AAIB Report - Microlight Accident

[912ul]

Noticed a special bulletin released today by the AAIB about a microlight accident last year which resulted in the tragic and sad death of the pilot and a 'fare paying passenger.'
It makes pretty damning reading and begs the question that many of us have been asking for a long time - just how safe are these so called 'air experience' flights in microlights??
The report points out startling deficiencies in the maintenance schedule of the microlight, the competence of the Inspector and the cavalier attitudes prevelant amongst the microlight community.
Having just lost their CTO who was, by all accounts, well respected at Gatwick one wonders what the outcome of all this will be. It is such a damning report I was surprised not to see comment about it anywhere on the web.

[Sliding member]

Yes I read that lastnight and it is pretty tragic. I've been looking into going for a microlight but this has really made me think. I suppose anywhere in aviation you can get incomplete history, unrecorded maintenance etc which was just part of the problem with this A/C but not correctly embodying a Service Bulletin is inexcusable and you'd think the inspectors should know about the construction of the A/C and differing rivets.
I would say the Air Exp flights are a safe in these as any other mode of flight although all these Air Exp flights are questionable really (commercial flight?)

[Barshifter]

Sliding member

Theres over a hundred of these types flying on the uk register at the moment its the first to suffer an in flight incident such as this that Im aware of.If you read all the report,it mentions all the main reasons as to why this accident took place.None of which point out that the design is faulty.There are some reccomendations following this report but the "Quik" aircraft are still flying and havent been grounded so that must say something.

The BMAA have issued the following statememnt


"The BMAA, with its regulator the CAA, will study carefully the
recommendations made in the report and will respond accordingly where
action has not already been taken."



Regards

Barshifter

[bar shaker]

If I may correct Barshifter on a couple of points... There are 72 Quiks on the register, not quite 100, but it is still the biggest selling flexwing for the past few years.

The aircraft were grounded, following the accident, when the modification was upgraded to "before further flight". A subsequent request for a second inspection also grounded some who could not get it done within the specified 5 hour limit and were faced with getting inspectors in or trailering to them.

The report is the worst I have seen from the AAIB, but follows an apparent trend for AAIB reports into microlight accidents. The report contains plenty of science and investigation, it also contains an alarming amount of supposition and links that are tenuous beyond belief, none of which should appear in a section entitled Factual Information. Clearly anyone who has ever criticised the CAA has a an anti-safety mindset and should not be allowed near aircraft :rolleyes:

There are already criminal proceedings taking place and its very likely that civil proceedings will take place after these. There are some huge voids in the report but as I know people involved in the case, I'd rather not comment on any of the specifics.

The only winners in this one will be the lawyers.

[Stafford]

The report itself is a bit raw of course and I feel for the families and friends of the victims.

The incident was tragic, but NOT typical of the microlighting fraternity and it's aircraft.

There will always be scope for human error and failures in the process to minimise it but don't tar the whole community with one incident which is, as you say, still sub judice despite the issue of this "report" into the public domain.

Microlight flying is a safe, exhilarating way to get us normal bods into the air and as I fly group A and Microlights I can assure you that there have been similar tragedies and human error in GA, and on our roads every hour of every day !

The fairly spectacular and avoidable nature of this incident just emphasises the waste of human life and consequent grief of the families. Life is dangerous, and some of us humans choose to accept manageable risk as part of the fun of flying but as a society, I can't help feeling that the developing HSE culture would have us all wrapped in cotton wool and monitored for individual thought and action. ALL my colleagues in microlighting are very responsible individuals with familes to think of so short cuts are unthinkable to them

I personally think certain aspects of the report is crap and there appears to be an element of emotion and knee jerk reaction involved for reasons I can't quite understand. Purely my opinion of course having read and re-read it several times.

[MadamBreakneck]

The only winners in this one will be the lawyers.

'Twas ever thus!

I read the report this morning - we mustn't forget that we're talking about people's deaths here, so a little respect is in order. There was also speculation about the underlying influences in a recent non-microlight fatality - see other thread (http://www.pprune.com/forums/showthread.php?s=&threadid=188385)

Perhaps the AAIB is just reporting what they see to be relevant facts to the case, as they did in the other case. And don't forget Barshaker, that the AAIB are part of DoT and not part of CAA.

Returning to 912ul's points, I don't think it begs his question at all. Perhaps he'd like to search out and report to us the statistics on serious accidents on microlight trial lessons (or helicopter or Tiger Moth or Jet Provost (http://www2.newsquest.co.uk/worcestershire/archive/2000/07/27/malvern_news_latest01ZM.html) trial lessons for that matter).

912ul is clearly trying to provoke argument by his misrepresentation of the AAIB's view about the culture within microlighting; "cavalier" and "prevalent" are not mentioned - for those who have not read the report, I quote "that a minority of their members are inadvertently undermining the positive safety culture being promoted by the BMAA". This is a very different issue and is perhaps worthy of a thread of its own. I partly agree with Barshaker, however, that a couple of sentences in the "Factual" section might have been better placed under "Analysis" - but that's hardly a big enough error to damn the whole report.

Finally, 912ul's dig at the loss to the BMAA of its shortly-to-be-ex-CTO is misplaced. I believe the new incumbent of the post is as well (if not better) qualified for the job than his predecessor was on joining the BMAA.

