AAIB investigation to Hawker Hunter T7 G-BXFI 22 August 2015 [Archive]

Courtney Mil

3rd Mar 2017, 12:24

Quote:
Recommend reading the entire report before taking the media's word for it; they don't have a particularly good record when it comes to aviation reporting. At over 400 pages, I suspect they have just read the summary so far.
TBH, there is absolutely no need for the vast majority of interested aviators (and ex aviators) to read "the entire report".

Anyone who cannot deduct the general flight safety lessons from the summary and conclusions of this accident report should not hold a pilots licence, as they don't have the necessary mindset/effective intelligence to be in command in the air, in anything other than perhaps a hot air balloon (no offence meant to balloonists).

The detailed report is for the benefit of those involved in the operation, planning and authorization of this type of flying activity and that is a pretty niche field.

If you feel you don't need to base your assumptions on the entire report, or just can't be bothered to read it, then you are missing a LOT of facts. The report explains the limitations of the evidence available and the contradictory evidence from various sources. Altitude and airspeed data and engine performance are just two of these, which are important factors.

The established facts, the tolerances of acquired data and the limitations of the evidence available are far from being a niche field. There is a lot of evidence in the body of the report that do not entirely match the summary - and I'm only half way through reading it so far.

Just to offer an example: "Disassembly of the Mk 30B and further testing identifed an open circuit across the rotor windings of the synchro-transmitter. It also confirmed that the power failure flag had come off its pivots, probably as a result of the accident impact.
Disassembly of the synchro-transmitter, and examination under a digital stacking microscope, identifed that one of the input wires to the rotor winding was broken, which could account for the open circuit. This damage was probably not accident related, but there was no way to determine how long this condition had existed."

And: "Cockpit video evidence indicated that the g-meter was not working during the accident flight". There's lots of information like that in the body of the report. But your expert examination of a summary would clearly dismiss that as relevant.

Stratofreighter

3rd Mar 2017, 12:40

A reminder to all posters that the British press will undoubtly monitor social media (yes, also this Pprune forum!) for quotes and the like. :*

Be careful what you post! :=

Especially now this is "hot news"... :rolleyes:

H Peacock

3rd Mar 2017, 12:41

The Mk30/Mk29 combination of altimeters is used in both the Tucano and Canberra, albeit with one in each cockpit. As the report states, the Mk30 is a very accurate servo altimeter, but without 115vac it will freeze. The Mk29 when used in Reset will effectively mimic the Mk30, but will still allow a different pressure setting to be used if needed.

If the Mk29 is left in Standby then it ignores the electrical input from the Mk30 and becomes a normal (none-servo) altimeter. It does have a vibrator to help eliminate stiction. In the Canberra the Mk29 was the main altimeter for the pilot (the nav had the Mk30) and was often used in standby mode. Although not quite as 'smooth' as the Mk29 it was perfectly useable for aeros. Spent many aeros sequences in the back of a Tucano watching the Mk29 in either mode and it was perfectly good in either!

Even if its wasn't covered in Hunter 'ground school', I'm just amazed that AH didn't wonder what the R/S knob on the LH Mk29 altimeter did in the Hunter. I simply can't comprehend any pilot (therefore naturally inquisitive) not wanting to know.

wiggy

3rd Mar 2017, 12:47

Thanks HP.

Onceapilot

3rd Mar 2017, 12:48

Having read the report, a couple of points that stand out:
The vapour plume from the fuselage, seen on video after the Derry turn, is not identified or commented on.
The considerable thrust reduction caused by the engine only achieving ~7500rpm in the pull-up compared with the 8100rpm for full thrust is not quantified.

wiggy

3rd Mar 2017, 12:54

Onceapilot

Having scanned the report again tucked away there do seem to appear to be a few "open items", mainly in the appendices, mainly in Human Factors: e.g. It was not known at the time of writing this report what caused the loss of thrust (such as pilot action, technical fault, etc) and so no HF analysis has been undertaken of it. However, in the course of the analysis of the in-cockpit video it was considered whether the pilot was aware of the loss of thrust and, if so, when. Such analysis assumes that the loss of thrust was not initiated by the pilot intentionally. If subsequent work by AAIB identifies that the pilot intentionally reduced thrust during the climb, then the analysis presented in paragraphs 17 and 18 is invalid.

elsewhere:

At present it is not known if the altimeter was serviceable and displaying the correct altitude during the loop. Technical analysis is on-going by AAIB which may provide further information on this point.

Pittsextra

3rd Mar 2017, 12:57

There is a lot of evidence in the body of the report that do not entirely match the summary - and I'm only half way through reading it so far.

Yet one assumes that the people writing the summary and those that have reviewed the report over the months of the consultation period are fully familiar with that detail and therefore the summary and its recommendations are entirely based upon the detail and accepted details - or you don't agree?

Courtney Mil

3rd Mar 2017, 13:11

Wiggy. Later in the report it also states:

"The rpm at pull up (derived from the spectrum analysis of the action camera audio) was 7,530 audio, which reduced to less than 6,800 audio, possibly as low as 6,500 audio during the upward half of the manoeuvre and was increased transiently to 7,210 audio. It was 7,010 audio at the apex. This was contrary to the pilot’s declared nominal power setting of increasing to full power at or shortly after the pull-up. The throttle was not visible on the video and so it is not possible to confirm whether the rpms were pilot selected or due to an engine malfunction."

The number of variations in engine RPM (from the graph in the report) during the manoeuvre do not make sense. I know of no one that continually and deliberately moves the throttle(S) around that much during a loop ("bent" or otherwise), particularly pre-apex.

Courtney Mil

3rd Mar 2017, 13:32

Pittsextra,

No, I don't. Not from what I'm reading in the body of the report. There are too many significant findings in the body of the report that are not reflected in the summary. Known instrument failures/malfunctions/miscallibrations and issues with the engine fuel control leading to very significant rpm reductions during the manoeuvre are all potential causal factors. In fact, I think they know the summary is incomplete as there are a number of issues where they have stated that they may report further on certain issues later. That smacks of an incomplete investigation.

Homsap

3rd Mar 2017, 13:35

So the pilot enters the manouvre at 185ft, his minimun height should have been 500ft, Entry speed 305 kts, should have been 350 kts, so at the point of entry things are no going well and negligent. Then full power is not applied, then the pilot fails to meet his target height of 4000ft and speed is 105 kts. In interview the pilot does not know the speed for the escape manouvre. Not really convinved that he had confused the speeds and safety gates between the JP3/5 and the Hunter, surely he knew what aircraft type he was flying. The report states he couldn't recall anything after the Wednesday before the accident, but while being treated at the accident site, he was lucid and reported feeling unwell prior to the flight. Yet this fact can not be established. Again if he felt unwell why did he continue with the display?

It will be interesting what the Police's next move will be. I would imagine he has tranfered his aircraft, cars and house into his wife's name by now,

wiggy

3rd Mar 2017, 13:49

Homsap

Regards AH's memories of the event and the hours/days around it, before calling "foul" you might want to Google the likes of Post-traumatic amnesia (PTA).

As for your final comment, harsh and uncalled for, to say the least.

Courtney Mil

3rd Mar 2017, 13:59

Homsap,

You seem either to be quoting the summary without reading the body of the report (which are very different) or you are being very selective and picking out bits that fit your assumptions.

Inform yourself before posting judgements, please.

Addendum regarding altitudes as an example (from the body of the report):

The rotational speed of air traffic control radar antennas is such that the information they receive is not updated sufficiently frequently for accurate tracking of aircraft that are continuously changing direction and speed.
Errors associated with aligning the recorded radar track with specific points on the ground include random errors and systematic errors. These vary for the different radar heads for a given aircraft track and complicate the mixing of positional data from different radar sources. Pressure altitude data, referred to as ‘Mode C’, from different recorded radar tracks can be more readily combined as this information is transmitted from the same aircraft's transponder.
Some of the Mode C altitude data was automatically flagged by the system as ‘Not-validated’, including a signi cant proportion of altitudes recorded during the accident display. However, this ‘Not-validated’ radar data appears reasonable when compared with the validated radar data and other evidence, such as the motion captured by imagery and results of photogrammetry analysis. Radar data validation is discussed further in Section 1.16.2.

Pozidrive

3rd Mar 2017, 14:02

Having read the report, a couple of points that stand out:
The vapour plume from the fuselage, seen on video after the Derry turn, is not identified or commented on...

It is, a whole paragraph.

Courtney Mil

3rd Mar 2017, 14:11

Indeed, it is covered in the report, Pozidrive, you are right. Too many others jumping to conclusion without reading the report.

For a year and a half now, people have been complaining about how long it's taken to publish. Now it's here, they seem unwilling to read it.

Onceapilot

3rd Mar 2017, 14:20

Helidogger

3rd Mar 2017, 14:23

http://www.pilotweb.aero/news/british_air_display_association_comments_on_aaib_shoreham_ac cident_findings_1_4915603

Homsap

3rd Mar 2017, 14:27

Wiggy...

I accept that he may later have suffered from from memory loss at a latter date, not least as he was placed into an induced coma.

I do not think my comments are harsh, if a pilot of a commecial flight crashed a aircraft as a result not abiding to DA/DH, approach speeds, or the regulated speed say below 10,000 feet, and as a result eleven people died, wouldn't we be calling it both professionally negligent and criminal.

Likewise, had the pilot been given too much morphine at the crash scene and died as result, wouldn't his family be calling the paramedics negligent and be suing the ambulance service.

But in fairness to the pilot, and putting aside any action by the police or CAA against him, whether he is in the right or wrong, I don't think anyone would want to carry the burden of guilt and in addition I would imagine 'on the balance of probabilty' through the civil court he will loose everything.

Again in saying I'm harsh, I do accept that in part the CAA are at fault as display authorision process is way out of date, which was the case in both this accident, the Gnat crash and others. Likewise you would think the local planning authority in conjunction with airports and the CAA, could place exclusion zones when displays take place, rather wasting their time investigating or persecuting people for illicit garden decking,etc..

Courtney Mil....

I think we all see things in a different way, and the 'selective' way I put it was as the events in terms of an error chain within say a few minutes, he may have misread the altimeter or ASI, or thought he was in a JP we will never know, as for the non application of power which might have been human error, if not had the engine malfunctioned, in any event in planning the display, I would hope the pilot might have had 'an escape plan' in the event of an engine or instrument failure at any stage of his display.

Courtney Mil

3rd Mar 2017, 14:57

I think we all see things in a different way, and the 'selective' way I put it was as the events in terms of an error chain within say a few minutes, he MAY have misread the altimeter or ASI, or THOUGHT he was in a JP we will never know, as for the non application of power which MIGHT HAVE BEEN HUMAN ERROR, if not had the engine malfunctioned, in any event in planning the display, I would hope the pilot might have had 'an escape plan' in the event of an engine or INSTRUMENT FAILURE [which he may not have known about] at any stage of his display.

Too many assumptions as usual.

The Old Fat One

3rd Mar 2017, 15:10

If you feel you don't need to base your assumptions on the entire report, or just can't be bothered to read it, then you are missing a LOT of facts.

And if you can't be bothered to read a point correctly and apply basic comprehension - quit posting.

I'll spell it out...

There are basic flight safety points to be deduced from the evidence presented in the summary. They are obvious to any professional aviator (as we both are/were) especially those trained to instruct/supervise/authorise (I was, I assume you were too).

Those basic lessons are both obvious and timeless - the detail does absolutely nothing to mitigate them in anyway whatsoever. It merely offers a much richer and deeper level of understanding of the actual events and contributing factors. Note also I refer ONLY to basic/general (or high level, if you prefer) lessons - not one word about blame, or how the contributing factors combined to create the outcome.

If you don't know what general lessons I refer to, I'm slightly shocked and can only wonder at your agenda, since I believe your knowledge of airmanship, flight safety and human factors to be at least as good as mine.

Maybe I'm wrong about that.

And now I'll depart and leave discussion those that want to debate the detail, comforted in the knowledge that regulations regarding air displays will be both strengthened and more rigorously enforced, thank goodness.

Cows getting bigger

3rd Mar 2017, 15:16

Well,I've read it all. My thoughts:

Entry to the manoeuvre has been demonstrated to be outside of normal parameters. This includes busting the base height of 500ft.

Some possible technical issues (engine RPM and altimeter). Note that the possible altimeter error would have displayed a value lower than actual. There's also evidence that the pilot had altered thrust demand during the loop manoeuvre during previous displays.

Continuing the loop from an apex of 2700ft was unachievable.

More interestingly and probable far more wide-reaching:

Questionable DA/DAE procedures/process.

Maintenance and maintenance (regulatory) oversight was lacking.

Lack of understanding about who owned the 'risk' at air displays.

Poor, occasionally non-existent, safety management at many levels.

Summing-up my initial, most worrisome, thoughts in a sentence - The air display scene lacked effective oversight and suffered from ingrained and institutionalised denial.

AH may have pulled the trigger, but the system both manufactured and gave him the gun.

Davef68

3rd Mar 2017, 15:24

Pozi,CM

I will give you the benefit of the doubt if you read what I wrote and confirm you understand.:rolleyes: The report identifies vapour, aparently from the wing tank area. The trail I refer to is from the fuselage/jetpipe and is visible in video online.

I know the one you mean, there is a short trail immediately after he comes over the top of the loop.

There is a vapour trail from the jet pipe area at a couple of points during the flight (e.g. at about 4 seconds in this compilation https://www.youtube.com/watch?v=Mr4POEBz81s)

From memory, does the Hunter not have a fuel vent pipe in that genreal area?

Courtney Mil

3rd Mar 2017, 15:33

There are basic flight safety points to be deduced from the evidence presented in the summary.

There is no evidence presented in the summary; the evidence is detailed in the body of the report. The summary is exactly what it claims to be. The flight safety recommendations are detailed elsewhere in the report. If you have found any in the summary then they are your own deductions based on incomplete knowledge of the facts.

Contact Approach

3rd Mar 2017, 15:37

Who actually has the time or enthusiasm to grind through 400 pages!?

Courtney Mil

3rd Mar 2017, 15:39

I do and I am.

G0ULI

3rd Mar 2017, 15:52

I will also be reading the report from cover to cover, but I fear it will be difficult to aviod confirmation bias while reading. At least I will try my best to approach the report with an open mind, even though we all "know" what happened. :ugh:

Pittsextra

3rd Mar 2017, 16:00

There are too many significant findings in the body of the report that are not reflected in the summary. Known instrument failures/malfunctions/miscallibrations and issues with the engine fuel control leading to very significant rpm reductions during the manoeuvre are all potential causal factors.

...can you expand this element? i.e. which instrument, which malfunction and how do you see it as a potential causal factor.

sika hulmuta

3rd Mar 2017, 16:33

As an ex Hunter pilot I shall read the full report before making any significant comment.

At the moment I will merely limit myself to saying the machine will happily loop at sea level at 300 kts and ISA, and gain height at the display weight. 350 kts is not required, and indeed may not be desirable if keeping the display tight is a priority.

Arfur Dent

3rd Mar 2017, 16:34

Authorised by the CAA to display two very different jets at low level. Confused and thought he was in a JP when he was actually in a Hunter? Not trained in the "escape manoeuvre" used to curtail a loop (i.e. an aileron roll).
That's pretty much what I heard on Radio 4 about 25 minutes ago.

H Peacock

3rd Mar 2017, 17:14

At the moment I will merely limit myself to saying the machine will happily loop at sea level at 300 kts and ISA, and gain height at the display weight. 350 kts is not required, and indeed may not be desirable if keeping the display tight is a priority.

Therefore you could enter your loop below 500ft knowing you'll gain height so you're still going to bottom out above it! But surely that's not the point. You could potentially fly from the apex of the loop through to S&L on the light buffet to fly minimum radius, but again not the point. A minimum entry speed/height at entry and more importantly at the apex are essential. (Also max speed for apex gate).

You say you were a Hunter pilot; AH was a pilot flying the Hunter - not quite the same!

ROBSAUSTINHEALEY

3rd Mar 2017, 17:25

So the primary cause of this dreadful, and avoidable, accident was pilot error; no great surprise as the AAIB Interim Reports had inferred as much. Whilst it can never be a comfort to those relatives and friends who lost so much so quickly, at least the reason why they died is now known.

