Shoreham Airshow Crash Trial

[tucumseh]

It's sad to hear these tales of the AAIB. I speak regularly to a retired senior engineering inspector, who is at pains to point out that (similar to MoD BoIs/SIs) what the public and courts see is seldom what the inspectors write. In both cases there is often a 'political' overrule. For example, the Chinook ZA721 and ZD576 reports seem very odd, until one reads the originals and views images that were removed. It is entirely possible the original inspectors' reports (plural, and they don't necessarily see each other's) from Shoreham bring out many of the issues the final report omits. Perhaps the AAIB headshed, or their bosses, don't want it revisited; but the inspectors do.

[LOMCEVAK]

G0ULI - you saidQuote:PPRuNe readers are in possession of information and/or experience that was not made available to the jurySorry but that's just not true. Many people gave evidence who have plenty of experience of fast jets, display flying in all its aspects, and the rest. In particular, there were two prosecution expert witnesses, and one defence expert witness, with oodles of time on fast jets - on ops as well as in displays. And the judge was meticulous in ensuring that all witnesses spoke clearly and without technical jargon, and making sure that the jury understood.

airsound

airsound,

I would like to add a caveat to what you have said. The expert witnesses presented aspects of their knowledge to the jury in response to the questions from the counsels. They have considerably more knowledge than that which was presented but they were not asked to, nor able to, pass that on to the jury. Similarly, some PPRuNers have knowledge that was not presented to the jury.

Leaving aside the tragic circumstances of the Shoreham accident, it has opened up discussion regarding the potential for cognitive impairment due to sustained low g manoeuvres. I most certainly had never heard this discussed before this trial and have never heard of any other incident that was attributed to such a phenomenon. I wonder if any other PPRuNers had ever heard of this prior to the Shoreham trial? To put my knowledge into context, I was one of the facilitators delivering the high onset rate g training to UK military pilots after this training was introduced following the Red Arrows Bournemouth accident and it was not included in the training package. Similarly, it was not covered during RAF centrifuge training. Therefore, it is highly unlikely that any of the AAIB investigators were aware of this at the time that they published their report.

Some of my assumptions above may not be valid but I am interested to know if anyone did know about this phenomenon before January this year.

[Dominator2]

LOMCEVAK,

I agree with all that you say. I do, however, consider that maybe we all suffer from Cognitive Impairment CI from time to time in every day life and yet we are not aware of it . The condition is known as not concentrating on a task, allowing ones mind to wonder, being too familiar with a situation and so becoming complacent. One would like to believe that a fast jet pilot, every time he strapped into a jet, would NOT suffer from any of these failings. If a pilot of a high performance jet does not maintain the required mental approach he/she should not be there.

I and many others, (maybe yourself included), believe that the lawyers played the game in the AH trial. If the judge had fully understood the personal attributes required to be a professional, successful and safe low level jet aeros pilot the trial would have been conducted in a different way. The expert witnesses would have been requested to explain in detail to the jury the discipline and professionalism required to perform low level areos safely.

To my mind CI is yet another modern day, made up ailment to make an excuse for human failings. We all think that we know what happened in the AH accident. Many of us will have been in similar incidents and only by luck walked away unscathed. We do, however, accept our personal failings and try to learn from them.

I know that what I have written is contentious but IMHO AH should accept full responsibility for his actions.

[charliegolf]

LOMCEVAK,

I agree with all that you say. I do, however, consider that maybe we all suffer from Cognitive Impairment CI from time to time in every day life and yet we are not aware of it . The condition is known as not concentrating on a task, allowing ones mind to wonder, being too familiar with a situation and so becoming complacent. One would like to believe that a fast jet pilot, every time he strapped into a jet, would NOT suffer from any of these failings. If a pilot of a high performance jet does not maintain the required mental approach he/she should not be there.

I and many others, (maybe yourself included), believe that the lawyers played the game in the AH trial. If the judge had fully understood the personal attributes required to be a professional, successful and safe low level jet aeros pilot the trial would have been conducted in a different way. The expert witnesses would have been requested to explain in detail to the jury the discipline and professionalism required to perform low level areos safely.

To my mind CI is yet another modern day, made up ailment to make an excuse for human failings. We all think that we know what happened in the AH accident. Many of us will have been in similar incidents and only by luck walked away unscathed. We do, however, accept our personal failings and try to learn from them.

I know that what I have written is contentious but IMHO AH should accept full responsibility for his actions.

I've read a lot of the thread and agree fully with this, especially the bit in (my) bold. Does anybody feel the routine was not badly flown?

CG

[Legalapproach]

Dominator2
I and many others, (maybe yourself included), believe that the lawyers played the game in the AH trial. If the judge had fully understood the personal attributes required to be a professional, successful and safe low level jet aeros pilot the trial would have been conducted in a different way. The expert witnesses would have been requested to explain in detail to the jury the discipline and professionalism required to perform low level areos safely.

You are wrong on a number of levels. Before posting did you read and hear all of the medical evidence? No? Did you read and hear all of the evidence given by the expert witnesses as to what was required of a professional, successful and safe low level jet aeros pilot? No? What makes you say that the judge did not fully understand the attributes required? What makes you say that the witnesses were not asked to explain the discipline and professionalism required to perform low level aeros safely?

As you say "We all think we know..." but that's a long way from actually knowing, based on all of the evidence available to the judge and the jury

[DODGYOLDFART]

This post is # 505 and despite all the assumptions and suggestions made, I remain completely puzzled as to who or what killed the innocent people on the ground. The trial in my opinion only clouded this issue further, I pray that when finally the Inquest takes place we will discover the truth and those killed can RIP.

[megan]

To my mind CI is yet another modern day, made up ailment to make an excuse for human failings Cognitive impairment is a recognised medical condition, a search of the term will inform. Whether it applied to this accident is another matter.

[flighthappens]

Cognitive impairment is a recognised medical condition, a search of the term will inform. Whether it applied to this accident is another matter.

it is.

However, I have been to at least 4 Aviation Medicine courses since 2006, with the last being in 2015, run by the military of two different countries (including the RAF) and until this case has not heard of it in an aviation context. Just saying....

[Nomad2]

Cognitive Impairment is a real thing.
I have suffered from it myself on many occasions.
However, when I tried to use it as an excuse for my piss poor performance, my boss insisted that in fact, I had simply made a mess of what I was doing because I wasn't paying attention/ trying hard enough/ was thinking about something else/ forgotten what I was supposed to do..etc.

CI my ass.

AH clearly made a balls of the manoeuver, probably because he thought for a moment he was in the JP.

Whether it was confusion with his other type, or something else though, isn't the issue.

He simply made a mess of the manoeuvre, and as the aircraft Captain he should fess up and admit his mistake- as we all have to do from time to time.

[Thud105]

I think that too many of the people posting here are conflating (both wilfully and accidentally) 'Justice' and 'The Law', when we all know they are VERY different things.

[airsound]

As someone who watched the defence’s comprehensive demolition of the prosecution case in the Old Bailey trial, and also someone who heard evidence from several prosecution witnesses that seemed to support the defence case, I would like to agree with everything Legalapproach says at post #505 above.

On the question of the existence or otherwise of CI in an aviation context, this is my understanding, which I hope might be helpful. I should stress that I am no expert on the subject.

Cognitive Impairment (CI)

CI is a not a medical condition - it is a symptom of one or more medical conditions.

Most, if not all, professional pilots are aware of CI, since it is the main symptom of altitude hypoxia, even if they have not heard the term.

Other causes of CI include alcohol (which some professional pilots are aware of!), and Transient Ischemic Attack (TIA) (more medical).

At the trial, cerebral hypoxia leading to CI was covered. Cerebral hypoxia again requires an underlying cause.

Whilst CI is not, or was not, a widely familiar term, I am aware of it's being quoted in MoD records around 2003.

The Service Inquiry into the death in 2011 of Flt Lt Jon Egging, Red 4, describes CI. It points out that it can occur in the recovery phase from G-LOC, and quotes examples.

A-LOC can involve, or lead to CI, although the Old Bailey trial highlighted differing opinions and research findings on the exact definition of A-LOC in ‘G impairment’.

As I understood the trial defence, AH’s pattern of mistakes and errors bore the characteristics of CI. The defence did not identify a specific cause of that CI; that would be for accident investigators to consider. The defence did raise the possibility that it could have been G-induced.

Hope that helps

airsound

[42go]

Ah well - that's it then - no more pulling g in case you grey or black out. I remember those aerobatic displays of old........................

[212man]

More from the AAIB: https://assets.publishing.service.gov.uk/media/5df89b7ded915d0931d74770/Hawker_Hunter_T7_G-BXFI_Supplement_02-20.pdf

[ExSimGuy]

In other words - "We still have no idea ?" :ugh:

[jivusajob]

In other words - the AAIB say cognitive impairment, DIDN’T happen. 😳

[212man]

In other words, the AAIB have just used 31 pages to stick two fingers up at Steve Jarvis.....

[DODGYOLDFART]

In other words, the AAIB have just used 31 pages to stick two fingers up at Steve Jarvis.....

However the critical question has to be - had this new AAIB evidence been available at the trial would it have had a significant affect upon the verdict?

[airsound]

DODGYOLDFART, you ask had this new AAIB evidence been available at the trial would it have had a significant affect upon the verdict?. But the AAIB specifically says (on page 10 of the supplement)None of the information was assessed to be new and significant evidence So presumably not

airsound

[Easy Street]

The evidence wasn’t significant to the AAIB because it didn’t cast doubt on the AAIB findings. It doesn’t follow that the same would have been true in court, where the findings were different. In particular, the weight of aeromedical opinion against CI might have made a difference.

[DODGYOLDFART]

The evidence wasn’t significant to the AAIB because it didn’t cast doubt on the AAIB findings. It doesn’t follow that the same would have been true in court, where the findings were different. In particular, the weight of aeromedical opinion against CI might have made a difference.

Yes but would the twelve good men and true have seen it the same way, or the judge come to that?

[Onceapilot]

Thank you 212man for posting the link to this AAIB Supplement. As I read this, the AAIB have examined and disagreed with many points of evidence. Additionally, am I right that they discount "CI" as an aviation medical condition? Where does that leave the legal situation from the trial and its judgement?

OAP

[langleybaston]

The difference between inspectors' views and reports, and the redacted political versions, is systemic and has been for many years.

