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Hawker Hunter down at Shoreham

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Hawker Hunter down at Shoreham

Old 30th Jul 2016, 15:29
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After all it is now common practice to charge doctors for failures in noticing patients symptoms and warning signs that lead to their deaths.
That is one reason the Chief Inspector of Air Accidents is going to be the first head of a new healthcare safety investigation body, to improve organisational learning and reduce the witch hunts.
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Old 30th Jul 2016, 19:05
  #962 (permalink)  
 
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Not quite as straight forward as Genghis the Engineer thinks. If criminal charges are brought against those involved then it is likely that the matter will be brought before the Crown Court and it will be up to a jury to decide the verdict. That will be a lay jury and given all the complex and technical nature of such a case, the AAIB investigation report, together with the opinions of expert witnesses for both the prosecution and defence will be crucial to such a trial.
The offence most likely facing the defendant(s) would be:
"SERA.3101 Negligent or reckless operation of aircraft
An aircraft shall not be operated in a negligent or reckless
manner so as to endanger life or property of others".

If the above is proven, the crime of involuntary manslaughter, where there was no intention to kill or cause serious harm but death was the result of an unlawful act or from gross negligence, must therefore follow.
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Old 30th Jul 2016, 22:22
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My point was not about the fine detail of legal process: which I deliberately avoided discussing, but that unless something is utterly and blatantly criminal, then that is not AAIB's judgement to make and indeed, they would be grossly failing in their duties if they tried to make that judgement.

Criminality is the Police's judgement to make, insofar as they make decisions about whether to put a case to CPS or other agencies for possible prosecution. It is not the Police's judgement to make whether anybody should receive recommendations about preventing a future accident - they are not competent to make such a judgement.

Hence the different approaches, and that the evidence gathered for each needs to be gathered in different ways.

G
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Old 31st Jul 2016, 09:18
  #964 (permalink)  
 
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I have to disagree. The AAIB investigation simply collects facts and looks for causes. The facts are unbiased and available to all. Any and all facts accumulated by the AAIB investigation should be available to the police, the CPS and the defence should it be deemed that a crime may have taken place. You can't simply say that as certain facts were established by the AAIB they must be excluded from any criminal investigation - that's unreasonable, and verging on a "pilots covering up for other pilots" position.

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Old 31st Jul 2016, 09:35
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Except where there are legislative bars, AAIB can share facts with CPS.
AAIB does not share its opinion or analysis.
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Old 31st Jul 2016, 09:47
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Thanks IOTC - that sounds as it should be.

PDR
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Old 31st Jul 2016, 10:42
  #967 (permalink)  
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Originally Posted by PDR1
I have to disagree. The AAIB investigation simply collects facts and looks for causes. The facts are unbiased and available to all. Any and all facts accumulated by the AAIB investigation should be available to the police, the CPS and the defence should it be deemed that a crime may have taken place. You can't simply say that as certain facts were established by the AAIB they must be excluded from any criminal investigation - that's unreasonable, and verging on a "pilots covering up for other pilots" position.

PDR
Not quite what I said.

The AAIB report is available to the police, CPS - or anybody else. That report of facts is, formally, only prepared to allow recommendations to be made, and support them. Hence that AAIB reports where they consider there to be no useful recommendations to be made, tend to be pretty minimal.

The rest of it can be made available, where due process shows that it should be released. It's not automatically available. I imagine that there's also due process somewhere if the AAIB want access to things the police have - and equally rightly so.

Making all of the evidence automatically available would be rather calculated to stop pilots being open with the AAIB. Given that it's in most of our minds more important to prevent future accidents than prosecute pilots who have made mistakes - that shouldn't be encouraged.

G
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Old 31st Jul 2016, 11:06
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Originally Posted by Genghis the Engineer
Not quite what I said.

The AAIB report is available to the police, CPS - or anybody else. That report of facts is, formally, only prepared to allow recommendations to be made, and support them. Hence that AAIB reports where they consider there to be no useful recommendations to be made, tend to be pretty minimal.
But the report isn't primary evidence - in fact it's heresay unless its preparation followed certain strict procedures.

The rest of it can be made available, where due process shows that it should be released. It's not automatically available.
This troubles me. The ADR/FDR/CVR data is primary evidence on a suspected crime scene and should automatically be available to a police investigation IMHO. The same should apply to any witness transcripts

Making all of the evidence automatically available would be rather calculated to stop pilots being open with the AAIB.
That's the bit that troubles me the most. I'm a chartered engineer - a Professional. A core part of my ethical code of conduct requires that I never conceal evidence even if it might place me or my employer in legal "hot water". If pilots will only admit their mistakes if they are assured that they won't face the consequences of their actions then this really calls their professionalism into question IMHO. People with that sort of mindset are not (IMHO) people who should be trusted with the lives of others.

YMMV (obviously)

PDR
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Old 31st Jul 2016, 14:40
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There was a case in Scotland after the Sumburgh helicopter accident. BALPA withdrew their appeal.