Should the CAA now consider rescinding their knee-jerk restriction on "vintage jets"? The media pressure on the Government (i.e. the CAA) to "do something" about these old jets endangering people on the ground should have been resisted at the time. After all, there was never any suggestion that the Hunter had suffered any form of structural or control problem. Whilst certainly not advocating any more restrictions on display aircraft, it would seem that the low-level manouvres of the Red Bull air racers, or indeed any other piston engined display aircraft were considered a much safer form of entertainment than "vintage" jets (err, how old are the Red Arrow's Hawks....?).

The AAIB recommendations include stricter licencing of air display pilots and will, no doubt, look closely at the maintenance regimes of all display aircraft. These, along with revised CAA guidelines for air-displays will now hopefully allow us to see these beautiful aircraft back in their natural environment. After all, air displays are second only to football in terms of popular support.

Tankertrashnav

3rd Mar 2017, 17:25

A reminder to all posters that the British press will undoubtedly monitor social media (yes, also this PPRuNe forum!) for quotes and the like.

If they do, could they note the following trivial, but annoying mistakes in terminology.

1. The last time anyone in aviation referred to "looping the loop" was c 1925.

2. "Stunt" is reminiscent of barnstorming displays from the same period. "Manouevre" is one of several possible alternatives.

3. The word is "aerobatic" not "acrobatic".

All above from BBC news today.

sika hulmuta

3rd Mar 2017, 17:33

Indeed HP. I merely point out that the entry speed and height was sufficient for the manoeuvre, and thankfully, yes I am not AH.

What I didn't say is that it will still happily go around at 280 kts, BUT you need full power to achieve the gates. I'm still reading, but it appears there were thrust variations in the climb, which is interesting. Why? is a good question here I think.

Alber Ratman

3rd Mar 2017, 17:34

And use the word "Aircraft" or "Aeroplane" , not "Plane".

2 sheds

3rd Mar 2017, 17:40

The BBC also elected to refer to "pilot error" in their sensation-grabbing headline.

Bigpants

3rd Mar 2017, 17:41

It might help the debate if someone was able to list the aircraft flown by AH during his RAF career and a rough idea of hours on type. I believe he was more experienced in flying the Jet Provost and given his age would not have thought he flew the Hunter during his years in the RAF.

Under pressure, it is possible a pilot might revert to type. Example, your hand goes to where the drag chute lever was for a type you flew years ago...

Cows getting bigger

3rd Mar 2017, 17:42

Should the CAA now consider rescinding their knee-jerk restriction on "vintage jets"? The media pressure on the Government (i.e. the CAA) to "do something" about these old jets endangering people on the ground should have been resisted at the time. After all, there was never any suggestion that the Hunter had suffered any form of structural or control problem.

Did you miss the 40 pages or so about maintenance/permits/airworthiness/ejection seats?

H Peacock

3rd Mar 2017, 17:44

The BBC also elected to refer to "pilot error" is their sensation-grabbing headline.

Well at least they got that spot on!

SASKATOON9999

3rd Mar 2017, 17:47

Hindsight is a wonderful thing!
Got "caught in the moment" - Maybe, "playing to the crowd" Maybe.
Has anyone here never, even once operated outside sop's in normal operations, just "to make it work"? 999.9% of the time it will work out fine!
Actions attributable to Human factors have, and will continue to kill significant numbers of people in aviation.
That said, it appears severe negligence has been proven and will very likely end in a significant jail term. I expect civil cases against bith the pilot and airshow committee are now in place. Can you blame them? No

CoolHead

3rd Mar 2017, 17:48

Most of the posts above rightly focus on the circumstances of the accident. But step back for a moment and let the numbers speak about risk. Most of the people attending air displays will have flown only as airline pax where the fatal accident rate (2002-2011) is about 0.04 fatal accidents per 100,000 flying hours. Some will have knowledge of general aviation where the AAIB report that the rate is 1.3 fatal accidents per 100,000 flying hours.

This AAIB Report suggests that there was one fatal accident per 2960 air display items in the period 2008-2015, but hasn't the courage to calculate the accident rate. Assuming each display item was 15 minutes (change the numbers if you like) that translates to 135 fatal accidents per 100,000 hours flown.

I doubt very much that Joe Public and his wife and children attending a display have any inkling of these relative levels of risk i.e. 3375 times higher than experienced on a commercial flight. Perhaps they should be told.

sidestickbob

3rd Mar 2017, 18:07

TBH I don't believe for a moment that this accident was anything to do with "reversion to type" or inadequate training in escape manoeuvres. I believe that this individual was well know for performing low aerobatics and in my experience leopards don't change their spots. This is a simple case of gross negligence on the part of the pilot and I hope justice is served.

Alber Ratman

3rd Mar 2017, 18:08

I as a licenced engineer and ex RAF airframe technician, am certainly concerned by the aspects of the cartridge life issues and maintenance holes that have been dragged up in this investigation. No doubts others in my field will retort that they have the right to do such extensions as they see fit in the BCAR world, I wonder if the insurance companies would agree. I doubt it.

Homsap

3rd Mar 2017, 18:18

sidestick bob...

Well said, it's nonsence 'reversion to type' do we know who was advising the AAIB on Human Factors because it is utter nonsense, yet I understand why it was flagged up, but you should always know the numbers for the type your flying. Also as someone has mentioned, this pilot had a track record of violating regulations in respect of Lancing College and Southport, although that rests with the regulators who took no action.

EDMJ

3rd Mar 2017, 18:18

Quote:
Should the CAA now consider rescinding their knee-jerk restriction on "vintage jets"? The media pressure on the Government (i.e. the CAA) to "do something" about these old jets endangering people on the ground should have been resisted at the time. After all, there was never any suggestion that the Hunter had suffered any form of structural or control problem.

Did you miss the 40 pages or so about maintenance/permits/airworthiness/ejection seats?

The CAA, the most liberal aviation regulator in Europe, set generous limits to operate within, some people chose to operate right up at the threshold of the limits and failed. Then there were the aforementioned airworthiness issues. Hence, the CAA could not have responded differently, and there will most definitely be more, namely that the limits will certainly be drawn tighter in an obligatory attempt to prevent something like this from happening again.

Whilst certainly not advocating any more restrictions on display aircraft, it would seem that the low-level manouvres of the Red Bull air racers, or indeed any other piston engined display aircraft were considered a much safer form of entertainment than "vintage" jets (err, how old are the Red Arrow's Hawks....?).

Lighter and slower, i.e. low energy aircraft of the Extra and Pitts type, need less space, and a misjudged rolling/looping maneuver is more likely to "only" kill the pilot.

To some extent with the benefit of hindsight, I'm wondering why rolling/looping maneuvers with high-energy aircraft were not taken off the airshow programs many years ago. At least Rolls-Royce's Spitfire and the Firefly crash at Duxford spring to mind...

overstress

3rd Mar 2017, 18:28

Bigpants: It might help the debate if someone was able to list the aircraft flown by AH during his RAF career and a rough idea of hours on type. I believe he was more experienced in flying the Jet Provost and given his age would not have thought he flew the Hunter during his years in the RAF.

It's in the report. On page 12, so not very far in at all!

The pilot joined the Royal Air Force (RAF) in 1985 and flew Jet Provost, Hawk and Harrier jet aircraft. He was a Qualifed Flying Instructor (QFI) on the Jet Provost between 1988 and 1990.
In his RAF Pilot’s Log Book, he had recorded his total flying time in military jet aircraft as:

Jet Provost MK 3A/5A - 934 hours
Hawk MK1/1A - 188 hours
Harrier T4/GR3, GR5/7 -517 hours

People should read the report really before cluttering up the bandwidth!

sky9

3rd Mar 2017, 18:36

I haven't read the whole report however on page 37 is a very brief report on the weather.
I spent the same day at Bournemouth and remember that what started as a very light wind became a southerly wind bringing in air from the continent with temperatures up to about 28 degrees. I do wonder whether the reduction in RPM could have been brought about by an inversion associated with the sea breeze. This is very frequent at Palma airport where in the summer the EPR and RPM both drop at around 700ft with a large increase in TAT.

I am very surprised that the weather in the report received so little attention; little more than 1/3 of a page, it was worthy of a greater depth of investigation.

Lima Juliet

3rd Mar 2017, 18:38

Pilot porked it, whilst others that could have stopped it, also porked it...

That is all...:(

Arfur Dent

3rd Mar 2017, 18:55

…. and total hours on the Hunter? In the last 6 months before the incident?

overstress

3rd Mar 2017, 19:03

Records indicated that the pilot had flown a total of 19 hours and 25 minutes in the Hunter during flying displays, including transit time. but you really should read this yourself in the report...

A total of 40hrs on type if I've read it correctly

Capt Scribble

3rd Mar 2017, 19:08

5:25 between May and Aug 15 as recorded on p19 as dispalays and practice. There may have been other flights as the full log book is not shown. 19:25 looks like total display and practice, 40+ on type.

doubletap

3rd Mar 2017, 19:09

How about we start by getting DAs issued/renewed by CFS rather than the Duxford/Goodwood mates network?

biscuit74

3rd Mar 2017, 19:24

All very depressing reading. Some depressingly familiar.

Like Arfur Dent, one point stood out for me.

That a pilot of his experience and background was prepared to fly displays in the Hunter without EVER having practiced the escape or ‘bail out’ maneouvre - rolling out of the loop and recovering from the ensuing dive – astonished me. I would have wanted to try that out a few times and ensured I knew the minima and limits on that.

OK, partly because many years ago I scared myself by continuing a pullthrough to eye-wateringly low level instead of rolling out (in a much simper aircraft of course!), because I wasn’t adequately competent at what I was doing, but also because I’d view it as a ‘get-out-of-jail’ card for the day when I’m not flying as accurately as I’d like. (Which of course never happens...)

That lack seems very surprising; I'd have thought normal personal survival thinking as well as very basic flying safety would have ensured that the escape option was at least practiced and its limits known. Over confidence, or blinkered thinking perhaps? After all, practice in that sort of machine must have been expensive.

Or am I being too simplistic? Any thoughts folks?

Onceapilot

3rd Mar 2017, 19:26

Thanks Davef
Quote:
Originally Posted by Onceapilot View Post
Pozi,CM

I will give you the benefit of the doubt if you read what I wrote and confirm you understand. The report identifies vapour, aparently from the wing tank area. The trail I refer to is from the fuselage/jetpipe and is visible in video online.

I know the one you mean, there is a short trail immediately after he comes over the top of the loop.

There is a vapour trail from the jet pipe area at a couple of points during the flight (e.g. at about 4 seconds in this compilation https://www.youtube.com/watch?v=Mr4POEBz81s)

From memory, does the Hunter not have a fuel vent pipe in that genreal area?

The vid clearly shows vapour streaming from the fuselage/jetpipe area in two separate occasions at the start of that recording. This is NOT the trail that was commented upon in the report and, IMO, is an important event that should be addressed.

Busbert

3rd Mar 2017, 19:34

It's rather worrying so see discussion in the media about the contents of the AAIB report being used as the basis for criminal proceedings.
People support Annex 13 investigations in the absolute understanding that the sole objective is to prevent future accidents. On this basis people don't avail of their 'right to remain silent' and the process of 'physical evidence chain of custody' does not meet the standards needed for a criminal investigation.
The process of criminalization of 'human error' undermines (future) Annex 13 investigations, as people will get 'lawyered up' before talking to investigators, and the standard advice is 'no comment'.
BALPA and other interested parties need to be robust on defending this point.

Madbob

3rd Mar 2017, 19:35

I do not know Andy Hill or have any "inside" information to add. All I can assume is that he had every intention of when he took of at North Weald to complete his display, RTB and land safely and get home to his wife that evening.

He had no intention to screw up in any way or risk the lives of innocent people. This was as tragic accident and that is all there really is to say. Yes it is very sad for the victims but nothing will bring them back and so censoring the hapless pilot, who put himself in serious danger and could himself have easily been killed won't achieve very much. He will still be feeling a strong sense of survivor's guilt and being sent to jail is not going to help him "learn from his mistake".

My own thoughts on how to prevent a recurrence of this tragic accident would concentrate more on the suitability for Shoreham as a venue for any kind of high energy air display. The location of housing, schools and generally high-density habitation in close and un-regulated crowds (outside the jurisdiction of the display organisers) and their proximity to the display axis makes this an unsuitable venue IMHO.

Air display flying can never be considered a zero-risk activity and the CAA and the public need to accept that. For my part, individuals need to be aware that standing or just being under or close to ANY aircraft taking part in a display is potentially dangerous. The fact that this was a former "vintage" military jet is not relevant. The only considerations are whether the aircraft was airworthy, being flown within its limits and properly maintained/operated. Hanging the unfortunate pilot out to "dry" won't do much to prevent a recurrance.......he certainly didn't mean events to turn out the way they did and he has my deepest sympathy; just as the families of the victims have my condolences.....

Local Variation

3rd Mar 2017, 20:05

Shoreham an unsuitable venue..? as in all that blue stuff south of the field.

Homsap

3rd Mar 2017, 20:11

Yes, the display pilot did screw up, why to we need to debate this?

wiggy

3rd Mar 2017, 20:13

Re AH having a "track record" with infringements : a bit meaningless without a context - anyone know how his violations compare with the norm for a similar period.

What strikes me about all this is that under pinning everything is that like madbob I very strongly suspect AH intended to go home that evening.

I really don't think anyone, and I mean anyone, would blow off knowingly being 700 feet low ( and low on energy generally) on a fast jet display at low level and continue looping through..a couple of hundred feet maybe if you are brave or daft, I don't know, but 700 feet low? I do wonder if the possibility of distraction/confusion for whatever reason is being underplayed?

Yes, the display pilot did screw up, why to we need to debate this?

Because it might prevent future accidents?

SLF3

3rd Mar 2017, 20:56

No one comes out of this with any credit. A complacent regulator who can't decide what his own rules mean, and permits what at best could be described as a Laissez-faire approach to compliance and record keeping. Maintenance organisations that seemingly Rationalise their practices after the event and sign stuff of against core documentation they don't have. Defects in primary instruments not recorded. No follow up to engine over speeds. Engine out of hours, preservation not done, ejector seats maintained at home and fitted with life expired components. Pilots approved to maintain certification for solo jet display based on flying a piston engine plane and follow my leader in a jet. The obvious conclusion (which Martin Baker seem to have reached) is that there isn't the money or competence out there to keep old fast jets flying to an acceptable level of safety. Sad, but seems to be inescapable.

pax britanica

3rd Mar 2017, 20:59

If Shoreham is to be classed as an unsuitable venue what about Farnborough with things the size of an A 380 displaying -the airport literally is in a town centre at one end and the other end (Laffans Plain) is way off the end of the runway and viewing areas. Flying manouvres away from the crowd line though heads them right towards housing estates and the town centre

I am not saying it should be stopped because I love the show but like may locals watch it from a point outside the airfield boundary so am now wondering if that will be stopped because while it is very clear from this report that more needs to be done on the safety front the normal regulatory reaction is a gross over reaction

Courtney Mil

3rd Mar 2017, 21:23

...can you expand this element? i.e. which instrument, which malfunction and how do you see it as a potential causal factor.

Sorry old chap, but I am not about to read and précis the entire report for you. You read it and you will see. If you are as interested in the factors as you have continually claimed to be, I'm surprised you are not already studying it.

wiggy

3rd Mar 2017, 21:57

Speaking as someone who is currently studying ATPL groundschool but has flown for many years (700+ hours, ppl(a),(h),mep,ir(r)) for fun it strike me that the main difference being private and professional pilots is attitude. Put simply it strikes me that for the professional pilots the key thing is not to f**k about,

TBH I'm struggling to get your point because of the time of day and the format.

I may be misunderstanding you, apologises if I am, but if you are trying to pigeon hole AH into a pilot "type" and therefore saying he was a particular "sort" of pilot and that in turn led to the accident I would be a bit wary.

