Absolutely Richard Dangle! This particular flight should never have happened. That said, the rather chilling thought is that it sounds, given the CO element, it may well have caused an accident/incident to someone at some other time unless the leak was picked up and sorted.

However, as well as CO appearing to be, possibly, the last link in the chain leading to this particular accident and the sad deaths of two people, what it ironically also revealed as a by-product, was a completely different can of worms involving one of them (as well as some people on the ground), namely, the legal basis for the flight itself and, quite probably, a host of other similar flights before it over the years.

No-one gloats over the death of people whatever the cause, particularly those of us who have lost several friends/workmates to flying accidents over the years. A majority of the discussion centres on why the flight took place at all. No-one knows exactly how/why the last few minutes played out as they did - some assessment has taken place based on ATC comms and Radar plots etc. To an extent, that is academic. However, much more of the focus of this thread has been on the "cottage industry" of such flights. You can read my views in earlier posts.

alphaman sums it up well - "A horrible tragic mess all round."

I do feel the (unprovable) carbon monoxide issue is being seized on by those, from the organiser to the regulator, to cover their own issues. Quite apart from everything else already described, it's more than a coincidence that, in the whole round trip, it chanced to incapacitate the pilot just at the one point in the flight when they encountered adverse meteorological conditions and got away from the VFR he was licensed for.

From the AAIB report:
"Post-mortem tests on the passenger showed a blood carboxyhaemoglobin (COHb) level of 58%, and the pathologist considered that he would almost certainly have been ‘deeply unconscious’ at impact."

Do you really think it possible for the passenger to be so badly affected and the pilot not? See page 48k - that's the page in the PDF.

Footnote 35 on that page says "The pathologist confirmed that the COHb level could be relied upon despite the length of time the body had been under water."



https://assets.publishing.service.go...4DB_Lo_res.pdf

WHBM, you will have seen my position from my previous posts but, yes, I can see that happening:-

Emiliano:- Dave, I'm feeling a bit cold, (as they approach the front or whatever - the freezing level was 3 - 4k) can we have some heating on if possible?

Dave:- Yeh, sure! No problems! {Cabin heating to "On"}.

Sadly, I think this is "Swiss Cheese" at it's best (or worst) in action. Just maybe Dave was in the position where, not only were the flight conditions getting on top of him, but the final straw was the cabin heating going on and CO taking over. Recovery of the plane (and I've seen nothing to say it has so please correct me if wrong on that) would prove the physical state of the heating controls.

But we have to go back to the main argument here; what were they even doing in the air at all that evening? As you say WHBM, some people are using it as the only "cause" when, in fact, neither of them should have been up there that evening. What a shame someone had not flown it earlier and reported it after feeling "unwell". And, thank goodness they were not 6 up over a built up area if it was CO. But, ultimately, what a shame Dave convinced himself that "It's fine, I can do this!" to himself!

Of course, the legal beagles will just be seeing who they can sue for max $$$'s which will ensure common sense gets thrown out the window..... That, dear reader, is another story......

Not an expert but I understand CO is likely to have effects long before it leads to unconsciousness. And even with enough to eventually kill, you may be still active for some time.
At what point might the pilot not be acting in his normal way? I don't think that can be ascertained.

Just thinking that the 'always' search for anything administrative, paperwork, license, etc is important but not looking for the cause of an accident.

The cause here, from the report, would appear to be CO poisoning and/or loss of control and /or pilot inexperience and/or weather..

I always feel that the actual lack of a certificate is not a cause. A pilot may have experience but no certificate or he may have a certificate gained only three or four hours flight time before. It is the lack of experience rather than the paperwork, surely, that is the hole in the cheese.

A couple of times I have been to airshows where pilots boasting that they got their PPL a couple of months before have been giving charity rides to people, even kids. My personal thought is "Are you stark raving mad?" Yes, technically the certificate says you can fly passengers (Non paying) around but other peoples' kids?

Sorry, thread drift for hobby horse.

ChrisVJ,

But a very relevant hobbyhorse

As you say Maoraigh1, who knows. In this case it seems there was some quite logical RT going on till almost the end. However, were the effects of CO creeping in before that and was David (Ibbotson) starting to feel the effects which caused him to seek continued VFR rather than IFR? Or was that a lack of experience as discussed by Chris VJ? When did CO start entering the cabin? We'll never know exactly but CO would now appear to be a factor in it all.

Agreed to a point ChrisVJ, at the end of the day its the pilot in that aircraft at that time and their ability to deal with what happens that will determine the outcome irrelevant to the bits of paper. However, the "Swiss Cheese" anology is a whole series of holes in a series of layers of protection (cheese) opening up which, eventually, as the last hole lines up, finally opens the path to disaster. Had there been no CO, the flight may have been fine. Had the flight left on time, it may have been fine. Had someone not asked for/put the cabin heating to "On" (if that was the fact) it might have been fine! Had he decided it was all getting out of hand and diverted to Guernsey, it might have been fine. You can play this game ad infinitum!