Madam Breakneck

[912ul]

Hang on a minute.................................
It costs very many thousands of pounds a year to keep a public cat aircraft in the year and the pilots who are allowed to fly 'fare paying passengers' in them are subject to extremely stringent training and the result is that passengers are transported in a safe, well maintained aircraft piloted by a professionally trained and responsible person.
The passenger who so tragically died in this instance had every right to expect that the aircraft he had paid to fly in was well maintained, safe to fly and was being piloted by a responsible and safe person.
The accusations being levelled by the BMAA are systematic failures of the Inspector system and failings in the responsibilities of pilots who have been granted huge concessions to maintain their own aircraft. The AAIB are only saying what many have said for years - there are those in the BMAA who give the rest a bad name. If proof were needed, just take a look at the BMAA chat group on Yahoo today. Is there one ounce of sadness, remorse or regret for the passenger who so needlessly died?? NO !!
It is all about attacking the AAIB for daring to aportion blame and a loss of freedom of speech because a few sensible people are trying to gag the loonies and prevent even more damage - that is the kind of attitude that the AAIB refers to.

[Stafford]

912

What do you expect from the microlighting community ? Flowers and wreaths a la Princess daft Diana ?

Thats not the style of anyone I know in microlighting and their sincere sympathy with the families of ALL involved in this tragedy goes without saying - we all share the same inherent, but very small risk of accident and fully appreciate the sentiments and grief of the victims loved ones.

There is, on the other hand, a necessary balance in ensuring that such human failings when they do occur (very infrequently) do not impinge even more on the rest of us by dint of a Nanny state mentality and knee jerk reaction all too familiar under the present style of Government we have today

The report does have some very fanciful comments which I believe belong in the "IMHO" category and not in such an important document.

[MadamBreakneck]

If proof were needed, just take a look at the BMAA chat group on Yahoo today. Is there one ounce of sadness, remorse or regret for the passenger who so needlessly died?? NO !! With respect, you don't appear to research your comments very well. If you go back to the postings on that group at the time of the accident itself, there was plenty of sympathy expressed for the families of both on board.

My sympathy goes out now to those whose lives are ruined by this accident, in whatever way, and I'm sure that many others on this and other forums will agree - that doesn't mean that we have to grieve loudly and in public; it's not the British way is it?

Madam Breakneck

[bar shaker]

912

Your post ignores the human failings that can occur in any otherwise good, workable system.

If a LAE forgot part of the service, would you scrap the Public Cat as it was flawed? There are statistics that show PubCat aircraft are more likely to have an engine failure soon after a service. An alarming number of GA engine failures are fatal. Should we scrap the LAE system?

Microlights are simple aircraft, with restrictions on their use which creates a safe, affordable category of aircraft/flying. The training of pilots is geared towards microlights in that PFLs are drummed in and basic maintenace is part of the sylabus.

One person who ignores a service schedule does not make a fleet of dangerous aircraft.

Microlight pilots are able to carry out their own basic maintenance, but many do not, prefering an experienced mechanic to do it for them. Alteration of the primary structure or the power plant requires an inspector's signature. Changing the oil and plugs does not.

To perform trial flights, the pilot must hold at least an AFI rating.

As for posts on the microlighters' group, the grieving was done 15 months ago and the pilot was well known in the part of the country where I live. Any loss of life in aviation is always sad and your comment implies that the microlight fraternity don't give a toss about the pilot or his passenger. Nothing could be further from the truth.

There are many questions missing from the AAIB report and there are many opinions in the report which neither help air safety nor have they any basis in fact. It is understandable for people affected to react in a protectionist way.

[Mike Cross]

It costs very many thousands of pounds a year to keep a public cat aircraft in the year and the pilots who are allowed to fly 'fare paying passengers' in them are subject to extremely stringent training and the result is that passengers are transported in a safe, well maintained aircraft piloted by a professionally trained and responsible person.
The passenger who so tragically died in this instance had every right to expect that the aircraft he had paid to fly in was well maintained, safe to fly and was being piloted by a responsible and safe person.
I would agree if you were comparing apples with apples but you are not.

There is a general principle that passengers in public transport operations are protected. For this reason we have regulations covering Public Service Vehicles, Passenger Ferries and Aircraft which are designed to ensure that a member of the public getting on a bus ferry or transport aircraft is protected.

However this isn't what happens in training, whether its on an aeroplane, motorbike, car or boat. If you are having a lesson it's not the same as being a fare-paying passenger where you are paying to be transported form A to B. You are undertaking an activity that is more hazardous than being a passenger of a public transport undertaking and that is a risk you accept. If you learn to sail, the boat doesn't need a Passenger Carrying Certificate. If you learn to drive the vehicle doen't need a public Service Vehicle Licence and if you learn to fly the pilot does not require an ATPL or a CPL and the aircraft does not require a Transport Cat C of A.

There are requirements that come in to play where payment is made either for the hire of the aircraft or to the instructor and these vary according to circumstances but these relate to the fact that payment is made, not to the fact that it is a trial lesson.

The suggestion in the AAIB report is that a modification was carried out incorrectly. In any safety regime it is always possible that someone will get something wrong with tragic results and there are many examples of this happening in public transport aircraft as well as permit types. Taking a "holier than thou" attitude to one airworthiness regime in preference to another is not the answer.


Final paragraph edited.
Heliport

[egbt]

Having read the report I wonder if the BMAA can survive if it does not make very major changes to it’s procedures and even bigger changes to it’s culture to ensure that they are followed.

IMHO everyone has a right to expect, when taking a flight in or buying an aircraft, that the aircraft conforms to the standards which the governing body says it does. I take Mike’s point about acceptance of risk but in this case the risk was being misrepresented –
The aircraft had not in the past been maintained to the schedules - a 200 Hr service at > 300 Hrs! (OK perhaps not directly relevant to this accident but an accident waiting to happen)
The mod was signed off by an inspector but was incorrectly done and not understood or checked properly.
There was essentially no paperwork and the wing had (probably) not been inspected per the schedule.
The inspector had signed that the paper work had been checked and was correct!
The BMAA’s inspection system shown to be in some disarray – putting it kindly!
The BMAA system, in the widest sense of the word, did not pick any of this up and revalidated the aircraft’s permit. Thereby failing it’s customers, in its duty of care and the duty it assumed by asking for and accepting a regulatory role on behalf if the CAA.