AH was a RAF creamie Instructor initially ( so by definition very well regarded in terms of flying skills right from the get go) then a fast Jet pilot with the RAF on what was at the time regarded as the most difficult single seat aircraft in the RAF, frankly you can't F'around or ignore procedures/gates in either job, especially in the Harrier. He then did and passed all the ATPL stuff you are currently studying and since then has several thousand hours as a commercial pilot on the Airbus in both seats, passing all the regular civilian sim and line checks. It just so happened he was also display flying the JP and a piston type., but he certainly wasn't a private pilot who had simply bought himself a jet to display.

I really really don't think AH would suddenly simply lose his professional "don't F**k about" attitude just because he was in a Hunter on a day off....but I do agree there may be issues with display authorisation, recency and exposure to the aircraft type

Pittsextra

3rd Mar 2017, 22:30

Quote:
Originally Posted by Pittsextra
...can you expand this element? i.e. which instrument, which malfunction and how do you see it as a potential causal factor.
Sorry old chap, but I am not about to read and précis the entire report for you. You read it and you will see. If you are as interested in the factors as you have continually claimed to be, I'm surprised you are not already studying it.

CM - Weak. I'm not asking you to give me chapter/verse on the whole report I was asking you to flesh out your own comment and what instrument YOU were talking about and why YOU think it is a causal factor when the AAIB have not.

Forget me and my opinion I'm just reading the AAIB final report which was something you had been waiting for, then when it comes suggest it's not a complete work.

Do the AAIB call things correctly that the start of the figure flown was too low or is that element still something of debate?

Jackonicko

3rd Mar 2017, 22:52

Wiggy observed that: "there may be issues with display authorisation, recency and exposure to the aircraft type."

That seems to me to hit the nail pretty accurately on the head.

It's always easy to blame the guy at the controls, and it is by no means my intention to do that. In my (perhaps over simplistic) view it seems fairly plain that the accident resulted from entering the manoeuvre too low, too slow, from failing to maintain thrust during the manoeuvre, and finally from failing to abort the manoeuvre when insufficient height was achieved at the apex.

But I would not agree with those who conclude that the pilot was wilfully or recklessly negligent, and would ask whether inexperience and lack of currency are not better explanations than a 'gung ho' 'cowboy' disregard for the consequences?

I hope that this does not cause offence, but I can't imagine that this pilot would be authorised by the Royal Air Force to display a swept wing fast jet in 2017. Why should the requirements for displaying such an aircraft on the civil register be so very different?

His Harrier experience seems to have been relatively modest (one tour?) and a long time ago - the GR3 had left frontline service by 1990 (That's 27 years ago). Do we think that he was so experienced (and current) on this category of aircraft that he should have been publicly displaying the Hunter with so few hours on type?

It's not as though he was a former service display pilot, a TP, or someone with bags of experience on swept wing fast jets, nor even someone who had lots of operational experience gained within the last decade - or even this century.

Courtney Mil

3rd Mar 2017, 22:58

Pittsextra, when you and I have finished reading the entire 452 page report and had time to digest it and understand it, I suggest we shall both be better placed to discuss it.

BTW, my willingness to debate does not include CA regulations, CAP or commercial risk analysis. But I am happy to discus hunter performance, display dynamics and pilot performance. I'm happy with primary engineering and regulations.

If, as you and I have discussed before, you should understand that I am not going to comment on CAA regulations nor their application of regulations, apart from those I have been involved with.

So discuss with me the technicalities of this accident, but don't bother trying to involve me in the issues that you and I have discussed a year and a half ago.

wiggy

3rd Mar 2017, 23:00

nor even someone who had lots of operational experience gained within.....or even this century....Gee thanks, now I feel really really old:ooh:...and it is way past my bed time. :ok:

Sillert,V.I.

4th Mar 2017, 00:41

The reasons for this accident and the reasons why it had such tragic consequences are not the same thing. Anyone still trying to blame one person for what happened is missing the whole point of that 400+ page report.

To those whose loved ones died that day and are trying to find some closure I would say this:

The accident happened because the pilot made a mistake. The final mistake which ultimately sealed their fate was made in a split second, under pressure and whilst flying upside down; hardly an ideal situation for decision making. To err is human; pilots are human and it is inevitable that they will sometimes make mistakes.

The reason why so many lost their lives was because a large number of people across a range of organisations failed to adequately assess and mitigate against the entirely foreseeable risk that a pilot might make a mistake. If those people had properly discharged their responsibilities, it is very likely that noone apart from the pilot would have been injured or killed. Unlike the pilot, their mistakes were made from the comfort of a safe seat on the ground, with many months or even years in which to find the right answers.

Continuing to hound the unfortunate pilot will achieve nothing beyond compromising future accident investigations. He may have made a poor split-second decision, but IMO not a negligent one; he will doubtless live with the consequences of that decision for the rest of his life and whatever his shortcomings may have been, I'd say he has already paid a fair price for his poor decision.

To those who think a prosecution of the pilot may serve as a warning to others I will say only this; I can conceive of no penalty which would act as a greater deterrent to a future airshow display pilot than the obvious consequences of flying a fast jet into the ground.

megan

4th Mar 2017, 02:25

To err is human; pilots are human and it is inevitable that they will sometimes make mistakes. Let he without sin cast the first stone. Agree Sillert, and no one has invented a new way of having an accident.

The well trained and highly experienced have come, or nearly come, to grief performing the same maneuver. British test pilot demonstrating the Hunter to the Swiss just made it, forgot about the impact on performance of the high altitude airfield, four T-38 (Thunderbirds) in formation impacted the ground, and of course the Thunderbirds F-16 more recently, as a result of a simple, simple error. In Australia we had a RAAF aerobatic team flying two seat Vampires impact while performing a roll, four aircraft and six people.

alo_XWCqNUQ

JEM60

4th Mar 2017, 06:04

sharksandwich

4th Mar 2017, 06:28

Sillert:"The accident happened because the pilot made a mistake. The final mistake which ultimately sealed their fate was made in a split second, under pressure and whilst flying upside down; hardly an ideal situation for decision making. To err is human; pilots are human and it is inevitable that they will sometimes make mistakes".
This is not accurate, a planned aerobatic schedule should not leave room for ad hoc decision-making.
Do you imagine the Red Arrows have to think about their next manoeuvre during a display?

Bigpants

4th Mar 2017, 06:32

WallyWitless

4th Mar 2017, 06:40

Not operating at Red Arrow standards seems to have been identified as part of the prevailing air display culture. That isn't the fault of any individual pilot. Culture evolves overtime. Hindsight is very good at illustrating how that cultural journey has occurred, it it rather less good at rectifying mistakes made during it. Mistakes that are not the fault of ANY individual pilot, let alone this one flying at a Charity event in an old plane at sleepy old Shoreham.

Consecutive errors, pilot goes into the loop too low being the final piece of the jigsaw. The likelihood & expectation of him rolling out at the top of the loop is being exaggerated in my opinion.

Cows getting bigger

4th Mar 2017, 06:57

Bigpants

4th Mar 2017, 07:11

And does he display two types? I remember an exceptional RAF pilot joining BA in 1996 and within a short time he was exceptionally dead because he chose to display a WW2 warbird and departed it at low level.

Hebog

4th Mar 2017, 07:12

The main point also not raised in the summary is that this jet has been flying since December 2010 without a valid Permit to Fly. It has been renewed by the current maintenance organisation and the one before several times despite having issues such as out of date seat cartridges, engine RPM limits exceeded (during Flight Test in June 2011), no AMOC with either company being valid.

If these had been more honest and not 'stretched' their abilities and permissions this aircraft would not have been flying. Had the CAA checked more thoroughly during audits on these companies the aircraft wouldn't have been flying and the companies maintenance licence revoked. However, what occurs in a CAA audit is it carried out by a team with sufficient knowledge and a proper examination of the aircraft undertaken or is it just a paper exercise?

mary meagher

4th Mar 2017, 07:20

Megan on post 80 has posted a video of a US event during a display at Mountain Home in Idaho of a Thunderbird making the same mistake. A miscalculation of the altitude available for the maneuver to be safely completed. Well worth listening to for the comment is extremely relevant to the Hawker tragedy.

In Idaho, nobody at all was injured, neither the pilot nor the 85,000 spectators.
Clearly, Mountain Home is more appropriate for an air display than Shoreham where it proved impossible to keep spectators clear of danger. Even the beach would have been better than the unrestricted airfield location.

wiggy

4th Mar 2017, 07:23

Homsap

Way back you said " this pilot had a track record of violating regulations in respect of Lancing College....."

Do you have a reference or source for that claim, e.g. some AAIB number?

Arfur Dent

4th Mar 2017, 07:25

gpbeck

4th Mar 2017, 07:35

I am not a pilot, but am pondering the report, not the incident.
What effect has the pilot's miraculous survival had on the report, with various species of lawyer circling? Has it helped?
He has 'no commented' on the events of the day. What would have been said about escape planning, for example, had he died?
In the past I've read many negative comments about ex military pilots in passenger jets. What about the opposite?
In a strange way, human factors seem to be everywhere. Even in the investigation process.
So how different would this report have been if the pilot had died? I need to read it again, ignoring pilot contributions.

Treble one

4th Mar 2017, 08:04

At long last people are catching on to what I've been saying all along. Low level display aerobatics in Fast Jets should be carried out by current, well funded professional aircrew. Would a serving RAF pilot be authorised to display with virtually no recent practice time? If you can't do it properly, don't do it at all or this happens and Gnats happen and Vampires happen etc etc.
The pilot was doing his best and the CAA should not have allowed him to continue with this "accident waiting to happen". AH was not superman. Neither are any of the others who jump from one type to the other. Test pilots do that and take a very long course to make sure they do it safely. They do not jump into an unfamiliar Fast Jet and do aerobatics based at 200' (or even 500') in front of thousands of people ( including me and my grandkids) without putting themselves and the rest of us at significant risk.
Stop this if you can't do it properly.
This, surely, must be the basic conclusion after such an appalling disaster

Currency on type very quickly became the 'elephant in the room' during this investigation. CAP403 has been significantly amended in this regard. IMHO there needs to be a balance between the extremely robust procedures put in place by the RAF and the currency and ISP rules regarding civilian flying displays however.

If for example the civilian world was to adopt the RAF currency/ISP rules it would almost certainly result in the end of flying warbirds/classic jets due to the sheer costs involved?

H Peacock

4th Mar 2017, 08:07

At the risk of cluttering up bandwidth does anyone know of another pilot in 2015 who was flying a commercial airliner, a Jet Provost, A Hawker Hunter and lastly a tailwheel light aircraft? It is a big ask to remain current and competent on 4 very different types given that some airliner groups like the Airbus can include three variants.

For example, in 2015 how many RAF Test Pilots were current on four types? A handful perhaps but, I doubt if any were also display qualified on two types which begs the question of why AH or the people regulating him thought this was an acceptable situation?

I'm not sure I buy that, apart from possibly confusing some limits/numbers etc. Some of the BBMF Bomber pilots have been current on 3, displaying 2 of them. Even current on 4 if you include the Chippie. Absolutely not an issue providing you put the correct 'cassette' in before you fly. Forgetting to put the gear down on the Dak 'cos you don't need to on the Chippie is a remote possibility, but the appropriate checks will always save the day.

kwh

4th Mar 2017, 08:10

It seems like an obvious point, but if the investigators say they do not know whether the altimeter was serviceable and/or accurate, but they do know that maintenance was demonstrably sub-optimal and that broken safety critical stuff was just not getting fixed, it's at least possible that he entered the loop at a height consistent with his experience of displaying in the Jet Provost (after all he wouldn't have been looking at the altimeter at 200 feet would he), but that everything thereafter was the result of cascading technical issues. If the engine RPM drop was a result of a technical or environmental issue, but then when he checked the altimeter at the top of the loop to see if he had enough height, it told him that he did, then the first time he realised it had all gone wrong was when he was heading for the ground.

Quick question about the focus on his not knowing about the minimum speed for rolling out at the top of the loop... I'm not a pilot, but I've flown as many arcade flight simulators as anybody... I assume that if you arrive at the top of a loop and realise in that moment that if you finish the manoeuvre you are going to end it in a crater, and you further realise that you don't know whether you can roll upright at your current speed without falling out the sky, do you not still have the option of just levelling off and flying away inverted until you can gain some air speed, and wouldn't that be the safe way out if you were a former fighter pilot comfortable with flying inverted all day long?

Arfur Dent

4th Mar 2017, 08:13

Thanks 111.
I just re-read something in the report where it states that the Display Authorisation to carry out low level aerobatics in a Hunter (AND a JP!!) was awarded by a CAA representative watching a display in an RV-8 piston engined home build!!!
There is the second elephant for goodness sake.
By the way, I am ex RAF and 3 tours on FJ.

wiggy

4th Mar 2017, 08:18

do you not still have the option of just levelling off and flying away inverted until you can gain some air speed, and wouldn't that be the safe way out if you were a former fighter pilot comfortable with flying inverted all day long?

Not a display pilot but IMHO you'd almost always be better off spot rolling ( unloaded) and then pulling out, certainly once you've gone past the horizontal. AFAIK most older military types have a relatively low negative g limit and I suspect those limits and ultimately the structure itself really might not like a hard "push out" from an inverted descent ....but others with more experience might think differently.

H Peacock

4th Mar 2017, 08:35

Quick question about the focus on his not knowing about the minimum speed for rolling out at the top of the loop... I'm not a pilot, but I've flown as many arcade flight simulators as anybody... I assume that if you arrive at the top of a loop and realise in that moment that if you finish the manoeuvre you are going to end it in a crater, and you further realise that you don't know whether you can roll upright at your current speed without falling out the sky, do you not still have the option of just levelling off and flying away inverted until you can gain some air speed, and wouldn't that be the safe way out if you were a former fighter pilot comfortable with flying inverted all day long?

As you approach the apex of the loop you should be including a bit more altimeter (bit less accelerometer) in your scan. You should therefore have a very good idea about the gate height call before you actually go over the top. You even have some ability to vary the pull in the 1st/2nd quarter to possibly back-off the pull - you'll get a bit more height at the expense of a lower IAS. If you see you'll not achieve the gate parameters then it is rarely the best course of action to spot roll to S&L at the apex; you'll be very slow and so could well depart. Instead, keep the pull on until the nose is now below the horizon - IAS building - unload the g then roll. Provided you do this all comfortably within the 3rd quarter all will be well.

The basics of the 'escape' is common sense. If not you shouldn't be in the cockpit doing LL aeros!

Arfur Dent

4th Mar 2017, 08:39

Exactly as "H" said and it becomes a "Cuban 8" and nobody would ever know that wasn't the plan all the time (spectators I mean). Google it.

Capt Scribble

4th Mar 2017, 08:45

The report seems to emphasise the he was not trained in the escape manoeuvre. I would suggest that anyone with experience of turning aircraft upside down or having been in military flying knows what to do when things do not work out. As has been said before in these posts, a UP recovery is all that is needed. AH will have taught those as a JP QFI as part of instrument flying and they are tested, or were in my day, as part of the IRT. So, Wiggy, you are about correct. Roll to the nearest horizon when speed is over a certain value, and if the nose is low, apply full power.

H Peacock

4th Mar 2017, 08:46

Exactly as "H" said and it becomes a "Cuban 8" and nobody would ever know that wasn't the plan all the time (spectators I mean).

I'm RAF taught, so my Cuban 8 has the half-roll on the way up. We call the one described above as a 1/2 Horizontal (8). I've never known why!

Arfur Dent

4th Mar 2017, 08:50

Different Cuba - I'm RAF too. Always rolled on the way down - does imply that in the Google pics. Anyway - we make a similar point eh?

bradleygolding

4th Mar 2017, 09:08

I just re-read something in the report where it states that the Display Authorisation to carry out low level aerobatics in a Hunter (AND a JP!!) was awarded by a CAA representative watching a display in an RV-8 piston engined home build!!!
There is the second elephant for goodness sake.
By the way, I am ex RAF and 3 tours on FJ. Yes that was the big WTF? moment for me in the report as well, although there were others. As I said on the Flypast Forum no one comes out of this 'smelling of roses'.

Treble one

4th Mar 2017, 09:12

Prior to this accident Arfur, that was within the guidelines as defined by CAP403.

The pilots display currency/DA's at the time was also within the CAP403 guidelines as they were. all of his paperwork was very much in order.