Scottish Court Orders Release of Sumburgh Helicopter CVFDR

Any chance the Sussex police would also turn to CAA to analyse the data?
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Old 31st Jul 2016, 18:39
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We must also bear in mind that The West Sussex Senior Coroner, Penelope Schofield, is also involved in the investigation of the cause and circumstances of these violent and unnatural deaths. The interesting point about the Coroner`s verdict would be whether " contributed by neglect " would be added.
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Old 31st Jul 2016, 20:06
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The AAIB does not lay blame
Overstress, there's probably some technical distinction, but simply stating facts can sound a lot like blame. For example here's a sentence from a random AAIB report:

The accident occurred as a result of the pilot continuing to land from a destabilised approach, rather than performing a go-around.
(Gulfstream 550, HZ-A6)

How does that differ from blame?
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Old 31st Jul 2016, 21:55
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Because behind that is all the reasons why the pilot failed to initiate a GA

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Old 1st Aug 2016, 13:00
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"What we identify as causes depends on whom we are communicating to, on the assumed contrast cases or causal back-ground for that exchange, and on the purposes of the inquiry. Thus, the subset of contributors to an incident or disaster that are seen as causal will be different depending on the purposes of the investigation.
  • If the investigation takes place for liability purposes, the concerns will be to decide who pays for damages or consequences, how to limit liability judgments, or how to deflect responsibility for damages to other parties.
  • If it is done for funereal purposes, the concerns will be how do we put the losses, often very personal losses, behind us, reassert our faith and trust in using the implicated operational system, and resume normal activities (e.g., after an aviation disaster, people still need to get back on an airplane and make use of air transport systems).
  • If it is done for political (power) purposes, incidents may be used as clubs or levers in struggles for control within or across organizations.
  • But if the goal is improving the reliability of the distributed human-machine system, the concerns should be to learn about how the overall system is vulnerable to failure, to develop effective strategies for change, and to prioritize investment.
Perhaps the greatest clue to the reliability of an organization lies in its reaction to failure.
Do not use investigations simply to justify the organization's motives (all of us, wherever placed in an organization, want to and try to do a good job).
Do not investigate with the a priori goal of finding out how others failed."


Quote from 'The Complexity of Error', page 173 onwards in
'Behind Human Error: Cognitive Systems, Computers, and Hindsight'.

This is a "heavy weight" technical review, but essential reading for those wishing to discuss aspects of human performance.

and a link from another discussion: http://www.safer.healthcare.ucla.edu...lPrimerDoc.pdf
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Old 2nd Aug 2016, 19:08
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Here is an extract from a preliminary AAIB release.
"The aircraft was taking part in an air display at Shoreham Airport during which it conducted a manoeuvre with both a vertical and rolling component, at the apex of which it was inverted. Following the subsequent descent, the aircraft did not achieve level flight before it struck the westbound carriageway of the A27.
Unless some kind of unforeseen event, such as mechanical or other technical malfunction occurred at a critical moment during this sequence, it remained the pilot`s sole responsibility to manage the effective flight path and energy state of the aircraft.
Once technical malfunction is ruled out, there will be little else but the reason(s) for a failure to manage effective flight path and energy management and monitoring by the pilot. Therein will lie the thorny issues of the whole spectrum of innocent error and mistake to neglect to recklessness.
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Old 4th Aug 2016, 09:56
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Chronus # 960, there is a significant difference between responsibility and blame (the human 'failed' thence blame.)
Responsibility can be identified before an event; blame only afterwards, as a biased construct of what is known with hindsight and usually attached to the last event, and the person most closely associated with it.
Investigations must consider a much wider remit; who approved, checked, authorised, or monitored the pilot, display, organisation, show location, etc.

“Responsibility lies with those who could act but do not, it lies with those who could learn but do not, and for those who evaluate it, can add to their capacity to make interventions which might make all our lives the safer.”
Phillip Capper – ‘Systems safety in the wake of the cave creek disaster.'
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Old 5th Aug 2016, 13:22
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Indeed. If it were questioned that those responsible for the supervision and regulation of the pilot had a part to play, then I suspect there would be more than one individual in the frame. Sounds like a whole bunch of work for various legal firms and expert witnesses.
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Old 6th Aug 2016, 08:36
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sounds like a whole bunch of work for various legal firms and expert witnesses.
Possibly, possibly not.

it's not hard to see this case failing the CPS code test, whatever the outcomes of all the various investigative agencies.

https://www.cps.gov.uk/publications/.../codetest.html

Given that whatever regulatory fallout from this accident is going to happen in any event and the pilot is hardly an ongoing threat to the public, I'm struggling to see a a public interest motive for prosecution, let alone the inevitable and formidable evidential challenges.

Not sure this is destined for criminal court...but what do I know?
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Old 6th Aug 2016, 11:22
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Before jumping to any public interest in a prosecution....no one has yet alleged any crime. That is still under investigation.

And then completely removed from the Shoreham incident, in a case where there have been multiple deaths, where there has been a huge impact on the local community, where the deaths have resulted from some crime, it is nearly inevitable that a prosecution would follow for that crime.

Mods

Could I please ask that this thread is closed / put on hold till the report is published in September?
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Old 6th Aug 2016, 13:08
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D Sqn, a request to closed a thread could indicate a closed or restricted mind re aviation safety. I sense a wide gap between a legal view and that of a professional pilot.
The thrust of recent discussion has been on process, seeking wider understanding.
Safety isn't driven by reports, where learning could be limited by the form of investigation (#959), or by what or who makes recommendations.
Safety, minimising risk for harm, is an ongoing process. Consider what has already happened, apparently as a result of the accident. What else might have been learnt by others because some thread aspect triggered a new viewpoint.
Open discussion, justified arguments, revised thoughts, actions ... precursors for safety.
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Old 6th Aug 2016, 15:48
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And I have tried to assist in the understanding of process relevant to this incident.

In any event, I will step down from this thread. I see very limited benefit in it staying open until further information is available.
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