Red Arrows Incident
Discussion
Interesting Health and Safety only pursued the manufacturers rather than the RAF, working practices at both seem to be to blame. For the RAF at original coroner
http://www.bbc.co.uk/news/uk-england-lincolnshire-...
"Seven RAF personnel, including Flt Lt Cunningham, had 19 opportunities to check the ejection seat firing handle and did not notice it was in the unsafe position"
"Flt Lt Cunningham's parachute should have saved his life, but the main chute failed to deploy because a nut and bolt had been fastened too tightly, the inquest heard"
Both items should be made more fool proof and also opportunities for foolish behaviour should be stopped at the work place.
Health and Safety should have helped both parties make things safer in the future by asking for penalties to be applied to both the RAF and MB. This is not a blame game at this point, the lawyers will do that side, this is getting better working practices in place so it does not happen again.
http://www.bbc.co.uk/news/uk-england-lincolnshire-...
"Seven RAF personnel, including Flt Lt Cunningham, had 19 opportunities to check the ejection seat firing handle and did not notice it was in the unsafe position"
"Flt Lt Cunningham's parachute should have saved his life, but the main chute failed to deploy because a nut and bolt had been fastened too tightly, the inquest heard"
Both items should be made more fool proof and also opportunities for foolish behaviour should be stopped at the work place.
Health and Safety should have helped both parties make things safer in the future by asking for penalties to be applied to both the RAF and MB. This is not a blame game at this point, the lawyers will do that side, this is getting better working practices in place so it does not happen again.
telecat said:
As before that tends to indicate that the Seat had been badly maintained But not by Martin Baker. Seems to be a bit of a white wash going on.
"badly" implies carelessly, which I doubt: "incorrectly" is more likely, & due to the manufacturer not updating the user on an issue. Hence why they're in the dock, rather than the military.Riley Blue said:
I recall an incident at Yeovilton some years ago when a Harrier pilot was ejected when taxying in after a display. He too was killed and in front of thousands of people at the annual air show. Whether the two incidents have something in common I couldn't say but two is two too many.
quoteYeovilton in 1975. RAF Harrier pilot was exiting aircraft and somehow fired the ejector seat sending it and him some 200' into the air. He had just taxied in following his display and the aircraft was parked in full public view by the old ATC tower ramp.
https://forum.keypublishing.com/showthread.php?773...
telecat said:
As before that tends to indicate that the Seat had been badly maintained But not by Martin Baker. Seems to be a bit of a white wash going on.
Listening to a report on the Beeb (radio) today it seems MB were aware of an "issue" and had told other users but for some reason hadn't informed the MoD, which suggests to me it was an error in the maintenance publication for which MB is the authority.Wild stab in the dark but I'm guessing this was something to do with the way the errant nut was torqued and to what value.
It's not uncommon for procedures to state the torque setting for a nut or bolt and to then add that it should be further tightened sufficiently to aligned the split-pin castellations in the nut and the pin hole in the associated bolt. Obviously this can lead to a very small percentage of over-torquing which, depending on the application, can be critical. I guess MB discovered that in this case it was critical and probably directed other users to employ alternative methods of nut-locking that didn't involve over-torquing (eg wire-locking).
Why they didn't tell the MoD is a bit odd.
I just re-clicked on that BBC link and I'm pretty sure it has changed significantly today.
While we are wittering on about the torque of nuts...
'It emerged during the hearing in 2014 that the ejection seat firing handle had been left in an unsafe position meaning it could accidentally activate the seat. It is thought one of Flt Lt Cunningham's seat straps had pulled it into this unsafe position on a sortie four days earlier.'
- perhaps a simple re-design so that a seat strap cannot pull the seat into an 'unsafe' position might be in order too.
I'm glad I don't run an ejection seat company. Over decades you save thousands of lives from certain death, then get nailed to the wall for missing one.
While we are wittering on about the torque of nuts...
'It emerged during the hearing in 2014 that the ejection seat firing handle had been left in an unsafe position meaning it could accidentally activate the seat. It is thought one of Flt Lt Cunningham's seat straps had pulled it into this unsafe position on a sortie four days earlier.'
- perhaps a simple re-design so that a seat strap cannot pull the seat into an 'unsafe' position might be in order too.
I'm glad I don't run an ejection seat company. Over decades you save thousands of lives from certain death, then get nailed to the wall for missing one.
Crossflow Kid said:
Wild stab in the dark but I'm guessing this was something to do with the way the errant nut was torqued and to what value.
It's not uncommon for procedures to state the torque setting for a nut or bolt and to then add that it should be further tightened sufficiently to aligned the split-pin castellations in the nut and the pin hole in the associated bolt.
From what I remember at the time, the nut at the correct torque sits flush with the top of the bolt, however "word of mouth" said that you needed two clear threads showing outside the nut for it to be considered "correct" which really just over-torqued the setup. This eventually lead to one seat being over torqued too much and not allowing the shackle to move as it should have done, compromising the seat. In fact once the report finally comes out I'd be very surprised if the phrase "two clear threads" wasn't in there.It's not uncommon for procedures to state the torque setting for a nut or bolt and to then add that it should be further tightened sufficiently to aligned the split-pin castellations in the nut and the pin hole in the associated bolt.
