Hawker Hunter down at Shoreham
Ah - having now read in detail the most recent AAIB Special Bulletin, I retract part at least of the thrust of my previous post.
It is now clear that there is a strong case to be made for the CAA to have significant indirect responsibility for the events which led up to this accident.
It appears there were plenty of holes in the processes and procedures on which they relied and it seems quite clear that some of the underlying assumptions were quite simply wrong, or overly simplistic. It looks strongly as though the CAA were not in fact doing the job which they are supposed to do. They thought they were... Oops.
It also seems that rather too much leeway was being given to what is best described as an 'old boy' network within at least part of the display community. There is no harm in that, per se; at these levels personal knowledge of the people involved is important, as is mutual trust. The snag with this is that personal acquaintanceship and friendship may inhibit or dilute the delivery of useful criticism. It shouldn't, but we are all human !
I still fear we may end up with overly pedantic nit-picking regulation in some areas, however for that we may have ourselves, as the flying community, largely to blame. Rats.
It is now clear that there is a strong case to be made for the CAA to have significant indirect responsibility for the events which led up to this accident.
It appears there were plenty of holes in the processes and procedures on which they relied and it seems quite clear that some of the underlying assumptions were quite simply wrong, or overly simplistic. It looks strongly as though the CAA were not in fact doing the job which they are supposed to do. They thought they were... Oops.
It also seems that rather too much leeway was being given to what is best described as an 'old boy' network within at least part of the display community. There is no harm in that, per se; at these levels personal knowledge of the people involved is important, as is mutual trust. The snag with this is that personal acquaintanceship and friendship may inhibit or dilute the delivery of useful criticism. It shouldn't, but we are all human !
I still fear we may end up with overly pedantic nit-picking regulation in some areas, however for that we may have ourselves, as the flying community, largely to blame. Rats.
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It is quite astonishing that the FDD 'was not provided with or was not aware of the display sequence.'
If the (very experienced) Flying Display Director had known that the aircraft was about to enter a loop, then seeing that it was too low to start such a manoeuvre, he could have called a STOP.
Which begs the following questions:
1. Why did the CAA initially accept and then quietly sweep under the carpet AAIB Safety Recommendation 2009-052: "It is recommended that the UK Civil Aviation Authority requires that the sequence of manoeuvres for a flying display is clearly specified in advance of the display and provided to the display organiser and that the sequence is practised prior to displaying to the public"?
2. Which CAA staff drafted this amendment for Edition 11 of CAP 403 in 2009: "the Flying Display Director is charged with circulating, prior to the event a written brief to all participants which will include details of manoeuvres to be flown at the event that are known and have been practised…"?
3. Which CAA staff then decided to omit the proposed amendment from Edition 11 (and all subsequent editions)?
4. Was this volte face approved at CAA board level or by other senior management?
In theory, there should still be a "paper trail" for all this for interested parties to follow.
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The CAA response (dated 20 Oct 2009) was as follows:
https://publicapps.caa.co.uk/docs/33/factor200910.pdf
Recommendation 2009-052
The CAA accepts this Recommendation in so far as, since the start of the 2008 display season, it has been a requirement for both display pilots and display organisers that any large formation or set piece display must have been specified prior to the display. The requirement to practice the display sequence is already covered in CAP 403, Ch 6, para 5.
However it is believed to be impractical to require that individual civilian display pilots specify a display sequence prior to the display and are then not allowed to vary it or modify it in any way later. Circumstances and weather conditions on the day of the display, such as time pressure in the display programme and wind strength, may make it safer to vary a display, for example by removing one or more manoeuvres from the approved sequence or by flying a flat display, rather than adhere strictly to the display originally specified.
The CAA accepts this Recommendation in so far as, since the start of the 2008 display season, it has been a requirement for both display pilots and display organisers that any large formation or set piece display must have been specified prior to the display. The requirement to practice the display sequence is already covered in CAP 403, Ch 6, para 5.
