It’s a simple fact that the AAIB does routinely apportion blame, by identifying pilots (and others) as responsible for events in which they played a role rather than looking for deeper ‘causes’ (they have only one human factors advisor on their staff). In the March bulletin, an airline crew are described as ‘Rushing to complete the pre‐takeoff procedures’. ‘Rushing’ is the act the report says they carried out, it is connected to the event, and therefore is blame. The report, by the way, contains absolutely no effort to address the repetitive nature of the fundamental issue, incorrect performance, and is deficient.

More importantly, AAIB’s primacy prevents effective investigation in cases where blame is exactly what’s needed (albeit through the courts). The Sala report’s almost total dismissal of the ‘grey market’ aspects of this crash is deeply worrying. We know the AAIB is an incredibly engineering-led organisation, despite working in a world where human factors are of much greater importance (just count the pages dedicated to the output of the two disciplines), but that shouldn’t mean it dismisses the fundamental causes, which in Sala, begin with the existence of the grey market and the total unwillingness of regulators (especially the UK CAA) to deal with it.

The two organisations are inextricably linked, as the most senior staff of both report in to the SoSfT, including for their ‘performance management’. It doesn’t take a genius to work out what the consequences of that are.

But as a football manager, whose view on air travel is that it’s highly regulated and very prestige, how would you even begin to know that you weren’t applying that care, when credible shysters are selling you charter? The CAA view that ‘The first part of the approach is to educate the travelling public’, which is not challenged by the AAIB, is fantasy. The first part has to be proper regulation. In this regard, and conveniently assisted by the very fortuitous CO finding, the report is a whitewash.

‘although the AAIB were very critical in their report language of the CAA’s record keeping with regard to pilot licensing.

I'm seriously outraged. The report actually said little that wasn't already obvious, and is an AAIB masterclass in impartiality. (having been through the AAIB process I've had read to me the statement read to anyone questioned after an accident. The AAIB state that they are there to find out why it happened, not to apportion blame or be involved in criminal or disciplinary procedures) An inadequate, and apparently unlicensed pilot was given the opportunity to kill himself and an innocent third party by a person who spat in the face of the rules in place to protect the paying public. While Henderson may have got away with the manslaughter charges I suspect the illegal public transport may see him accomodated by Her Majesty for some time.

The loosening of the rules around "cost sharing" has made illegal charter even harder to pin down. Illegal charter has always happened, in my job I've seen angry pilots take an illegal charter pilot behind a building and administer some discipline. I run an AOC and live with the onerous burden of the oversight and compliance we are expected to deal with daily. I've watched a PPL with 200 hours laughing at commercial crews because he was being paid to fly a PA28 with paying customers to an airport for a good amount of cash.

I've seen the "cost sharing" websites and calculated the advertised costs of the flight against the real costs and worked out that some people are making hefty profits. Helicopter pilots taking sightseeing flights down the Thames not realising that an AOC doing the same thing has to have a non-standard flight plan in place, he thinks it doesn't apply to him as he's private and "all that **** is AOC ****" actually it applies to him as well.

This was a high profile accident, it highlighted a serious problem in UK aviation. This is a PROFESSIONAL PILOTS RUMOUR NETWORK, a lot of people on here are PPL's, and many high time ATPL's, well get this, ignorance of the rules and claiming "I'm private" is not acceptable, you share the sky with all of us making a legal living, you live by the rules we do, because when it goes wrong, if you're outside the rules you'll be in a world of hurt and all the pro's will be commenting on what a c### you are. I'd really like to see more people on here questioning what they want to do when flying, because some pilots on here have vast levels of experience, have made a lot of the available mistakes and have knowledge in many useful areas, perhaps the Private Flying Forum could be steered more this way.