What the "paperwork" does do is try and put in checks and balances (additional layers of cheese) such as currency/recency requirements to ensure all ticket holders of whatever licence it is meet, as a minimum, certain standards/currency levels in attempt to to set a safety baseline and that baseline differs from a "private" operation compared to "commercial" operation to further reduce the risks for operations in the commercial world. So, if through ignoring the licences, this resulted in a pilot getting out of their depth, yes, it was an "airmanship" contribution to the accident for Emiliano as that particular hole was allowed to line up along with all the rest of the holes (late departure, poor weather, CO, etc, etc, etc). B&W limits, even just "paperwork", were ignored! Indeed, if the "paperwork" had not been ignored (and assuming the pilot had oodles of IFR/Night/Type experience), the irony is that this flight would not have departed just on the strength the "paperwork" was incorrect so this accident would not have happened. Purely by chance it would have been blocked by simple "paperwork admin". But, as I said previously, another accident may have happend at some other time to some other people - who knows!!! It is an absolute mess!!!!

I think many who have contributed to this thread have agreed we'll never know exactly why this accident happened, but that there were lots of things wrong with this flight and all we can do is learn as much from it as we each can. What many are saying is that, what this tragic event also flagged up by chance was the issue of "grey charters", graphically exposing another significant issue which, again, no-one knows quite how big an Industry problem it is (ie in the law being broken/insurance being invalidated etc, etc). We have argued this as well in previous posts so I don't want to re-run that hare again here! So, we have two distinct lines to this thread running in parallel which, actually, seem to affect each other - a bit like cross-coupling between two wires; no direct connection but "mutual EMC interference".

If the flight had been a simple PPL and his friend Emiliano heading back from a couple of days in France, this thread would have been a few sad pages long tops - even allowing for the football aspect. If it had been a commercial accident, again, a few (more?) sad pages long tops. The fact it was seemingly an illegal flight is why so much interest has been generated here. And, as Richard Dangle said, "....... Now we (the aforementioned professional aviation community - or at least most of us) hope the ensuing legal action will at the very least provide impetus to a long overdue change to the ambiguous regulations and dangers to the unknowing public that flow from them." is what this is all about now on that score. As for the rest of the sorry tale, just make the most of the real/possible learning points. Best that can be done - which won't suit the legal beagles one bit - but will provide them with endless fees as, unlike here on PPRuNe, they get paid to argue - we do it for free!!!! :ok:

I totally disagree: the "paperwork" as you describe it, is at the heart of this accident - it is there for a reason, to protect the pilot & anyone in or around the aircraft, from suffering the consequences of any mechanical failure or poor weather; it is not ancillary or immaterial, it's fundamental to why the aircraft crashed - it should never have been doing what it was doing, or flown in the manner in which it was flown, in the first place. The lack of a suitable qualification begs the question as to why - was the pilot not able to attain the necessary qualifications? In which case, why not? There seems to be evidence the pilot was considerably experienced in some aspects of flying; perhaps that experience lulled him into a false sense of security, & a feeling that this experience superseded his lack of qualifications to operate the flight. If that's the case, we're not dealing with someone who could reasonably claim ignorance of the rules or their meaning.

The UK advice for PPL holders offering charity flights is here: https://www.caa.co.uk/General-aviati...arity-flights/ - I expect that similar advice is offered elsewhere, in which case, pilots who adhere to it are presumed to be mature enough to understand the implications & act accordingly. If you feel that's not happening, perhaps make representations to the appropriate authorities to find out why?

Flying has always been an activity that requires a very clear understanding of the rules: ignorance is no excuse, & if people choose to ignore them, then I'm afraid then they're accountable for the consequences of their actions. In this case, the buck stops with the pilot, & the people who allowed him into the cockpit, & the paper trail will determine who that is.

^^ this exactly, so no need to for me to repeat it.

But I will fall back on the p-word again. You can be a professional (as in a noun) in an occupation because you are paid for doing it. Of you can be professional (as in an adjective) in the manner in which you conduct yourself within an occupation, whether you are paid or not. Anybody involved in aviation (in any of its forms) who operates with a disregard to regulations, compliance and such things as licencing are unprofessional.

Period.

"Paperwork" implies such things are mere bureaucracy, which they most certainly are not.

Apologies for labouring the point, but I don't think the waters are remotely muddy here so personally I'd rather the key issues are kept clear of any form of obscuration, however well-intentioned.

Alfaman,

With respect, your direction to the directions for UK charity flights is almost exactly what I am talking about.

In principle, the gaining of a PPL license, or here a PPL, a Recreational Permit or, for instance, an Ultralight license in the USA, grants the owner the right to carry some/a passenger. I am sure most of us know pilots who are steady and reliable hands when they get their license but I'm sure some of us know pilot's who have plenty of hours we wouldn't trust with our lives. The directions lay out the paperwork (and I do not denigrate paperwork,) required and suggested. It does not even suggest that waivers be in writing.

A while ago I was invited to an event where flights were being offered to kids belonging to an organisation that fostered youth interest in aviation. Being a low time mature pilot I declined. Later I read that they had given a record number of flights that day. One of the pilots was quoted as saying that he was happy he got his license three months previously as he had always wanted to give flights at one of those events. This not in a Colt or C150 but in something a good deal more demanding.