However it is believed to be impractical to require that individual civilian display pilots specify a display sequence prior to the display and are then not allowed to vary it or modify it in any way later. Circumstances and weather conditions on the day of the display, such as time pressure in the display programme and wind strength, may make it safer to vary a display, for example by removing one or more manoeuvres from the approved sequence or by flying a flat display, rather than adhere strictly to the display originally specified.
https://publicapps.caa.co.uk/docs/33/factor200910.pdf
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Thanks for posting that NF, and we see that's how they killed the AAIB recommendation:
They took the recommendation to specify and observe planned display sequences, they gold-plated it to the extent of excluding any specified and practised plans B, C, D... or W (for weather?), then declared that the duly gilded recommendation was impractical and just let their display pilot pals wing it without the poor Flying Display Director having a clue as to what's coming next.
It was tosh of the first order for the CAA to pretend that "circumstances and weather conditions on the day of the display, such as time pressure in the display programme and wind strength" couldn't be communicated to pilots before their displays, together with instructions to cancel or vary the display in accordance with an approved "plan B".
The questions remain: which CAA staff were responsible for this nonsense, and how could anyone else have fallen for it?
They took the recommendation to specify and observe planned display sequences, they gold-plated it to the extent of excluding any specified and practised plans B, C, D... or W (for weather?), then declared that the duly gilded recommendation was impractical and just let their display pilot pals wing it without the poor Flying Display Director having a clue as to what's coming next.
It was tosh of the first order for the CAA to pretend that "circumstances and weather conditions on the day of the display, such as time pressure in the display programme and wind strength" couldn't be communicated to pilots before their displays, together with instructions to cancel or vary the display in accordance with an approved "plan B".
The questions remain: which CAA staff were responsible for this nonsense, and how could anyone else have fallen for it?
Last edited by N-Jacko; 14th Mar 2016 at 18:59.
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However it is believed to be impractical to require that individual civilian display pilots specify a display sequence prior to the display and are then not allowed to vary it or modify it in any way later.
Even a Plan B (most typically due to low cloud, e.g. a flat display) should be a written and practiced Plan B, and it must also be in the hands of the FDD.
My plea to the CAA is this: getting this right does not need draconian regulations. What is needed is cool heads and plain common sense to fine-tune the regs for safer display flying, backed up by an unambiguous implementation policy.
When I trained for a DA (some years ago, and I never actually finished the job and became a display pilot), what I was told was that you have a defined display, but that everybody accepted the need for flexibility in that to meet circumstances as they change on the day - for example knocking off a loop that was looking wrong, or extending the display because the display director had asked due to the next item going U/S. But, my understanding was that this was within the broad approved scope of your display, and not just freelancing.
G
G
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Pre-inquest review hearing has been held. According to reports the police are asking for release of information gathered by the AAIB to help with their investigations. Does anyone think that this will not be permitted by the high court.
If the AAIB during investigations establish that a possible cause could also be a criminal act (for example deliberate cutting of hydraulic pipes, false record keeping) then do they have to or have a duty to report this to the police? After all most professionals have a duty within their profession and are legally bound to do so if they have reason for concern.
If the AAIB during investigations establish that a possible cause could also be a criminal act (for example deliberate cutting of hydraulic pipes, false record keeping) then do they have to or have a duty to report this to the police? After all most professionals have a duty within their profession and are legally bound to do so if they have reason for concern.
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Did not the same happen post Clutha? I suspect High Court action may be a legal technicality where third party deaths, particularly on this scale, are involved?
I doubt that in AAIB's eyes either Shoreham, or Clutha were other than accidents - awful tragic accidents with appalling loss of life, but still accidents.
One of the things I've noticed however is often a peculiarity of court cases related to aviation accidents is that a large role of the trial is to determine whether a crime was committed at all. It makes for a very different dynamic to my understanding of how the judicial system works.