And before the flaming starts I have no particular interest in PFA vs BMAA wars as I am not associated with either, although there is a strong probability I will be moving from a certified a/c to a permit one in the near future.

[Barshifter]

bar shaker


Nope not 72 theres 126 to be precise according to G-INFO on the uk register.The 72 your are confused with I think are the the ones that have been affected by the mandatory mods as mentioned in the report.



Check here (http://www.caa.co.uk/application.aspx?categoryid=60&pagetype=65&applicationid=1) to find out.

Cheers

Barshifter

[MadamBreakneck]

Having read the report I wonder if the BMAA can survive if it does not make very major changes to it’s procedures and even bigger changes to it’s culture to ensure that they are followed. Let us hope that the new Chief Inspector is able to pull this off. Without the BMAA we wouldn't have had any worthwhile microlights in the UK at all, and they are all that many of us can afford to fly.

It is worth considering just how rare in-flight break-up is these days, even with the weaknesses in the inspection regime which the report identified. After all, even Public Transport cat machines fall apart sometimes (engines falling off Boeings, tails off Airbus, cargo doors off McDonald Douglas, and a big fire aboard Concorde, for instance:eek: )
Madam B

[bar shaker]

egbt

The points you raise are, as I see them, valid with the exception of the last permit issued. The aircraft had undergone a 200hr service which baselined the maintenance requirements so, in this matter, the signature was correct.

The age old rule on buying any aircraft, permit, CoA, whatever, is if the aircraft paperwork does not seem right, then walk away.

The BMAA have already undergone a massive overhaul of the inspector network and have implemented most if not all of the recommendations long before the report was issued. They, I hear, are about to appoint a new Chief Inspector who brings with him a wealth of experience. We can only wait and see what a future appointment brings.

In their audits with the CAA (also criticised in the AAIB report) the BMAA were seen to be complying with their remit.

Human factors have let down a system. The system may have needed improvement, but it was assumed to be working well until this incident. The systems that were in place were built from experience and I am sure that the new ones will be built on experience too. The regulation empire that we all fly under is based on previous experience. We should not forget that we are one of the most heavily regulated countries in the world and, as far as microlights are concerned, we are by some margin the most heavily regulated. That regulation did not stop this accident and whilst the aircraft in question is sold throughout the world, the failures occured under our heavily regulated regime.

This brings its own questions. There are those that say if you impose regulations, people will generally comply with them, but they will go no further. The FAA impose considerably lighter regulation on GA and none on their microlight fleet. Their level of fatality is slightly less than ours (per hour flown). Is this because more responsibility is put on the aircraft owner/pilot to ensure that the aircraft is up to scratch.

Who has not collected an aircraft from an annual and flown it on the basis that it will, at that time, be at its most reliable?

Barshifter, yes you are correct. I was quoting the figures from the AAIB report.

This report raises many interesting questions. The correct answer is often not the most obvious answer. In saying that, the report is very focussed on the BMAA and, as such, has missed or overlooked many questions which I consider equally important.

As to the survival of the BMAA? This is the only case of structural failure that in an extended recent history. We learn from experience, some of it tragic. We would not be where we are now unless we learnt from tragedies and we will be in a better position when we have fully learnt from this tragedy.

[egbt]

Bar Shaker,

I think you will find that the 200 hour service related to the engine only; there is no evidence that the wing had been stripped and inspected as required and the report suggests that if it had been the problem might have been discovered. Also (from memory of my earlier reading, it’s too late to re-read!) the a/c should have been air tested by the distributor/manufacturer each year but was not, I accept that this may not be a permit renewal requirement.

Regarding the paperwork and buying an a/c I fully agree and would in any case have a survey of some sort done. However without suggesting that it would have happened in this particular case, if you have a blank Tech log and a certificate from the regulatory authority that the log book is signed up and correct what’s to stop an unscrupulous owner adding the missing entries?

I agree with your other comments (except that as an ex engineer I never trust anything straight from maintenance!) and with Madam B and also hope things get sorted - but lets not get too side tracked by the thankfully rare occurrence of in-flight break-ups. Failures in maintenance, servicing schedules and documentation requirements does no one any favours and certainly not the paying customer, the casual passenger or the owner.

As the man said, if you think maintenance / safety is expensive, try an accident. Unfortunately some people seem to have forgotten this old saw. I for one will certainly probe a little more before accepting a ride in other people’s a/c (including certified ones)

Edit: I was remiss in not throwing some mud in the CAAs direction.



Penultimate paragraph edited.
Heliport

[VP959]

Caution is needed here, as I know for a fact that one of the AAIB investigation team spent more than one whole day surfing the internet chat rooms deliberately looking for "evidence" of a "poor safety culture" amongst microlighters to support his theories.

This is the "evidence" that went into the assertion in the report.

This is somewhat akin to reading a few internet motoring fora, which are often full of rhetoric about speed cameras, unsafe car performance modifications and over-zealous policing, and then concluding that all motorists have an inherently poor safety culture.

This report lacks balance and falls well below the impartial standard I have come to expect from such a formerly well respected body. Added to reports from visitors to Farnborough, who have told me of derogatory asides and comments made about microlight aircraft, I am of the view that the AAIB itself suffers from inherent and somewhat unwarranted bias against these aircraft.

I will refain from discussion on the actual accident details, as the matter is clearly sub judice now that a charge of manslaughter has been laid. I suggest we voluntarily restrict this debate to general points about the BMAA, the AAIB, the CAA etc, rather than fall into the trap of being overly specific.


Absolutely right - keep it general.
Others take heed.

Heliport

[egbt]

This is the "evidence" that went into the assertion in the report.

