heeded it and Sean Cunningham's parachute would have opened. At any time, but especially given this fresh evidence, that is one hell of a jump.

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