As a UK TACEVAL Met. evaluator in 2 ATAF and 4ATAF I was told very firmly by the team leader "you cannot write that!" Thus cannabis on the window sill of a Met Office was allowed to grow to crop, and incompetence and indifference to continue unremarked.

In another life, my damning annual inspection report of a civil airport Met. facilities was greeted with horror.

The honest strivings of experts at about PSO/Gp Capt level are routinely subverted. Those who protest do not climb the greasy pole.

Fact of life, and not only UK.

[OvertHawk]

In other words - the AAIB say cognitive impairment, DIDN’T happen. 😳

Actually no... The AAIB say that their analysis of the evidence does not indicate that Cognitive impairment DID happen. Subtle difference but important one.

[pr00ne]

By its very nature you cannot ever comprehensively and without doubt EVER prove the definite existence of Cognitive Impairment.

[DODGYOLDFART]

By its very nature you cannot ever comprehensively and without doubt EVER prove the definite existence of Cognitive Impairment.

I wonder what the Inquest will make of this report when it resumes following the adjournment? Anyone got a clue as to when this will be?

[falcon900]

It is difficult to read the AAIB supplementary report without gaining the impression that they were somewhat peeved to have been required to write it. It does not evidence their customary open mindedness, instead reeking of a desire to bury CI by whatever means they can. It seems to start from the premise that it doesn't exist, and seeks out all the material they can find to support that premise.
For my own part, I have no idea whether there is such a thing as CI or not, but having had the subject raised by this tragic series of events, I remain unclear whether it does or not. The AAIB supplementary report reads rather like a publication of the flat earth society; "The earth is flat, and here is all the evidence we have found to support this view........" and has not dispelled my curiosity.
As it transpired in court, it didn't matter what the AAIB thought, but just what the Jury did. That they could conceive of the possibility that there could be a state of mental impairment with onset ahead of the currently fully accepted stages of mental impairment does not seem at all unreasonable, and rather more to their credit than the AAIBs latest contribution is to theirs.

[H Peacock]

The AAIB supplementary report reads rather like a publication of the flat earth society; "The earth is flat, and here is all the evidence we have found to support this view........" and has not dispelled my curiosity.

F900 - You're 180 out, it's the CI brigade that'll be arguing that the world is flat; the AAIB are simply stating from all of the available evidence that it's still round!!

[LOMCEVAK]

There is a distinct difference between an accident investigation by an appointed organisation (AAIB) and a manslaughter trial in a court of law. The conclusions drawn from the analysis undertaken by the former with respect to low Gz CI will be based upon the balance of probabilities of whether or not CI occurred and it appears that they found no evidence that it did, only that some sources consider that it exists (whilst others do not). However, for a guilty verdict to have been given by the jury in the criminal court the prosecution would have to have proven beyond reasonable doubt that CI did not occur. Therefore, the two criteria are different.

[OmegaV6]

As LOMCEVAK says, this is a common problem in criminal trials. The defence raise the hypothesis that a situation occurred - self defence/misunderstanding/whatever - and the prosecution are then required to disprove it. There is no requirement for the defence to prove anything .. just to raise the matter as a "possibility". Trying to disprove a negative hypothesis is extremely difficult as the only possible way is a positive proof, and in most accident situations that is highly unllikely.

[Onceapilot]

Hmmm, I am guessing that the situation here has considerable ramifications for Law?

OAP

[Easy Street]

Hmmm, I am guessing that the situation here has considerable ramifications for Law?


It does seem to raise doubt over whether the display pilot of a high-performance aircraft could ever be found culpably negligent. Anyone who’s taken a passenger flying in a fast jet knows how utterly overwhelming the experience can be for the senses and the cognitive ability of the untrained human brain; it’s a truism that we were built for 1g straight and level. Training and experience can overcome that to a greater or lesser extent, but the record shows that even trained and experienced pilots have sometimes found themselves unaware of impending disaster. If all it takes to escape the charge of negligence is to cite the possibility that decision-making was impaired by temporary reduction of blood flow to the brain (something that happens as a matter of course during high-performance manoeuvring) then the only controls available on such activity are of the sort we’ve seen since Shoreham: much tighter constraints on flying to minimise the impact of ‘inevitable’ accidents.

[DaveJ75]

The AAIB are excellent at engineering and technical analysis but incredibly poor at understanding the fleshy bit holding the stick. Good grief, the supplement reads as if written by a GCSE student who skimmed through a human factors book while waiting for the bus. Another pointless waste of taxpayers money.

[LOMCEVAK]

The AAIB are excellent at engineering and technical analysis but incredibly poor at understanding the fleshy bit holding the stick. Good grief, the supplement reads as if written by a GCSE student who skimmed through a human factors book while waiting for the bus. Another pointless waste of taxpayers money.

DaveJ75, could you please give some detailed examples of precisely what parts of the report you are referring to in order to justify your statement above?

[tucumseh]

I’d say the supplement reads more like something MoD would write. It won't have liked being sucked in to this, and will be aghast at what has been claimed in the RAF's name by the CAA. Has the AAIB chosen sides?

The supplement could be a smokescreen. Will the Coroner blow it away and ask the obvious question about certification and oversight?

[Asturias56]

I'm sure the Coroner won't reopen the Inquest - can't see a reason in law to do so - it's a matter of opinion at the end of the day - the CAA v. the pilot's medical team

[TC_LTN]

I'm sure the Coroner won't reopen the Inquest - can't see a reason in law to do so - it's a matter of opinion at the end of the day - the CAA v. the pilot's medical team

You seem to miss the fairly fundamental point that the Inquest has not yet taken place!

[Asturias56]

You seem to miss the fairly fundamental point that the Inquest has not yet taken place!

apologies - it's dragged on so long I assumed the trial had taken place after the Inquest .............

[Chugalug2]

[/left]
apologies - it's dragged on so long I assumed the trial had taken place after the Inquest .............

I suspect that the Inquest will be well worth waiting for, Asturias. It all rather depends upon the Coroner, and this one seems interested in the wider events that led up to this tragedy. Just a little more patience...

[ORAC]

https://www.theargus.co.uk/news/18196211.shoreham-airshow-inquest-held-without-jury/

Shoreham Airshow inquest to be held without a jury

The coroner who will probe the deaths of 11 men in the Shoreham Airshow crash has vowed to carry out a “fearless and impartial” investigation.

The highly anticipated inquests into the 2015 tragedy in which a Hawker Hunter jet exploded into a fireball on a busy dual carriageway are to take place in September 2020, it has been decided.

Speaking on Wednesday, senior coroner Penelope Schofield thanked families for their patience and acknowledged it would be five years since the tragedy before the inquests actually got under way.

A pre-inquest review at Centenary House in Crawley on Wednesday was told that the inquests would take place in a six-week window from September 14. Mrs Schofield also said it was her decision that the inquests would not have a jury.......

[Ddraig Goch]

Can anyone tell me why?

[Tashengurt]

Can anyone tell me why?

I can't tell you why but my guess would be a combination of the fact that the case has received so much publicity that an untainted jury would be impossible to find and that the volume of specialist and technical information would prove difficult for many to understand.

[tucumseh]

Can anyone tell me why?

Juries can ask awkward questions. There'll be a few sighs of relief in the CAA, AAIB, HSE and MoD!

[Fortissimo]

When the police were asking the High Court for access to AAIB Shoreham witness statements (which the Court refused), the judges were also looking at a spat with the Norfolk Coroner, who wanted access to the CVFDR for the Lord Ballyedmond AW139 accident. The Lord Chief Justice added to the judgement in that case by stating:

“In the absence of credible evidence that the investigation into an accident is incomplete, flawed or deficient, (my bold) a Coroner conducting an inquest into a death which occurred in an aircraft accident, should not consider it necessary to investigate again the matters covered or to be covered by the independent investigation of the AAIB. […] [T]he findings and conclusions should not be reopened.”

It will be interesting to see how Ms Schofield interprets that direction.

[Ddraig Goch]

Thank you both for your swift and judicious replies.

[ORAC]

https://www.theargus.co.uk/news/18540821.shoreham-airshow-disaster-inquest-put-back-year-2021/

Shoreham Airshow disaster inquest put back a year to 2021

[DODGYOLDFART]

https://www.theargus.co.uk/news/18540821.shoreham-airshow-disaster-inquest-put-back-year-2021/

Shoreham Airshow disaster inquest put back a year to 2021

I for one am very glad that at last the CAA is getting round to investigating the issues surround the term cognitive impairment. However delaying the inquest for another year I fear will be much regretted by all concerned.

[H Peacock]

I for one am very glad that at last the CAA is getting round to investigating the issues surround the term cognitive impairment.

Absolutely agree; the sooner they ‘file’ CI where it belongs the better!

[Ridger]

I for one am very glad that at last the CAA is getting round to investigating the issues surround the term cognitive impairment

I note the article mentioned CAA review of CI. I fear that might not take long... Some proper research into the area is needed.

[DODGYOLDFART]

Ridger AFAIUI ever since the trial several recognised "authorities" have been turning summersaults in an attempt to come up with an agreed definition of what CI is and how it should be applied to aeronautical situations. Whilst everyone I have discussed this with seems to agree that finding an agreement on the specific terms involved is bad enough but then when you turn to the issue of how such terms may be applied the famous "can of worms" starts to be mentioned. One thing that clearly stands out with hindsight, is that the defence team really played a flanker when they got the Court to buy into the CI concept.

What ever happens now I do not envy the people who will be involved with the Inquest. However in my advanced years I hope I will be able to get my brain around whatever they come up with.

[tucumseh]

One must bear in mind that the AAIB report left the CAA without a name, and the judge was less than impressed with some prosecution witnesses. In fact, it is by no means certain the pilot would have been found guilty even if CI had not been raised. Yes, it must be looked at by regulators, but I suspect the CAA (and MoD) will be hoping it serves as a diversion.

[airsound]

As ever, Tucumseh makes some good points.

I’ve spent quite a lot of the last few decades watching and commenting on aerobatic displays at air shows, and I also sat through most of the Old Bailey trial. I have to say that one of the more extraordinary moments of the trial for me was when I first saw the film of the start of the fatal manoeuvre. My immediate reaction was ‘what on earth is he doing?’ It didn’t make sense. And my professional knowledge of Andy Hill was as a very competent display pilot.

