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-   -   Hawker Hunter down at Shoreham (https://www.pprune.org/accidents-close-calls/566536-hawker-hunter-down-shoreham.html)

3Faze 30th Jul 2016 15:29


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.

Chronus 30th Jul 2016 19:05

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.

Genghis the Engineer 30th Jul 2016 22:22

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

PDR1 31st Jul 2016 09:18

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

D SQDRN 97th IOTC 31st Jul 2016 09:35

Except where there are legislative bars, AAIB can share facts with CPS.
AAIB does not share its opinion or analysis.

PDR1 31st Jul 2016 09:47

Thanks IOTC - that sounds as it should be.

PDR

Genghis the Engineer 31st Jul 2016 10:42


Originally Posted by PDR1 (Post 9457128)
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

PDR1 31st Jul 2016 11:06


Originally Posted by Genghis the Engineer (Post 9457219)
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

3Faze 31st Jul 2016 14:40

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?

Chronus 31st Jul 2016 18:39

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.

PrivtPilotRadarTech 31st Jul 2016 20:06


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?

Genghis the Engineer 31st Jul 2016 21:55

Because behind that is all the reasons why the pilot failed to initiate a GA

G

safetypee 1st Aug 2016 13:00

"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

Chronus 2nd Aug 2016 19:08

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.

safetypee 4th Aug 2016 09:56

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.'

Cows getting bigger 5th Aug 2016 13:22

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.

The Old Fat One 6th Aug 2016 08:36


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?

D SQDRN 97th IOTC 6th Aug 2016 11:22

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?

safetypee 6th Aug 2016 13:08

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.

D SQDRN 97th IOTC 6th Aug 2016 15:48

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.

The Old Fat One 7th Aug 2016 09:04

D SQDRN 97th IOTC, I would guess your knowledge of the law well exceeds mine and I was not looking for a debate. My point is a simple one (and primarily intuitive + school of life informed).

Were I a gambling man, I would give pretty decent odds that the pilot will not face a prosecution.

I've been known to be wrong....many times.

Chronus 8th Aug 2016 17:56


Originally Posted by D SQDRN 97th IOTC (Post 9464967)
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.

Perhaps before you step down from the box could you enlighten us on the recent High Court hearing of the application by the police for access to evidence held by AAIB. The only information available at present is that the judges have "reserved judgement". Now what does that mean. Would it be right to guess that they are in deep contemplation about the verdict. The matter must surely be of interest, given that the police are looking for evidence to prosecute and should their win their day in court, then the chances are that some sort of charges are likely follow shortly soon after.

9 lives 8th Aug 2016 18:16


the application by the police for access to evidence held by AAIB
With my very modest understanding of investigative matters, I understand that both the AAIB and the police are to act within their mandates and to act in the interest of the public. And there's only one "the public" as I see it. Therefore, ultimately though perhaps approached from different directions, I would hope that the single public interest can be defined, and supported in the efforts of both entities.

The AAIB meets the public interest while not appointing blame. The police support the greater public interest of investigating events which might have a criminal offense involved, while maintaining that innocence exists unless guilt is proven.

The public interest is not, or less met, if safety is not advanced, if innocent persons are falsely prosecuted, or if people guilty of an offense against law are overlooked.

Gliderboy1 8th Aug 2016 19:04

Concerning how police involved
 
I'm interested in aviation and live in the area and was at Shoreham on the day.

What is really concerning me is about how Sussex police have made an application to the high court for priviliged documents and info including cockpit footage from the AAIB in so far as their own manslaughter investigations against the pilot Andy Hill. In so doing the police have to pursue the Secretary of State for transport legally. A bizarre situation.

I'm highly worried about this as the AAIB are the authority on investigating the accident, above the police obviously. If the police are successful in obtaining this information which enables them to follow through with their investigation and maybe take a certain course of action or decide on such action now, with the AAIB report or judgements in abeyance, that the police may directly or indirectly (from other government departments) have undue influence on the AAIB report outcomes. It could involve other government departments too. It just isn't right for me and I wouldn't be surprised if we have interference from too many vested interests in governments departments and organisations, that potentially a political and hidden judgement is made so far as causation of the accident in AAIB reports.