Ibbotson would have known his license status, could have saved a lot of expense and hassle by just killing Sala when they first met, rather than getting into a doubtful aircraft without a valid license on which he was intending to be paid. Henderson gave him the weapon and desreves the opprobrium of the entire aviation community, the MacKays claim they thought Henderson was acting legally. Come off it chaps, it was all very cheap and you thought you were just getting a good deal, and lets face it you have history with aviation, you know how expensive it can be. And for the biggest fool of the lot in my opinion, the man who claims great aviation knowledge and experience, who's pronouncements about PBN approaches recently have shown just how worthless your knowledge and impartiality are, I give you the Rt Hon Grant Shapps, Secretary of State for Transport, the man who unmuzzled the "cost sharing" rules and made illegal public transport so much easier. Take the smarmy smile off Grant, you've been terribly quiet about this, a statement from you on how Illegal Public Transport will be tackled would be good, or maybe I'm a bit wrong about you and you won't stoop to such hypocrisy knowing that certain members of the media will flay you alive. I've given a lot of my time over the last 30 years to many aviation safety causes, there's an occasional word of thanks which I always greatly appreciate, but F### you Grant, I'm not giving my time (which actually costs my company) any longer while such an egregious fool as you spins in his big leather chair and riks the lives of the public and the employment of thousands of people in this country.

Yes I'm outraged, F###ing outraged! I work my arse off and risk my home and all my assetts to keep AOC staff employed when people try to steal from me and my team, then kill an innocent and cause untold damage to the industry I've worked in for over 30 years. This case frankly sickens me.

SND

Every aircraft owner I have hired from has been motivated by financial interest. They don't want their precious asset lost without recompense from the insurance company. So they check what the aircraft is being used for, they check on what licence/ratings are held by the pilot, they check whether they are current and whether the intended use is completely legal.
In this case the owner, the trust company, has handed the aircraft over to an aircraft manager without any legal agreement as to how the aircraft is to be used and seemingly without recourse to financial indemnity for any professional incompetence.
Of course the owner, may have just have been acting on instructions from the beneficial owner. The beneficial owner being a professional person who full well understands the professional management of assets, you have the aircraft owner, the beneficial owner and the aircraft manager all acting in a reckless way with nobody prepared to put a check on the other parties.

I, too, was disappointed by the bland statements in the report. It would be difficult to get much out of it if you hadn't followed this thread here. I wonder what part of "Investigation" in their title led them to this apparently deliberate minimalist approach.

I was also surprised how much of the detail of the Malibu, which I always thought, being pressurised etc, was a sophisticated aircraft, came over as little different to my PA28.

That is my focus with that forum. It seems like it's all been said there before, but probably time to start going around again.....

Yes, there have been many times, when I've been flying something fancy, or well equipped, when an unplanned event during the flight reminded me that it's just a plane, and I'm just a pilot. I can go bump in the plane about as easily as in my 150, if I don't apply the same care in each!

Very well said, SND. This is a truly appalling story. I am a (long time) private pilot and ex-instructor married to a commercial pilot, so I have a foot in both camps so to speak. That a private pilot was masquerading as a qualified commercial pilot is effectively fraud, Plenty people must have been aware of it.

My simplistic view is first that every pilot has a duty of care to his or her passengers, regardless. Ibbotson failed us all by what reads to be a cavalier and illegal approach to that duty. That taints us all in the eyes of the public.

That cavalier approach to safety and law appears to have been part and parcel of how this aircraft was being operated. It cannot have been accidental or due to unintended 'oversights'.
Given how firmly the CAA imply they will prosecute on any minor operational transgressions we may carry out, I do hope they will pursue this strongly, even if a conviction is unlikely to result, This is worth doing to try to discourage some of this 'grey' illegal activity and to make Joe & Joanna Public more aware and more alert to the risks.

I agree. Once again, very little bang for an enormous amount of tax-payer funded buck. Like most of their reports, it's minimalist in the areas you want to learn about and exhaustive in areas of limited or no relevance. It's hard to see why endless pages detailing which parts of the aircraft apparently broke off first as it sailed past Vne will help flight safety... I particularly enjoyed the insightful discovery that pilot and pax weren't unconscious before climbing into the aircraft. I learnt a lot from that. In addition to monitoring my CO indicator, I'm going to be ensuring I'm fully conscious before every flight now. And obviously not operating illegally!