VP, do you have evidence for that statement? I'm not disputing the assertion that the chat rooms etc may have been reviewed but if this just pointed the investigators in the right direction that IMHO would be reasonable. On the other hand, using such information unsubstantiated would indicate some very serious issues.

Fully agree regarding the specifics of this case.

[VP959]

Yes I do.

I took a telephone call at home from Mr Brian McDermid from the AAIB and wrote detailed notes about our hour long conversation. He very clearly and specifically told me that he had spent a day reading through the messages on the microlight Yahoo forum and others, gathering evidence of what I believe he referred to at the time as a "endemic lack of a safety culture".

I was also told, again by Mr Brian McDermid, that an article published in my name would be quoted (out of context, as it happens) to substantiate this view. This was at the beginning of this year, when the draft report was being prepared.

I was so concerned by his stance that I telephoned the AAIB the next morning and expressed my concern to a more senior investigator. I was reassured then that this would be unlikely to go into the report and that it was "background". I complained about the attitude of the investigator, but was again placated by reassurances from a more senior investigator.

Those who know who I am, and know of the considerable airworthiness responsibilities I've held, will perhaps understand why this stance by the AAIB enraged me somewhat.

I guess this means that my long-preserved anonymity on here is now blown, but exposing these flaws in our regulators seems worth it.

[egbt]

VP

An excellent post and position statement

As I said before I have no axe to grind regarding the BMAA however like you I am concerned about safety and appropriate regulation.

I don’t think it contradictory to wish you could luck whilst holding to the views expressed in my first two posts. :ok:

[VP959]

Good luck is indeed needed EGBT, but not for me.

The person needing all of the luck, good wishes and support from the aviating community as a whole is the one that feels he is being made a scapegoat for a tragic accident.

Having been appraised of all of the facts, listened intently to much of the gossip and spent a great deal of time conducting my own enquiries, I am convinced that the AAIB report is significantly flawed.

Critical factors, such as the fact that the aircraft was being flown at an IAS 25% above Va in an area well known locally for severe low level turbulence with the wind in the N to E sector, were glossed over.

The design reserve factors in the structure, which are lower by far than currently accepted by the CAA are another area that does not get proper attention in the report.

All told this report falls below an acceptable standard with regard to impartial investigation of the facts and I know that I am not alone in having come to this conclusion.

I am deeply saddened that such a well-respected body as the AAIB could publish such a report, particularly as the result has been to drive a 61 year old man, who acted with the very best of intentions to help a friend, into probable bankruptcy and possible loss of freedom for the rest of his life.

We are not talking about a professional, paid, engineer here, but an unpaid volunteer who gave freely of his time for very many years to help others achieve and maintain the joy of flight. In my view, as aviators we all need to act in concert to defend our fellows, whatever form of flying machine we choose to leave the surly bonds of earth.

VP

[DFC]

I have read the report and find that it is balanced and fair.

To my reading, it explores all relevant issues in the case investigated and based on the available evidence makes a finding of the most probable cause and the issues both relevant to that probable cause and other possible causes.

Simple things like not having the required placard with the required information for the passenger may seem petty or irrelevant to some but that attitude that certain legal requirements are petty or irrelevant or can be ignored is exactly what the AAIB see as the start of a slippery slope that needs to be stopped.

One can go to certain airfields in the UK and out of a sample of microlights will find a proportion have undocumented and uncertified modifications. Many would be minor and not of any serious consequence. However, the fact that they exist shows what the AAIB quite rightly in my opinion describes as a minority of operators who choose to ignore or are unaware of legal requirements.

A microlight operator I know of when faced with an airworthiness problem decided that under no circumstances would the BMAA be informed because "if the CTO finds out he will ground all the aircraft and how will we make money then".

That is a quote from a very experienced microlight pilot about a common microlight type. Having experienced that attitude to flight safety, not only would I agree with the AAIB comments but would say that they are only skimming the top.

Regards,

DFC

[Keith_Negal]

There is no one in microlighting who was not shocked by this terrible event and who has not reviewed their own conduct as a result of the lessons learned.

CAP 735 calculated that microlights had a fatal accident rate of 18 per 1,000,000 hours flown, compared with 23 for gliders, 18.1 for helicopters and 13.9 for light aeroplanes. Furthermore, as is the case in all forms of aviation, the overwhelming majority of fatal accidents in the period in question resulted from pilot error, not airworthiness.

Anyone who has read the AAIB report from cover to cover several times as I have over the past 6 months cannot but wonder if the AAIB itself has lost the plot here.

There may be weakenesses in the BMAA Inspector system as there are in every system without exception.

Keith




Post edited.
Your final comment was totally unacceptable while there is a an alleged manslaughter case pending.

[Genghis the Engineer]

It came out on Tuesday, but since Keith is chairman of the BMAA, presumably he was party to discussion of pre-publication drafts of the report.

G

[bar shaker]

DFC

If you only consider the facts given prominance by the AAIB in the report, then you would come to that conclusion.

There are other factors that have been dismissed or overlooked that, when integrated with the AAIB's own scientific data, support an entirely different outcome.

Your views on microlighters are unfounded and, I suspect, urban myth. Just as some GA pilots have done, I am sure, if you look hard enough, you will find a microlighter that has fitted a GPS without sending in a mod form. You cannot totally dismiss a system because a few rogues who decide to ignore it.

Your suggestion that a school have not reported a fault for fear of having a fleet grounded is, I believe, pure fantasy. If I am wrong, then it is your duty to report the matter to the CAA and I would urge you to do so today. Once you have done so, perhaps you can tell us the details.

[Keith_Negal]

What appalls me most is not the tosh talked by people like DFC but that the AAIB inspector took the time to read this junk from the lists and then used it to reach his conclusions.

Forget the rhetoric and read the accident statistics. Things that are wrong must be put right but microlighting is at least as safe as any other form of recreational aviation.