The question of whether or not his 40 odd hours in a Hunter over the last 5 years or so was enough quickly became a very valid point of course......

As a former FJ pilot yourself, I wonder if I gave you the 'keys' to one of your former mounts and said 'go away and work up a display routine', how many hours would you want me to sign you off for to make sure you were ready to go in front of the public?

bradleygolding

4th Mar 2017, 09:21

I understand that this was all in the guidelines and that all of his paperwork was all in order. My question is how on earth did the CAA ever think that being able to renew a DA for a fast jet via a piston GA aircraft was okay?

eal401

4th Mar 2017, 09:32

To some extent, I agree with SILLERT. BUT... If I make a split second bad decision in my car and and kill 11 pedestrians at a bus queue, then I am afraid that the full force of the Law would come down on me. Killing 11 people with a bad decision in an aeroplane can be no different. I would not like to see him penalised by the Law, but I am afraid that you cannot have one law for cars, and another one for aircraft, where, technically, the offence is exactly the same.

I was waiting for someone to make this point.

The fact that AH wanted to flying the display and go home is irrelevant. The same applies to the driver who has one drink too many, or drives at 90 on the motorway, or runs a red light.

It just seems from some posts that if you commit a significant error and kill people, so long as you are in a plane "that's OK then"

The only thing that I get from this sad event is that it's now not just the pilot and air show director who require jail time, but those responsible for maintaining the aircraft too. Anyone who disagrees can go and stand in a room with the families of the dead and discuss it with them.

McDuff

4th Mar 2017, 09:36

Avitor

4th Mar 2017, 09:45

I have held my tongue on this but, I have always thought he did not properly prepare for the manoeuvre he was about to perform.....in other words he ballsed it up. The detail is all over this thread. Closing ranks on here will not help those who grieve.

kwh

4th Mar 2017, 09:56

I was waiting for someone to make this point.

The fact that AH wanted to flying the display and go home is irrelevant. The same applies to the driver who has one drink too many, or drives at 90 on the motorway, or runs a red light.

It just seems from some posts that if you commit a significant error and kill people, so long as you are in a plane "that's OK then"

The only thing that I get from this sad event is that it's now not just the pilot and air show director who require jail time, but those responsible for maintaining the aircraft too. Anyone who disagrees can go and stand in a room with the families of the dead and discuss it with them.
You can't do that {prosecute the pilot} if he didn't wilfully do anything that he knew broke the rules, you really can't - the whole non-fault incident reporting and improvement system sort of depends on it. I mean, in catastrophic incidents it is incredibly rare to have surviving aircrew in any position to prosecute for being fallible, so the gain in successful prosecutions would be tiny, but what would be lost? The next time a Human Factors incident occurs with a live pilot who can describe why they did what they did to investigators, they won't, and perhaps hundreds of people will die in identical crashes that could have been prevented as a result.

Yes, if somebody drives a car & makes a mistake because they misread a bend and kill somebody they go to jail for it, but that's a bug in our current traffic safety system not a feature that air crash investigators need to emulate...

homonculus

4th Mar 2017, 10:34

To use this analogy, if someone speeds or is drink driving they break the law and are prosecuted. If AH did not have a medical or other paperwork, fine - prosecute him too. However if you travel at 30mph round a bend but skid on ice and kill someone prosecution is far from certain and the same applies here. An error of judgement should not be a crime.

Rabid calls to jail him will cost the taxpayer a fortune and destroy a family for no benefit. It may even further harm GA and the weekend amateurs generate tax and jobs.

As a doctor at the sharp end I make mistakes - any doctor who doesnt is a liar. Whether those mistakes cause harm is more luck than anything. I learn from them, educate to eliminate them and try to impose unrealistic standards upon myself but at the end of the day if something goes wrong I carry insurance so my patient can be put right as much as possible.

The families may well go down this path and a civil court will have to weigh up all the imponderables raised in this thread and the report. That will be hell for both them and AH. But jail??? No

DaveReidUK

4th Mar 2017, 10:34

What was needed to escape the manoeuvre? As well as the other measures mentioned, the speed needed to before starting to roll out. I flew the Hunter a loooong time ago, but 105kts seems to me to be less than control speed.

Clearly the AAIB don't agree:

"From the apex height and airspeed achieved in the accident manoeuvre, and for up to at least four seconds after passing the apex, it would have been possible for an appropriately trained pilot to fly a straightforward escape manoeuvre in G-BXFI which would have prevented impact with the ground by rolling the aircraft through 180° back to erect flight and then pulling out of the dive to regain level flight."

funfly

4th Mar 2017, 10:36

What better example of holes in cheese ?

G0ULI

4th Mar 2017, 11:05

The unique aspect of this incident is that the aircraft crashed away from the display area, killing and injuring people who had no involvement in the air display. If you pay to watch an air display, you accept that there is a small element of risk watching aircraft maneouvre at close quarters. Persons away from the display area have no idea that they may be at risk, or may have taken a deliberate decision to avoid such risks. The public outside of a display area are entitled to believe that the organisers of air displays and pilots have taken every step to avoid and mitigate any risk to general members of the public going about their daily business. That certainly did not happen at Shoreham. Various factors served to increase the risks of an accident happening, the display area, the type of aircraft, aircraft maintenance, weather conditions and pilot experience on the type. Ultimately the blame must be laid before the pilot who was responsible for an error of judgement and a failure to take action to recover from the maneouvre by rolling the aircraft upright and out of the loop when this was still possible.

Should criminal proceedings take place, jail sentences for the organisers or pilot might not be seen to be justice in relation to this incident, but it will certainly act as a warning to organisers of future displays as to the consequences of inadequate planning and safety considerations. Air displays are extremely popular, but general members of the public who choose not to attend are entitled to expect the highest level of protection from these activities. That is what makes this incident so tragic, because the controls that will now be enforced will serve to limit some of the activities and aircraft that make air displays so popular.

homonculus

4th Mar 2017, 11:20

so let me get this right Gouli - you jail the pilot to dissuade future display organisers. If I may say so that sort of justice is more common in some foreign dictatorships than England.

I fully agree people who had not intended to watch the display were killed. I am not sure that makes the death any different in the eyes of the law or indeed many of us. however the decision on the display line was that of the organisers and the CAA (!!), not the pilot. The report states he was correctly positioned along the display line. Had he been displaying off line he would have committed an offense.

I am not getting into what should happen to the organisers - I have no expertise or knowledge there - but your arguments seem to shift blame if there is any to shift legally from the pilot.

Hebog

4th Mar 2017, 11:45

The problem is trying to ascertain when the pilot knew he had a problem that needed resolving.

If he knew at the apex that there was a problem and he didn't take the appropriate action ie emergency measures this could be deemed negligence but maybe he was unaware at the time due other factors such as altimeter mis-reading the height, the engine not having the thrust he thought he had etc and it wasn't till he was half way down the loop or near the bottom that he had a problem.

Does any ex hunter pilot know what the 'emergency' plan would be then... eject and leave the aircraft to its own devices or try and plant it somewhere safer and maybe kill yourself trying..

Treble one

4th Mar 2017, 11:51

I think we may find that there are 'other considerations' to be taken into account in this accident.

Like the need for justice to be seen to be done?

G0ULI

4th Mar 2017, 11:54

homonculus

4th Mar 2017, 12:08

kwh

4th Mar 2017, 12:16

An incident occured where many completely uninvolved people were killed or injured away from the air display area. There were a combination of factors that ultimately led to this tragedy, but the primary factor has to be that the pilot misjudged the maneouvre.

A large number of people had their lives irrevokably changed that day as a result of an incident that should have been avoidable. Whether criminal proceedings take place, or not, is a matter for the judiciary. What penalties might be imposed are again a matter for the judiciary. I am merely pointing out that the sentences imposed by our courts frequently do not directly reflect the case being considered but are intended to act as a deterrent to others who might be tempted to act in a similar manner, or avoid their responsibilities towards public safety. I would suggest corporate manslaughter charges are a distinct possibility in this particular incident.

I make no judgement as to the potential outcome but clearly there is a public demand that a price and compensation for the victims be paid. For that to happen, someone will have to be held responsible.
You can't deter humans from being fallible, it is a symptom of the human condition. You can put hard legal constraints around activities to make them safer, like making drink driving illegal, knowing that this mitigates the overall risk by reducing incidence of drunk driving which is a specific activity that increases risk significantly, but you really can't prosecute people for failures of perception or faulty decision making under pressure without setting flying safety back to the dark ages. If the pilot knowingly broke safety rules, that would be grounds for prosecution, conviction if you could prove it beyond reasonable doubt, civil liability on the balance of probabilities. If the pilot complied with all the rules but the maintainers & operators didn't, prosecute them and make an example of them, if the air show organiser broke the rules then prosecute them, but if everybody followed the rules, the rules themselves are clearly inadequate...

DaveReidUK

4th Mar 2017, 12:18

The report states he was correctly positioned. Had he been displaying off line he would have committed an offense.

No he wasn't.

Leaving aside the height issues, the horizontal profile started to go wrong from the point where he rolled more than the required amount during the climbing segment of the "bent loop", with the result that the final track was broadly aligned with the A27 instead of the display line (2.2.1).

cessnapete

4th Mar 2017, 12:20

kwh

4th Mar 2017, 12:22

I am not sure there is a public demand for criminal as opposed to civil proceedings gouli. time will tell. In the meantime I hope professional pilots will reflect on the precedence this might set for aviation and try to avert a witchunt that might effect many of us in the future

I agree with Hebog that any considerations will not be that simple. But I dont think we can judge HA's decisions against that of an established hunter pilot. The regulator and the rules are satisfied for this display to be conducted by a pilot with perhaps only 60 hours on type and a degree of self education. He will be judged by those standards, and others may need to answer as to whether the standards were adequate.
Irrespective of the criminal liability question as it attaches to the maintainers/operators in this crash, if they bear any responsibility, one hopes that the civil liability does attach to them, so that their alleged decision to cut corners to save money backfires spectacularly enough that others learn the appropriate lesson...

kwh

4th Mar 2017, 12:44

GOULI
To completely mitigate the risk to people not involved or attending an air display, due possible aircraft malfunction or pilot error as you appear to want, is unrealistic.
You would need to sterilise(i.e temporarily remove all the inhabitants)in the area around and under the intended flightpath of display participants. In this case no off airfield spectators on all roads under the flightpath, all local highways closed to traffic, large police presence to enforce, and empty most of Shoreham town.
or of course ban all air displays.
Nothing in life is risk free. This was a tragic accident and knee jerk reactions are not the solution.
If you tell a million people that the potential for getting a Hunter through their sunroof or their bedroom window or into their kid's primary school is just something they have to live with as long as there are airshows, then the 20,000 air show enthusiasts might be a tad disappointed by the nature of the solution proposed by local voters...

Courtney Mil

4th Mar 2017, 12:50

Sadly, for an aviation forum where one might expect a degree of knowledge of the subject under discussion, there are the usual unfounded assumptions and accusations going on here.

The ones that stand out are:

This pilot had a track record of violating regulations in respect of Lancing College

Please provide evidence of your accusation.

The pilot porked it

No where in the evidence in this or previous reports is there evidence to support your libel. In fact, the body of the report contains a number of statements that the reason he continued the manoeuvre could not be determined although possible explanations were given including obscuration of the digit counters by the altimeter needle and glare, etc. You have no basis for your claim.

Full power is not applied

The engine was not producing full power, the report is clear that it could not be determined what the pilot had selected with the throttle and that previously this mark of Avon engine had produced less than maximum power for reasons that were never determined.

The pilot made a mistake

See my earlier comments. What mistake do you think he made?

If I made a split second bad decision

What was the bad decision? With the amount of doubt cast on various unserviceabilities and obscuration of the Altitude counter, there is every possibility that it was a good decision based on bad information.

The display pilot did screw up

Nowhere in the report, nor in previous reports has this ever been stated. The report is careful to list a number of different mitigations, which you have clearly ignored or not read.

The accident happened because the pilot made a mistake

See my previous remark. You have no grounds to draw that conclusion.

confused and thought he was in a JP

No evidence for that assumption whatsoever.

So the primary cause of this dreadful, and avoidable, accident was pilot error

Where does the report say that? The report clearly never states that. The report clearly states why that conclusion cannot be drawn.

It appears severe negligence has been proven

Please show me where there is stated evidence in the report to support that conclusion.

This is a simple case of gross negligence

In the same way that the Mull of Kintyre accident ended up with the same verdict made by someone equally blind to the burden of proof as you clearly are.

B2N2

4th Mar 2017, 12:56

Despite some of you arguing that an accident is an accident...entry height was lower then his authorization allowed, entry speed was lower then usual for this maneuver and apex height was lower then usual.
All links in the chain of events....controlled by the pilot.
Whether the fuel diaphragm had anything to do with the engine not being at full power but we'll never know.
However airspeed an altitude should have been noticed.

Courtney Mil

4th Mar 2017, 13:13

B2N2,

Page 29 of the report - picture. At X750 feet on the altimeter, the broader part of the needle obscures the thousands of feet and the tens of thousands of feet on the counter.

From page 128 of the report:

‘Analysis has been undertaken to identify the scope of human actions and/or decisions to have contributed to the loop being continued when below the pilot’s stated minimum height at the apex. It is not possible to determine which, if any, of these actions took place based on the evidence available for the HF analysis, but the following accounts are considered credible and feasible:

a. The altimeter may not have been seen or read at the apex of the loop as a result of scan pattern, high workload, allocation of attention, distraction (for instance, from detecting a reduction in thrust during the climb or the airspeed being lower than expected), and/or visual limitations (such as contrast and glare).

b. An inaccurate perception of aircraft height may have been obtained, specifically, that the aircraft was higher than it was as a result of the altimeter displaying the incorrect altitude, a misleading or ambiguous display of the altimeter digit drum [height counter], the altimeter digit drum [height counter] being partially obscured, and/or the altimeter being misread.

c. The minimum height required at apex may have been recalled incorrectly.

d. An escape manoeuvre may have not been selected as a result of the limited time available to select and implement the action, and the guidance and training that the pilot received with regard to performing an escape manoeuvre at the apex of a loop in the Hunter.’

RAT 5

4th Mar 2017, 13:19

You can't do that {prosecute the pilot} if he didn't wilfully do anything that he knew broke the rules,

So the pilot enters the manouvre at 185ft, his minimun height should have been 500ft, Entry speed 305 kts, should have been 350 kts,

In interview the pilot does not know the speed for the escape manouvre. Not really convinved that he had confused the speeds and safety gates between the JP3/5 and the Hunter, surely he knew what aircraft type he was flying.

This has no personal attention, just general human behaviour considerations.

In commercial flight training we are taught to identify the root cause of an error. It can be a long way before the error becomes apparent. What we emphasise is errors will happen; it is what you do next that is important. "When in a hole, stop digging" is one mantra. Equally, "realise you are in a hole and climb out." However, how did you dig the hole in first place = root cause. Low energy at entry seems to be a root cause, but... it was exacerbated by not following PPPPPP. Not having made Proper Preparation of knowing the escape manoeuvre before entering a possible deadly manoeuvre could also be a root cause, and it occurs earlier in the chain. A Swiss Cheese indeed.
As to point one I assume the entry height and entry speed were wilfully actioned. Why they were wrong is for debate: confusion of type (back to PPPPPP) or lack of attention?
I fly light a/c aerobatics and not being very current nor hot at them I make sure there are lots of margins buffering my performance, and I've read the manufacturer's notes about the what & how. Equally, before attempting any of these I have a QFI polish my stall & spin recovery technique. PPPPPP.
It would be blatantly unfair of CAA to start knee jerk reactions towards other displays. One muppet crashes a Ferrari because they drive it beyond their capabilities doesn't cause a blanket ban on all Ferraris being driven as they were designed. If a crash-causing fault is found, that is something else.
If it is true that the CAA authorisation & oversight might be involved, then I would suggest they look inwards first and sort that out before looking outwards. However, they might want to audit their display authorisation department to see if there is another Shoreham waiting to happen.

DType

4th Mar 2017, 13:44

SLF here (though I have held the controls whilst looping a Meteor), but I do not understand why rolling out at the top of a loop is not awfully easy.

