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Thread: Martin Baker faces prosecution re Red Arrows ejection death.

  1. #31
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    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.

  2. #32
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    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."
    I had just got round to seeing the glass as half full instead of half empty, when some sod came and drank it......

  3. #33
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    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.

  4. #34
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    https://www.pprune.org/military-avia...ingham-16.html

    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 at 17:36.

  5. #35
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    I had just got round to seeing the glass as half full instead of half empty, when some sod came and drank it......

  6. #36
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    I think reading the BOI is a more valid .

  7. #37
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    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.
    I had just got round to seeing the glass as half full instead of half empty, when some sod came and drank it......

  8. #38
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    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.

  9. #39
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    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.

  10. #40
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    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. https://www.gov.uk/government/public...awk-tmk1-xx177
    I had just got round to seeing the glass as half full instead of half empty, when some sod came and drank it......

  11. #41
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    Further BBC report about the prosecution

    http://www.bbc.co.uk/news/uk-england...shire-43031833
    I had just got round to seeing the glass as half full instead of half empty, when some sod came and drank it......

  12. #42
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    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 .

  13. #43
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    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...

  14. #44
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    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.

  15. #45
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    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.

  16. #46
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    Quote 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.

  17. #47
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    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 at 17:17.

  18. #48
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    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.

  19. #49
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    Simple question: Is not the shackle a common part used on all MB seats from year dot?

  20. #50
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    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.

  21. #51
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    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 at 00:56.

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