Keith

[VP959]

Although the accident data quoted by Keith Negal is undoubtedly correct, the law will not normally overly concern itself with broad statistics when dealing with a specific case.

We all know that a volunteer system is unlikely to be perfect, as Keith has pointed out. Nevertheless the future of amateur flying under the auspices of the BMAA, PFA or BGA may well hang in the balance as a consequence of any highlighted imperfections.

I would speculate that a random sample audit of a few inspectors, using some carefully chosen questions to test their knowledge of some the deeper ramifications of the airworthiness of structures might show "failings in an organisation".

When a man's freedom is at stake then it is quite reasonable to expect people to go to extraordinary lengths to prove their innocence.

Many of us may have to live with the repercussions of this for a long time to come.

VP

[SteveR]

Will somebody puleeze publish the link to the report? (I'm crap at finding my way round their site nowadays).

Steve R

[Genghis the Engineer]

http://www.aaib.gov.uk/publications/formal_reports/2_2005_g_styx.cfm

It may take you several cups of coffee to get through!

G

[mark147]

I'm a bit confused with the various opinions above. Having read the discussion, I went and read the report from end to end and I have to say that it seems the AAIB did a reasonable job:

They investigated the facts and arrived at a probable cause for the accident. They then looked a little wider to investigate the circumstances that led to the defects in the accident aircraft. Surely, that is their job?

I didn't interpret the contents of the report as a damning indictment of the BMAA's processes (even the recommendations are that some of the procedures be reviewed, not that they be scrapped).

However, since the investigation points quite convincingly to a structural failure, of which one major causal factor was the failure to carry out an AD correctly (and not to subsequently spot the error), it does seem reasonble to attempt to recommend actions that may prevent the same thing happening in future.

As a PPL(A), it does concern me that whilst a trial lesson in a light aircraft would require a public transport CofA, the same thing in a microlight could be done in an aircraft that had at best a sketchy maintenance history. It's also worrying that there is no clear procedure for an inspector to be assessed as competant to do their work.

Back to the report, even the paragraphs hinting at a minority that resent interference by the CAA are written carefully, using the word 'inadvertently' and pointing out that the minority referred to might actually be competant to question certain regulations but that this might have caused others to be caught up in an air of anti-regulation without that competence and understanding.

However, given all that, if this report is actually being used by some to blame the inspector for this accident then that is also wrong since it's absolutely clear from the report that there was a long chain of events here (as in almost all air accidents).

I would also concede that only some of the report's recommendations are actually relevant to the actual accident (but arguably all do have safety implications).

Mark

[VP959]

"However, given all that, if this report is actually being used by some to blame the inspector for this accident then that is also wrong since it's absolutely clear from the report that there was a long chain of events here (as in almost all air accidents)."

The only blame so far arising from the long chain of events leading to this tragic accident has fallen upon the inspector. He has been charged with manslaughter and is currently on bail.

As far as I am aware no other action is being taken, except for the inevitable tightening of procedures, as recommended.

I feel inherently uncomfortable that a man who chooses to voluntary help a friend do some work on his aircraft, for no charge, ends up with his life in tatters. All is not quite so clear-cut as the report makes out, which further complicates the issue of blame.

Even if found innocent he will still have to bear the burden of the loss of life of a friend and that of an innocent passenger. He also has to bear the very considerable financial costs from legal representation, whatever the outcome. I understand that the BMAA do not provide financial assistance for their volunteers. Perhaps the PFA and BGA are the same; all are reliant upon volunteers, I understand.

Whether this is right and proper is a matter for others to consider and decide, but I cannot help but feel that it undermines the future viability of any BMAA, PFA or BGA voluntary posts that carry any airworthiness responsibility.

VP

[Sans Anoraque]

Sorry VP959, but good intentions is not a valid legal defence. People have died , and IF it is his negligence to blame, then he deserves to pay the price.

[VP959]

In virtually every aircraft accident report I've read, there have been a chain of actions taken by different people that led to the eventual tragedy. This one is much the same.

Why should one link in that chain carry the entire burden of blame?

In my experience, there is rarely one very clear, absolutely definitive, cause for an accident.

I faced a BoI many years ago, after having missed something through lack of foresight that nearly caused the loss of a Canberra. The words of the BoI chairman still ring in my ears "You are only getting away with a formal reprimand because you were foolhardy enough to fly in the aircraft after signing that the TI was safe". The chain of events leading to this incident was so far-fetched as to still cause disbelief amongst those who hadn't witnessed it.

Needless to say, this has caused me to exercise a great deal more care from that day on, but I regret to say that I have still missed the odd potentially dangerous item from time to time. We should, perhaps, accept that human fallibility is a generic attribute that we have to accept to a limited degree.

VP

[DFC]

Keith,

While I may be talking "tosh" and am only an outside observer wrt microlights, perhaps you should pay a visit to Wantage and ask the manufacturer who is having to make structural repairs at their factory to a certain microlight type how is it that aircraft with structural defects are being flown in for repair?

Or better still ask those operators who fly the aircraft in, how they deemed the aircraft to be fit for flight with a structural member disconnected through cracking?

The reason why I am familiar with that case is because I was at an airfield the day they found the crack. I was more shocked to discover that rather than trailer the aircraft to the factory, it was flown there.

It is cases like that that make observers like myself think that the AAIB were only skimming the surface.

The fact that there was a senior member of the BMAA presenting themselves for an instructor renewal flight test and proposing to the FI examminer to fly at a weight above the maximum allowed and then creating a fuss because the FIE refused along with the latest information that "it is up to individual instructors if they want to fly within the maximum weight limitations or not"........all leads me to expect that there are many large instructors out there that take large trial flight people up in aircraft that are above the allowed weights (either seat or MTOW limitations). Thus they are uninsured, illegal and open to claims if something goes wrong even if it is unrelated. The BMAAs "it is up to the individual" is simply not suficiently strong guidance.