It seems that, in many areas not just aviation, rules are there for those who choose to follow them and are no longer enforced. This can only end in the break-down of civilisation when the vast majority of rule followers finally decide "sod it, I'll just do as I like", whether that is taxing their car, not shoplifting or something much more serious.
The regulatory organisations seem to assume that everyone will do as they are told. They tell us that they have no money to enforce, yet enforcement could bring lots of revenue in the form of fines and penalties (if the money was correctly allocated by government).
Many of us law-abiding citizens are outraged, but nobody cares about us, so the decline in standards will continue until we reach a tipping point and it might be too late then to drag it back.
Aviation has been getting safer and safer due to the strong regulation, but we see it being relaxed and Boeings are no longer built to a proper standard because of self-regulation and cases like this are the tip of the iceberg. Who or how may have to die for the tide to turn?

Perhaps the focus of the AAIB report is naturally more upon the causal factors rather than the contributing ones?

What is almost laughable able if it weren’t so serious is the outrage from guys like SND after the fact.

The guy who he would engage with in this type of event for helicopters at the CAA would be only too pleased to get his teeth stuck into someone who was operating illegally - so that he hasn’t means a lack of evidence or lack of shouting / informing from those suggesting its widespread....

Having stood beside CAA staff watching grey market aircraft appear out of the low overcast, doing their home-made GPS approaches into VFR airports, having sat in meeting rooms with them to discuss exactly this topic, having provided lists of aircraft, crew, passengers, and flights, all of these things, and seen them do NOTHING, I can lay my life on the fact that you don’t know what you’re talking about.

SND takes one view; another large AOC owner has been bold enough to voice that he might just ditch his certification and go grey market, on the grounds that he’ll never be prosecuted, and if he were, the fines would be a fraction of what he pays in fees and the costs of ‘compliance’.

Try calling ACA, see what they say. https://www.theaircharterassociation...legal-charter/

And then, think how it feels to see the billionaire you’ve carried in your twin jet, week in, week out, disappear from the schedule, and then spot him walking out to his ‘friend’s’ PC12 for his regular trip... Fury gets nowhere near covering it.

Anyone who operates a helicopter in the UK will know the individual im referring to at the CAA and will as sure as im sat on my iPhone making predictive text fails will to a man know the absolute veal this guy would get involved with someone he thought was operating illegally. You sir have never sat next to this guy and watched anyone do something illegal.

So like I said either the shouting hasn’t been loud enough or the evidence hasn’t been there.

As an aside given the causal / contributory elements of this accident the causal parts had nothing to do with the economics of the flight.

The economics had everything to do with it; no grey market, no PA46, no unqualified pilot, no deaths.

CAA Prosecutions Says everything you need to know.

extrapolate that to not getting out of bed and you can be even less outraged...

however as I’m sure you’re an educated individual once the emotion is taken out of it perhaps the low prosecution number suggests either it isn’t a problem or if it is then the evidence isn’t there or more likely the regulations/guidance are so poorly worded prosecution is impossible..... and yet some champion this authority over EASA. Be careful what you wish for.

Tho list of prosecutions for 2018-2019 is interesting All PPLs, except for one which might be CPL(H). Three are document and reporting irregularities.

Unimpressive, but understandable, sadly - I wonder if the lack of grey charter prosecutions is because the people doing these will likely hire expensive lawyers. Hence it's easier to pursue the PPL offenders rather than the bigger fish. Minnows don't bite back much - and 'authority' looks to be doing soemthing.

A few years ago we had a single piston-engined vintage helicopter reglarly fly low (below 1,000ft) overhead on certain weekends. This was not long after a couple of high profie helicopter crashes in urban areas.
A bit of investigation found that I could pay for a flight in this device, despite it being flown by a PPL. A quick email to the CAA and a phone call from them to ask me a few questions and it all stopped. So it seems like the rotary enforcer at CAA is doing their job.

So they stopped, but were not prosecuted; they were handed down no sentence and paid no fine; they kept the profits of their enterprise.

That's OK, is it?

I completely agree but we also need to consider the CO aspect as well; a correctly authorised operator/pilot would not have done well with the suspected levels of CO

When the scale of illegal public transport is so well known and often very visible I find it disappointing in the extreme that the CAA's lists of (a mere handful of) prosecutions are almost exclusively PPLs with documentation lapses, failure to read NOTAMs or bad nav.
Where are the prosecutions for the hundreds of cases of illegal charter?
It seems clear the CAA enforcement branch must be taking an easy line.