Read through the AAIB report again last night.
Pitts - personally I don't see an issue with human factors that caused the aircraft to take-off that morning. It was reported 999 at EGKR and expected to remain so. In that machine, VFR on-top under Radar control, was not unsafe. The decision to abort overhead EGTR and RTB was sound, and initially executed without additional risk. The flight back was uneventful to begin with and would have remained so (EGKR approach and landing were not hampered by Wx) if the plan had not changed.
We can't - and shouldn't - exclude humans from the equation and no amount of "rule creation" or "kit solution" will do that. There is always a balance between risk and other matter and only a human will make those complex decisions. As many have noted, simply saying "pilot error" does not help prevent recurrence, and so more analysis is needed. With the benefit of hindsight we can identify decisions that now look to be unwise and so the pertinent human factor question is: why did those decisions at the time look to the pilot to be the most appropriate responses given the information held and the options realistically available?
Carrying on with the flight sequence, this is where it seems to me things began to go wrong:
1. Getting a text to say EGLW was open - relevant as it presented an option not planned & prepared for. It would add pressure to check the information and to plan approach, etc. It would also allow for distraction of thought to what subsequently would happen - quicker response time to pick-up the client once the Wx improved - and hence add to the factors weighed in making the decision whether to continue RTB or to divert. Options at this moment were to respond that cloud was too bad to get through, or to try use resources to plan / execute the divert if it is available.
2. Asking LHR Special for confirmation that EGLW was open and would accept the landing. Given location, speed, etc this put time pressure on the task of getting below cloud but the option was to orbit above cloud whilst the matter was researched and reported back.
3. Deciding to drop through a "sucker hole" to get below cloud rather than orbiting.
4. On getting below cloud, finding the base to be very low in a flight environment filled with obstacles, continuing with a "normal" approach; flying the dog-bone holding pattern. Options at that time include going straight back up and rejecting the diversion, or alternatively going into a (noisy) OGE hover over the river.
5. Possibly being distracted (radio frequency change, for example) whilst executing a more challenging manoeuver in conditions that were certainly less than ideal; option of completing one task before commencing another.
Interested to learn if others agree that the relevant chain of events starts where I put it or somewhere else. I agree that prior interaction with the client, with other clients and with management are relevant to the decision process in accepting / attempting / rejecting the diversion. Also interested to hear if others see more "decision points" in the sequence.
Based on my interpretation (valueless, as I am neither an AAIB investigator nor a lawyer), the verdict of the inquest was not accurate as it cites perceived client pressure and Wx in relation to the decision to lift from EGKR. I suggest above that there was no safety problem with that decision or with the decision to RTB. The perceived client pressure was a factor in the decision to divert to EGLW and I would have liked to see both the AAIB and the inquest to have focussed more on the human factors that led to that decision, and to subsequent decisions once the descent through the sucker hole commenced.