Where there's a murder, robbery, drugs have been sold - there's little doubt that a crime was committed. The question is - by whom?
Where there's an air crash - there's no question who was in charge - but if it comes to court, the question is - was there a crime? In the vast majority of cases that, surely, is far from clearcut. That CAA loses, I believe, 75% of prosecutions that are contested reinforces that point.
G
One of the things I've noticed however is often a peculiarity of court cases related to aviation accidents is that a large role of the trial is to determine whether a crime was committed at all. It makes for a very different dynamic to my understanding of how the judicial system works.
Where there's a murder, robbery, drugs have been sold - there's little doubt that a crime was committed. The question is - by whom?
Where there's an air crash - there's no question who was in charge - but if it comes to court, the question is - was there a crime? In the vast majority of cases that, surely, is far from clearcut. That CAA loses, I believe, 75% of prosecutions that are contested reinforces that point.
G
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Interesting Contrast
"Arrests after girl, 7, dies while playing on a bouncy castle"
"A 27-year-old man and 24-year-old woman from the firm that runs the bouncy castle attraction were arrested on suspicion of manslaughter by gross negligence."
“It was a freak gust of wind that caught everyone unaware,” said Ray Smith, a representative of the Showman’s Guild of Great Britain. “It actually pulled the safety stakes out of the ground.”
"A 27-year-old man and 24-year-old woman from the firm that runs the bouncy castle attraction were arrested on suspicion of manslaughter by gross negligence."
“It was a freak gust of wind that caught everyone unaware,” said Ray Smith, a representative of the Showman’s Guild of Great Britain. “It actually pulled the safety stakes out of the ground.”
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Probably a "formality".
Unless they were aware that a tornado-strength gust was likely, I suspect that a court would be more inclined to agree that they had taken "all reasonable precautions" by staking down the castle.
Unless they were aware that a tornado-strength gust was likely, I suspect that a court would be more inclined to agree that they had taken "all reasonable precautions" by staking down the castle.
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Justice
Yes, arrest on "suspicion of manslaughter by gross negligence" is a long ways from a conviction, but I found it interesting that jumpy house operators are swiftly charged in a case like this, while no one has been charged in the much more serious and clear-cut Shoreham case.
Being American, I know little of the English legal system, other than the comical wigs, but I have some grasp of the concept of justice. These jumpy house operators are being held to a higher standard than display pilots, which I think is exactly the opposite of what should be happening.
Being American, I know little of the English legal system, other than the comical wigs, but I have some grasp of the concept of justice. These jumpy house operators are being held to a higher standard than display pilots, which I think is exactly the opposite of what should be happening.
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These jumpy house operators are being held to a higher standard than display pilots, which I think is exactly the opposite of what should be happening.
I wonder if the jumpy house operator followed the manual, did the soil tests, drove the anchor stakes in at the specified angle, just the right depth, and so forth.
Any pilot has a very specific set of instructions and limitations within which to operate. Excursion from those may be evident in the case of accident. The jumpy house operator might have thought they'd set everything up well, but did they have as well defined guidance for jumpy house set up and operation, as any pilot would for even a simple flight maneuver?
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but did they have as well defined guidance
But, we digress . . . . .
Once upon a time, I worked in Health and Safety, and spent a lot of time learning my way around the various UK legislation.
No surprise - factories were the greatest generator of H&S rules, but fairgrounds were in second place behind them (third, slightly surreally, was herring processing).
The understanding that fairground rides of any sort can be very dangerous has been with us for over a century.
Rospa have a whole page on bouncy castle safety here, which links various other documents.
Okay, with an aeronautical engineering degree, I could work out the loads on a castle and safe values on anchor points fairly accurately in half an hour. I wouldn't expect a fairground type operator to have my level of knowledge - but I would certainly expect them to understand RoSPA and related rules and guidance, and have access to rules of thumb on when things get dangerous. If there's evidence they didn't, there's no excuse.
