Shoreham crash and "Just Culture"

[Chronus]

This week, the High Court is expected to rule on whether the police may have access to key material, including flight deck voice recorder, to enable them to continue with their criminal investigation into last year`s disaster at Shoreham Air Show. Police access to confidential AAIB information is bound to ignite the controversial issue of "just culture" and criminalisation in air accident investigations.
As the AAIB report is not expected to be released until 2017, it would seem that justice impatient, needs to be served earlier.

[Two's in]

Chronus,

There's already a detailed discussion underway in this particular area on the Military Aviation forum here:http://www.pprune.org/military-aviation/566533-hawker-hunter-loss-shoreham-airshow.html

Some of that discussion is even reasonably informed...

[TCAS FAN]

Just Culture Definition
Individuals are not punished for actions, omissions or decisions taken by them that are commensurate with their experience and training but which result in a reportable event; but where gross negligence, wilful violations and destructive acts are not tolerated

[Chronus]

The debate, which I thought may be worth encouraging, was whether the interest of justice prevailed over confidentiality.
The disclosure in the ‘interests of justice’ principle is enshrined in European law, under Article 14.3 of EU Regulation 996/2010 (the Regulation). The Regulation reinforces the principles of ICAO Annex 13 which provides for international standards and recommended practices in relation to air accident and incident investigations, the primary objective of which is to prevent future accidents and incidents and not to apportion blame or liability. Inevitably, while the official air accident investigation and any criminal investigation are intended to remain entirely separate, the paths of the two investigations inevitably cross on numerous occasions throughout the process and are driven by entirely different agendas.
The fundamental principle which should underpin all accident and incident investigations is ‘just culture’. As Recital 24 of the Regulation clearly states, civil aviation systems aim to ‘promote a non-punitive environment facilitating the spontaneous reporting of occurrences’. Yet some argue that increasing pressure and, to some extent, public clamour to attribute blame and immediately criminalise investigations, as was seen in the aftermath of the Germanwings tragedy when the French public prosecutor was prominent in early public announcements, might be harmful to and fetter future accident investigation and reporting.
It therefore boils down to a very precarious tight rope balancing act.

[bvcu]

'flight deck voice recorder' ??? on a Hunter? we had a cassette recorder for the student on ETPS T7's for inverted spinning, but no CVR........

[dsc810]

There were several go-pro type cameras installed - at least one of which as I recall from what has been said by the AAIB in an interim statement had a good view of the instrument panel/controls.

[glad rag]

Just Culture Definition
Individuals are not punished for actions, omissions or decisions taken by them that are commensurate with their experience and training but which result in a reportable event; but where gross negligence, wilful violations and destructive acts are not tolerated
The perfect management stichup!

[WindSheer]

Some of the posts here seem to be pushing more of a no blame culture - not a good thing.
A just culture sits between blame and no blame. Errors, mistakes etc are tolerated and looked upon as opportunity to learn. However, if someone wilfully violates a clearly defined system then they can prepare to face the consequences.
You cant hide behind a 'just culture'. If serious misconduct is evident, we can expect police intervention. Pilots failing alcohol screaning will be a good example........!

[Fire and brimstone]

No answer the OP.

After 30 years in aviation, I am yet to see this "just culture".

It is a rather sick statement that needs burying in the archives of aviation.

There is no just culture. If the management want a certain decision / certain persons put in their place, it will happen regardless of the rights, wrongs, or the associated laws.

It's a bit like arguing life should be fair. If you want fairness, DO NOT work in aviation.

List of suggested banned statements:-

1. Safety is our No.1 priority no compromises.

2. "Just culture". So untrue it has to be in inverted comma's at all times.

3. We have the finest FRMS system in the world.

[ATC Watcher]

I was involved in implementing the principle of Just Culture in a former life, it works relatively well in our so called "western culture " , but South of the 40th parallel and after 15 East , the concept slowly fade away to local reality.
.
JC works relatively well for incidents , not so well when there are casualties around .JC principle is to encourage , even reward, incident reporting , and to be able to do so without fear of being blamed. It is not an " out of jail" free card .