H Peacock

4th Mar 2017, 13:46

Page 29 of the report - picture. At X750 feet on the altimeter, the broader part of the needle obscures the thousands of feet and the tens of thousands of feet on the counter.

CM. If a stude at BFT did similar and claimed to have mis-read his alt by 1000ft due to an obscured readout I'd kick his behind and want to know why he wasn't glancing indoors to monitor the dials during the pull-up of the loop. Apex gate is most certainly not a single 'snapshot' glance indoors. Furthermore, the % difference between 2700ft and 3700ft is huge.

Now say a court of law wants to find a C130 captain not guilty of taking off someone's head due to a faulty rad-alt, then so be it, but to claim that is the actual reason is a very poor excuse. You could apply similar to the 'possibly mis-read' altimeter.

Arfur Dent

4th Mar 2017, 13:47

Courtney
Report P 2-4-2-5 Monitoring by the Pilot
"The pilot could not explain why he continued…."
"Height and speed achieved was similar to that achieved at the apex of 4 looping manoeuvres the pilot conducted during 2 displays in a JET PROVOST the previous weekend."
What do you think that implies??

Courtney Mil

4th Mar 2017, 13:53

Arfur Dent,

He could not explain lots of things because he received injuries in the crash, was placed in an induced comma and has suffered PTSD and memory loss. It implies nothing, but you are inferring more than you have evidence so to do.

Courtney Mil

4th Mar 2017, 13:57

D Type. Again read the full report. He stated he did not recall the minimum speed for rolling out at the apex. Large aileron inputs at low speed do not always deliver the expected results in high performance aircraft. Case in point, rolling at high aoa in the F4 resulted in roll reversal and departure.

CHfour

4th Mar 2017, 14:12

@ Courtney Mil

rolling at high aoa in the F4 resulted in roll reversal and departure

Wouldn't the aoa be reduced by unloading prior to rolling though?

biscuit74

4th Mar 2017, 14:22

I am more than a little puzzled by the approach of some here.

The basics of the accident are fairly clear from the AAIB's report. The final manoeuvre was entered from too low a height, at too low a speed and the engine was not delivering full power during the climb into the manoeuvre, for reasons unknown.

The pilot's background and overall experience suggests that he should have been well capable of recognising this was not going according to plan, both in position and available energy. Most of us would presume that would involve changing the plan, not continuing. It is why we try to have alternatives available in flying, to cater for the unusual/unexpected.

That the pilot did not abandon the manoeuvre seems to be either an indication of gross misjudgment of the physical situation or an indication of over confidence or 'press-on-itis' - under the pressure of being on display. Not the first of us to fall foul of these, and sadly highly unlikely to be the last. Those two have killed many pilots over the years and given many more of us bad frights. Unfortunately it appears the pilot cannot throw any more light on any of this.

The underlying root causes which led to those errors require more consideration and go much wider than just a series of cumulative errors by the pilot on the day, but the first level 'causes are clear.

Throwing in things like altimeter discrepancies seems to me simply an attempt at a smoke screen - interesting and well worth debate for future but surely quite irrelevant here, given the direction in which that error would have shown itself. As for the technical failures of maintenance and associated paperwork, while they are appalling and indicative of corner cutting, possibly for cost reasons, they are not germane to the accident per se.

I don't want to see this pilot pilloried for a disastrous series of errors, any one of which any of us might make (though I'd hope most would manage to spot the trend before the lost cause point!) but I don't believe it does the cause of flying and flying safety any good to be seen touting pointless excuses as a 'get-out'. That has happened too often before and as a result lessons are not properly learned.

Courtney Mil

4th Mar 2017, 14:25

CHfour, I use it simply as an example of how one cannot necessarily apply techniques from one aircraft to another.

Wetstart Dryrun

4th Mar 2017, 14:29

Courtney Mil

4th Mar 2017, 14:34

Biscuit, basically sound points, but look at the words you use.

Reasons unknown
Suggests
Presume
It appears
Seems to me

I prefer the well considered, thorough and neutral language of the experts that crafted the report. I do not consider the summary to be reflective of a number of issues that cast enough doubt on certain events on the day. Apart from that, they have raised plenty of recommendations that should contribute to safety in the display circuit.

None of it provides hard evidence of negligence, error or deliberate act on behalf of the polit.

Courtney Mil

4th Mar 2017, 14:35

Wetstart, thank you. You make the point I was aiming at very well.

Two's in

4th Mar 2017, 14:37

I don't want to see this pilot pilloried for a disastrous series of errors, any one of which any of us might make (though I'd hope most would manage to spot the trend before the lost cause point!) but I don't believe it does the cause of flying and flying safety any good to be seen touting pointless excuses as a 'get-out'. That has happened too often before and as a result lessons are not properly learned.

Biscuit 74 - When I hear hoof beats, I think horses, not zebras. Your point neatly encapsulates our aviation predilection for ignoring the obvious, in spite of the evidence. This often because we either know the individuals concerned, or we falsely conflate experience for infallibility. Every point exhaustively made in the AAIB report is a factor, but if the manoeuvre had not been entered low, slow, and under powered, the outcome would have been very different and none of those factors would have come into play. Even after the train of tragic events had been set in motion, there were still further opportunities to change the result that were either not recognized, or not taken. We can't change if we won't learn, however unpalatable those lessons may be.

mrangryofwarlingham

4th Mar 2017, 14:41

CM

I note your comment about PTSD.
I didn't see any mention of that in the report. Maybe I overlooked it.
Do you have the page reference please?

H Peacock

4th Mar 2017, 14:50

Maybe could have / should have done better. However, I believe the manoeuvre would have been completed successfully if the engine had reached and maintained full power.

For me, this is the primary cause.

At 100kts, upside down, the aircraft have to go into a vertical dive to gain flying speed, or enter a spin with injudicious control input.

'Primary cause', absolutely not. If he initiated the pull-up 50ft higher the manoeuvre would probably have been successful. But again pull-up height was not the root cause. Continuing to fly the loop having failed to achieve the correct gate parameters was the root cause. If the engine was misbehaving and caused a lack of performance then the pilot is solely responsible for noticing the problem and then taking a suitable course of action.

As highlighted in previous posts, the actual apex of the loop is not the best place to try to spot roll out if it. No, neither do you wait for the vertical when it's too late. Ease off on the pull, let the nose continue to drop below the horizon, IAS rapidly increasing, aileron roll 180 then ease out. You could probably achieve the entire recovery within 1000ft or less.

Wetstart Dryrun

4th Mar 2017, 14:52

I was a hunter QFI.

...and you?

mrangryofwarlingham

4th Mar 2017, 14:59

Wetstart

And the absence of usual safety margin for such eventuality.

IMHO if he had another 100ft the accident would not have happened. You can see he was on the buffet in the last few seconds and with left wing drop a couple of seconds away from impact.

So for me you can say lack of full engine power was the primary problem, and absent such problem it wouldn't have been an accident.
However, knowing the type had this engine issue...you need a safety margin in case the problem manifested itself on the day.

It has been discussed earlier on other threads that starting height and speed don't matter so long as he made the gate. Those threads didn't really offer a clear view on whether he made the gate or not.

CM...you think when AH was at the apex he checked the gate, and because he saw x750 he thought he was at 3750 feet, even though he knew he had started outside his usual practice parameters and would not have seen a lowered rpm or an altimeter reading on the way up?
I think some here don't share your confidence.
What is crystal clear are the pilots comments about gate height. If he genuinely thought he was at 3750 then he was in the gate but with only a 250ft safety margin.

Why didn't he roll off the top?
Some people who are familiar with JP flying use the technique of rolling off the top at too slow a speed to get undemanded yaw for spin training.
Maybe this went through his mind when he was at the apex.
Then again, why should it if he genuinely believed he was at 3750.

Courtney Mil

4th Mar 2017, 15:00

mrangryofwarlingham,

It is not in the report. That information comes from elsewhere, but I doubt any of us would be surprised that it is a result of the accident.

biscuit74

4th Mar 2017, 15:03

Courtney, thank you.

You are quite correct I used words and phrases deliberately couched to make it clear that I do not consider myself an expert in aerobatics or (certainly not) in fast jet operations. I feel from the details within the report there is scope for debate about what went on in the cockpit, what was observed and how it was judged, or not. I agree that the clarity of the experts' neutral language was helpful.

My background in this has been more as a team leader endeavouring to develop good safety thinking habits amongst strong minded young professional engineers, who all start out believing themselves to be invulnerable, infallible and (all but) immortal - much like young pilots, whom I have also had fun training. Occasionally I have found more 'hedged' phrases get through better when discussing Human Factors, which this accident involves, through and through. Perhaps I was being too careful, part of which may be due to recollection of the challenge of having to face a bunch of QCs once, to justify a technical position. Needed great care...

I don't see any evidence at all of deliberate act by the pilot towards the accident, rather errors of omission, accumulating. What constitutes negligence becomes a matter for thorny legal debate in my experience. I'd rather not go into that one, since it involves experience, judgment, presumed professional capability etc. Let's just say that can be 'challenging'.

Twos' In - totally agree. The real frustration is that accidents like this have cropped up again and again.

It seems as though (sorry CM!) we can learn and change habits for a while, then the lessons get forgotten, perhaps because other things become more immediately of concern. 'Safety drift'?
An old pilot and engineer many years ago said to me he reckoned incidents and accidents tend to have around a twenty year 'cycle time', by which point the folk originally involved have moved on, retired or forgotten the problem. Depressing if even marginally correct !

mrangryofwarlingham

4th Mar 2017, 15:05

CM

It's difficult to challenge your other source if not disclosed.
But I will say I find no comment about it in the report, and I don't think it is on point whether he is or is not suffering from PTSD.

Courtney Mil

4th Mar 2017, 15:08

Biscuit, understood.

Courtney Mil

4th Mar 2017, 15:11

Mr Angry. I'm sorry I cannot and will not disclose the source. I will say that I have no contact with the display pilot. The report deals solely with the circumstances surrounding the accident, it does not and should not comment on his current state of health.

That's all I have to say on that matter.

Radgirl

4th Mar 2017, 15:13

It is claimed he received what is called the head injury protocol ie he was given a prolonged general anaesthetic or what the media called an induced coma. There is very little reason for this other than a head injury.

Any 'induced coma' will produce profound retrograde amnesia. The head injury may cause long term memory loss and amnesia. Now add in PTSD

ANY comments or statements he has made since the accident are IMHO worthless. Even if he cannot recall the minimum speed for rolling out at the apex this does not mean he did not know it at the time.

Arfur Dent

4th Mar 2017, 15:17

Courtney. What did you think about the pilot's lack of total and recent experience on type and the system of awarding a DA on a Hunter having demonstrated a display sequence on an RV-8?

mrangryofwarlingham

4th Mar 2017, 15:29

CM

As you say, the report should not comment on his current health.
Therefore I find your comment about PTSD unhelpful.
Given the strong warnings about the press perhaps looking at this thread, it would not be pleasing to see headlines about alleged PTSD thanks to your unhelpful comment.

Having now made the point, I will also comment no further in this regard.

Courtney Mil

4th Mar 2017, 15:35

Arfur, I have not been in civil aviation since the 1970s. I don't know enough about current regulations and currency requirements to make a legally valid comment. That's why I stick to comments about the technical aspects, the hunter, display flying and flying issues. Sorry I can't help more, but I won't comment on issues I do not feel suitably qualified to express an opinion.

neila83

4th Mar 2017, 15:40

Interesting how different the reaction here is to when a pilot from a less developed part of the world makes a mistake that leads to a crash. I wonder if the pilot of KL801 had survived you'd be making all sorts of excuses for missing his height gates and why that isn't negligent. Something to ask yourself.

It would be negligent if the CPP weren't at least considering the possibility of a prosecution. Some pilots seem to have a strange view that their profession should be immune from prosecution, absolutely whatever the circumstances.

11 people are dead and some here don't seem to have absorbed that reality, some posts are alarmingly close to 'it was an accident, accidents happen, everyone should move on.'

A prosecution would allow the facts to be established and whether there was negligence. Certainly missing all the entry gates and carrying on as things deteriorated leads to that possilbity. If there wasn't neglicence, that will be established either prior to the decision to prosecute or in court.

I can imagine that it may cause the families considerable pain if there is any perception of him 'getting away with it', or the aviation community circling the wagons around their mate.

Treble one

4th Mar 2017, 15:40

Arfur-as stated earlier the report confirms that the pilots paperwork was completely in order.
The fact that it now seems ludicrous that his DA was valid for all types he flew (at the time of the accident) is not his fault-that's the fault of the system.
Of course CAP403 has been significantly altered post this accident to reflect the concerns you rightly raise.
Like I said in an earlier post-as a FJ pilot yourself-how many hours would you need (assuming you were current on type) to work up a display that you would happy to get a DA evaluation on (could ask you the same CM?)

Wetstart Dryrun

4th Mar 2017, 15:41

For the spamcan drivers please let me give you an analogy to ae type you can relate to.
A Hunter does not leave the ground until 130kts. A Cessna will float off at 50kts

A Cessna f upside down at 35kts is going to finish up steep nose down. Low enough and the engine is spluttering its going to crash

As for the low start height, a while back I used to do e few seasons of aeros to, i think the same rules. This was discussed extensively on related threads. I recall those rules as 100ft flyby, 200ft turns and loopy things recover by 500ft BUT may continue descent to 100ft once recovery by 500ft is certain. This did my head in, so I just flew to approx 500ft min. However, pulling up from a low-level pass to a vertical manoeuvre was ok in my book. It would seem the AAIB have a different view.

Slow to realise it's going pear shaped? If you follow a link from a thread about the goldfish club authored by 'Tarnished', he describes a Hunter flameout in the cruise where realisation ony occurred when the motor had run down to windmill rpm and air was spilling out the intakes.

The last 2 T7 cat 5's I recall are a Boscombe ac which had a linkage failure mid 90's and a Brawdy jet on the break downwind that never spooled up.

The T7 has a gated switch by the throttle that bypases the FCU in the event of failure (that's novel- I wonder why)

If this aircraft had a history of erratic engine performance then there are serious errors of judgement allowing to be displayed - but that leads me back to primary cause.

mrangryofwarlingham

4th Mar 2017, 15:50

Yet the report says at EGSX it was 112kts on this day...
Slower than the normal 120kts.

DType

4th Mar 2017, 15:52

Roll Out Problems
CM
Thanks, makes sense to me now.

Courtney Mil

4th Mar 2017, 15:58

Mon plaisir, DT.

mrangryofwarlingham

4th Mar 2017, 16:02

I can see the daily mash tomorrow

Ex Hunter QFI says "serious errors of judgment" in allowing a defective aircraft to be displayed.
Ex FJ pilot says pilot currently suffering from PTSD

:=

Courtney Mil

4th Mar 2017, 16:11

Uncalled for and unhelpful. Not good, Mr Angry. You may have just written their headline for them for no good reason than pushing your own opinion.

Having now made the point, I will also comment no further in this regard.

It seems you chose to after all.

Arfur Dent

4th Mar 2017, 16:28

111 - Sorry, you did ask that before and I have been slow to answer.
I never did LL aeros but I was in the end of course aeros comp at Valley so I was reasonably good at them (then).
Assuming I was current on the Hunter, I would work out a sequence and get it approved by peers. I would probably spend 2 or 3 hours trying it out to see if it all hung together at 10,000' then 5000'.
When competent at those heights I would practice over the airfield at 1-2000' with aforementioned peers critiquing in the bar afterwards. So, about 6 hours so far. Then I would do a couple of practices at 500' then ask you (or someone suitable) to give me a DA. Thereafter, throughout the display season,I would run through my display over the airfield down to my limits at least once a week after work.
Probably fallen into your trap but that's about what the real display guys did back in the day. Would cost a fortune which is why present day civilian display pilots don't do it, I guess.

Super VC-10

4th Mar 2017, 16:36

The report says that he took off with a tailwind - which would mean a lower takeoff speed, would it not? :confused:

langleybaston

4th Mar 2017, 16:36

CM and others like-minded: I was a simple Met man. I watched the news that dreadful day, doubly dreadful because I am a Sussex man and know Shoreham and Lancing college well. Indeed as a lad I remember Miles Aviation and the old 1930s main building.