---------

The difference to me between the BMAA and the PFA system is that the BMAA is the one where members of the public pay for the ability to fly in a permit to fly aircraft (trial flights). Thus I believe that it should have the more rigerous oversight system in those areas.

If people want to build their own aircraft, maintain it to a poor standard and kill themselves then that is up to them. That is why I see no serious problem with single seat unregulated microlights restricted to class G airspace. However, expecting the paying public to fly in aircraft that for whatever reason may not be what is advertised is a different matter.

-------
Bar Shaker,

I am not a Policeman and thus have no responsibility to report matters to the CAA that have no safety effect on me. However, the microlight industry is not that big and the example I used above is easily checked by Keith if he chooses to do so.

Could the fact that microlighting has been taken from a totally unregulated industry to the current situation of limited regulation present a situation where there are people within the industry who remember the "freedom" of unregulation and try to retain such "freedoms" as much as possible even if it means bending a few rules or doing what outsiders might considder dangerous when compared to the more regulated parallel areas of aviation?

Personally, having spent some time looking at the idea I can't see how one can make money by operating a school in the microlight industry unless corners are cut.

Regards,

DFC

[Genghis the Engineer]

I can at-least answer that last question. I don't believe that anybody does make money by operating a microlight school in the UK - they make money by operating a microlight business. When you combine a school, maintenance facility, hangerage provider, and often aircraft dealer as well - it's possible to make a living. But, it's common that the school is at the centre of that.


Incidentally there is a deep iniquity regarding seat weights that microlighters rightly feel aggrieved about. Most light aircraft are designed and stressed (including normal and crash loads) to 77kg per seat [the same applies to airliners]. All microlights are designed and stressed to at-least 86kg, and the majority to rather more (the latest are getting up to 120kg per seat). Yet, whilst in a light aircraft or an airliner it's perfectly legal for a 140kg adult to occupy a seat that was never designed for that sort of load, in a microlight an 87kg adult in an 86kg seat is deemed to be unacceptable.

Personally I'd much rather see all aircraft seats stressed to at-least 105kg (which would cover 99%ish of the adult male population, and a higher proportion of the overall human population), but it seems unfair that a considerably higher standard is applied here to microlights than to any other class of fixed wing aeroplane.

Of-course, anybody taking any aeroplane outside of overall weight and balance limits is a dangerous idiot and should be treated as such. I am only talking about seat limits here.

G

[Russell Gulch]

Several minor aspects of the AAIB report are factually incorrect, or at least misleading.

Their reference to cockpit placard and their quote of ANO Article 9A(6) is incorrect. The correct wording is "...certificated to an International Requirement”.

You would have thought their research would get that simple fact right.

Further, their use of the term "pop rivet" is misused, because "Pop" is a registered tradename and unless the AAIB investigation has accurately determined the maker, then they should use a more generic term.

I know these are very nitpicking points, but the AAIB have a duty, due to the very seriousness of the investigation, to be wholly accurate. Indeed, their own wording reports on minor details found as a result of their investigation (and not necessarily having a direct bearing on the accident).

[cubflyer]

I read the AAIB report prior to reading this thread. It is interesting that several people have the same impression as me, that this report was not the best ever researched and written by someone in the AAIB. I have generally been very impressed by the AAIB's work, I went on a 2 week accident investigation course a few years ago and was very impressed by the calibre of people from the AAIB.
I know nothing technically about flexwing aircraft so cannot comment about that part of the investigation, but I think there were far too many general comments not strictly anything to do with the accident and too much personal opinion. The investigator did the AAIB a great dis-service by trying to lump together trivial admin rule infractions with major airworthiness issues. To a mindless bureaucrat who knows no better, then not fitting an "admin" placard might be the same as not carrying out some essential maintenance. However I would have thought that an AAIB engineer would be able to differentiate between the two. Does he really want to bring down all improtant safety issues to the level of fitting a placard that is there to protect someone's arse in the CAA and has no bearing on how to operate the aircraft or its airworthiness.

I am not a BMAA member, I have occasionally flown in a microlight. Ive found it great fun and most microlight fields Ive visited have been well run and machines seemingly well maintained- often looking in a lot better condition than the average public transport C of A club Cessna or Piper!! From my experience I would say that there are the odd maverick in all forms of aviation, probably most are involved with public transport C Of A aircraft.

[DFC]

Thanks Genghis.

I agree with your point. When I did my research it was purely with the idea of operating a training school. I can see that other areas could help support the flying end and generate more income.

I did not know that about the seats! Makes me wonder about the seat below me when I pull 6g! I remember the decathalon having past problems with the back collapsing during aeros. Seems I better read up on the seat limits! :)

Regards,

DFC

[Genghis the Engineer]

It'll almost certainly be designed to fail at just above 170lb (190lb for aerobatic aeroplanes) x the g-limit x 1.5.

So, increase the pilot weight by 50% and you have no safety factor. Not an aspect of aircraft approvals that I've ever been all that comfortable about.

G

[VP959]

I've never been comfortable with this seat weight anomaly, and curiously neither have a large number of microlighters.

The Yahoo group that Mr McDermid from the AAIB spent so long perusing, is dotted with complaints from microlighters that their 86/90kg seat weight limits are too light and pleas for manufacturers to voluntarily increase their approved limits to a higher figure by extra testing or modification.

As G has pointed out, many microlight manufacturers have responded to this safety concern, raised by these fellows with an "endemic lack of a safety culture" and are now offering much higher seat limits.

One microlight, with which G will be familiar, has actually been tested to a seat and seat belt limit of over 130kg.

I wonder just how many light aircraft or public transport aircraft have seats and belts approved for over 20 stone people at +/-4.5g vertically, +/- 3g sideways and +9g forwards?