So the question raised for me then - a question which remains unanswered to this day - was, why did he do that? I suggest, nobody knows. And we probably never will.

airsound

[Ridger]

Ridger AFAIUI ever since the trial several recognised "authorities" have been turning summersaults in an attempt to come up with an agreed definition of what CI is and how it should be applied to aeronautical situations

I completely agree - CI is far too broad to agree on in a specific acute context. De-coupling from the accident, I would say that is a major reason to motivate research, perhaps of assessing cognition at sub A-LOC levels in a centrifuge. If meaningful data were produced it would add another solid reason to not erode safety margin...

[Easy Street]

I completely agree - CI is far too broad to agree on in a specific acute context. De-coupling from the accident, I would say that is a major reason to motivate research, perhaps of assessing cognition at sub A-LOC levels in a centrifuge. If meaningful data were produced it would add another solid reason to not erode safety margin...

I don’t think it takes much of a leap to imagine what that research might find. As Gz increases, more and more cognitive capacity will be devoted to resisting its effects (mainly the anti-g straining manoeuvre, but also things like planning how to position head and neck). Physical discomfort will also have an effect on spare mental capacity. Taken to an extreme well beyond Shoreham, at +9g in old-style kit there isn’t much of it left!

In the context of culpability, the effects I mention are all ‘known knowns’ and trained for. Pilots, and especially display pilots, should not be able to *choose* to expose themselves to the high ‘g’ environment and then claim that its entirely predictable effects excuse them from responsibility.

At issue, I think, is whether unpredictable ‘medical’ CI is distinguishable from the predictable effects of Gz. The research will need to be very carefully designed to separate those things, if indeed it is possible to do.

[Two's in]

This whole CI argument is very circular. Military operators have understood for many years the stresses, strains and limitations of human physiology when exposed to extreme G forces. That's why FJ pilot selection is as rigorous as it is, that's why age is known to be a key factor in maintaining the physiological performance required and that's why fundamentally, it's a young person's domain. I genuinely don't understand the apparent surprise and confusion that putting an individual into this environment who is almost certainly not performing to the same physiological standards as they were 20 years ago, may lead to issues with Cognitive Impairment.

Yes, I am proposing that age should be a discriminator in high performance flying. A lengthy study on the instances and effects of Cognitive Impairment could be avoided altogether by a quick check of display pilot's birth date and flying recency.

[Easy Street]

Yes, I am proposing that age should be a discriminator in high performance flying. A lengthy study on the instances and effects of Cognitive Impairment could be avoided altogether by a quick check of display pilot's birth date and flying recency.

I hope you mean ‘high performance display flying’ (in which case I could be persuaded to agree) and not other areas of high performance flying where the consequences of momentary lapses are better mitigated. Andy Hill was 51 at the time of crash: capping high performance aviation at an age below that would have a huge impact on air forces’ training throughput requirements and, to compound that, availability of instructors. And unless MFTS sorts its act out it’d reduce RAF fast jet pilot careers to less than a decade! :E

[DaveJ75]

A lengthy study on the instances and effects of Cognitive Impairment could be avoided altogether by a quick check of display pilot's birth date and flying recency.

Ah, I see - so you only crash after a certain age? This is great news for young pilots everywhere!

[dagenham]

i dont want to state the obvious or be accused of being a modern day witch finder general - but there is a simple solution.

If Andy is capable, willing and able why not strap him into a centrifuge and see what happens.......the trial is done and it could really help with the science and the benefit could be significant?

am i too optimistic ?

[Timelord]

I can’t believe we are still going round and round this debate. Surely everybody who has ever strapped into an ejector seat ( which excludes all of the lawyers and most of the doctors) and has read the AAIB report knows exactly what happened. He was no where near current or experienced enough in the Hunter to be displaying it in a confined area. He was signed off for displays by a few old mates and on the day screwed it up. Just like most of us have screwed up at some time but, by the grace of God, without these consequences.

[Just This Once...]

Nailed it.

[Bill Macgillivray]

Timelord,

How right you are - unfortunately!!

Bill

[Bob Viking]

I think I’ve made my feelings pretty clear in the past but I have to ask, what end state do we all want from this?

If CI is actually a thing we need to be scared of then surely that is the end of all display flying. Who in their right mind would pay to go and watch people throwing high performance machinery around in close proximity to crowds if that individual might, at any time, lose the ability to think and act rationally?

Even military pilots who are current and competent on type could apparently be prone to CI at any time let alone civilians with low experience and currency levels.

If, as I suspect, AH became confused or overloaded (maxed out as previously explained) then surely the CAA must mandate that all civilian pilots of FJs must undergo far more rigorous assessments and possess far more experience and recency on type than AH possessed on that fateful day.

I last flew the Jaguar in 2007. I had 600 hours on type. That is not dissimilar (Although actually far better) to AHs level of FJ recency when he crashed (bearing in mind JP was his aircraft of expertise not the Hunter). If you gave me a handful of hours to refresh on a Jag and asked me to do LL aeros I’d tell you to take a running jump. If you asked me to fly something similar to the Jaguar but not the same (ie a Phantom) I’d again tell you to get lost.

Even if you told me to do a LL display in a Hawk (2750 hours and increasing by the day) I’d still say no.

LL aeros are not my day job (even though flying FJs is) so I wouldn’t dream of performing them for a crowd.

The bottom line is that a lawyer managed to successfully argue for the presence of CI on that day. In saving his own bacon (understandably so and quite possibly completely legitimately) surely AH may have brought forth the end of all civilian, and maybe all military, LL displays?

As I said many posts ago. There is no way I will take my family to any air show with old jets flying unless I can be damn sure the person flying them is competent and qualified enough to be flying it. Right now, I honestly am not sufficiently assured that is the case.

I realise there are people who wish to stick up for AH (and good on you for doing so) but this FJ pilot is just not convinced. I fully understand that doesn’t matter one jot. The only person who will need convincing is the Coroner when the time comes.

BV

[just another jocky]

Shame it's taken 557 posts to finally arrive here.

[Homelover]

my professional knowledge of Andy Hill was as a very competent display Pilot

airsound

Really?? And how would a journalist know how competently he conducted pre-flight planning? How would you know how competently he considered the particular idiosyncrasies of a display venue? How would you know how thoroughly he considered the effect that OAT, wind and pressure altitude would have on his display profile? Or how competently he reacquainted himself with the controls, switches and Instruments of the Hunter cockpit before he displayed a type he had a slack handful of hours on in the last six months?

This military FJ pilot, with my professional knowledge, has a different opinion of AH’s competence and preparedness, which is rather more akin to Timelord’s and Bob Viking’s.....

[DODGYOLDFART]

Shame it's taken 557 posts to finally arrive here.
Having looked closely at all the recent posts on this subject I guess that we are in fact all largely singing from the same hymn sheet but perhaps not exactly the same verse.

BJ has put this very succinctly in his two post on here

My concern throughout is that the findings of the judge in the trial - CI, could become the standard get out clause for major screw-ups in the future. So a huge responsibility now rests on the shoulder of the Coroner to get it right this time. How I have no idea but I wish her well!

[DaveJ75]

CI, could become the standard get out clause for major screw-ups in the future

Or a prosecuting QC could legitimately argue that a display pilot who didn't fly with sufficient margin for error to account for factors including CI could be considered negligent?

[airsound]

Homelover ...how would a journalist know...
Ouch!

Without getting into arguments about whether journalists are capable of investigating things that most people may not know about, I’d like to say that I’m happy to be described as one.

But perhaps of more relevance is that I’ve been an air show commentator for more than forty years, a time that started towards the end of my twenty years’ RAF service.

As a commentator, I had researched and observed Andy Hill displaying in various aircraft. I had met him, and discussed his displays with him. I had read about his commendable time on the Harrier force, his time as an aerobatic instructor, and his many airline captaincy hours. I had formed the impression that he was habitually a meticulous preparer for any flight.

However, I would be the first to accept that I don’t know the detailed answers to the questions that you pose, Homelover, about his preparedness on a particular day. But nor would many others, I suggest, perhaps even you? That doesn’t mean that he couldn’t be described as very competent. You and some others differ, clearly.

I do, also, come back to his Old Bailey trial, which I attended for virtually all of its eight weeks. AH was acquitted of gross negligence manslaughter not because of smooth barristers, although his defence team was very good. No, he was found not guilty because sufficient believable evidence, much of it to a high technical standard, was produced in court to cast doubt on the prosecution evidence. Whatever, the jury was unanimous, after about seven hours of consideration.

airsound

[Bob Viking]

I realise you know AH and feel a sense of loyalty towards him.

You talk of commendable time on the Harrier and being an aerobatics instructor and an airline pilot. But how much of that was recent or relevant enough to sitting in a Hunter on the day in question?

I could stand next to a Typhoon and very convincingly talk to you about how I could fly it but that ultimately would mean nothing.

BV

[Chugalug2]

There are at least three contributory factors here for the coroner to consider, when he or she finally gets round to it; pilot, aircraft, and venue. The emphasis here has been almost entirely on the former, plus or minus CI. The latter two would suggest a poor, extending to none existent, degree of regulatory oversight. As tuc has previously suggested there are a lot of people hoping that the pilot, plus or minus CI, will take centre stage in that consideration lest attention also be drawn to the latter two factors.

[Easy Street]

There are at least three contributory factors here for the coroner to consider, when he or she finally gets round to it; pilot, aircraft, and venue. The emphasis here has been almost entirely on the former, plus or minus CI. The latter two would suggest a poor, extending to none existent, degree of regulatory oversight. As tuc has previously suggested there are a lot of people hoping that the pilot, plus or minus CI, will take centre stage in that consideration lest attention also be drawn to the latter two factors.

The CAA doesn't escape so easily even if attention is 100% focussed on the pilot. The civil display pilot certification and currency regime was woefully lax by comparison to its military equivalent. Which, you might well observe, makes a change :hmm:

[DaveJ75]

The latter two would suggest a poor, extending to none existent, degree of regulatory oversight.

Completely agree with you and Easy Street.

CI or not, there was an unchecked atmosphere in which a display pilot could nibble away at the margins until the inevitable happened. This accident had already been happening for years already and no-one really did anything about it. Frankly, I thought the CAA, and to a lesser degree, the airshow supervision, were jointly culpable to some extent.

[GeeRam]

Completely agree with you and Easy Street.

CI or not, there was an unchecked atmosphere in which a display pilot could nibble away at the margins until the inevitable happened. This accident had already been happening for years already and no-one really did anything about it. Frankly, I thought the CAA, and to a lesser degree, the airshow supervision, were jointly culpable to some extent.

