the defence ‘human factors’ expert witness, Dr Stephen Jarvis ... adduced seven, eight, or possibly even twelve, piloting errors in the 23 seconds leading up to the aircraft’s arrival at the apex of the accident manoeuvre (the bent loop). They included:
- Unexplained power reduction.
- Continuing the turn beyond the appropriate inbound track.
- Failure to notice low speed.
- Pitch oscillations.
- Incorrect roll in the vertical.
- After, the apex, the failure to eject. That would have been a rule-based action, from his training.
Dr Jarvis did not include the failure to conduct an escape manoeuvre as one of his errors, because he said that was not his area of expertise.
Also not mentioned in his evidence, but clearly visible in the cockpit GoPro camera footage, was the fact that the aircraft was lined up on the road, apparently intentionally, during its final descent. Why would any pilot in his right mind do that, unless he was under the impression that he was lining up on a runway?
Dr Jarvis pointed out that one type of accident is an accumulation errors, which are not independent. In this case he was unable to find any relationship between the errors. The chances of that happening, he said, were astronomically improbable. That makes them very difficult to explain - other than by some degree of cognitive impairment.
He was asked about the possibility of this all being due to “extremely bad piloting”. He couldn’t accept that. AH was a very experienced and expert pilot, he said. Bad piloting didn’t fit, when he made ten or more errors in 23 seconds.
This is readily explained by the condition known in the military aviation profession as being ‘maxed out’, or stretched beyond the limits of mental capacity. Most often seen in student pilots, its recurrence is a common reason for suspension, whether in initial training or under carefully supervised conditions on postgraduate courses such as the Qualified Weapons Instructor Course. Many a current and capable second- or third-tour aviator with greater ability than AH has failed the latter by becoming ‘maxed out’ despite operating at what most would consider peak performance. The condition is typically suppressed outside the training environment by the application of a process known as ‘flying supervision’, which begins with regulations setting out minimum qualification and currency requirements and upon which a layer of professional judgement is applied, culminating in a signature authorising a particular sortie. Even the most experienced and expert military aviators are limited in what they are permitted to do when outside of currency stipulations, in part because of the risk of making errors and mistakes while ‘maxed out’.
He’s in front of an audience
Widely known in professional circles, and most especially in the display world, as one of the *very* highest risk factors for poor decision-making and self-induced pressure, while performing and even on the ground beforehand. Evidence: B-52 Fairchild AFB 1994, C-17 Elmendorf AFB 2010, Tucano Linton-on-Ouse 2009, plenty of other case studies, and the enormous quantity of military regulation that existed to control flypasts, role demonstrations and displays even before the Shoreham accident.
he’s on peak performance
Not a barrier to becoming 'maxed out', see my QWI course example above. More significantly, the statement is way beyond the bounds of credibility given AH's currency and experience on type.
gash, complacent behaviour doesn’t fit
A straw man argument in relation to the sequence of errors recounted. AH could have been doing his very best at that point in the occurrence. The key to our profession is not putting pilots in a place where their best is not good enough.
I am being deliberately tongue-in-cheek with all of this because I can’t think of many sortie profiles more likely to stretch a pilot beyond the limit of their mental capacity than a low-level aerobatic display at a tricky venue with patchy currency and less than 20 hours on type. Frankly I find it astonishing that a human factors expert would offer the pilot's supposed 'experienced and expert' status as an absolute barrier to poor performance, given countless historical examples of 'experienced and expert' pilots performing very poorly indeed.
Originally Posted by legalapproach
Easy Street et al
Ah yes, the court of opinion that hasn't heard any of the evidence. I have done my best to try and encapsulate the medical position
Few, if any on here are disputing the verdict duly reached in court of law; perhaps that makes our discussion off-topic given the word 'trial' in the thread title. However you should be unsurprised to learn that the verdict and medical position have been examined carefully by military authorities, as the outcome could be taken to infer that the military is unaware of the potential for CI at relatively low G, which would be a significant issue for legally-accountable aviation duty holders. So you'll have to take it as read that some of us may be more informed on the medical position than you think. Your statement of that position was enough to prevent the criminal standard of proof from being reached, but I'm afraid it won't wash with the majority here.