So the simple ex Met man sees an aeroplane fly into the ground on a perfectly good weather day. It turns out that it kills and maims many people on a road that he knows well.

What is he to make of it in his simple, ill-informed way? Pilot error, or unserviceability or a combination of both? I don't think many contributors above are attributing the tragedy to unserviceability alone.

So to my simple mind the matter resolves itself into determining the degree of culpability, does it not?

Just asking.

Treble one

4th Mar 2017, 16:39

Arfur-thank you.
This is how I understand current RAF display pilots would do it-The current Typhoon Display pilot is down to around 1000ft as his base height as I understand and is now practising over CBY. He's spent more than 6h getting there though (how many more I'm not sure)-and of course he has much better synthetic training aids than you probably had (or a civilian pilot would have).
And of course he flies the Typhoon as his day job....so no additional currency required either.
No trap intended-and what you say regarding the cost of doing all this for a civilian pilot....hence a balance needs to be found for civilian display pilots?

hum

4th Mar 2017, 16:44

For me the key to this tragic accident is power reduction - especially in the first half of the looping manueuvre. No-one knows why this happened. In my opinion no display pilot whose brain is functioning normally would apply anything less than full power in the first half of a low-level loop - especially if entered slow. I believe something starts to go horribly wrong at 12:21:50, about 35 sec before impact.

http://i50.photobucket.com/albums/f318/gerryhum/why%20low%20power_zps8gubft8b.jpg (http://s50.photobucket.com/user/gerryhum/media/why%20low%20power_zps8gubft8b.jpg.html)

At this stage he had positioned nicely and needed to accelerate for a few more seconds before pulling up, power is around 7700 RPM, its a nice day, no cloud, off-crowd wind, Lancing college to the right, only 20 degrees to bend during the loop... then there is a power reduction to less than 7000 RPM... that does not make sense.. he needs to accelerate.. Just before pull up power increases to 7500, but then around 2 sec later it reduces to less than 6700 before increasing to around 7200.. this is a really strange thing to do, and, I believe, a highly significant event that led to the low energy state at the apex of the manoeuvre.

I think it possible the pilot may have suffered some sort of transient 'cognitive impairment' .. Apart from the totally illogical power reductions, another clue for me is that with an off-crowd wind of about 15 Kts, with only 20 degrees or so to 'bend' - he rolled too much (about 60 deg) on the way up, that, too, does not make sense.

A Transient Ischemic Attack could posibly explain this tragedy. A close relative of mine had one of these while driving a few years ago and described it as 'like waking up having just being born' while on a roundabout. It took about 20 sec to recover and never happened since.

I believe the possibility should be considered.

Courtney Mil

4th Mar 2017, 16:44

Langley, long time no speak. Hope all is well with you

In simple terms, any culpability is for legal investigators to determine. It is not the remit of the AAIB and even less so of some armchair experts here who seem happy to assume they know more about the events than the AAIB team.

From what I've seen in the various reports, there is too much stated doubt in the report at this stage to draw any legal conclusions. Despite the will of the people.

H Peacock

4th Mar 2017, 16:45

The report says that he took off with a tailwind - which would mean a lower takeoff speed, would it not?

Tailwind takeoff = same IAS, higher GS. Therefore more runway.

Pittsextra

4th Mar 2017, 16:54

Courtney - it is perhaps admirable the loyalty shown in playing devils advocate that very many possibilities are possible and actually the fact remains that all of this is "on the balance of probability". Few are calling for or would want the pilot to be prosecuted because it wouldn't really achieve very much and he is also a victim of the broader failures highlighted in the report.

What sticks in the caw is this high ground that personally I think starts to become silly. From the outset of this accident hackles got raised if/when anyone dared to suggested the figure flown looked scruffy. You in particular threw a doubt over the start height being low by suggesting maybe you could pull up from a low pass and until the nose was x deg it wasn't technically aerobatic etc, etc. Regardless of wishing to discuss that now, nobody is racing to go on record with that defence and the BADA statement suggests that human factors trump technical ones.

I asked you to clarify your own remarks about which instrument you saw as having an issue and what casual affect it may have. You don't want to answer because you can't answer. I didn't want to put words in your mouth but I'll assume you refer to the altimeter because of your post No.125 (for now) which I'll quote here for ref:-

B2N2,

Page 29 of the report - picture. At X750 feet on the altimeter, the broader part of the needle obscures the thousands of feet and the tens of thousands of feet on the counter.

From page 128 of the report:

Quote:
‘Analysis has been undertaken to identify the scope of human actions and/or decisions to have contributed to the loop being continued when below the pilot’s stated minimum height at the apex. It is not possible to determine which, if any, of these actions took place based on the evidence available for the HF analysis, but the following accounts are considered credible and feasible:

a. The altimeter may not have been seen or read at the apex of the loop as a result of scan pattern, high workload, allocation of attention, distraction (for instance, from detecting a reduction in thrust during the climb or the airspeed being lower than expected), and/or visual limitations (such as contrast and glare).

b. An inaccurate perception of aircraft height may have been obtained, specifically, that the aircraft was higher than it was as a result of the altimeter displaying the incorrect altitude, a misleading or ambiguous display of the altimeter digit drum [height counter], the altimeter digit drum [height counter] being partially obscured, and/or the altimeter being misread.

c. The minimum height required at apex may have been recalled incorrectly.

d. An escape manoeuvre may have not been selected as a result of the limited time available to select and implement the action, and the guidance and training that the pilot received with regard to performing an escape manoeuvre at the apex of a loop in the Hunter.’

The point b. of the AAIB report isn't replicated faithfully however in your post. What it should show is this.

"That the aircraft was higher than it was as a result of the altimeter displaying the incorrect altitude 61"

Where 61 refers to this comment by the AAIB:-

61 The RAFCAM report was prepared before the results of the altimeter testing were available.

So on the basis that the AAIB do not then cite the altimeter as causal to the accident and in their own summary from page 166 [2.3 Technical issues relevant to the accident flight] they summarise that section dealing with the altimeter as follows [page 168]

Overall, whether in servo or standby mode, the left altimeter would have indicated a lower altitude at the apex of the accident manoeuvre than the aircraft actually achieved.

That is why I suggest the AAIB do not give greater emphasis to any altimeter issue in the overall summary to the accident.

You wanted to wait until the AAIB published their final report, its taken a while, its a comprehensive document, you say you've read it all but its incomplete. If you take that view have the grace to be unambiguous with the reason why i.e:-

From what I've seen in the various reports, there is too much stated doubt in the report at this stage to draw any legal conclusions. Despite the will of the people.

I can only speak personally but the legal conclusion is not a factor in any comments but the debate on things of a flight safety matter can be misdirected if focus is distracted on things that simply are less important than others.

Bravo Alpha One

4th Mar 2017, 17:32

I registered specifically to comment on the AAIB report.
I could not possibly comment on the aviation aspect as I have never flown FJ, but there are things in the report that concern me. It has been pointed out that the pilot started his "bent loop" way too low, too slow and with insufficient power applied, and no escape procedure was attempted. Likewise there seem to have been "strange" power variations after entry.
I see from above at #164 "hum" has just beaten me to it, but I just wanted to say that the idea of a possible TIA is what occurred to me when I read the report. I have witnessed such an event [not in the air] on more than one occasion, and if I had not done so no-one would have been aware that it had happened. TIA is often called a "mini stroke" but stroke symptoms do not manifest. Hence video recording of the pilot would not necessarily show anything wrong.
Extreme confusion lasting for a very few minutes was very disturbing, all the more so because there was no external physical sign of anything wrong. It was only confirmed later by a professor of vascular medicine [following Ultrasound, CT & MRI scans] that a TIA was most likely responsible. He further opined that it had left no trace and might never recur.
If that had happened to the pilot on the run in he would be unlikely to realise it unless he "felt funny". The report from the first responders states "He was treated by a doctor and nurse at the scene. He was described by the doctor as “fully aware of what was going on around him and not confused in any way”. The doctor recalled that the pilot, when asked if he felt unwell before the crash, replied “yes”. The investigation could not establish if the
pilot understood the intent of this exchange, in what way he might have felt
unwell, or if this was his answer.

Lemain

4th Mar 2017, 17:34

I'm perhaps the least qualified person here to suggest the cause or causes of the accident (though most accidents turn out to be a sequence of problems not a single factor). I've read the report in full twice and (I think) every post so far on this thread, carefully.

Eleven unconnected people were killed. Whether they were unlawfully killed is for the Coroner. As an engineer (and low hours PPL) I understand Newton's Laws as they apply to aircraft. Whether the aircraft had structural 'failure', power 'failure', instrument 'failure' or whether the pilot had mental or physical 'failure' it is perfectly predictable that a large mass will continue in the same direction unless another force is applied.

The eleven people were killed because a large mass travelling at high velocity, laden with kerosene smashed into them. That was clearly the 'CAUSE' of the deaths. Certainly all the pilots on this thread will follow the argument that the vectors of all display aircraft should be calculated before the display is approved. It is very easy to do mathematically.

I suggest that there have to be special and compelling reasons to approve a display that has a proportionate chance of anyone being harmed if the pilot or the aircraft fail at any stage in the display.

One poster earlier mentioned Farnborough. Good point. Maybe that's an exception, not my call. Of course Blackbushe is practically in the circuit as is Lasham.

sika hulmuta

4th Mar 2017, 17:35

Hum, I agree. I don't understand why anybody would want anything less than max thrust in the first part of a loop unless they are extremely fast to start with. Which he wasn't. You ensure you get the energy, assess at the top, and fly accordingly.

Also this was a fast jet display, and noise is part of the show. Its almost mandatory to have max noise at the appropriate time for the crowd. Which this was.

6700 - 7200 is a long way back on the thrust lever. To state the obvious, that was either pilot instigated, or a mechanical problem. If a pilot issue, I really can't understand why.

I agree he seems in good shape, till the pull up, possibly slightly before. But then it all goes wrong... Why? I also think cognitive impairment for some reason is possible, but seemingly not approached in the report. Unless I missed it...

biscuit74

4th Mar 2017, 17:39

Super VC 10 -

Would a tailwind not mean a higher groundspeed required? It should not however affect the airspeed required at take-off.
The report says the pilot lifted the nose at 112 knots instead of 120 knots. It does not speculate why, simply saying before that the take=off was longer than usual due to high air temperature & tailwind.

Super VC-10

4th Mar 2017, 17:57

H Peacock, thank you. Biscuit74, Yes, it does.

Getting back to the possibility of confusion between types (Hunter and Jet Provost), would 112 kt be an appropriate take-off speed for the Jet Provost? Could the pilot's mindset have been that he was flying a JP display even at this point?

Lemain

4th Mar 2017, 18:07

Since I was here and intrigued see https://www.flightglobal.com/FlightPDFArchive/1954/1954%20-%202210.PDF all depends on the variant and other factors.

It unstuck. Unfortunately.

mrangryofwarlingham

4th Mar 2017, 18:07

H Peacock

Other way around.
That's why aircraft tend to take off into wind.

Tay Cough

4th Mar 2017, 18:09

sika,

But then it all goes wrong... Why? I also think cognitive impairment for some reason is possible, but seemingly not approached in the report. Unless I missed it...

Easy to miss, then seemingly not considered further...

1.13.1

Courtney Mil

4th Mar 2017, 18:12

Pittsextra, I'm probably not going to address your accusations point by point at this to,e of the evening, Pittsextra.

The block you repost was simply a copy and paste, so, if you think it's not faithfully replicated I can't really help you.

The process of summarising long reports is not something we have discussed before, but I do recall your lack of experience in the process of compiling the reports and investigating the incident. Similarly you are now simply searching for points to argue (as you did before), but the STBF altimeter mode is unlikely to be of much significance apart from the fact that, due to lag, it would still have been indicating that the aircraft was still climbing at apex. I have no idea of the relevance of that because that was no commented upon.

The only places I have commented upon as being incomplete where areas where the report refers to "further investigation" whose conclusions have not yet been declared.

I did not choose to search through the 452 pages in order to give you a reference because I was still reading it and also answering other people's questions elsewhere. You are not the only person asking me for help with this. I'm sure you finally managed to work it out for yourself.

The last thing I will discuss with you here is that your position has been very clear for 18 months. If you wish to take issue with the AAIB, the owners, the engineering and regulatory authorities, be my guest. Not my area. I can only comment on fast jet aeros, high performance operations and jet technical matters and, as you will see from my posts in this threat, that is what I limit myself to here.

That is all.

Pittsextra

4th Mar 2017, 18:16

CM - dismal, just dismal.

Raikum

4th Mar 2017, 18:16

Courtney when you said
" He could not explain lots of things because he received injuries in the crash, was placed in an induced comma and has suffered PTSD and memory loss. It implies nothing, but you are inferring more than you have evidence so to do."
As a medical fact, an individual cannot suffer from PTSD unless he has full recall of the incident. That is one of the primary pre-conditions for the diagnosis. This is set out in DSM V (in full the 5th edition of the Diagnostic and Statistical Manual of the American Psychiatric Association-the bible of all psychiatric illnesses). He may well have other conditions but he cannot suffer from PTSD if he has no recall of the accident.

mrangryofwarlingham

4th Mar 2017, 18:16

112kts is too fast

90 sounds about right from memory

Super VC-10

4th Mar 2017, 18:21

Thank you, Mr Angry.

Courtney Mil

4th Mar 2017, 18:30

125 kits, for the Hunter, though.

Courtney Mil

4th Mar 2017, 19:10

Another common theme here is the entry heigh for the Manoeuvre. The report touches on this, but does not give it the "importance" that some here tend to attribute to it. We discussed this a few months ago, but let me reiterate.

AH was cleared to 100 feet for flypasts, etc. It is perfectly legal to enter an earobatic manoeuvre from that altitude as long as the manoeuvre itself isn't performed at that altitude. It is also legal to let down to that altitude at the nd of the manoeuvre once the (e.g.) 500 foot base height has been assured.

The entry height in this case is, therefore, not relevant. For further explanation please refer to our earlier discussion on this forum.

Super VC-10

4th Mar 2017, 19:17

I say that the entry height was relevant. Had he been 300' higher to start with, there would have been no accident, although he might have busted the 500' base height.

RetiredBA/BY

4th Mar 2017, 19:22

If this guy really did think he was in a JP there is no way he would have used less than full power on pull up into a 4 g loop.

Lemain

4th Mar 2017, 19:23

Courtney Mil -- It is perfectly legal to enter an earobatic manoeuvre from that altitude as long as the manoeuvre itself isn't performed at that altitude.

One would imagine that any "manoeuvre" is defined, in a legal and aviation sense, to commence at the instant it is "entered"? For example, "landing" is not just the instant the wheels touch the ground. "Landing" commences at some earlier stage -- somewhere between finals and coming to a standstill. Obviously you cannot be said to be in the "manoeuvre" of landing if you are descending vertically in a spiral dive three metres above the runway, at 190kts. "Landing" is a manoeuvre that requires a sequence of events. I'd suggest that "manoeuvre" includes preparation for entry, entry, and then successful completion. In this case the completion was not successful.

Capt Scribble

4th Mar 2017, 19:30

The aircarft could have still hit the ground if the manoeuvre had been started from 500ft but mishandled, but I would acknowledge that this was a contributory factor. The engine power, or lack of, is also not a cause as a check of the apex gate parameters would have showed whether it was safe to continue the loop. In my view the cause was pulling through with insufficient height to complete the manoeuvre, what led to that error will probably never be known.

hum

4th Mar 2017, 19:30

I agree Courtney, AAIB acknowledged this in their report into the 1992 Spitfire accident at Woodford..

http://i50.photobucket.com/albums/f318/gerryhum/DA%20limits_zpsb5oufxye.jpg (http://s50.photobucket.com/user/gerryhum/media/DA%20limits_zpsb5oufxye.jpg.html)

bladder100

4th Mar 2017, 19:45

Going back a'piece... mention of the 'vapour trail' prior to this 'manoeuvre' may have been an FCU vent tank, start vent tank, or the cyclonic oil breather from the engines oil labyrinth sealing system...?

Perchance??