And the disaster that was Shoreham was preceeded only a month or so earlier by the Gnat crash at Carfest at Oulton Park, that by luck didn't also result in ground victims.......and also left a question regarding pilot experience and currency.

[dastocks]

Completely agree with you and Easy Street.

CI or not, there was an unchecked atmosphere in which a display pilot could nibble away at the margins until the inevitable happened. This accident had already been happening for years already and no-one really did anything about it. Frankly, I thought the CAA, and to a lesser degree, the airshow supervision, were jointly culpable to some extent.
I had a quick scan through the AAIB report for the Hurricane that crashed at the 2007 Shoreham Airshow, only a few hundred metres from the 2015 disaster location. Other than pointing out that the aircraft had crashed 250m from Lancing College the report didn't discuss the risks to lives and property on the ground at all.

I really don't think CI is worthy of investigation by the AAIB or CAA at all. What they need to be doing is looking at the more general risk to people on the ground arising from pilot error and/or incapacitation, or even technical failure of the aircraft itself. One possible mitigation for pilot error/incapacitation might be a second pilot on the aircraft to monitor and intervene. This would obviously limit the types of aircraft that could take part.

[Fortissimo]

One possible mitigation for pilot error/incapacitation might be a second pilot on the aircraft to monitor and intervene.

Do you mean like LTC Mark McGeehan, the sqn cdr in LTC Bud Holland's RHS for the Fairchild B52 accident who lost his life trying to monitor and intervene?

[OvertHawk]

Do you mean like LTC Mark McGeehan, the sqn cdr in LTC Bud Holland's RHS for the Fairchild B52 accident who lost his life trying to monitor and intervene?

He lost his life failing to monitor and intervene!! (And failing to supervise and command as well)

Very sad indeed.

OH

[Easy Street]

Excuse the thread drift...

He lost his life failing to monitor and intervene!! (And failing to supervise and command as well)

Very sad indeed.

OH
You need to correct that bracketed slur on a dead man who exercised more command and leadership than everyone else involved in that sorry tale, combined. Bud Holland was not under McGeehan’s command or supervision. As the Wing standards pilot Holland reported directly to Wing leadership so in command terms they shared common superiors. In supervisory terms, if anything, Holland was supposed to supervise the squadron commanders on the leadership’s behalf. McGeehan complained about Holland’s conduct to Colonel Pellerin (who ended up being fined for dereliction of duty), banned squadron pilots from flying with Holland, and flew as co-pilot if any of his rear crew had to fly with him. Not sure what else he could have done as a commander or supervisor. Who knows whether any monitoring or intervention could have saved the day? Given prior occurrences and the degree of personal animosity between the two men I’d have been unsurprised if Holland simply ignored McGeehan or even fought him on the controls. But there’s no evidence for any of that. McGeehan’s biggest definite failing was flying at all, but that’s easy to say when he would have been under pressure to do so from his superiors, who clearly weren’t too concerned about Holland and needed a display for the families’ day. The command and supervisory failures, both on the day and through the long build-up, were all theirs. Retract.

[megan]

What more could McGeehan have done OvertHawk?On 10 March 1994, Holland commanded a single-aircraft training mission to the Yakima Bombing Range, to provide an authorized photographer an opportunity to document the aircraft as it dropped training munitions. The minimum aircraft altitude permitted for that area was 500 feet (150 m) AGL; during the mission, Holland's aircraft was filmed crossing one ridgeline about 30 feet (10 m) above the ground. Fearing for their safety, the photography crew ceased filming and took cover as Holland's aircraft again passed low over the ground, this time estimated as clearing the ridgeline by only three feet (1 m). The co-pilot on Holland's aircraft testified that he grabbed the controls to prevent Holland from flying the aircraft into the ridge while the aircraft's other two aircrew members repeatedly screamed at Holland: "Climb! Climb!" Holland responded by laughing and calling one of the crew members "a pussy"

After that mission, the crew decided that they would never again fly with Holland and reported the incident to the bomb squadron leadership. The USAF squadron commander, Lieutenant Colonel Mark McGeehan, reported the incident to Pellerin (commander of the 92nd Operations Group) and recommended that Holland be removed from flying duty. Pellerin consulted with Holland and gave him an oral reprimand and warning not to repeat the behavior, but refused to take him off flying duty. Pellerin also did not document the incident or the reprimand, nor did he notify his superiors, who remained unaware of the incident. McGeehan then decided that in order to protect his aircrews, he (McGeehan) would be the co-pilot on any future missions in which Holland was the command pilot. Evidence suggests that after this incident, "considerable animosity" existed between Holland and McGeehan.

https://en.wikipedia.org/wiki/1994_Fairchild_Air_Force_Base_B-52_crash

[dastocks]

Do you mean like LTC Mark McGeehan, the sqn cdr in LTC Bud Holland's RHS for the Fairchild B52 accident who lost his life trying to monitor and intervene?
Others have commented on the circumstances surrounding that accident, and it's pretty clear that the Air Force chain of command failed in allowing Bud Holland to continue flying. All I would add is that the accident occurred during practice and damage/loss of life was confined within the Air Force base so, to that extent, the system worked.

[Ridger]

What they need to be doing is looking at the more general risk to people on the ground arising from pilot error and/or incapacitation, or even technical failure of the aircraft itself

You're in luck - the CAA have done it. Take a look at the new CAP403 and you'll see swathes of guidance around risk assessment of threat to life on the ground 'in the event of'. You may have noticed a pre-pandemic reduction of planned airshows as a result of this...

[GeeRam]

You're in luck - the CAA have done it. Take a look at the new CAP403 and you'll see swathes of guidance around risk assessment of threat to life on the ground 'in the event of'. You may have noticed a pre-pandemic reduction of planned airshows as a result of this...

And the selling and/or grounding of a number of vintage/classic aircraft as a result.

[dastocks]

You're in luck - the CAA have done it. Take a look at the new CAP403 and you'll see swathes of guidance around risk assessment of threat to life on the ground 'in the event of'. You may have noticed a pre-pandemic reduction of planned airshows as a result of this...
Meanwhile, work has started on building a new IKEA store and 600 homes on land to the west of Shoreham airport which is likely to reduce even further the scope of any future airshow at that location.

[POBJOY]

And the selling and/or grounding of a number of vintage/classic aircraft as a result.

Interesting that least guilty party in all this (The Hawker Hunter) has to a degree been used as a scapegoat (to the public) when in fact it seems to have performed 'as required' and even ironically allowed the pilot to live**. This was quite convenient for the 'Authorities' as it diverted attention away from the authorities obvious lack of implementation of the system.
This is where the real problem lies. Even in 2014 there were layers of 'supervision' quite suitable to oversee Air Shows, and normal rules in place to ensure safety.
In the case of Shoreham these 'layers' had been eroded to the point that control of the 'system' was lacking, and mistakes not being picked up. Shoreham is as very 'tight' display arena and probably not really conductive to a high energy machine that is trying to stay within crowd vision, it therefore should have been part of the 'system' that the current rules of the time were observed back to the point of a DA being issued. The Stable Doors have now been firmly secured and indeed virtually nailed down ,which in itself was an over reaction to an 'in place systems' failure to exercise reasonable control.
** The Aircraft was not responsible for this dreadful accident.

[Legalapproach]

I can’t believe we are still going round and round this debate. Surely everybody who has ever strapped into an ejector seat ( which excludes all of the lawyers and most of the doctors) and has read the AAIB report knows exactly what happened. He was no where near current or experienced enough in the Hunter to be displaying it in a confined area. He was signed off for displays by a few old mates and on the day screwed it up. Just like most of us have screwed up at some time but, by the grace of God, without these consequences.
Timelord I was one of the lawyers and have strapped myself into an ejection seat on a number of occasions. Even took the pins out and took it flying.

[Cat Techie]

Timelord I was one of the lawyers and have strapped myself into an ejection seat on a number of occasions. Even took the pins out and took it flying.
Do you hold a PDA to display? Can you tell me why a man operating a machine and having full control of the machine at all times as AH had (in video evidence) and killed people escape any form of justice? If it had been a car, it would have been due care and attenion at least. CI is bull. If you had CI,the Hunter would have behaved like Jon Egging's Hawk. Unloaded and fallen out of it's manoeuver. It was criminal that the prosecution screwed up this case. I hope the jury at the inquest are not swayed by subjective arguement. There was back pressure on the control column of that aircraft the whole time. So much at the end as AH knew he had made a massive error. I am with BV in his views on this.

[Legalapproach]

Cat Techie

You've seen and heard all of the evidence given in the trial then? In what way did the prosecution screw up the case? Was it in not calling you as an expert?

[POBJOY]

Two of the points in this case are:- Have the relatives really been given a true picture of the situation, and do they feel that some sort of closure is possible with the real lessons being learnt.
Have lessons been learnt that actually make sense to those in involved with the aviation world.
The display world is virtually a bubble within the overall CAA system, and this can be a positive factor with participants sharing experiences, maintaining good safe standards, and in the main this is how it worked. In this very sad case these 'standards' failed at several points, and what should have been check points in the entire process were lacking. If you do not recognise 'publically' that there were failings (not just on the day) then is a lesson learnt. With the charge bought the jury gave a sound judgement because they were only being offered a limited choice.
The 'system' was guilty in allowing this dreadful accident to occur when it failed to implement those regulations/checks designed to prevent such a happening, which went back to the DA issue, and continued to the oversight of the actual display. Display regulations are 'focussed' on crowd safety but when machines in use are utilising space outside of the normal circuit then the normal ANO regulations apply to protect the public at large. This of course should have been a factor in the 'suitability' part of display planning, and 'now' has had the effect of reducing the number of airshow venues.
If an inquest has the remit to explore 'all' the factors leading up to the event then at least the relatives will have a better understanding of how it could happen.

[Timelord]

Timelord I was one of the lawyers and have strapped myself into an ejection seat on a number of occasions. Even took the pins out and took it flying.

Legalapproach: I apologise and stand corrected. It doesn’t change my views though.

TL

[Legalapproach]

Time Lord

Sorry to pick you up but I do get irritated that so many people make authoritative statements about facts or more particularly the evidence in a case (not you necessarily) when they are not in possession of all the facts and they are wrong.

Can I remind everyone that the trial lasted for about two months. The jury heard from numerous expert witnesses (on both sides) as well as eye witnesses and had access to a number of videos and reconstructions (most of which did not feature on the TV news and so will have been unseen by the armchair experts). In all the jury heard something in the region of 150 hours of evidence. That's why I become somewhat cross when I read so many people saying "I know what happened" "The jury got it wrong" The Prosecution was criminally negligent"

Everyone is entitled to their own view and I respect an opposite view if based on all and accurate relevant facts.