VP

[bar shaker]

I would add that Genghis posted some very helpful stuff, for those who have a staple diet of pies, about getting your seat limit increased. The post gave the maths involved in proving that you were safe and I was very grateful to read it.

Six hours a week for six months, down the gym, means that I am now a mere slip of a pilot at 76kg :)

[Genghis the Engineer]

I wonder just how many light aircraft or public transport aircraft have seats and belts approved for over 20 stone people at +/-4.5g vertically, +/- 3g sideways and +9g forwards?

Helicopters only I suspect, which tend to be quite rational about the subject - unlike group A FW which is generally a bit of a mess.

G

[DFC]

Genghis,

CS-23 and CS-VLA make interesting reading regarding seat weights.

CS-23 goes into great detail about loadings in various directions for seats and seat belts.

However, the general weight on the seat used "to show compliance with requirements" seems to be just that - a notional weight that is used to show compliance - not a limitation. If it was a limitation then loking at the part where minimum weight is specified, if taking that to be a restriction one could never fly the aircraft with that seat empty!

Since minimum weights per seat may be specified to show compliance with the requirements, are they saying that seats can not be empty even if the C of G is within limits?

My reading of the specified weights (which are only options under CS-23) are that they are used to prevent designers using overly light individuals to acheive unrealistic figures.

However, that aside, if the CAA say that it is a restriction then it is a restriction and organisations interested in flight safety need to consistently and constantly send out a clear message that the rules are to be complied with..........until they can get the rules changed.

Regards,

DFC

[MadamBreakneck]

My reading of the specified weights (which are only options under CS-23) are that they are used to prevent designers using overly light individuals to acheive unrealistic figures. Isn't the minimum seat weight requirement a hangover from the days (BCAR-S issue 1) when microlights had to show that they wouldn't go outside W&B limits at the four points of Max cockpit weight; full fuel
Max cockpit weight; no fuel
Min cockpit weight; full fuel
Min cockpit weight; no fuel
I wonder if that's where the hard-edged maximum seat weight requirement grew from too.

Genghis seems to know about these things, perhaps he'll clarify.

MadamB

[Genghis the Engineer]

The 86kg value (previously 90kg) in Section S used for W&CG requirements is still there for weight requirements, but there's been a partial de-coupling.

So, a microlight must have an empty weight not greater than MAUW - 86kg/seat - 1hrs fuel at maximum continuous power. This is identical to the requirement in CS.VLA for non-aerobatic light aeroplanes.

However, whilst it was originally coupled also to the CG and structural requirements, that's been de-coupled in recent years out of necessity. So, It's now possible to use any higher (than 86kg) weight the designer selects so long as at the permitted seat / fuel loadings the aircraft remains within CG limits, and the structural requirements are met for the seat/harness/surrounding-structure at those higher seat limits.


If you look at CS.23 or FAR-23 (or part 25), they are subtly different in that the empty weight issue is still there (albeit using slightly different numbers, typically 77kg/seat and 30 minutes fuel), but there is no CG issue - it's assumed that the pilots of part 23 aeroplanes are capable of doing W&CG calcs (whether this is true or not is a moot point, but they've been trained to :E )

G

[Deaf]

" it's assumed that the pilots of part 23 aeroplanes are capable of doing W&CG calcs (whether this is true or not is a moot point, but they've been trained to"

Decades of flipping through things like the crash comics suggest that more training ie CPL rather than PPL leads to more problems in this area.

[DFC]

Genghis,

You said: So, a microlight must have an empty weight not greater than MAUW - 86kg/seat - 1hrs fuel at maximum continuous power. This is identical to the requirement in CS.VLA for non-aerobatic light aeroplanes

To my reading all that does is set a maximum weight for the aircraft structure (including engine).

Where in relation to the above limitation does it say that having a structure that meets that requirement, it is illegal for each seat to be filled by 96Kg individuals and the fuel load reduced so that MTOM and C of G limitations are complied with?

Does the seat limit only arise because the designer has designd a placard showing a limitation? :)

Having had some time to think about it, I think that I would prefer to be sitting on a seat whose legs would crumple under me in an accident than be sitting on a seat that would hold firm and transmit all the shock load to my spine.

Regards,

DFC

[Genghis the Engineer]

S 23 Load distribution limits
a) The ranges of weight and c.g. within which the aeroplane is to be safely operated must be selected by the applicant.
b) The c.g. range must not be less than that which corresponds to the weight of each occupant, varying between a minimum of 55 kg for the pilot alone up to the maximum placarded weight with a pilot and passenger, together with a variation in fuel contents from zero to full fuel. The placarded maximum [occupant] weight must be not less than [86 kg] per person. (See AMC S 23 b).)

S 25 Weight limits
Maximum weight. The maximum weight must be established so that it is:

a) not more than:

1) the highest weight selected by the applicant;
2) the design maximum weight, which is the highest weight at which compliance with each applicable structural loading condition and each applicable flight requirement is shown.
b) not less than the weight which results from the empty weight of the aeroplane, plus a weight of occupant(s) of [86] kg for a single-seat aeroplane, or [172] kg for a two-seat aeroplane, plus the required minimum equipment, plus fuel [for at least 60 minutes flight at maximum continuous power.]

c) [not less than the weight which results with one (86 kg pilot) occupant, required minimum equipment and maximum fuel. (See AMC S 25 c).)]