I have no idea whether the parents who signed the waiver allowing the kids to fly that day were advised that their kid might be flying with a pilot who had 60 hours total. We have signed waivers for our kids to go on camps and in hindsight we knew very little of the activities and supervision so I won't blast the parents. Life and growing up are not risk free anyway, but I would not want to be the organiser who had to say, "Well, he was qualified . . . ."

Our kids all got 30 min Flight School flights when they were 13 or 14. When we took the two eldest boys they did not both go up at the same time. (Could not do that to MrsVJ) They are both helicopter pilots now! RCAF put them in the same squadron and they even flew together. (I did not think they'd do that.) Now one of them is civilian I worry a little less..

Chris VJ - you're talking about something different to this accident, & to a certain extent, it's a red herring. The pilot in this aircraft is reported as having approximately 3500 hours total time, approximately 30 hours on type. He wasn't inexperienced at flying; he was also reasonably experienced on this aircraft. The issue stems from his lack of qualification to conduct the flight in the conditions he flew under. Had he complied with his licence, the aircraft would not have been where it was, therefore it would not have crashed. The aircraft was not certified or maintained in accordance with the requirements to conduct that flight either, therefore the opportunities to address the mechanical defects with it weren't available. The whole point of having a more robust licencing system, & more aggressive maintenance regime for aircraft carrying paying passengers, is to make sure such issues are caught & addressed before a passenger ever steps foot inside the aircraft. By ignoring them all, every single chance of keeping this aircraft safe was missed. No system can ever protect against wilful disregard of the rules & regulations by those who know them but chose to ignore them.

The issue of low hours pilots conducting charity flights does indeed have risks attached to it, the legislation & guidance is clear on that. It is still the licence holders responsibility to understand the requirements of the flight they are conducting, & to do so appropriately. Whether there is more risk attached than if the pilot was flying a friend or family member - I'm not sure why there would be - if they're conducting the flight correctly, why would their relationship with the other passengers make any difference? Surely someone offering assistance to a charitable event is already demonstrating a social conscience - they're donating their time for a good cause, after all. That doesn't strike me as the behaviour of someone who's likely to fly recklessly. You say you'd be uncomfortable to fly under such circumstances - that's fine, the guidance makes clear provision for that by placing an obligation on the pilot & the organiser to make sure you're aware of the circumstances - if you're unhappy, then you don't take part. Unfortunately, in this accident the poor passenger was denied that option & denied the protections of the system he had every right to believe he would be protected by - not because the aircraft wasn't fit to be flown, but because it should never have been airborne in the first place.

As an aside, I (pre pandemic) take part in charity driving events: these involve passenger rides around one of our race tracks - coned as a road circuit, so not at race speeds, but with the opportunity of stretching the car & showing some of it's capabilities, traffic permitting. The insurance, risk assessment, & briefings, both written & verbal, are very thorough. The rules are very clear & punishment for transgressing them is swift & final with no right of appeal. I've also run the events occasionally & have exercised the option to remove drivers for misbehaving: it's very well policed, very well marshalled, after all, there's no room for error when you're dealing with safety. I've no reason to believe flying events wouldn't be operated to the same criteria, I'd be horrified if they weren't.

Mr Henderson appeared in court today. He was granted bail and will go on trial in October 2021.

https://cimg7.ibsrv.net/gimg/pprune....67b320670b.jpg

Why is it so long to wait for justice? It will be nearly 3 years since the crash before the trial starts.

Between 2010 and 2019 295 courts have been closed - and this is pre covid restrictions on the number of cases to be heard in a day.

I guess the only amendment to your observation above is the use of the word "relevant" as a prefix to the word "experience". This not only influences the physical activity of flying in the conditions encountered, but also the overall attitude to the "management" of this flight as it progressed.

"Bad attitudes" are just as dangerous (or maybe more so???) as "bad flying skills"! Back in my time as an Instructor I have banned fully qualified and experienced (on paper) people undergoing an initial Club Check Flight from flying Club aircraft just based on their attitude - I just showed them the door (and rang ahead to the other Clubs on the field to warn them of what I had done!). The fact their flying was sometimes relatively poor was very much a secondary reason. You can train out poor flying skills with a bit of coaching - a poor attitude is far more difficult to correct!

It also looks very much like "experience" bred "complacency" here, something that commercial operations work hard to prevent, hence why regular check flights etc are so important. As you said further on in your post,

Thank you, yes I agree with all you've added.

Ddraig Goch because there is a huge backlog in the courts with simple cases waiting up to 2 years for something simple and the whole system threatening to collapse.
https://www.bbc.co.uk/news/uk-54737289

RTE news : Trial of man who organised flight in Sala fatal crash

http://www.rte.ie/news/2021/1018/125...h-court-trial/

He's pleaded guilty...another trial and inquest to come.

Due process will - one hopes - take care of the legal specifics on the flight. The bigger question (for me) is will commercial aviation learn the lessons of inadequate regulation and clamp down for good on the loopholes between commercial operation and leisure flying? One can only hope.

RIP and thoughts still with all the families involved.