Also JC as we know it in Aviation is not really fit for military operations, and I would dare to add , nor for an airshow accident. So using the term in here is somehow inappropriate I would say.

[captplaystation]

Surely the correct procedure would be to let the accident investigation come to its conclusion, and if, as may be likely, some culpability is suspected, employ a court order to be given access to any evidence in the possession of the AAIB.

Anything more "pushy" could be held as interfering with/delaying the production of the accident report, which should overwhelmingly be the 1st priority.

[Tinribs]

If a pilot knows he may not fly below 500' above a large group of people, except for take off or landing, and sees many more collected under his planned display area what should he then do?
If a pilot knows that such groups collect ever year should he undertake the flight?

[G0ULI]

If prima facie evidence of wrongdoing, criminal activity, carelessness, malpractice, or indeed the exact opposite exists, it should be made available to investigators, no matter what the original reason for gathering or recording that incident. The very fact that people might modify their behaviour in response to the knowledge that everything they do is being recorded is telling in itself.

It appears that air display organisers and pilots have been playing a bit loose and fast with the rules for quite some years. So long as no one gets hurt and the public get to see an exciting display, its okay, right?

Well, no it isn't. The odds may be a million to one against a serious incident, but sooner or later that chance event happens, and without the additional safety factors built in by the rules, people get hurt. It is always a combination of factors and investigators need to be able to access all the data to arrive at the correct finding. That result may not be "fair", but it should at least be an accurate account of events.

[Magplug]

The display line was well defined and the risk management of the display took into account the surrounding built up areas so that risk management cannot be called into question. Sadly that management did not account for spectators gathering in unauthorised areas outside the field precisely where those poor souls perished.

If it is proven that the pilot entered the manoeuvre too low/slow then it comes down to an error of judgement made by an experienced pilot in otherwise favourable conditions. Unless someone can prove recklessness or negligence on the part of the pilot.... a single error of judgement is hardly enough to convict for involuntary manslaughter.

Thankfully we don't have the attitude of some of the Mediterranean nations where the mentality is... 'If somebody dies - Somebody must pay'.

It is right and proper that relatives of the bereaved get answers to all their questions, but let the man be judged upon the facts... not by cheap newspaper headlines whipping up the relatives into a frenzy of revenge.

[Cows getting bigger]

Magplug, yes I agree stick to the facts. Those killed were not only "spectators gathering in unauthorised areas outside the field" - there were people going about their own business. It is this fact which probably opens the biggest can-of-worms. :(

Personally, I'm not minded for an individual public flogging as there is enough evidence to say that display pilots crash on a fairly regular basis - it happens. It will be more interesting to understand the various slices of Swiss cheese contributing to this tragedy and whether any individual hole, or combination of, could have been reasonably foreseen.

[PrivtPilotRadarTech]

there were people going about their own business.

Quite right, CGB. The Hunter impacted on a 4 lane road, and flaming wreckage slid down it at an oblique angle for about 100 meters. Any suggestion that the public had no business being there is absurd. I'm thankful there wasn't a traffic jam.

[PDR1]

I'm not sure what is being said here. In this country causing death through negligent or reckless behaviour is a criminal offence - are people suggesting that pilots should be exempt from this? If I drive at 60mph down the high street and then due to ice on the road I don't make the corner at the end, ploughing into a bus queue and killing people, the proximate cause of the crash may well have been the ice, but I will be tried for manslaughter or death by dangerous driving and probably convicted.

In driving at 60mph I would have exceeded the limits of my "display authorisiation" and in doing so in icy conditions with nearby pedestrians I would have shown a negligent/reckless lack of "carmanship".

If someone breaks the known rules, authorisations and limits of good airmanship and people die as a result I would expect a criminal prosecution. We don't see it happen that often simply because of the very unusual feature of this crash - the pilot actually survived.