S 561 General
a) The aeroplane, although it may be damaged in emergency landing conditions, must be designed as prescribed in this paragraph to protect each occupant under those conditions.

b) The structure must be designed to give each occupant every reasonable chance of escaping serious injury in a crash landing when proper use is made of belts and harnesses provided for in the design, in the following conditions:

1) Each occupant experiences, separately, ultimate inertia forces corresponding to the accelerations shown in the following:

c) Each aeroplane with a retractable landing gear must be designed to protect each occupant in a landing with wheel(s) retracted under the following conditions:

1) A downward ultimate inertia force corresponding to an acceleration of 3 g;
2) A coefficient of friction of 0.5 at the ground.
d) Except as provided in S 787, the supporting structure must be designed to restrain, under loads up to those specified in sub paragraph b) 1) of this paragraph, each item of mass that could injure an occupant if it came loose in a minor crash landing.

e) Where the failure of all or part of the engine mounting structure could result in an engine following a trajectory that could pass through any part of the normal crew accommodation or fuel tanks, the attachment structure must be designed to withstand an ultimate inertia force corresponding to an acceleration of 15 g in that direction.

S 786 Protection from injury
a) [Each seat and its supporting structure must be so designed that in the event of a collapse of any or all of the landing gear units the risk of serious injury to the occupant is minimised.] (See AMC S 786 a).)

b) Rigid structural members or rigidly mounted items of equipment, must be padded where necessary to protect the occupant(s) from injury during minor crash conditions.

[AMC S 786 a) (Interpretative Material)
The seat support structure should be designed, as far as is practicable, so as to prevent spinal or other serious injuries to the occupant in a minor crash landing in which the landing gear may have collapsed. It is recommended that rigid structural members are not located in a position likely to cause injury in such a crash landing and that energy absorbent materials should be used under the seat structure to reduce the impact loads being applied to the occupant’s spine.]

S 1519 Weight and c.g.
a) The maximum weight determined under S 25 a) must be established as an operating limitation.
b) The c.g. limitations determined under S 23 must be established as operating limitations.
c) The empty weight and the corresponding c.g. positions must be determined in accordance with S 29.


S 1557 Miscellaneous markings and placards
a) Baggage compartment. Each baggage compartment must have a placard stating
the loading limitations.

b) Fuel and oil filler openings. The following apply:
1) Fuel filler openings must be marked at or near the filler cover with the minimum
fuel grade and fuel/oil ratio.
2) Oil filler openings must be marked at or near the filler cover:
i) with the grade; and
ii) if the oil is detergent or non detergent.

c) Fuel tanks. The usable fuel capacity of each tank must be marked either at the selector or on the gauge (when provided) or on the tank if this is translucent and visible to the pilot in flight.

d) In-flight engine starting. A placard must be provided stating any limitations to be observed during in-flight engine starting.

e) Loading
1) The following data must be placarded in each aeroplane so as to be plainly visible to the pilot:

i) Empty weight [(actual);]
ii) Maximum weight;
iii) Maximum and minimum cockpit load;
iv) Cockpit load conditions for two-seater flown solo;
v) [Fuel load limitations for the range of allowable cockpit loads.]

2) [Removable ballast.] If removable ballast is used, the place for carrying ballast
must have a placard stating instructions for the proper placement and securing of the removable ballast under each loading condition for which removable ballast is necessary.
f) Aerobatic manoeuvres. A placard prohibiting aerobatic manoeuvres and intentional spinning must be plainly visible to the pilot.

G

[DFC]

Thanks Genghis.

So as I read your quotes, the designer chooses the limitations which must be placarded. The minimum weight chosen (and placarded) can not be greather than 55Kg but could be zero. The maximum weight chosen must be at least 86Kg but could be more. It is all up to the designer who could design and aircraft that could be operated with 1 50Kg pilot or 2 100Kg pilots provided that was determined during the design and testing and the limits were placarded and the overal microlight limitations were acheived.

Isn't the microlight supposed to be a simple aircraft! ;)

Thanks again.

Regards,

DFC

[LINEFINDER100]

I have always been impressed by the excellent dispassionate nature of AAIB reporting. But recently there has been a lapse. As an example, in the 10/2005 G-HASO report, the AAIB made inappropriate recommendations for mods to the Thielert diesel engine, after FOD ingestion. The LBA (German 'CAA' responsible for the aircraft's certification) rejected their proposals, pointing out that the 'protection' offered by the mod was against a mechanic leaving a tool in the previously filtered air inlet - and aviation mechanics should not do that! Well done LBA and a win for common sense!

Unfortunately, the AAIB report tried to justify their recommendation in the face of this rejection. Methinks they protesteth too much.

Dave

[WorkingHard]

LINEFINDER100 - I have to agree. I read most AAIB reports that come my way, especially those relating to GA, and find an element of "conjecture" creeping in. Can any one surmise why this may be the case or are we simply mistaken?

[VP959]

Speaking as one who had a bit of a serious "up and downer" with the said Mr McDermid of the AAIB, I am of the view that the organisation has lost it's way.

I spoke to Mr McDermid's senior a few days later and expressed my concern over the apparent lack of impartiality shown. The response I received was luke warm and reflected an apparent lack of interest in only reporting the hard facts relating to the case in question.

Whether the resultant bias is due to deliberate managment intervention, poor direction or by a lack of interest by the staff I do not know. I do feel very uncomfortable about such a well-respected organisation squandering it's hard won reputation in this way though.

VP

[Ranger One]

Well a manslaughter prosecution has now been mounted, see the new thread I started here: http://www.pprune.org/forums/showthread.php?t=208990

(mods - feel free to merge threads).

WRT to the previous posts on this subject, I have a general point to make. I feel some posters are missing the point. Microlighting is a *sport*. It's wrong thinking, IMHO, to compare the safety of microlights to transport cat. aircraft. 'Paying passenger' notwithstanding. I'd expect to be, and feel, moderately safe on board a high-end coach on the motorway. I'd expect to be, and feel, less safe as a 'paying passenger' in a souped-up WRX hurtling through a forest on a 'rally experience' ride. Extreme example, but I trust the point is made.

R1

[BRL]

Going to close this one as there is a thread already running. Click on the link in the post above this.