Cat Techie

You say AH was in 'full control' throughout.

Can you just remind me what the evidence was of the aircraft over the top and in the 3rd quarter of the loop?

Was that the evidence of all of the experts and in particular of the pilot expert witnesses who were present at Shoreham and who witnessed the flight?

Can you remind me, please of the medical evidence regarding oxygen de-saturation and the effect it has on (i) learnt motor skills, (ii) awareness and decision making capabilities?

In JE's case it was believed that he blacked out, in AH's it was at a lower level and produced symptoms similar to hypoxia. CI does not necessarily = unconscious. It's impairment not loss of consciousness.

If you are Norfolk based, when the world returns to normal I would be more than happy to meet up and talk through the evidence with you - I'm sure we can find a suitable hostelry. It's a genuine offer but be advised you're buying and I haven't had a decent pint of Adnams or Wherry for some months. You may or may not change your mind.

[Bob Viking]

Since you are in possession of all the facts could you please answer me a question.

What proof is there that AH suffered from oxygen desaturation whilst flying?

Is it a theory that he suffered a lack of oxygen to the brain whilst airborne or a medically proven fact?

Earlier I remember it was reported that he said he was not made aware, during his RAF service, of anti-G straining techniques.

This and several other things are where many of us take issue.

He was presented to the jury as a highly experienced pilot. Firstly, a highly experienced pilot of fast jet aircraft in the 21st century would be intimately aware of the effects of G.

Secondly, during his RAF service he completed roughly two flying tours before leaving to fly airliners.

We can surely agree that no matter how many airliner hours you get it will not improve your ability to fly low level fast jet aerobatics.

I would also suggest that someone who has completed two flying tours is not ‘highly experienced’. We all thought we were at that stage in our careers but to be honest what we all need at that stage is protecting from ourselves and our self perceived indestructibility.

If you now take that self professed flying expert and fast forward through 20 years of relative inactivity in the fast jet sense you do not have a recipe for perfection.

If you stuck me in an airliner for twenty years and then asked me to fly any single engine, swept wing fast jet trainer (similar to a Hawk) and asked me to fly displays in public I would not suggest that would be a great idea.

You are obviously a legal expert and I am not. AH’s defence team did what they were paid to do and won their case.

Surely, as a result of that legal defence the only morally correct outcome from this case is to put a complete stop to all displays of privately owned fast jet aircraft (and probably any aircraft capable of sustained high G).

All those that leapt to the defence of AH and his outstanding experience will need to accept that in doing so they may have brought an end to the thing they love so much.

I’m not suggesting they should have thrown him under the bus but the cat is now out of the bag and you’ll struggle to get it back in.

If I, as a currently serving fast jet pilot, am saying that I will not go anywhere near a display of such aircraft how would a discerning member of the public feel?

In summary, you say it annoys you that people question the outcome of the trial but you are more than happy to question the experience of many highly experienced people. People who have formed their opinions over many 1000’s of hours of flying fast jet aircraft.

We can all accept that AH was not criminally negligent. What we are struggling to accept is why he was displaying a Hunter on that fateful day.

BV

[beardy]

I don't think that the defence had to prove CI, just show that it was a possible explanation, sufficient for the jury to have reasonable doubt that the charges against AH were untrue. The burden of proof is for the prosecution to show that manslaughter and endangering an aircraft took place. The prosecution failed to show that convincingly to the jury.
This was an adversarial event not an inquiry. In my opinion AH did not win so much as the prosecution lost. I don't think that the prosecution could have shown that CI did not occur. He has been found not guilty of the specific charges brought against him. However, he has to live with the event and the deaths in which he was involved.

[Legalapproach]

Bob Viking

Beardy is correct.

There was no proof that AH was but it would be a difficult thing to prove anyway. The burden on the prosecution was to prove that AH was guilty of Gross Negligence Manslaughter. Once there was credible evidencethat he may have been suffering from CI then it was for the prosecution to disprove it.

Before people start saying that in future anybody could claim CI and the prosecution could never disprove it, that is rubbish. There would have to be some credible evidence to support such a claim either factual, medical or a combination thereof.

There was sufficient evidence to raise a credible case and not only did the evidence exist but the jury accepted it as credible and possible. The jury could have rejected the evidence if they so wished.

Regarding AH saying he was not made aware of anti-G straining during his training that was misreported. What he actually said was to the effect that when he went through training G training was not dealt with as formally and to the extent that it is now. That was an agreed position with the prosecution experts. The newspapers misreported it as him saying something along the lines of he didn't know anything about anti-G straining.
I am afraid there was a lot of misreporting in the press. As an example when I cross-examined one of the prosecution expert witnesses it was reported in the papers that my colleague had cross-examined that particular witness. On that particular day my colleague was not even in the country, he was in New York. I use that as a non-contentious example.

As to levels of experience, AH was a creamie and then Harrier pilot. The prosecution experts all considered him to be a highly experienced pilot. Those experts were themselves highly experienced ex military pilots



In summary, you say it annoys you that people question the outcome of the trial but you are more than happy to question the experience of many highly experienced people. People who have formed their opinions over many 1000’s of hours of flying fast jet aircraft.

But not a single minute in court listening to the evidence. A lot of those people have applied their experience to newspaper reports (which may have got it wrong), the AAIB report which did not look at all the evidence the jury did (it wouldn't be the first time the AAIB have got it wrong) or a video shown on the news that was but a part of the video evidence. I don't have a problem with people questioning the outcome of the trial I do have a problem with people doing so without knowing all or even a fraction of the true facts. In a professional capacity I am sometimes asked by friends about my views on the outcome of a particular case and my response would always be along the lines of "Well it does seem surprising but I didn't hear the evidence. Pilots v the jury? who is likely to be the better judge 3000hrs flying and maybe up to 10 hours reading what may or may not have been the evidence or 150 hrs seeing and hearing all of the evidence and then hearing argument from both sides.

I really don't want to open the floodgates but like my offer to Cat Techie I will happily sit down with you at some point, if you want, and try and explain what the evidence actually presented in court was.

[airsound]

Bob Viking, Beardy, Legalapproach

Not only is Beardy correct in the detail of what Legalapproach says, but he also makes a very good point when he says that AH has to live with the event and the deaths in which he was involved He does indeed, and that situation is not made easier by the fact that his own survival in such an accident was at the extreme end of unlikeliness.

airsound

[beardy]

Once there was credible evidence that he may have been suffering from CI then it was for the prosecution to disprove it.

This is I think the crux of the matter for many of us experienced pilots. I wasn't at the trial, I haven't seen nor have I read the evidence transcripts. But, I have difficulty reconciling that credible evidence, as reported from the court, with personal experience. It is those personal experiences that the jurors did not posses. Perhaps that is both a strength and weakness of trial by jury and adversarial trials.

[airsound]

Beardy you say I haven't seen nor have I read the evidence transcripts. But, I have difficulty reconciling that credible evidence, as reported from the court But the thing about what was reported from the court by national papers is that it was, by and large, misleading, or at least incomplete!

Much of the national press took their information from the prosecution's opening statement - which, by the way, the prosecution team had distributed beforehand to all and sundry in a 53-page document. So reporters could report it as if they'd actually heard it said in court.

Thereafter, for the rest of the eight week trial, the national press was often noticeable by its absence. So they mostly missed the defence's expert evidence that later persuaded the jury. I had occasion to point out this shortcoming to a senior broadsheet reporter later, but he was not interested.

airsound

[just another jocky]

As an experienced (20+ years, nearly 4000 hours) fast jet pilot, my instinct is with BV et al. I don't doubt the weight of evidence considered, and I have not read or seen it either, but watching the video time and again (at the time, I was a Hunter display pilot) , I struggle to understand anything other than he screwed up. Perhaps we could meet for that beer ( or 2 ).
His defence did their job, the prosecution lost the case.
All mho.

[beardy]

When I say reported from the court I wasn't referring exclusively to the main stream press. Many on this forum have helpfully summarised the defence submissions concerning CI. Like many on this forum who have read these summaries I still find it difficult to reconcile personal experience with the descriptions.

[Bob Viking]

It’d be fascinating to take you up on the offer but it’d be a very long way to come for a free beer. I suspect it would be somewhat of a net loss on my behalf.

BV

[Easy Street]

It’d be fascinating to take you up on the offer but it’d be a very long way to come for a free beer. I suspect it would be somewhat of a net loss on my behalf.

BV

It would definitely be a loss as he wasn’t proposing to buy the beer. In fact, the opposite!

[Bob Viking]

I clearly need to learn to read better. To be fair, I’ve had more than a couple tonight so it should come as no surprise that my comprehension is lacking somewhat.

BV

[Legalapproach]

For my part I am happy to travel pretty much any distance for free beer

[tarantonight]

As an experienced (20+ years, nearly 4000 hours) fast jet pilot, my instinct is with BV et al. I don't doubt the weight of evidence considered, and I have not read or seen it either, but watching the video time and again (at the time, I was a Hunter display pilot) , I struggle to understand anything other than he screwed up. Perhaps we could meet for that beer ( or 2 ).
His defence did their job, the prosecution lost the case.
All mho.

I speak in general terms, but with a tad of personal experience included.

A Crown Court Trial is a certain amount of Theatre. Facts are facts, but speculation and interpretation play a part.

I saw the footage of Shoreham like all of us, but I, or anybody else, will never know what happened in that cockpit. Clearly only one person does. Or does he?.

There are clearly a huge amount of FJ Pilots on here who have the experience and knowledge to watch the footage and come up with a rational explanation or view. At the same time, who can truly say that incapacitation did not play a part? A particular set of circumstances in a very short space of time could end in the inevitable, but unless the one person who knows (whatever the circumstances) tells all, the rest of us will never know.

My thoughts are that this subject will forever polarise.....................

TN (Sitting On a Fence)

[Chugalug2]

BV :-
All those that leapt to the defence of AH and his outstanding experience will need to accept that in doing so they may have brought an end to the thing they love so much.

Why? If no-one had 'leapt to his defence', if AH's defence had failed in its task and he had been found guilty, what difference would that make to subsequent events? Whether pilots are negligent or not, whether CI exists or not, Shoreham was an accident that had already found a place to happen. Much the same could be said of many other venues, possibly all. In which case what would bring an end to the thing so loved is this accident, whatever its cause. This was simply the time and place where all the holes lined up and with such tragic consequences, the least of which would be an end to high performance display flying.

