I understand that the Health and Safety Executive is to
bring a case against Martin-Baker Aircraft Company Limited for an alleged
breach of health and safety law. The alleged breach is in connection with the
death of Flight Lieutenant Cunningham, a pilot of the Red Arrows aerobatic
team, as a result of an inadvertent displacement of the ejection seat firing
handle whilst his Hawk aircraft was stationary on the ground. Crucially, Flight Lieutenant Cunningham died
not because the ejection seat fired inadvertently but because his parachute did
not open.
Before I go on, I must declare an interest. In a couple of days, on 30 September, I will
celebrate the 52nd anniversary of becoming the 664th
pilot to save their life using a Martin-Baker ejection seat. A year or so later, I attended a gala dinner
at The Dorchester after Martin-Baker notched up their 1000th success. Not a single ejection, within the design
limits of the seat had been unsuccessful.
Subsequently, several thousand more, 7506 precisely, are here today because of the
brilliance of Martin-Baker engineering.
Writing to me in October 1964, Sir James Martin, Managing Director and
Chief Designer said “as the person responsible for the design of all our
various ejection seats, it naturally causes me great pleasure (to hear about
your escape).” At the same time, Sir
James extended a “hearty” invitation to have lunch and visit the works. It took me until the 50th
anniversary year, 2014, to accept the invitation. Meantime, for the rest of my flying career, I
happily entrusted my survival to Martin-Baker seats. It is vital not to underestimate the
psychological effect of knowing that you were flying with the world’s best and
most reliable escape apparatus. Put
simply, Martin-Baker was a benchmark for engineering excellence and reliability. Visiting the factory in September 2014, it
was impossible not to be impressed by the sheer dedication and attention to
detail in every aspect of their Denham factory.
During my RAF career of nearly 35 years, I had the duty to
investigate 2 high-profile aircraft accidents, one of which resulted in the
death of 9 crew members. The aim of the
accident investigation is to determine the cause and much mental effort is
devoted to isolating the root cause of the accident from other factors which
merely contributed to the accident. I
expect that this inquiry team, together with its convening authority, would
have been presented with a similar challenge.
The trouble with aircraft accidents is that they often result from a sequence
of events, none of which, in isolation would necessarily have caused the
accident. The day that “Murphy’s Law”
strikes the sequence of events, design failure, technical failure, maintenance
error, human error etc, has been allowed to continue to a conclusion. It follows that, quite often, humans can spot
things before they go wrong, interrupting the fatal chain before catastrophe strikes. Often, humans are unaware of the dangerous
turn of events and so they do nothing.
Very rarely, humans disregard the warning signs that their expertise and
training should have equipped them to see.
In this case, the inquiry will determine whether any personnel had been “negligent”
and whether they should be held to blame for their action or inaction. Proving negligence is not straightforward for
the living and, at least in my day, almost impossible for the deceased. Often, in the absence of categorical proof, sleeping
dogs must be left to lie. This doesn’t,
however, prevent lessons from being learned and procedures to prevent
recurrence being enforced. Hopefully,
before all this occurs, risk assessments will have identified most, but
crucially never “all,” of what could go wrong.
I do not know very much about the “Military Aviation
Authority” since this tri-service organisation replaced the Inspectorate of
Flight Safety which used to be responsible for accident investigations in my
day but I do not suppose that the principles of investigation are very much
different. I am certain there will have
been a meticulous inquiry in this case.
It is therefore somewhat surprising that the Health and
Safety Executive should consider that military business falls within their judicial
terms of reference. More fundamentally,
I wonder what possible public interest there could be in rehearsing a very
expensive inquiry and then failing to get a conviction (for fail they surely
will for the reasons I have outlined above)?
Quite what washing dirty laundry in public will do for morale is very
hard to see and undermining the perceived integrity of life-saving systems in
such a public way is surely not a sensible thing to do. If it is Flight Lieutenant
Cunningham’s kin who are driving the prosecution, I hope they get what they
want but I have to say, as one who is married to the widow of a victim of a celebrated
bit of flying and engineering negligence, I would have advised differently.
The court case will be expensive, time consuming and will,
regardless of the result, undermine confidence in the good order and discipline
of the service. For those of us who are dismayed (and very frightened) by the
remorseless erosion of defence capability in recent years, it beggars belief
that scarce human and financial resources should be diverted from fighting
posture to political correctness.