Reds Incident 8 Nov 11 [amended title]

[Mayfly]

[Xplumberlives]

That's GOOD news, now just waiting for the MAIIB Report to be published!

[Mayfly]

News about Red 5 replacement

http://www.raf.mod.uk/reds/teamnews/index.cfm?storyid=2030DCBC-5056-A318-A806794DE2CFEC50

[Xplumberlives]

Good news, thanks Pam!

[Mayfly]

After sending a full report to the CPS it has been declared there will be no prosecutions in the death of Red Arrows pilot Sean Cunningham.

BBC report Here

[Mayfly]

The inquest has finished and the Coroners report is out.


http://www.bbc.co.uk/news/uk-england-lincolnshire-25943211

[Molerat]

SI report on line https://www.gov.uk/government/publicati ... tmk1-xx177

[Molerat]

Martin Baker to be prosecuted by HSE
http://www.bbc.co.uk/news/uk-england-li ... e-37475298

[Spitfire]

Having read the report in full I am struck by the incredible sequence of seemingly unrelated events that conspire in the end to create the scenario for an 'accident' ... this has come to my attention when watching the TV programme where they analyse civilian airline crashes and it stuns me how things heap upon one another in random patterns to culminate in a catastrophe.

I have mentioned before that in law there are 2 types of definition of an accident and why it occurred ..

There is the 'Causa Causans' - literally translated as the 'causing cause' - he was ejected - the chute didn't open - he sadly suffered fatal injuries ...

Then there are the 'Cause Sine Que Non' - literally translated as 'without which not' - the ejection seat handle had been moved in previous flights due to incorrect use of the groin strap - the safety pin incorrectly inserted - the failure to notice the pin incorrectly inserted because of seat height - the overtightened bolt - the shackle failure ... and more ... all these things worked together to create that ONE catastrophe at that ONE moment ... unbelievable really. Had any one of those things NOT happened it may have never happened or have been survivable.

The testing and analysis to arrive at the correct conclusion post event is also to be applauded - the thoroughness is incredible - the identification and correct analysis of every scuff mark and scratch on that handle is stunning ...

Martin Baker's prosecution is maybe to be expected for some of the 'Cause Sine Que Non' but even the RAF have had to change maintenance procedures and briefings as a result ... for instance - the habit of reinserting the safety pin into the firing handle by feel alone whilst on roll out and eyes out of the cockpit is 'sloppy' in the extreme and an example of how even the best of the best can get complacent. That in itself not the actual cause - but a contributory factor overall. I bet they don't do that now.

Sad - but a LOT of lessons learned .. I wonder, however, what other 'causes' are building in other sequences .. makes you think.

[Aceyone]

Interesting analysis of a tragic accident,your point regarding the sequence of seemingly small incidents leading to the sad death makes me wonder how many other possible accidents such as this were terminated at some stage due to just one of the causes being noticed or fixed in time !

[Spitfire]

Interesting analysis of a tragic accident,your point regarding the sequence of seemingly small incidents leading to the sad death makes me wonder how many other possible accidents such as this were terminated at some stage due to just one of the causes being noticed or fixed in time !

Yes that was partly my point - I also wonder how many accidental sequences such as this were, or are, halted by one very diligent engineer or one pilot who noticed ...

I was particularly struck by the fact that it was so 'easy' to thread the groin strap through the seat firing handle - it should have been impossible .. design fault which has probably been sorted now

[Mayfly]

Not sure if this has been posted in this thread before but it makes interesting reading...


https://www.gov.uk/government/publications/service-inquiry-into-the-accident-involving-hawk-tmk1-xx177

[Ramshornvortex]

If you're interested in some first class analysis of the background to this whole sad affair (way before the holes in the Swiss Cheese lined up), then read this thread on PPRuNe (military), particularly the contributions from Engines, Easy Street and Tucumseh: http://www.pprune.org/military-aviation/584971-martin-baker-prosecuted-over-death-flt-lt-sean-cunningham-2.html

[Spitfire]

All very interesting - that 'Engines' seems to know his stuff ...

Yes - the 'causing cause' was the shackle failure that lead to chute not deploying and there seems to be fingers pointing at the Reds maintenance there...

But what fascinates me is all the other things that lead to the 'swiss cheese holes lining up' ( ) which are not technical but practical .. some of which I've mentioned above...

1) Why is it possible, at all, to thread the groin strap through the seat firing handle?
2) Why was the seat firing handle so badly misaligned? BUT yet it still let the safety pin be reinserted - if incorrectly - and more importantly NOT safe!!
3) Why was that not noticed by maintainers or the pilot? (Yes due to seat height adjustment - but that should have been known about and allowed for!!)
4) Why had the pilot got into the very bad habit of reinserting the seat safety pin whilst rolling out and eyes out of the cockpit?

So many imponderables and hopefully a LOT of lessons learned ... and as the 'Engines' says IF the pilot had not died then the incident would not have been investigated in such depth and not highlighted the many issues that were discovered subsequently to the death. So he may not have died in vain - sad though that is.