[Cat Techie]

Legal approach, you are correct. I am well aware that the cornerstone of our legal system is that one is only guilty by trial, if the jury believes that it is beyond reasonable doubt. The person under trial did not take off from North Weald with any intention of hurting anybody. He was going to fly a display in an aircraft that he had PDA to display. There was no intent to commit a crime.

The CPS believed the case was strong enough to raise charges for a trial. Nobody has ever been tried for causing death by gross negligence by an aircraft crashing into people in the United Kingdom before. No surprising that the last time a death on the ground by a flying display crash was by John Derry aircraft exceeding its design limits (although didn’t the Vulcan crash at Syerston kill servicemen on the ground a year later?) The defence team did what they were paid to do. Defend their client. The prosecution should have seen any pitfalls in their case and covered all angles. They did not.

My first aero experience was in a Chipmunk at the age of 14. I can remember when G effects come into play from my first flight in a loop. I have done so since in a Tucano with the same effects and in an Extra 300 (that has been the most fun I have ever had sitting in an aircraft). I have had the privilege of FJ trips on my time on Jags included G pull ups to the maximum of 4.5G that as a Cat B passenger as the P1 was allowed to put me under (and dropping a 1000 pound dumb bomb in a dive attack and recovery, the loading is not short, it is several seconds and I could tell you as I was filming the attack at the time). Maximum effect of course was always at the bottom with Earths attraction, hardly anything at the top.

A lack of FDR information for an old war bird was always going to hinder the investigation for accurate information. It has been an issue with all military FJs for many years until recently. However, the radar information is accurate enough to tie to the video for the AAIB to track the flight path. There are enough ex and current Hunter pilots on here that have said the facts of the SOP for Hunter aeros. Errors were made from the start, before any extra forces to the body were applied.

The BCAR system he was operating under was so full of the swiss cheese holes compared to the military system that Bob and I worked under. That is also true as far as engineering was concerned as it is massively weaker than the commercial aviation sector I work in. Flying an aircraft with life limiting parts out of date does invalidate the insurance on the aircraft I maintain, and I have grounded aircraft when dates have been missed by others. That Hunter had seat carts that were outside of the OEM use by shelf and fitted life dates. The OEM defines safe life in my book, not an engineer that has never been in the process of design and certification to make that decision or define such. The Thunder City Lightning crash reinforces my view on such matters. That is of course not in the scope of the pilot to decide, bar he should be aware of the state of his aircraft from the tech log of his aeroplane and he carries the responsibility of anything after he has signed the acceptance document. I could be totally wrong of course if BCAR section A states otherwise, however my understanding is that any PtF ex military aircraft should use similar recording documentation to when it was in service. A Form 700 with the F705 / F725 sector recording forms as a base line. It should have (if not computer controlled as commercial operators have to as a minimum) a forecast of maintenance dates and life limiting parts. A failure of the CAA regulations or the CAMO for the airframe? The pilot signing for an aeroplane should perhaps asked the question, where was the information? End of the day, was that aircraft within the policy of its insurance to fly? I doubt the insurers will argue that.

I am aware of how commercial pilots operate their aircraft. They must be dynamic and also passive as too much dynamics is bad for the self-loading freight. “Autopilot Inoperative” is almost at no go for the airlines I have worked for. It is almost a last resort to release the aircraft with AP/YD inop. Most Captains will not take such an aircraft will that system deferred from use. Soon as V2 is called, positive rate of climb and gear is retracted, the AP is selected. It will not be deactivated until landing depending on the CAT state of the aircraft and Decision Height. The joke that 1000 airliner hours is worth 1 hour of Fast Jet time, certainly for the old school does have a grain of truth. Currency for an RAF pilot PDA is not measured in months, it is measure in having currency in days.

End of the day, 11 people died on a Saturday afternoon due to a person that was controlling a vehicle hitting them. The inquest with the evidence will decide if it was accidental, open, misadventure or unlawful. It will be legal with no jury so up to the presiding coroner to judge the evidence. I assume depending on the result will be if civil actions may be taken. I heard that the aircraft owners’ insurers had admitted liability ages ago but have no idea if they had settled out of court with the affected. None of my business to enquire further.

I was down at NW last year, chatting to a civil FJ owner about things and Shoreham came up. He was damming about AH and that day, the unprofessionalism of the flying. Entry and gate heights and the lack of recognition to bail out of the sequence as it was going pear shaped. That was from PPL jet flyer. I didn’t disagree. If I killed someone on the road by not driving my car correctly, I doubt cognitive impairment would be believed by any Jury trying me. Just my opinion.

[megan]

John Derry aircraft exceeding its design limitsI hope you are not inferring that Derry knowingly exceeded limits, from what I understand the issue was design flaw in the wings leading edge D section. The coroner's jury recorded that Derry and Richards had "died accidentally in the normal course of their duty", and that "the deaths of the spectators were accidental", adding that "no blame is attached to Mr. John Derry".

[Haraka]

There was talk in the Industry post the Derry accident about redux bonding, bonding and bolting, variations on the prototypes being involved in the failure. IIRC I'm not qualified to comment ,ust overhearing this later, Perhaps somebody might amplify ?.

[longer ron]

ISTR there was no proper 'D' box structure/nose ribs for the DH110 leading edge, built to the same basic design used on vampire/venom.
Obviously it was redesigned for the Sea Vixen.

[POBJOY]

Indirectly the 'system' was on trial in this case and therefore by only charging the pilot (who was rightly cleared of the charge) it effectively closed the book and did not expose the real gaps that existed. Remember this was an 'authorised' display not an ad hoc event, and therefore as such should have been subject to compliance with the then rules governing the day.
The fact that the DA was deficient, and that the final back stop (the ability to stop the display if required) was not implemented, are in my mind the most significant factors which allowed this accident to happen. Both these situations were present BEFORE the actual failed manoeuvre took place, and in the case of the STOP call the obvious failure in this not happening when the display machine was well below its initial height at the display start was again BEFORE any G induced element was possible. On the day not only did the pilot fail to observe the requirements, and safe practice, but the system in place to act as the overall regulator failed in equal terms to do its job. Whether this is relevant to an inquest I am unsure, but it was relevant to the event on the day and therefore in my mind should be part of the decision process to give a proper picture of what went wrong.

[Finningley Boy]

I heard at the time (but am not sure) that Andy Hill had his DA for the more powerfully engine Hunter FGA9, not the T7 which he flew? I recall it reported at the time that he stood in at short notice for the intended display pilot?

FB

[KarlADrage]

I heard at the time (but am not sure) that Andy Hill had his DA for the more powerfully engine Hunter FGA9, not the T7 which he flew? I recall it reported at the time that he stood in at short notice for the intended display pilot?

FB
DAs are not type specific, let alone sub-type specific. They are category specific, however.

[Easy Street]

DAs are not type specific, let alone sub-type specific. They are category specific, however.

A good example of the disparity in rigour between military and civil display regulation.

[Treble one]

Just as a matter of interest, did anyone ask in court when this CI started?

Was it when he did the preflight checks? After he took off? When he was running in? When he was too low and slow into the accident manoeuvre? When he was too low at his gate height and didn't act? When he didn't attempt an escape maneouvre.....I don't know.

When was it?

[LOMCEVAK]

DAs are not type specific, let alone sub-type specific. They are category specific, however.
I am afraid that, as a DAE with Category G on my approval, I must correct you. In Category G (single engine jets) DAs are type specific. Therefore, AH would have had a DA for 'Cat G (Hunter)'. They do not differentiate between different Marks of a given type. DAE approvals are by Category only and not by type. Please note that since this accident Cat G has been further subdivided into G1 and G2 for straight wing and swept wing single engine jets although this makes no practical difference to the award of a DA but it does with respect to currency..

The difference in maximum thrust available between Hunters with Avon 200 series engines (F(GA)9, F58 etc) and those with Avon 100 series engines (eg. T7) makes no real difference to how you fly a display. I have practised in a T7 for a F(GA)9 display without any changes to how I flew, other than considerations for the reduced external view to the right due to the cockpit and canopy shape. A manoeuvre flown in a 200 engine Mark at full throttle should be capable of being flown in exactly the same way and from the same airspeed in an aircraft with a 100 series engine. If it cannot then, in my opinion, insufficient safety margin has been allowed.

[KarlADrage]

Apologies for the duff info, Lomcevak. Is Cat G the only one which that applies to? I'd always been led to believe that DAs were not type specific.

[LOMCEVAK]

No Problems. CAP1724 Chapter 9 gives the details of the Categories and Groups. However, some categories are also annotated by type and this table could be misleading! I will try to find where in this CAP it states that.
Rgds L

[DODGYOLDFART]

Just as a matter of interest, did anyone ask in court when this CI started?

Was it when he did the preflight checks? After he took off? When he was running in? When he was too low and slow into the accident manoeuvre? When he was too low at his gate height and didn't act? When he didn't attempt an escape maneouvre.....I don't know.

When was it?

I would be surprised if many contributors to this thread are not yearning to get answers to your questions. We can only hope that the Coroner is similarly minded!

[Cat Techie]

I hope you are not inferring that Derry knowingly exceeded limits, from what I understand the issue was design flaw in the wings leading edge D section. The coroner's jury recorded that Derry and Richards had "died accidentally in the normal course of their duty", and that "the deaths of the spectators were accidental", adding that "no blame is attached to Mr. John Derry".

Badly worded, Megan. I remember vaguely reading a report on the accident that on a previous Mach One pass, it was noticed that some structural deformation was apparent. It was mentioned by his observer. Of course Derry didn't know his aircraft was going to disintegrate. Nor did the design team. Life was cheaper then. Joe Bloggs was a nobody and claims direct didn't exist.

[lsh]

Does the fact that the display was started using a "bent loop" manoeuvre indicate that the venue was unsuitable?

lsh

[airsound]

Cat Techie
Errors were made from the start, before any extra forces to the body were applied.
Errors were undoubtedly made - but not from the start. They seemed to have started at a point a few minutes into the display that came to be known as Point X.