But why should different rules apply to pilots than to the rest of the population?

PDR

[Chronus]

'flight deck voice recorder' ??? on a Hunter? we had a cassette recorder for the student on ETPS T7's for inverted spinning, but no CVR........
Here is what the police said:


"Detective Chief Inspector Paul Rymarz, who is leading the investigation, said: "The application is to enable Sussex Police to obtain access to legally protected material including cockpit recorders and footage, expert reports and some documentation."

The two judges who heard the application last week have reserved judgement.

[Methersgate]

I'm not sure what is being said here. In this country causing death through negligent or reckless behaviour is a criminal offence - are people suggesting that pilots should be exempt from this? If I drive at 60mph down the high street and then due to ice on the road I don't make the corner at the end, ploughing into a bus queue and killing people, the proximate cause of the crash may well have been the ice, but I will be tried for manslaughter or death by dangerous driving and probably convicted.

In driving at 60mph I would have exceeded the limits of my "display authorisiation" and in doing so in icy conditions with nearby pedestrians I would have shown a negligent/reckless lack of "carmanship".

If someone breaks the known rules, authorisations and limits of good airmanship and people die as a result I would expect a criminal prosecution. We don't see it happen that often simply because of the very unusual feature of this crash - the pilot actually survived.

But why should different rules apply to pilots than to the rest of the population?

PDR
The same issue comes up in marine accident investigation, where the MAIB takes the same stance as the AAIB and has equivalent powers.

There really are good public interest reasons for establishing exactly what happened, and, as far as possible, why it happened, even at the cost of not prosecuting someone who might have committed a crime, in all such cases. It is often more important that it does not happen again, than that someone is punished.

In merchant shipping we have seen the criminalisation of deck and engineer officers has been pushed by public opinion to absurd lengths - to the point indeed where two officers were held in jail in South Korea for two years because they had "caused pollution" when in fact a tug and barge had crashed into the side of their correctly anchored, correctly positioned, correctly lit, immobile, vessel.

Be very very careful of what you wish for. I strongly urge aviation people not to go down the path of encouraging prosecutions of flight deck and cabin crew members.

[Thridle Op Des]

Interestingly a semi-precedent has been set, albeit under Scottish law, though according to Lord Jones, not a precedent:

Scottish Court Orders Release of Sumburgh Helicopter CVFDR - Aerossurance (http://aerossurance.com/news/court-orders-release-cvfdr/)

[4468]

Let's say (hypothetically) the aircraft entered it's tragic manouvre from an altitude that was 50' too low. (no accurate rad alt? Misleading visual clues on the ground?) Let's say, it entered at a speed that was 5 knots slower than usual? Let's say any 'gate' over the top was slightly out?

Non of these things 'should' happen.

But would those things represent wrecklessness, or an error of judgement??

Display pilots are human. Just like all of us. The very finest pilots/doctors/racing drivers/armed police are not immune from error.

Should we be judged on our human failings. Or the magnitude of the unintended consequences of those failings?

I don't have the answers. But nor do I think these are 'stupid' questions.

Of course maybe the individual concerned was just a wreckless ripsh1t who deserves to have the book thrown at him? He certainly must have fooled a huge number of people on the way up if that's the case though.

That doesn't seem terribly plausible to me.

[PDR1]

Let's say you pass a speed camera at 34mph in a 30mph limit.
Let's say you repeat that each day for the next three days.

Does this indicate recklessness?

You would suffer a minimum 12 month driving ban as a result.

The margins of exceedance are massively smaller than those exhibited by the driver of the Hunter in this case...

PDR

[bvcu]

just clarifying as the wording would lead some to think of CVR's and FDR's which i would have thought would be treated slightly differently to a GO PRO etc which are not aircraft equipment

[PDR1]

As far as I can see the CVR and FDR data is material evidence at a potential crime scene - I see no reason why it should NOT be made available to police investigators.