It's right the AAIB work entirely independently free of fear of consequences, then the police decide on criminal actions. The families of the victims would understand. This should then allow a view on the requisite levels of considered criminal negligence in manslaughter to decide what happens with a case against the pilot, if at all . I just wouldn't trust the police making judgements to pursue the pilot (with a case to the cps) backed up by the level of public angst of how it was ever possible this accident came about, someone looking for an easy scapegoat (the pilot) and politicians playing lip service to this.

The police have high instances of corruption and I really don't trust their meddling when irrespective of use of AAIB reports in criminal cases, if possible - effectively two parallel enquiries are on going seperately by two government departments with no wish to contradict, which it will be very hard not too.

Aviation accidents are caused by many factors normally and I just don't see how the pilot could ever be criminally responsible. But with officiousness of the police on his heels it wouldn't be too hard I doubt for them to present a case to the cps to prosecute. On the other hand the AAIB report is likely to mention many aspects to the accident, and it's right that Mr Hill is given the opportunity for the more independent AAIB and not police to act freely in the first instance. The worrying this is the police will have to take advice on causes etc, and the AAIB are the authority anyway, so this backs up my argument.

Jonzarno 10th Aug 2016 11:05


I just don't see how the pilot could ever be criminally responsible.
I don't see why not: for example a pilot might knowingly fly an aircraft with a technical fault, or deliberately exceed the design limitations and, as a direct result, cause an accident resulting in death or injury. I think that would justify a charge of manslaughter.

For clarity: that comment is made as a general point only and is specifically NOT in connection with this awful accident about which I know only what I have read here.

JEM60 10th Aug 2016 18:49

Gliderboy. If you made a mistake in driving a car, and killed 11 people as a result of that mistake, then you would be in serious trouble. Flying an aircraft, and making a mistake resulting in 11 deaths, then surely it's not difficult to realise that the same penalties will apply.

Chronus 10th Aug 2016 19:10

Glider Boy 1 as a person interested in aviation and making a remark as to how a pilot could ever be held criminally responsible wishes to be informed about the matter.

Here are two incidents which may offer some explanation and clarity to him.

Gol Lineas Aeras 737 Brazil mid air with a Embraer Legacy in 2006. The pilots of the Legacy were convicted on criminal charges.

The sad case of Captain Glen Stewart`s criminal conviction as a result of the incident on approach to Heathrow in 1989.

Both the above are well documented and full details are available on the internet.

Pilots, both private and professional, flying for recreational purpose or hire and reward carry a heavy burden of responsibility. It is a well known and often spoken proverb that flying whilst being the safest mode of transport is also the least forgiving of error of any kind whatsoever.

Bergerie1 11th Aug 2016 14:19

Glen Stewart should never have been prosecuted, the CAA made a great mistake when they decided to do so.

H Peacock 12th Aug 2016 13:57


Glen Stewart should never have been prosecuted, the CAA made a great mistake when they decided to do so.
Spot on Bergerie1, it was a travesty. BA's handling of the whole affair was also dreadfully incompetent.

Never Fretter 12th Aug 2016 16:41

Jem60

The difference is there is very little new to learn from 'another' road death tragedy.

Chronus 12th Aug 2016 18:53

All a matter of perspective and roles. For those who have lost dear and loved ones justice must be done. For those who must learn from mistakes and shortcomings an investigation must be carried out and from both we strive for it not to happen again. The price paid for it all is always heavy. Sometimes there are also other innocent victims. In forfeiting his life Captain Glen Stewart became such a victim. Captain Asseline, whose A320 crashed infront of a crowd of spectators , in 1988 at Mulhouse- Habsheim and received a jail sentence for involuntary manslaughter, was another victim.

tmmorris 16th Aug 2016 06:00

I'm not sure about that, NF - we just don't investigate and learn any more. Latest A34 crash is a case in point (notorious accident black spot for many years but no action taken as yet).

dsc810 16th Aug 2016 07:53

The A34 is , becasue of the amount of traffic carried a perfectly safe road in terms of the number of people killed per mile per number of vehicle journeys taken.
It is not a 'killer road' and does not feature in any of the most dangerous roads in the UK type professional surveys - though the pile-up do tend to be spectacular, the resulting hold up very lengthy and as a result it is nationally "newsworthy".