At Shoreham, yes, perhaps some double standards - but the most recent AAIB report does certainly show where some serious questions might be asked of the FDD. On the other hand, maybe they have, and we just don't know about it.
G
No surprise - factories were the greatest generator of H&S rules, but fairgrounds were in second place behind them (third, slightly surreally, was herring processing).
The understanding that fairground rides of any sort can be very dangerous has been with us for over a century.
Rospa have a whole page on bouncy castle safety here, which links various other documents.
Okay, with an aeronautical engineering degree, I could work out the loads on a castle and safe values on anchor points fairly accurately in half an hour. I wouldn't expect a fairground type operator to have my level of knowledge - but I would certainly expect them to understand RoSPA and related rules and guidance, and have access to rules of thumb on when things get dangerous. If there's evidence they didn't, there's no excuse.
At Shoreham, yes, perhaps some double standards - but the most recent AAIB report does certainly show where some serious questions might be asked of the FDD. On the other hand, maybe they have, and we just don't know about it.
G
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I don't have a problem with the arrests of the jumpy house operators. It's possible that they knew it was too windy, or it may have been a sudden gust. That can be sorted out. However, I doubt they had airspeed indicators or more than a tiny fraction of the training even a lowly private pilot like myself gets. In the end, the wind did it, they didn't actively cause the accident. They can only be guilty of failing to anticipate the hazard.
Shoreham, on the other hand... According to the AAIB, the Hunter "appeared to be responding to the pilot's control inputs".
The Hunter ended up exactly where he put it. Other control inputs, other outcomes.
Shoreham, on the other hand... According to the AAIB, the Hunter "appeared to be responding to the pilot's control inputs".
The Hunter ended up exactly where he put it. Other control inputs, other outcomes.
It is quite astonishing that the FDD 'was not provided with or was not aware of the display sequence.' Marry this up with what CAP 403 states about not doing ad-hoc and unrehearsed manoeuvres. The FDD would therefore not have known, could not have known, if he was or wasn't witnessing an impromptu manoeuvre or two. Granted, G-BXFI's routine may have been to script, perhaps a flawed script, but how can a FDD manage aerial safety if he doesn't know what the pilot is going to do?
Although Canada, Australia, USA and other display regimes are stated, South Africa has a rather onerous but simple system. Full written display sequences (entry height, speed, direction, linking manoeuvres and the whole nine yards) must reach the FDD well before the show. Then, all aircraft doing aerobatics must do a validation in front of the FDD - no validation, no display. And finally, all display pilots must personally attend a safety briefing by the FDD (often multiple briefings are held to accommodate those far away).
And finally, my hobbyhorse again: Ban downward vertical pull-through manoeuvres in high inertia jets. Had these been banned, this Thread wouldn't exist.
Although Canada, Australia, USA and other display regimes are stated, South Africa has a rather onerous but simple system. Full written display sequences (entry height, speed, direction, linking manoeuvres and the whole nine yards) must reach the FDD well before the show. Then, all aircraft doing aerobatics must do a validation in front of the FDD - no validation, no display. And finally, all display pilots must personally attend a safety briefing by the FDD (often multiple briefings are held to accommodate those far away).
And finally, my hobbyhorse again: Ban downward vertical pull-through manoeuvres in high inertia jets. Had these been banned, this Thread wouldn't exist.
If in doubt, the FCC would watch video replays of the display and examine the position of the control surfaces at particular times to assure themselves the pilot was completely in control of the aircraft.
CAP 403 was 'written around' the Farnborough display regulations which had been developed by SBAC over many years of experience.
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The Hunter ended up exactly where he put it. Other control inputs, other outcomes.
Every person displaying, even the Red Arrows, had to have their displays observed and validated by a team of experienced test pilots from the Flying Control Committee; I have known them tell ATC to instruct the pilot to break off his display and land on several occasions when they decided it didn't meet their exacting standards.