Philoctetes

4th Mar 2017, 20:29

Me thinks every thing has been said, but not everyone has said it yet!

mrangryofwarlingham

4th Mar 2017, 21:23

Raikum

Thank you for your interesting post.
This is also my understanding...hence why I wanted to challenge CM on the point but he seems to have clammed up.
Either someone gave him information in confidence (bad judgment it seems) which was blurted out onto the internet, or as your post suggests to me no such information was given to him yet he pretended for some reason that he had some external source to this information only to be called out because medically PTSD is not consistent with total memory loss.

CM

You've been rumbled mate. Not that you're my mate....but let's try to keep the BS off the thread.

Note to journos....you'd better not print the inaccurate PTSD stuff. It was at best ex FJ BS.

cobol

4th Mar 2017, 21:28

I'm just glad the pilot lived.

He alone has to wake up every day knowing he has killed several people. The vocation that was his life is gone, he can never be part of a respected professional group again, either at work or as his hobby.

His home life will never be the same again; neighbours will judge, friends will doubt. For him, every curtain twitches.

If he could remember the events surrounding the event, perhaps cause could be found. Only blame will remain; his forever.

Remember these pilots, less fortunate than this pilot, perhaps more fortunate:

Glen Stuart
James Thain
Kevin Hunt

- from whom we all learned lessons that have enhanced aviation safety to this day. None of them lived happy and rewarding lives after their event, they all paid their price for their mistakes, whilst those behind the scenes who also made mistakes remained at their desks free of all guilt and collected their pensions.

For the Shoreham Hunter pilot, 2017 is the first year of a the rest of his life he would never have wanted to live.

Courtney Mil

4th Mar 2017, 21:33

Mr Angry, you're getting personal now. No need to do that. Our discussion is finished.

JEM60

4th Mar 2017, 21:35

Cobol. Being a bit pedantic here, but Capt. Thain didn't make a mistake. It was a lack of knowledge by all concerned about how slush degrades acceleration. He was eventually absolved of all mistakes, if I remember correctly.
By pure coincidence, I met him at his home a few years before he died, when my farmer friend collected some equipment from another farm. I didn't know who he was until my friend was making out his cheque. Another coincidence, I dated Capt Rayment's niece for six months . He lost his life in that accident.

n305fa

4th Mar 2017, 22:46

While I understand the discussions regarding the completion of the final manoeuvre and the performance of the pilot I would politely suggest that this the final stage in a chain of failings which includes the airworthiness of the aircraft, management of risk, training requirements, proactive regulatory oversight etc. It's incredibly easy to focus on the final event, for perfectly understandable reasons, but I feel that the root cause of this tragic accident lies much deeper than the completion of the final manoeuvre.

I would also suggest to those that are criticising the AAIB report that they have spent considerable time examining a greater volume of evidence and expertise outside the AAIB than we could every have access to. I'm not suggesting that they are infallible, I'm just saying that they have probables considered most of the issues mentioned on these pages and, for good evidential reasons, found them to be irrelevant. I think that if the AAIB included everything that was considered and dismissed during their investigation the report would be considerabley larger that it is.

I expect many of you may disagree with me and I respect that, I just felt that I would throw out my thoughts for consideration.

Airbubba

4th Mar 2017, 23:00

By pure coincidence, I met him at his home a few years before he died, when my farmer friend collected some equipment from another farm. I didn't know who he was until my friend was making out his cheque.

I believe Captain Thain's post-accident career was the inspiration for this often cited anecdote about a 1960 landing miscue:

The Captain of the Pan Am B707 which landed at Northolt instead of Heathrow was (allegedly) asked by ATC for his intentions. "I guess I'll take up Chicken Farming" was the reply.

http://www.pprune.org/rumours-news/528264-boeing-747-dreamlifter-lands-wrong-airport-4.html#post8165751

H Peacock

5th Mar 2017, 00:04

H Peacock

Other way around.
That's why aircraft tend to take off into wind.

Mr Angry. I've re-read my post (copied below) and will stick by it! If the wind is from behind my Ground Speed is IAS + wind (higher). Therefore ground run is longer and I will use more runway.

Tailwind takeoff = same IAS, higher GS. Therefore more runway.

megan

5th Mar 2017, 02:35

cobol

5th Mar 2017, 03:07

You are right of course JEM60.

My post implies otherwise; what I was getting at was he was blamed, vilified by many I'm sure due to his high profile PAX. From what one can learn from an internet search; he was sacked, it took 10 years for him to clear his name, he never flew again, and he didn't live to a ripe old age. Probably not the life he would have chosen given a choice.

He took the blame for years, but the reason was found elsewhere, later. Today, from what the industry learned at his expense, we are safer now.

G0ULI

5th Mar 2017, 03:20

Having worked my way through the factual part of the report, I think the following observations might be pertinent.

The aircraft was maintained to as high a standard as could reasonably be expected for an ex military aircraft of that age. There were a few minor niggles and oversights, but nothing that materially affected its overall airworthiness.

The failure to set or achieve the full engine power setting may have been a distraction that initiated the events that followed. Although the g forces involved in the loop shouldn't have been physically debilitating, they certainly don't help the mental processes when things are starting to unravel.

The observations regarding the bent loop all contain caveat error bars as to speeds and heights. If you consider the worst possible readings from all the error bars and total them together, there is no way that this maneouvre could have been completed without ploughing into the ground. The median readings still result in an accident. Even the most optimistic estimates would have resulted in a most serious breach of display flying limits.

Even without specific training, a pilot who becomes aware that the apex height of the loop is too low, has two proven escape routes. Roll the aircraft upright coming down off the apex, potentially risking a stall and spin, or rolling the aircraft upright into a dive before reaching 45° nose down. The second option may result in excessive g forces on the airframe, but better than trying to pull it around the rest of the loop with not enough height.

By my estimates, the aircraft was perhaps only actually at 2,700 feet agl rather than 3,700 feet at the apex of the loop. The under reading altimeter that the pilot seems to have used as a reference may have been showing even less height than that! Surely a glance outside the cockpit would reveal that something was very wrong for an experienced display pilot? That sort of height difference from what you expect to see should be obvious even without looking at the altimeter - which is telling you the situation is even worse than you thought.

Given those circumstances, I would imagine the shock of seeing something so different occuring from the normal display profile could cause a person to freeze up at the controls or try desperately to continue to haul it round in an effort to tighten the loop. Reason tends to go for a walk when panic sets in, so you just keeping pulling back on the stick and hope for the best.

Despite all the other contributory aspects of this incident that are considered in extreme detail in the report, it really does come down primarily to pilot error. Initiating a maneouvre at too low an altitude, with too low an airspeed, and too little power on the way up, then a failure to abandon the display program when it became obvious that something had gone very wrong.

Of course the AAIB report is not about establishing blame but to identify the cause of an accident, so no matter what opinions are formed from reading the report, it remains for others far more qualified to establish if there is an element of blame to be attached to anyone or any organisation. It may well be that the ultimate decision is that this was just a tragic accident caused by a momentary error of judgement and thus unavoidable.

JEM60

5th Mar 2017, 05:28

Airbubba. Yes it was a chicken farm that we visited.
Cobol. Thanks for that. He was not a well man when I met him. Sad in so many ways. Regards, John.

n305fa

5th Mar 2017, 06:40

G0ULI

Just a quick point about the airworthiness of the aircraft.

Mandatory requirements not met, components beyond mandatory lives, defects not reported, limit exceedances not reported ( and therefore not investigated). I don't deny the aircraft appeared to function correctly but if it did not meet the requirements of its Permit to Fly (AAIB finding) how can it be considered airworthy.

Tay Cough

5th Mar 2017, 07:12

Initiating a maneouvre at too low an altitude, with too low an airspeed, and too little power on the way up, then a failure to abandon the display program when it became obvious that something had gone very wrong.

You missed "why did a highly experienced display pilot initiate the manoeuvre a mile or so too early and go completely off his planned axis?"

I'm sure there's a video on the Tube of You showing the same pilot flying the same display in the same aeroplane a week or two earlier elsewhere. It may be worth a comparison.

PDR1

5th Mar 2017, 07:22

I think when Gouli says "airworthy" he means in the sense of "functional - capable of flying in the intended manner" rather than "legally airworthy". In other words none of the issues which may have stopped it being legally airworthy played any part in the accident.

wiggy

5th Mar 2017, 07:23

I think that's a fair point TC, in that there's perhaps been an understandable obsession with debate over entry height ( now hopefully put to bed), gates at the top and escape options. IMHO the seconds leading up to the start of the manoeuvre are of just as much interest, certainly if we want to get a full picture of the accident, rather than a snapshot of the one bit that obviously went badly wrong.

H Peacock

5th Mar 2017, 07:37

...in that there's perhaps been an understandable obsession with debate over entry height ( now hopefully put to bed), gates at the top and escape options. IMHO the seconds leading up to the start of the manoeuvre are of just as much interest, certainly if we want to get a full picture of the accident, rather than a snapshot of the one bit that obviously went badly wrong.

Had Andy not been able to start his car and get to his aircraft the accident would not have happened. Had the Hunter not started - same. Had he had a snag on-route - same. Had the DD not cleared him in to display - same. But none of these were the cause of the accident. Perhaps many possible reasons why, but by not achieving the correct gate parameters and then continuing with the loop was the cause of the accident. That's the whole point of why the 'gate' is there, it's a black & white go/no-go point!

sika hulmuta

5th Mar 2017, 07:43

I agree Tay Cough, the low and erratic power settings, abrupt pull up way too early in good weather at a venue familiar to the pilot flying a display he had performed before, then skewing apparently needlessly way off axis in the bent loop and pulling through when obviously too low just doesn't add up for an experienced display pilot.

But little of of this seems to be discussed in any detail the report...

SLF3

5th Mar 2017, 08:01

Arfur Dent

5th Mar 2017, 08:06

HP Cock is absolutely correct. The entire purpose of a "Gate" is to make sure you have enough height to complete your intended manoeuvre. It is absolutely fundamental to the continued survival of a LL aerobatic pilot. You MUST make your gate which you have adjusted for airfield elevation and weather. If you don't make it, you must have another plan in place in order to continue your display. Everything else is just noise. If you forget to check (??) then you go to plan "B". You must not carry on regardless.

DaveReidUK

5th Mar 2017, 08:06

I wonder what the discussion would be if it had been this Typhoon?

It would probably run to about 150 posts ...

http://www.pprune.org/military-aviation/182254-typhoon-close-call-riat.html

wiggy

5th Mar 2017, 08:31

It "the gate"is absolutely fundamental to the continued survival of a LL aerobatic pilot.

Agreed, but it also appears from report the AH didn't make the entry gate ( speed) at the bottom of the gate by a significant margin. Everybody keeps banging on about gates as if they are something new or mysterious but I'm sure as a current display pilot and also as far back as his previous aeros training in the RAF AH would have been just as aware of the importance of gates as we all are here. Just as importantly as you rightly say Arfur D the pilot would have been interested in his " continued survival" on the day.

What bothers me is as I said a while back regarding the "top" gate - these weren't minor gate infringements where one might be tempted to "wing it", he was (according to the AAIB) almost 50 knots slow at the start of the manoeuvre (i.e. the pitch up) and around 700 feet low at the top. IMHO something is not quite adding up.

n305fa

5th Mar 2017, 08:37

One poster states the plane was as well maintained as an ex military plane of this age could be maintained. Another states it did not meet the requirements of its airworthiness certificate. The idea the defects were minor niggles is hard to justify. Whether the condition of the plane was material to this accident or not, the inescapable conclusion is these old fast jets should not be flying.

SLF

I'm not trying to be pedantic, I was just paraphrasing bits from the report, specifically the AAIB finding (83 I think) that states the Conditions of the Permit to Fly weren't met. They're in a much better place to make that assessment that I am, and probabley a number of other posters.

SLF3

5th Mar 2017, 09:09

Problems with altimeters, degraded seals in the fuel system, preservation procedures not carried out, out of date ejector seat cartridges, ejector seats maintained in a 'home facility', engine over speeds with no remedial action, known defects not documented, maintenance documentation missing, no OEM back up. I agree none of these appear to have materially contributed to the accident, but good reasons not to display fly the plane.

Largely inevitable given the age of the plane and the resources available to maintain it. Martin Baker have voted: no longer safe.

The amount of time the pilots get to practice on type is also, I suspect an issue, and explains why most of the accidents with historic planes listed in the report are described as 'loss of control'.

Uplinker

5th Mar 2017, 09:18

I haven't read the whole thread, so forgive me if I am saying something already mentioned.

If this pilot was an experienced display pilot, and he missed the entry gate and the top gate, and skewed off the display line, and having missed both gates, did not take evasive action, then he must have become mentally incapacitated in some way? By which I mean befuddled or confused rather than becoming fully unconscious.

Or did his instrumentation tell him he had hit both gates at correct height and speed?

I am not trying to exonerate him, but why else would he have continued the loop attempt?

mrangryofwarlingham

5th Mar 2017, 09:29

Uplinker

Maybe that will be the defence case v the argument there was no impairment in possible court cases to come ?

Jetstream67

5th Mar 2017, 09:34

CM. If a stude at BFT did similar and claimed to have mis-read his alt by 1000ft due to an obscured readout I'd kick his behind and want to know why he wasn't glancing indoors to monitor the dials during the pull-up of the loop. Apex gate is most certainly not a single 'snapshot' glance indoors. Furthermore, the % difference between 2700ft and 3700ft is huge.

Now say a court of law wants to find a C130 captain not guilty of taking off someone's head due to a faulty rad-alt, then so be it, but to claim that is the actual reason is a very poor excuse. You could apply similar to the 'possibly mis-read' altimeter.

There is a huge difference in visual cues for altitude for +/- 1000 feet at those heights ...

armagnac2010

5th Mar 2017, 09:50

This one was also slightly below minima.

https://www.youtube.com/watch?v=gJkNtgK76AM

triskele

5th Mar 2017, 09:50

So we have a capable chap who appears to have acted not so well, partial incapacity would fit this frame. As an old and bold Doc I was interested in the fact that the pilot spoke 'yes' to the paramedic, then was put in an induced coma. Perhaps a lingering symptom of his incapacity may have led the hospital doctors to think it due to the crash injury. Induced comas are not done lightly, yet our man walked out a couple of days later.

Jet_Fan

5th Mar 2017, 10:19

Lemain

5th Mar 2017, 10:44

The doctor recalled that the pilot, when asked if he felt unwell before the crash, replied “yes”. The investigation could not establish if the
pilot understood the intent of this exchange, in what way he might have felt
unwell, or if this was his answer.

If the doctor had asked him "Are you a hippopotamus?" he might have given the same reply. Presumably they had to put this in the report for the sake of completeness, but the report makes it clear there is nothing to be learnt from the reply "yes".

WallyWitless

5th Mar 2017, 10:52

if they are going to play the ''temporarily incapacitated'' card as his defence, it's gonna be very handy for him to start remembering some stuff

there are some very angry people in this part of world who won't give him that much benefit of the doubt I'm afraid

you've flown all the way from Essex perfectly OK, you've a bit of previous for showboating at displays, we need an explanation as to why you were disastrously too low to start with

and it ain't looking good

mothminor

5th Mar 2017, 11:23

If this pilot was an experienced display pilot, and he missed the entry gate and the top gate, and skewed off the display line, and having missed both gates, did not take evasive action, then he must have become mentally incapacitated in some way? By which I mean befuddled or confused rather than becoming fully unconscious.
If this was the case, did this also apply to his incident in the JP at Southport?

Lemain

5th Mar 2017, 12:45

Wally Witless -- if they are going to play the ''temporarily incapacitated'' card as his defence, it's gonna be very handy for him to start remembering some stuff

there are some very angry people in this part of world who won't give him that much benefit of the doubt I'm afraid

There is no 'defence' needed until there is an accusation (and a formal charge). Is there an accusation apart from being PIC at the time of the crash? If so, what is the accusation and who is making it?

DaveReidUK

5th Mar 2017, 13:03

There is no 'defence' needed until there is an accusation (and a formal charge).

Nor even then.

If there were to be a prosecution, which would ultimately be up the the police and CPS, they would have to convince a jury of his guilt (of whatever charges are laid).