Once again, you need to have been present in court to know that sort of thing. Except that, for this particular set of evidence, there was a very good local press report by Michael Drummond of the Shoreham Herald. His report ties in with my own contemporaneous notes. It refers to the evidence of Dr Steve Jarvis, a well respected aviation human performance/safety specialist. Dr Jarvis was a defence expert witness, but his credentials had been confirmed by Wg Cdr Nicholas Green, an RAF Av Med consultant, who was an expert witness for the prosecution

Dr Jarvis listed between eight and twelve inexplicable and unconnected errors made by AH. They all occurred in a period of 22-23 seconds. He said that the chances of so many independent errors occurring like that were very remote.
https://www.shorehamherald.co.uk/news/crime/these-12-errors-by-shoreham-airshow-pilot-andy-hill-show-he-was-cognitively-impaired-expert-says-1-8824257

Incidentally, this also goes some way to answering Treble one’s question
Just as a matter of interest, did anyone ask in court when this CI started?

And if you want to deduce when Point X was, I suggest you look at Fig 11 of the AAIB report, and correlate it with Dr Jarvis’ trial evidence.

airsound

[Bob Viking]

I know you know a lot more about the trial than I do so I have another question.

Were any of AH’s previous Hunter sorties examined in so much detail?

Is it possible that all the inexplicable errors on the accident sortie were actually the actions of an inexperienced and ‘maxed out’ pilot? Is it possible he had made similar mistakes before that were never caught?

I’m not here to put AH on trial again but, since you are in a position to answer questions, I thought you might help to assuage some of our concerns.

BV

[Easy Street]

Dr Jarvis listed between eight and twelve inexplicable and unconnected errors made by AH. They all occurred in a period of 22-23 seconds. He said that the chances of so many independent errors occurring like that were very remote.

This is the particular piece of evidence that I and many other FJ pilots have a very great deal of difficulty in accepting. The sequence of errors is absolutely characteristic of someone who has gone off ‘the plan’, inadvertently or by design, and is devoting an increasing proportion of their mental capacity to getting back on ‘the plan’. All the time this is going on they are at increased risk of making further errors, some directly related and some not. This is not even something you need to be especially experienced to recognise: a first tourist ‘creamie’ QFI is expected to be able to diagnose it. It is just the sort of thing that happens (frequently) to student pilots - fortunately with the large safety margins applied to such flying. It’s also quite common in air combat, in which it can often readily be discerned from the other aircraft. Throttle mishandling (one of AH’s apparently ‘unlinked’ errors) is not unusual when struggling for capacity with attention mostly focussed outside the cockpit. Ask any Tornado back-seater how many times they had to chivvy their pilot to put the wings or manoeuvre flaps in a more suitable position while “dogfighting” ;) - it is just these sort of things that get missed under stress by pilots of all experience levels. For a more accessible example, anyone who has taken music lessons will know how the tiny mental distraction created by one error can sometimes set off a chain of further random errors that ends with your learned routine breaking down entirely - that’s how I experienced it in cockpit, and as professional musicians do, you learn to recognise the mental signs and do something about it. But importantly you never become immune to it.

In the latter regard I struggled hugely with Dr Jarvis’s reference to AH’s level of experience as making such a sequence of errors a “very remote“ possibility. Setting aside the question of how much of his experience was relevant, it seemed to me to fly in the face of 40 years’-worth of progress in HF which has largely succeeded in persuading senior airline captains, 4000hr QWIs and consultant surgeons that they are far from infallible. If such individuals make fewer such sequences of errors it’s mainly because they’ve learned how to stop the initial (inevitable) error from cascading. There’s the rub: that a pilot as supposedly experienced as AH continued the display for so long while off ‘the plan’ is something that might easily have seen him convicted had Dr Jarvis’s “very remote” assessment been more effectively challenged to reduce the weight it lent the CI argument.

I accept that the case is done and AH has been given the benefit of the doubt to which he is entitled. But I am very interested to see how these matters will be handled at the inquest, by HF research and teaching and ultimately by regulatory systems in years to come.

[airsound]

Bob VikingWere any of AH’s previous Hunter sorties examined in so much detail?Yes. Three or four Hunter displays were shown in court, from a combination of internal and external videos. None of the errors was present in any of the displays.

airsound

[Bob Viking]

Thanks for your reply. I suppose it was inevitable they would have looked at previous sorties.

I need to be careful I don’t sound like a stuck record (I’m sure I do already).

You’re absolutely correct that, having not been at the trial, I am not in possession of all the facts. I still cannot believe however that one bad sortie out of 4 or 5 from an ‘experienced’ pilot is definitive evidence of a medical event.

We’ve all had bad days in the cockpit. I would say, circumstantially, that those bad days are/were more prevalent during our earlier days on a particular type.

I would argue that few, if any, of those bad days could be attributed to an instance of oxygen starvation induced CI. But then, who knows? I’m not a doctor.

BV

[RetiredBA/BY]

A manoeuvre flown in a 200 engine Mark at full throttle should be capable of being flown in exactly the same way and from the same airspeed in an aircraft with a 100 series engine. If it cannot then, in my opinion, insufficient safety margin has been allowed.
Are you really saying that a jet being flown with 10,000 pounds of thrust, at full throttle, can be duplicated by a near identical aircraft using only its max thrust of 7,500 pounds of thrust. Example : pulling up for a loop at say 350 knots and 4 g.with 10 k of thrust will certainly not produce the same speed and dimensions when using only 7.5 k of thrust.

I have never flown a Hunter but the JP3 and 4 had similar thrust variations, 1750 and 2,500 pounds, simply no comparison, particularly in vertical manoeuvres. I find what you say hard to believe.. Perhaps you could explain and at least satisfy my curiosity.

[Big Pistons Forever]

As I understand it before he started the maneuver he was well below the minimum height above ground specified in his authorization and in level 1G un-accelerated flight. How was this not a conscious choice made by the pilot ?

[LOMCEVAK]

Are you really saying that a jet being flown with 10,000 pounds of thrust, at full throttle, can be duplicated by a near identical aircraft using only its max thrust of 7,500 pounds of thrust. Example : pulling up for a loop at say 350 knots and 4 g.with 10 k of thrust will certainly not produce the same speed and dimensions when using only 7.5 k of thrust.

I have never flown a Hunter but the JP3 and 4 had similar thrust variations, 1750 and 2,500 pounds, simply no comparison, particularly in vertical manoeuvres. I find what you say hard to believe.. Perhaps you could explain and at least satisfy my curiosity.

For low level looping manoeuvres in a Hunter I entered with sufficient speed and used maximum thrust to exceed the gate height by a comfortable margin and to apex at a mid range speed. If I then flew a version with less thrust available I could either pull the same g and have a slightly lower apex height and lower apex airspeed or I could slacken the pull in the second quarter and make the same apex height with another airspeed reduction. Theoretically, I could enter with the higher thrust version at a lower IAS than I did and make a lower apex height and airspeed, and if I attempted the same pull up profile in a lower powered version the apex height and airspeed could be marginal for safety or even fail to make the Gate Height. However, I never entered loops in a Hunter with so little safety margin with respect to pull up airspeed or thrust; perhaps others did. The only exception to this was that for an upward half loop I was prepared to enter 20 KIAS slower in a large engine version than in a small engine one although with that amount of thrust I never really had to unless the cloudbase was marginal such that I needed an absolute minimum apex height.

With respect to pull-up heights, you can pull up for a loop from the flypast minima on your DA and AH was not below this although air display permissions will restrict the area where you can come below the SERA 500 ft minima. Obviously, if you pull up lower you need more speed to make the same apex height and airspeed.

The videos shown in court of other displays and practises by AH did not, as airsound has said, show any of the critical errors that occurred in the Shoreham accident display. However, they did show errors such as inadvertent airbrake out in the upward half of a loop, infringing display lines etc. As BV has said, we all make mistakes so everything needs to be put into context and in the case of this accident that is very complicated, and simple conclusions relating to potential CI on the accident display cannot, in my opinion, be made based upon the other videos.

The errors listed by Steve Jarvis also need to put into context. Some were errors of judgement such as the pull-up point for the manoeuvre, the angle rolled through etc. Again, these are errors that are easy to make in a display depending on the visual cues available to the pilot. Therefore, whilst there most certainly were some totally inexplicable errors made during this manoeuvre, some can be explained as known HF issues associated with display flying.

One aspect that has been commented upon very little is training related to displaying a Hunter. At the time of the accident CAP403 referred to training for 'escape manoeuvres' only as a ground training 'emergency' item. There was no requirement for a pilot to practise them during training for the award of a DA on a specific type or in a specific category, and no requirement to demonstrate proficiency in them as a requirement for the award of a DA. Unless specific training has been given regarding rolling a swept wing jet at low airspeed and then such a manoeuvre practised a pilot almost certainly would lack confidence in flying a rolling escape manoeuvre in a Hunter at 105 KIAS and, therefore, may be reluctant to do so. The AAIB report indicates clearly that a Hunter in the display configuration flown at Shoreham can be rolled safely at 80 KIAS so flying an escape manoeuvre at Shoreham was totally feasible. The report also indicates that it was possible to extend at least 4 seconds past the apex with a maximum instantaneous performance pull and then still perform a safe rolling escape manoeuvre.

With respect to Gate Heights and the requirement to respect them in looping a swept wing aircraft such as the Hunter, another essential aspect of initial display training for someone whose display experience is mainly on light aeroplanes for which a Gate Height protocol is not applicable for simple looping manoeuvres is to really emphasise this additional requirement and not to use established habit patterns from previous types.

Nothing that I have said above is new with respect to this tragic accident. However, I felt that, perhaps, it was worth refreshing upon some aspects.

Rgds
L

[CAEBr]

. Three or four Hunter displays were shown in court, from a combination of internal and external videos. None of the errors was present in any of the displays.

airsound

I'm not a medical expert, but does this not suggest therefore that that particular display routine / aircraft physiological regime was not severe enough to cause AH an issue - under normal circumstances. Therefore, the issue is what made the Shoreham display different? Was it that AH's physiological tolerance was lower for reason or reasons unidentified or was it just a bad day in the office?

[POBJOY]

Surely the main focus of this dreadful incident is who is going to present the evidence of events ' leading' to it for the coroner to assess.

The scenario was indeed avoidable had even the basic rules of both display authorisation, and the display on the day oversight been implemented,

The regulations were in place to prevent such incidents,and yet it appears little attention has been given to their significance.and indeed their failure to prevent the situation on the day.