The road nearby which IS dangerous as it carries far less traffic but has a very high accident rate for its traffic rate is the Wantage to Hungerford A338.

Hebog 16th Aug 2016 16:42

If it is as simple as pilot error as everyone is convinced off, as the 1st AAIB report stated 'the aircraft appeared to be responding to the pilots control' then why have the CAA not lifted the blanket ban on Hunters flying.
I see no reason if this was the case that they could lift the no flying rule but keep the 'no aerobatics are to be performed and not exceeding xxx speed'. After all the Vulcan was only allowed to 'fly' but no aeros so same principles could be implemented. After all the Vulcan going down would probably do as much if not more damage than the Hunter.
The Gnats are able to fly again, after a sort period. Even the Red Arrows after their bad year with the loss of 2 pilots were not grounded for this length of time.
Think there is more information that the AAIB and the CAA have yet to release, after all they have only covered the basic facts of events on the day, airshow organisation, confirmation as to legality of the aircrafts permit in all their reports. No actual details as to the physical investigation of the aircraft itself has been provided as yet.

PrivtPilotRadarTech 17th Aug 2016 00:25


why have the CAA not lifted the blanket ban on Hunters flying.

The Gnats are able to fly again
Perhaps the distinction is because the AAIB report on the Gnat is done, and the one on the Hunter is not. Or perhaps it is due to the relative severity of the two accidents.

The AAIB did a good job on the Gnat report, impressive technical work using the amateur videos to calculate angles of bank and pitch, and all available info to calculate airspeed and altitude.

Hebog 18th Aug 2016 08:11

Don't think either have anything to do it with it. The Gnat was flying before the report was published. If you go by severity then all Airbus should have been grounded immediately after the Germanwings tragedy but weren't.
At the end of the day if you carry out a risk assessment on a Hunter under new regulation of basic transit flights with no aeros, it would show there is no greater risk than a Boeing 737. After all to establish risk you have to look at the hazard and its severity against the likelihood. In this case yes the hazard could be deemed high (but so could a Boeing 737) but the likelihood provided all the safety measurements are in place such as weather, trained experienced pilot, flight restrictions, good maintenance is low (for both) making this an accepted low risk. After all no flight is ever 100% safe, so if this is the CAA target it will never be achieved.

Chronus 18th Aug 2016 19:00

This is a safety issue for both,those in the air and those on the ground. Would any pilot having to do an emergency landing choose a busy motorway and risk more lives. If he did, is it likely to lead to a criminal prosecution.
In this instance it remains to be determined whether after the failed aerobatic manoeuvre the pilot knew or should have known that his course was taking him towards a busy public highway and had the means to avoid it. In the event that no technical fault or malfunction affected the aircraft, then the only outcome can be that the aerobatic manoeuvre was not carried out with all the adequate planning required and generous margins for all unforeseen events and circumstances involved.

PrivtPilotRadarTech 18th Aug 2016 20:17


If you go by severity then all Airbus should have been grounded immediately after the Germanwings tragedy but weren't.
There's a couple of important distinctions between the Germanwings and Hunter tragedies, and between the grounding of all Hunters and grounding of all Airbus A320-211's. They seem obvious to me, aren't they obvious to you?

If you're getting at the idea that political realities are the reason Hunters are still grounded, you may be right. That's life.

The Old Fat One 22nd Aug 2016 07:43

Fairly tidy little summary of where all the investigation are at, timewise

Silence marks Shoreham air disaster first anniversary - BBC News

with insurance details here

http://www.bbc.co.uk/news/uk-england-sussex-37121498

Hebog 27th Aug 2016 08:16

No more info than has already been available for months in regards to the investigation. Why does it take 3 highly respectable judges nearly 3 months to decide if the Police can have info from the AAIB. Surely that should be decided much quicker given the circumstances or are they are awaiting the AAIB investigation to be finalised. If so, they are then deciding on behalf of the CPS if there is case or not which is also wrong.


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