It's not up to a defendant to prove his/her innocence.

Super VC-10

5th Mar 2017, 13:08

I'm getting the impression that Wally Witless is closely related to a victim. Their contributions here are not going to achieve or change anything. As others have said, any prosecution is down to the CPS. Should there be a prosecution, it does not necessarily mean that there will be a conviction. Once a prosecution has either been ruled out or taken place, then the inquest can conclude.

aox

5th Mar 2017, 13:22

if they are going to play the ''temporarily incapacitated'' card as his defence, it's gonna be very handy for him to start remembering some stuff

Apart from the above post already pointing out there is as yet no accusation, if that eventually does happen, it won't be up to you or any other interested parties to make assumptions or prior judgements or misstatements about what the defence might be.

What evidence do you have about alleged incapacity, or about a defence rightly or wrongly based on it?

None at all, I would suggest.

A couple of people above have quoted remarks from a doctor interviewing the pilot shortly afterwards. It would be fair to judge that as inconclusive.

If someone is injured or ill, they might be asked questions or tests to establish their comprehension of their situation or how injured they are - what is your name, what time of day is it, do you know where you are, please look at my fingertip and follow it with your eyes as I move it, and so on.

Asking someone if they are or were feeling unwell, and they are in shock and possibly not paying full attention and don't quite realise the tense involved in the question, isn't proof of anything, and doesn't seem to have been taken by the AAIB as such.

We are told the pilot has been interviewed by the police. He may well be again in future. If testimony from those interviews is produced as evidence in court (for example, an answer to a question were you feeling unwell before the flight), then the court will be in a position to decide on that evidence.

Until then, and it may never happen, your declaration or assumption that the defence might rely on incapacity has no basis in fact.

WallyWitless

5th Mar 2017, 14:01

The idea of temporary incapacity was being offered here as a reason for the accident happening. There is (at the moment) only the weakest possible circumstantial evidence to support that - which is that the pilot was making consecutive mistakes, I believe that was said, sorry but that is pretty weak stuff. It could be right but it's still pretty weak theorizing if not pure speculation.

I had previously tried to say why 2 of those mistakes may not be pilot error at all really or should have downgraded import. The lack of thrust during the climb isn't the fault of the pilot. Not rolling out at the top is somewhat understandable especially if that isn't even a formal training requirement - that's really not going to help is it & again isn't imo directly 'the fault' of the pilot if that is the lax aviation display 'culture' existing at the time. (I'm just going off the report there & do not mean that people were not adhering to regulations or not doing their best to keep everyone safe)

I just wanted to be seeing a fair discussion which the first half of this thread didn't seem to be to me. I am seeing a more even handed conversation now. But not here to cause trouble, I am just interested. I apologize for the tone of my previous post & will shut up now - you are welcome to think & may be right to suggest that this is a good idea.

Bravo Alpha One

5th Mar 2017, 14:11

Quite apart from what I said at #168, I should imagine it unlikely in the extreme that anyone would be fully rational and feeling well having just been ejected* through a mass of blazing debris at god-knows-what speed as one's aeroplane fell apart, no matter what had happened prior to impact.
In fact, it must be considered almost miraculous that the guy survived at all.
* Yes, I did read that he declined to use the MB escape system, but he was ejected to the extent that he left the aircraft.

Homsap

5th Mar 2017, 14:29

Aox...

You make some good points and to add the case of the AH fan club is losing credibility.

The problem is that the CPS/Police might take the approach that prosecution my not be in the public interest, compounded with the fact that the CPS/Police might think AH has suffered enough. Criminal law sometimes works that way, but oddly the Crown Court would probably be kinder to him, based on the fact it would be decided by a jury on the 'without reasonable doubt' basis.

However a civil case would be based on the 'balance of probabilities' in which I think AH would be slautered financially.

The fact it that AH may have claimed he felt ill before, as someone stated, knowning that you were about to die, but perhaps it was an untruthfull statement to cover himself, in the same way AH claimed the entry was at 500ft, not that he can remember and evidence suggests otherwise. Also a bit odd that previous displays were reviewed on the Hunter, yet not the JP incident at Southport.

Finally, in respect of misreadining of instruments, the report states Class One Medical, but no references to restrictions in respect of corrective vision, as possibly, it is unlikely at the age of 51, corrective vision might be an issue, as it was in a Grob 115/Glider mid air acccident, which stated from memory that while there was a restriction in repect of corrective vision in respect of P1, yet glasses/or contacts were recovered from the accident. Did AH require glases, was he wearing them?

Heathrow Harry

5th Mar 2017, 14:35

Biscuit wrote:-

"That the pilot did not abandon the manoeuvre seems to be either an indication of gross misjudgment of the physical situation or an indication of over confidence or 'press-on-itis' - under the pressure of being on display. Not the first of us to fall foul of these,"

brings to mind the Phenom crash at 'Bushe .... in that case the pilot MUST have realised he was far too fast and long but he still tried to land............

We all get fixated sometimes

Heathrow Harry

5th Mar 2017, 14:38

"Their contributions here are not going to achieve or change anything."

ever heard of the Great British Press? If they take it up the CPS will have charges out in an hour

wiltshireman

5th Mar 2017, 15:31

The simple fact is that he was too heavy with fuel having transited low level from North Weald and had no vertical energy. Just appalling and has put the vintage jet display circuit in a difficult position.

Lemain

5th Mar 2017, 16:03

Dave Reid -- If there were to be a prosecution, which would ultimately be up the the police and CPS, they would have to convince a jury of his guilt (of whatever charges are laid).

It's not up to a defendant to prove his/her innocence.

The report isn't conclusive hence the discussion here. The pilot is a highly experienced and respected military and commercial pilot, with a licence to fly type, and a current medical. There does not appear to be any single reason why this happened; or the report would have highlighted it.

Yet this tragedy happened and killed eleven people. That resulted in widows, orphans, businesses who'd lost key staff, cost of funerals, homes repossessed, loans unpaid,... Massive costs both human and financial. Just as we all cover ourselves for our 'third party' damage to others with our home and motor insurance it is perfectly proper for those involved in displays to carry appropriate cover. No doubt they are covered but as we all know our insurers insist that we do not admit liability. If we do, we may forfeit cover. So it is unrealistic to expect the parties involved in the tragedy to make public statements.

I don't see this as a police/CPS matter but rather some kind of class action by those who have lost so much. I'm sure everyone here would hope that insurers or others have already dug deep into their pockets to help mitigate the financial consequences to those whose lives have been shattered. It'll end up in court, blame will be apportioned by lawyers and monies paid out.

The only winners are the lawyers.

DaveReidUK

5th Mar 2017, 16:18

I don't see this as a police/CPS matter

Rightly or wrongly, the police obviously beg to differ:

Sussex Police to review the Air Accident Investigation Branch's report into the Shoreham air crash (https://www.sussex.police.uk/news/sussex-police-to-review-the-air-accident-investigation-branchs-report-into-the-shoreham-air-crash/)

It may be just a CYA exercise, but these things tend to take on a life of their own.

langleybaston

5th Mar 2017, 16:21

Sussex Police has received the final report from the Air Accident Investigation Branch into the Shoreham air crash and will begin looking at the report in detail with our independent experts.

One wonders who the independent experts are ...... more expert than AIIB ........ not an easy to find trawl is it?

Lemain

5th Mar 2017, 16:27

Dutystude

5th Mar 2017, 17:00

This is so sad. Normally the only fatality in these occurrences is the pilot and we, the aviation family, no matter what the ins-and-outs, say "unlucky Mate, God Bless"

That AH survived changes nothing. It was an error of judgement. We do not have to live with it: AH does!

Heathrow Harry

5th Mar 2017, 17:10

"One wonders who the independent experts are ."

lawyers & people who can give an opinion on if there is a case that can stand up in court etc etc

Unfortuantely a Court case could turn VERY nasty indeed -worse if it is a private prosecution - then you'd have 11 sets of lawyers asking questions

DaveReidUK

5th Mar 2017, 17:11

Dave Reid -- The Coroner will almost certainly have asked the police to investigate whether any crime was committed. The Coroner has to determine whether the killing was unlawful, accidental, etc. Indeed I think the Coroner always involves the police?

Quite so.

My understanding is that Sussex police are investigating the possible case for prosecution on charges of manslaughter and/or breach of the ANO (2009) Section 138: "Endangering safety of any person or property: A person must not recklessly or negligently cause or permit an aircraft to endanger any person or property."

airpolice

5th Mar 2017, 17:31

I started this thread to discuss the AAIB Report, not to second guess it or come to any conclusion about blame.

My recollection of reports at the time is that the traffic lights were holding the cars that were hit.

From page 117 of the report. Section 1.18.7.2

The organisers of the 2015 Shoreham Airshow had identified that the junction of the A27 was a popular location from which to view the display. The AAIB was informed that in previous years several hundred people had been observed at the road junction between the A27, Shoreham Bypass, and the Old Shoreham Road, and in the grounds of a nearby, now closed, public house. The display organisers and the local emergency services had been concerned about the road traffic risk to these crowds and the display organisers had taken steps to minimise the number of people in this area.

The ground operations risk assessment identified the hazard as, ‘Fast moving trunk road. 70 mph dual carriageway Traffic lights and queuing traffic.’ and
proposed the action as ‘Traffic management plan in place. No right turns. Traffic Lights off and 40 mph limit in place.’

Traffic Lights off

The ground operations risk assessment.... proposed the action ...Traffic Lights off. And yet......

The manoeuvre was continued and the aircraft struck the ground on the northern side of the westbound carriageway of the A27 close to the central reservation with a ground track at a slight angle to the direction of the road. When it struck the ground it broke into four main sections. Fuel and fuel vapour released from the fuel tanks ignited. In its path were vehicles that were stationary at, or in the vicinity of, the traffic lights at the junction
with the Old Shoreham Road, and pedestrians standing by the junction.

In its path were vehicles that were stationary at, or in the vicinity of, the traffic lights

Leaving aside why the Hunter came down there, why were the traffic lights at red when that was already identified as a threat?

This is not hindsight, people had discussed this before the show.

mothminor

5th Mar 2017, 17:52

airpolice.

The risk identified was that fast moving traffic may injure spectators, not that a pilot causing an aircraft to crash onto the road may injure car drivers.

DaveReidUK

5th Mar 2017, 18:16

why were the traffic lights at red when that was already identified as a threat?

They weren't at red. They had been disabled (see above) and in fact many of them had covers on them.

http://i4.mirror.co.uk/incoming/article6320947.ece/ALTERNATES/s615b/The-moment-of-impact-on-the-A27-at-the-Shoreham-Airshow-circled.jpg

airpolice

5th Mar 2017, 18:17

Mothminor, I understood that risk to be mitigated by the 40 MPH limit.

The lights on green was to prevent a build up of cars.

Was it not the (closed off) right turn lane signals that were bagged?

sika hulmuta

5th Mar 2017, 18:23

I truly feel for the families and friends who lost loved ones in this tragic accident, and can fully understand the obvious anger and frustration behind some of the posts here, having lost personal friends and colleagues in aviation accidents myself.

At the end of the day we need to understand what happened. As an ex QFI and trainer in several aviation outfits, I know how easy it is to say " you did this wrong you did that wrong" and list a hundred points that could have been done better. But that achieves very little. You need to understand "why" things happened to learn and prevent them happening again.

In this case the AAIB have produced an excellent factual document, and identified many possible contributory reasons with recommendations for change, but for no doubt good reason they have refrained from stating the Why" about the final manoeuvre. The AAIB deal in facts, not speculation.

That AH got it wrong is not in dispute. The question is Why? And with the greatest respect to the majority of people on this forum, unless you have displayed such machines, you cannot begin to comprehend the issues involved.

It is easy to point the finger of blame, demand public lynchings and that he is hung out to dry, but from where I am sitting there are too many unanswered questions to say "AH you are culpably negligent.".

Having been in the display circuit myself I have zero tolerance for cowboys, but in my professional opinion using the data on the report, the lead up to and the final manoeuvre do not make any airshow or JP or Hunter sense. AH would have had to have been stark raving bonkers to deliberately fly the machine as it was flown.

If this does come to a court case, I hope that informed facts are presented and that it doesn't become a legal lynching by a silver tongued silk... Otherwise we will learn very little for the future and it will destroy the "Just Culture" which presently exists in the UK aviation world, spearheaded by the AAIB.

G0ULI

5th Mar 2017, 18:31

Although the AAIB has a lot of in house experience, they rely on outside experts to analyse and test specific components and also to provide expert commentary as to human factors.

Those same experts can also be employed by the police or any other party to provide expert testimony in a court case.

Just because the AAIB report cannot be used to assign blame, that does not mean that the contributors to the report cannot be compelled to give evidence in a criminal or civil trial. That includes members of the AAIB team if a judge rules that their testamony is necessary for a complete understanding of the matters being considered.

Lemain

5th Mar 2017, 18:39

Sika halmuta -- AH would have had to have been stark raving bonkers to deliberately fly the machine as it was flown.

Eh?

sika hulmuta

5th Mar 2017, 19:02

Hi Lemain,

You obviously have never flown the Hunter and I'm not about to attempt to give you a fast jet conversion on this forum. :E

Chronus

5th Mar 2017, 19:08

Talk of traffic lights, what utter rubbish ! If any sort of warning lights are to be considered, then consider this. Are gates for aerobatics not a form of stop /go junction. Anyone with even a an hour or two of aerobatics training would have known the purpose of escape gates. In the sense of traffic lights he just jumped the red. Look at the photo posted by Dave Reid. See the traffic lights, look at the inferno, it is 980 degrees c in there. Dante comes nowhere near it. For all those poor souls engulfed in it,it is like napalm. Death descended out of a clear blue sky to claim them in the most horrific way. What sort of an error was it. I`d have thought most of those who lost their dear ones would consider it was gross. Is this a case involving the public interest, I`d say yes it is. The pilot has lost his memory of the event. How could any normal human being live with such a memory. Denial is the only way I`d have thought. Before anyone jumps down my throat, I`d add I do not known the victims or their families. My sympathies remain with them. Sika hulmuta talks about silver "tongued silks" and "just culture" and hopes it will not become a legal lynching. Why, because we need to learn. What have we learned from this one. Simply this, some bloke goofed, big time. So my response to Sika is go tell that to the marines.

Lemain

5th Mar 2017, 19:18

Hi Sika -- You obviously have never flown the Hunter and I'm not about to attempt to give you a fast jet conversion on this forum.

Ha! I've never had the innate aptitude. The desire, yes :) My point is this: Are you saying the pilot was "stark raving bonkers" or that his flying was not deliberate? Or Flight 9525? You left a hanging pregnant pause. What are you really saying?

Bravo Alpha One

5th Mar 2017, 19:57

May I just ask some of the people on here who HAVE flown the Hunter; is it at all possible to be flying one and mistake it for a JP, or are they very very different [not just from a performance point of view, but e.g. cockpit layout]?

sika hulmuta

5th Mar 2017, 20:25

Hi Lemain,

OK for clarification, I have no reason to doubt his competency as he was legally authorised as fit and able to fly the flight. His paperwork was in order. And I do not believe he was anything other than deliberate and professional in approach if you follow his flight profile up to just before the loop, and certainly not stark raving bonkers!.

His profile was highly accurate up until a point just prior to the pull up. Then the pattern changes. Dramatically. And the manoeuvre, as has been pointed out by many others was marginal at least at many points, with several apparent poor decisions made. He was more or less on axis (20 deg ish by my reading?) at the start of the loop then skews off 60 or so degrees. A lot anyway. Why?

The thrust changes are strange and nonsensical to put it politely. Bluntly, fast jet flying is largely about energy control. As an experienced fast jet pilot he would have had that hammered into him from day one, regardless of type. And in a manouvre like this you pump as much energy into the system as you can to start with, then mediate it later.

All I'm saying is there is a lot unexplained in the report. I really don't believe he deliberately did anything wrong or iffy, or is the cowboy others have suggested.... but it ended in disaster and the accident has, and continues to cause a huge amount of pain and hurt.

We need to cognitively understand why, and not be driven by natural emotional desires and jump to conclusions to "hang the guilty bastard" if we are to prevent a similar future accident.