I was on Tornados on 617Sqn when it happened and every seat had to be checked for this. While I didn't know Flt Lt Cunningham as any more than "just another growbag" as our paths probably only crossed once or twice during see-in/off's before he left 617 for the Reds, it was a bit of a shocker when for us all on the Sqn when heard what had happened.
Edited by IanH755 on Monday 22 January 20:34
saaby93 said:
Riley Blue said:
I recall an incident at Yeovilton some years ago when a Harrier pilot was ejected when taxying in after a display. He too was killed and in front of thousands of people at the annual air show. Whether the two incidents have something in common I couldn't say but two is two too many.
quoteYeovilton in 1975. RAF Harrier pilot was exiting aircraft and somehow fired the ejector seat sending it and him some 200' into the air. He had just taxied in following his display and the aircraft was parked in full public view by the old ATC tower ramp.
https://forum.keypublishing.com/showthread.php?773...
telecat said:
As before that tends to indicate that the Seat had been badly maintained But not by Martin Baker. Seems to be a bit of a white wash going on.
There's no 'seems to be' at all.MOD/Govt making sure its failings aren't washed in public....and so MB having to 'take one for the team'.
aeropilot said:
telecat said:
As before that tends to indicate that the Seat had been badly maintained But not by Martin Baker. Seems to be a bit of a white wash going on.
There's no 'seems to be' at all.MOD/Govt making sure its failings aren't washed in public....and so MB having to 'take one for the team'.
To me the majority of blame is quite clearly MB however the incorrect pin position should have been picked up.
ecsrobin said:
aeropilot said:
telecat said:
As before that tends to indicate that the Seat had been badly maintained But not by Martin Baker. Seems to be a bit of a white wash going on.
There's no 'seems to be' at all.MOD/Govt making sure its failings aren't washed in public....and so MB having to 'take one for the team'.
To me the majority of blame is quite clearly MB however the incorrect pin position should have been picked up.
ecsrobin said:
aeropilot said:
telecat said:
As before that tends to indicate that the Seat had been badly maintained But not by Martin Baker. Seems to be a bit of a white wash going on.
There's no 'seems to be' at all.MOD/Govt making sure its failings aren't washed in public....and so MB having to 'take one for the team'.
To me the majority of blame is quite clearly MB however the incorrect pin position should have been picked up.
https://www.pprune.org/military-aviation/584971-ma...
The couple of ex-RAF ground crew that I work with also agree with a lot of what is posted in that thread, and think it likely M-B are being made the scapegoat for MOD's failings.
aeropilot said:
Worth having a read of this thread.....especially the last few pages from post #289 onwards.
https://www.pprune.org/military-aviation/584971-ma...
The couple of ex-RAF ground crew that I work with also agree with a lot of what is posted in that thread, and think it likely M-B are being made the scapegoat for MOD's failings.
I started to read it but it had more grumpy old men than PH glad to see PPrune hasn’t changed https://www.pprune.org/military-aviation/584971-ma...
The couple of ex-RAF ground crew that I work with also agree with a lot of what is posted in that thread, and think it likely M-B are being made the scapegoat for MOD's failings.
saaby93 said:
Riley Blue said:
I recall an incident at Yeovilton some years ago when a Harrier pilot was ejected when taxying in after a display. He too was killed and in front of thousands of people at the annual air show. Whether the two incidents have something in common I couldn't say but two is two too many.
quoteYeovilton in 1975. RAF Harrier pilot was exiting aircraft and somehow fired the ejector seat sending it and him some 200' into the air. He had just taxied in following his display and the aircraft was parked in full public view by the old ATC tower ramp.
https://forum.keypublishing.com/showthread.php?773...
ecsrobin said:
How can you blame the engineer/RAF who tightened a bolt based on a manual produced by MB that was incorrect as the manufacturer didn’t tell the RAF an amendment had been produced.
To me the majority of blame is quite clearly MB however the incorrect pin position should have been picked up.
The Service Investigation (SI) claimed that the 1990 Ammendment Bulletin put out by Martin Baker had not been received hence MB taking the hit on an administrative charge.To me the majority of blame is quite clearly MB however the incorrect pin position should have been picked up.
However that neatly ignores the fact that there was a 2002 report by Quinetiq/BAeS/MB that addressed the scissor shackle problem (which was witheld from the SI).
Ginetta G15 Girl said:
ecsrobin said:
How can you blame the engineer/RAF who tightened a bolt based on a manual produced by MB that was incorrect as the manufacturer didn’t tell the RAF an amendment had been produced.
To me the majority of blame is quite clearly MB however the incorrect pin position should have been picked up.
The Service Investigation (SI) claimed that the 1990 Ammendment Bulletin put out by Martin Baker had not been received hence MB taking the hit on an administrative charge.To me the majority of blame is quite clearly MB however the incorrect pin position should have been picked up.
However that neatly ignores the fact that there was a 2002 report by Quinetiq/BAeS/MB that addressed the scissor shackle problem (which was witheld from the SI).
Probably never informed MB who it should have been sent to instead.
As many in the know have pointed out, really surprised MB pleaded guilty on this.
Slightly OT. But I read that the MK10 seat has no top handle just a seat handle. Years ago I was told the top handle was preferable unless in a real hurry because it put the pilot in a better position to withstand the ejection force. Is this a change of priorities or are modern seats less violent on the spine?
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