PDR

[PLovett]

a single error of judgement is hardly enough to convict for involuntary manslaughter.

Oh yes it is. Happens in courts around the world day in and day out and I am referring to reputable legal systems here.

As far as I can see the CVR and FDR data is material evidence at a potential crime scene - I see no reason why it should NOT be made available to police investigators.

Here you run into the conflict between accident investigation and criminal investigation. The legislation surrounding aircraft accident investigation requires the handing over of such data. However, in a criminal investigation this would amount to overruling the defendant's fundamental right to silence. This is why in a lot of jurisdictions there is the protection that such data cannot be released for purposes other than the accident investigation.

Should there be a ruling that the data is to be released to the police I would imagine that there is going to be a very quick appeal lodged and it will be challenged up the judicial chain. In the meantime you can obtain an order that the data is not to be released pending an appeal.

[G0ULI]

There is no fundamental right to silence in UK law.

"... it may harm your defence if you fail to mention, when questioned, something you later rely on in court. Anything you say ..."

Anglo Saxon law traditionally allowed for the payment of compensation to a victim's family in lieu of imprisonment or physical retribution. Locking people up for prolonged periods in jail is a comparitively modern trend, fines or physical punishments were much more likely to be used as a deterrent to wrongdoing.

[doyll]

Sorry, but the Shoreham crash was an avoidable accident just waiting to happen. We had been 'dodging the bullet' for too many years and it finally happened.. I've been to many airshows and seen some extreme accidents. Thank God all were in controlled areas with no spectators or innocent people to be hurt in. We simply cannot have these big powerful jets performing over populated areas. It simply is not safe to do so.

Perfect example of maneuver executed from too low an altitude.
https://www.youtube.com/watch?v=dohKKp0EvTs
Look familiar?
That stunt manover requires that the pilot climb 2,500 feet before executing. Investigators say he only climbed to 1,670 feet before he went into the spinning roll.

U.S. Air Force Thunderbirds Air Demonstration Team involving four Northrop T-38 Talon jets crashed during operational training on 18 January 1982, killing all four pilots. Airforce concluded mechanical problem; jammed stabilizer on the lead jet. There were no Thunderbird shows for 18 months after that. What was good? They were not doing the maneuver over populated terrain!

Bottom line here is things need to change so we do not see another Shoream accident, and if that means no more potentially dangerous maneuvers by big aircraft, then that is what it has to be.

[PDR1]

I disagree. It's perfectly possible top do fast-jet displays at an acceptable level of safety. It just requires proper planning and execution.

Unfortunately the Shorham case seems to have been lacking in one and/or the other. It is quite proper for the relevant authorities to want to determine whether that lack was criminally reckless or negligent.

PDR

[Chronus]

"Those who do not learn from history are doomed to repeat it." These were the words of George Santana, a philosopher. Its meaning does reflect the object of a so called Just Culture, the aim of which is to prevent recurrence of accidents and incidents by encouraging active and transparent reporting of safety occurrences as well as full participation in safety investigation instead of punishing those involved.
The aviation community has increasingly been concerned over a trend in criminal prosecutions of aviation professionals. That reports and material emerging in accident investigations seem to find their way into court rooms. Could this therefore have a detrimental effect on the true purpose and aim of accident reporting and investigation.
The dilemma is therefore is how to strike the right balance between the needs of improving safety in aviation and the recognition of the justice system`s legitimacy to investigate and prosecute any suspected criminal acts that may have been involved.
At the present time there is no quick fix to this long standing dilemma as to how to go about finding a resolution to the conflict between such two powerful and capricious masters, aviation safety and administration of justice.
No doubt the two eminent High Court judges who heard the Sussex Police application last week are currently wrestling over precisely this point.
I await their ruling with great anticipation. After all it will be down to such judges that this dilemma will eventually be resolved.

[4468]

It is quite proper for the relevant authorities to want to determine whether that lack was criminally reckless or negligent.
Or for (unprejudiced) completeness:

Whether it was an error of judgement!