Originally Posted by
Maoraigh1
................ At what point might the pilot not be acting in his normal way? I don't think that can be ascertained.
As you say
Maoraigh1, who knows. In this case it seems there was some quite logical RT going on till almost the end. However, were the effects of CO creeping in before that and was David (Ibbotson) starting to feel the effects which caused him to seek continued VFR rather than IFR? Or was that a lack of experience as discussed by
Chris VJ? When did CO start entering the cabin? We'll never know exactly but CO would now appear to be a factor in it all.
Originally Posted by
ChrisVJ
...... I always feel that the actual lack of a certificate is not a cause. A pilot may have experience but no certificate or he may have a certificate gained only three or four hours flight time before. It is the lack of experience rather than the paperwork, surely, that is the hole in the cheese. .......................
Agreed to a point
ChrisVJ, at the end of the day its the pilot in that aircraft at that time and their ability to deal with what happens that will determine the outcome irrelevant to the bits of paper. However, the "Swiss Cheese" anology is a whole series of holes in a series of layers of protection (cheese) opening up which, eventually, as the last hole lines up, finally opens the path to disaster. Had there been no CO, the flight may have been fine. Had the flight left on time, it may have been fine. Had someone not asked for/put the cabin heating to "On" (if that was the fact) it might have been fine! Had he decided it was all getting out of hand and diverted to Guernsey, it might have been fine. You can play this game ad infinitum!
What the "paperwork" does do is try and put in checks and balances (additional layers of cheese) such as currency/recency requirements to ensure all ticket holders of whatever licence it is meet, as a minimum, certain standards/currency levels in attempt to to set a safety baseline and that baseline differs from a "private" operation compared to "commercial" operation to further reduce the risks for operations in the commercial world. So, if through ignoring the licences, this resulted in a pilot getting out of their depth, yes, it was an "airmanship" contribution to the accident for Emiliano as that particular hole was allowed to line up along with all the rest of the holes (late departure, poor weather, CO, etc, etc, etc). B&W limits, even just "paperwork", were ignored! Indeed, if the "paperwork" had not been ignored (and assuming the pilot had oodles of IFR/Night/Type experience), the irony is that this flight would not have departed just on the strength the "paperwork" was incorrect so
this accident would not have happened. Purely by chance it would have been blocked by simple "paperwork admin". But, as I said previously, another accident may have happend at some other time to some other people - who knows!!! It is an absolute mess!!!!
I think many who have contributed to this thread have agreed we'll never know exactly why this accident happened, but that there were lots of things wrong with this flight and all we can do is learn as much from it as we each can. What many are saying is that, what this tragic event also flagged up by chance was the issue of "grey charters", graphically exposing another significant issue which, again, no-one knows quite how big an Industry problem it is (ie in the law being broken/insurance being invalidated etc, etc). We have argued this as well in previous posts so I don't want to re-run that hare again here! So, we have two distinct lines to this thread running in parallel which, actually, seem to affect each other - a bit like cross-coupling between two wires; no direct connection but "mutual EMC interference".
If the flight had been a simple PPL and his friend Emiliano heading back from a couple of days in France, this thread would have been a few sad pages long tops - even allowing for the football aspect. If it had been a commercial accident, again, a few (more?) sad pages long tops. The fact it was seemingly an illegal flight is why so much interest has been generated here. And, as
Richard Dangle said, "....... Now we (the aforementioned professional aviation community - or at least most of us) hope the ensuing legal action will at the very least provide impetus to a long overdue change to the ambiguous regulations and dangers to the unknowing public that flow from them." is what this is all about now on that score. As for the rest of the sorry tale, just make the most of the real/possible learning points. Best that can be done - which won't suit the legal beagles one bit - but will provide them with endless fees as, unlike here on
PPRuNe, they get paid to argue - we do it for free!!!!