The actual Display authorisation appears to have been somewhat lacking in its remit, and this was then compounded by the lack of the actual display oversight which failed to alert and indeed stop the proceedings when the basic criteria fell below the requirements. All this took place before the claimed G induced situation and was therefore very relevant to the outcome. The whole point of DA's and a proper visual check on the day is to protect both the public and pilots from such a scenario 'developing' , and is very important where you have a high energy machine operating in a somewhat 'confined' display arena. This thread has well discussed the actual event, and the various 'issues' that occurred, however the coroner may well find that the 'system' itself was lacking in this case, and therefore a better understanding of the situation may arise.

[Caramba]

I am very aware that I am a guest in this Mess, and have only ever had a single flight in a JP (tho regularly fly light aircraft). I have however been an expert witness and was very aware that I had a duty to do the job properly.

It seems that much of the reportage of this trial was lacking in veracity but nevertheless accepted and as such forms the basis of strongly expressed opinion.

So - Lomcevak, Airsound, Legalapproach: “The videos shown in court of other displays and practises by AH did not, as airsound has said, show any of the critical errors that occurred in the Shoreham accident display. However, they did show errors such as inadvertent airbrake out in the upward half of a loop, infringing display lines etc.“

Was it not the case that the suggestion that AH had infringed display lines part of the prosecution’s attempt to characterise AH as cavalier in his approach to flight and display safety? But that the allegations regarding display lines were refuted in court and that the prosecution and one of the expert prosecution witnesses (JW) exposed as not having done their homework properly?

I ask only as a seeker after truth.

Caramba

[Legalapproach]

Caramba - yes

A prosecution expert witness had not researched the permissions properly and in any event, with the exception of the JP incident at Southport, the criticisms related to notional crown lines during practice displays. There were a number of criticisms leveled by the prosecution nearly all of which ended up being binned. In a way it was a shame that many were ditched at an early stage as we had a some interesting video's of the one of the prosecution experts not necessarily adhering to the rules he was using to criticise AH. Showing them would have made for some uncomfortable moments in the witness box.

[airsound]

Before I make any more responses, I would like to reiterate that I am not an FJ pilot, and I am not questioning the undoubted experience levels of several posters here. What I am trying to do is to make sure that the trial evidence that led to AH’s being acquitted is clearly known about and understood.

Easy StreetThe sequence of errors is absolutely characteristic of someone who has gone off ‘the plan’, inadvertently or by design, and is devoting an increasing proportion of their mental capacity to getting back on ‘the plan’
Dr Jarvis made the point that, in his wide experience of studying errors by pilots, he’s usually able to discern a reason, or reasons, for them. And that there’s often an initial error that then leads to a series of others - but in such a case they are all linked. In the 23-odd seconds of the errors by AH, he couldn’t find any relationship between the errors. He went on to say that the statistical likelihood of such a series of events was very low, making this a very rare event for which he could find no explanation other than some kind of cognitive impairment.

ES, you also mentioned in passing that ‘going off the plan’ isnot even something you need to be especially experienced to recognise: a first tourist ‘creamie’ QFI is expected to be able to diagnose it
Coincidentally, AH was himself a ‘creamie’ QFI before going to Harriers.

You also mention, about very experienced pilotsIf such individuals make fewer such sequences of errors it’s mainly because they’ve learned how to stop the initial (inevitable) error from cascading.But the point was made in court that the start of the sequence of errors was not in a particularly high workload part of the flight - one of those had just been successfully completed.

Bob VikingI still cannot believe however that one bad sortie out of 4 or 5 from an ‘experienced’ pilot is definitive evidence of a medical event……[and] few, if any, of those bad days could be attributed to an instance of oxygen starvation induced CIThe defence case was one of ‘cognitive impairment’. A medical event was only one possible cause of that. And oxygen-starved CI was also a ‘may be’.

*****

One interesting aspect of the case was that the prosecution, faced with the convincing evidence of Dr Jarvis, chose not to engage a ‘Human Factors’ expert to challenge him.

airsound

[Treble one]

Thank you Airsound

I'm not a FJ pilot, but I'm a scientist, and I look at things based on evidence and probability. The thing I have most difficulty with here is that I am being asked to believe that all of these things went wrong in 20 seconds or so, caused by an effect no one can fully explain, or indeed prove happened, that 'came on' at exactly the wrong time, when there was no evidence of it ever happening in the individual before, or at any time before the tragic manoeuvre in this flight. That's a very unlucky lining up of holes in a lot of cheese. My antennae are twitching. Because the flying in the accident manoeuvre could also be explained by the actions of an inexperienced pilot on type, who simply got it wrong?

Sorry, that's the scientist in me kicking in. When I hear the clip clop of hooves on the road, I think horses, not zebras.

[Chugalug2]

Sorry, that's the scientist in me kicking in. When I hear the clip clop of hooves on the road, I think horses, not zebras.
Or maybe Coconut shells? I realise that this thread is about the trial and its outcome, but isn't it about time that dissatisfaction with the verdict by some gave way to a more general concern about the overall state of the managing of public display flying in the UK? Many here want to vent their spleen on AH and/or CI because they see them as presaging a crackdown on future display flying (if indeed there be any at all). I agree that a crackdown is likely and may well be called for by the Coroner. May I suggest that many here would have been aware of the organisational shortcomings that have emerged from this tragedy but pre-existed for years beforehand. It is those shortcomings that paved the way to Shoreham and to its tragic outcome. There was gross systemic failure here and like other gross systemic failures revealed within this forum nothing was done to cure it, thus leading to yet more needless death.

[POBJOY]

There was gross systemic failure here and like other gross systemic failures revealed within this forum nothing was done to cure it, thus leading to yet more needless death.
Well Chug I for one think this is the real problem, and the limited scope of the legal charge that focused only on one person has certainly obscured the 'big picture'.
However does the proposed coroners input allow a wider view of this situation, and can it begin to give the relatives of those involved some indication of how AH was not the only one involved. As I have prev alluded, the display authorisation system was intended to give a greater element of safety control to the display world, was not too onerous to comply with, and not unreasonable in the context that in the norm pilots had to 'perform' in the aircraft of intended display, and demonstrate the manoeuvres intended. To a degree this became even more important as ex military jets came on the scene where pilots may not have the tot time or 'regular' flying on type to be as current compared to what would have been normal when in mil service. When you add display locations that are not 'fast jet friendly' in the case of an emergency landing or ' space' the DA system becomes even more important as especially with the added potential input of a display director*. This position* was not unknown in the display world before the actual formal DA system was instituted, and I well remember the classic Biggin Hill Air Fair events that were basically 'self governing' to a large degree but contained a high degree of oversight by a designated person. Needless to say certain 'jet teams' (not the Reds ) were not always totally compliant with the UK normal accepted rules and I well remember one year when the crowd got well and truly 'Dyed' after a rather low and close run by a certain team although I do not recall any complaints.** Sadly the display world 'as was' will never return in the UK despite it having a very reasonable safety record, and I feel that this is due to the 'System' failing in its duty rather than just an individual getting it wrong on the day. The question is will this be part of a coroners remit !!
** It was not repeated the next day so no doubt words were spoken that evening at the rather splendid party. (this system worked well)

[airsound]

PobjoyThe question is will this be part of a coroners remit !!Well, we (and the families) will have about 14 months to wait to find out. But actually, as far as the aviation world, and particularly the air show world, is concerned, the primary safety follow-ups from the accident are surely the AAIB and the CAA. Did the AAIB’s recommendations address your concerns? And the CAA follow up? Which AAIB recommendations might prevent another Shoreham?

airsound

[Chugalug2]

Pobjoy :-

The question is will this be part of a coroners remit !!

Coroners are very individual as to what they see as their 'remit'. Some see it as not making waves, a theme that runs through the British Establishment like a stick of rock. Others see themselves as duty bound to finding out the real reasons why those who are the subject of their investigations died in such a violent way. The Oxford Coroner was very much of the latter persuasion and, though representing an 800 year old institution, had no hesitation in telling one yet to score its first century that there was something wrong with its bloody aircraft, ie that they were unairworthy! As airsound wisely comments we shall just have to wait to find out in this case which 'interested parties' are called to give their evidence and what use is then made of that evidence, but I hope that it is rather more comprehensive than the two organisations he instances and who have so far given us their tuppence-worth.

Meanwhile here is what the Coroners Service says of itself :-

https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/859076/guide-to-coroner-services-bereaved-people-jan-2020.pdf

[POBJOY]

[QUOTE=airsound;10830517]PobjoyWell, we (and the families) will have about 14 months to wait to find out. But actually, as far as the aviation world, and particularly the air show world, is concerned, the primary safety follow-ups from the accident are surely the AAIB and the CAA. Did the AAIB’s recommendations address your concerns? And the CAA follow up? Which AAIB recommendations might prevent another Shoreham?

As i see it the AAIB reported on facts and evidence,and the CAA are part of the 'system' under scrutiny. If we cut through all the 'legal fencing' the one stark fact that sticks out is that the 'primary' cause of the accident was starting a vertical/rolling manoeuvre too low and slow on what was a hot day. The fact that no attempt was made to exit this situation only compounded what was already a poor decision made before any G induced factors were present. The display organisers were empowered to comment on this as part of the standard safety procedure and even if they had no speed readout available the low height was 'observable'. Stones and glasshouses now comes to mind as we all know one of the factors associated with airshows is (no one wants to break off a display),and that is the 'dangerous' part of the scenario, and why there was a system to prevent it. It so happens that i have just re read an excellent book by a former Hunter pilot who only flew the T7 after he finished the Chivenor course.He makes the point that the 'climb' performance of the T7 was considerably less than the single seat version in use at the same time. !!!

[Background Noise]

The display organisers were empowered to comment on this as part of the standard safety procedure and even if they had no speed readout available the low height was 'observable'.

Can we just put to bed the fallacy that he was 'too low' entering the manoeuvre. This was, and still is, perfectly acceptable. It was explained again by LOMCEVAK and is common practice in both civ and mil displays.

With respect to pull-up heights, you can pull up for a loop from the flypast minima on your DA and AH was not below this although air display permissions will restrict the area where you can come below the SERA 500 ft minima. Obviously, if you pull up lower you need more speed to make the same apex height and airspeed.

[LOMCEVAK]

It so happens that i have just re read an excellent book by a former Hunter pilot who only flew the T7 after he finished the Chivenor course.He makes the point that the 'climb' performance of the T7 was considerably less than the single seat version in use at the same time. !!!

You have put 'climb' in inverted commas so it is not clear to precisely what you are referring. But, with respect to T7 performance at the density altitude and mass that G-BXFI had at pull up at Shoreham, an entry at 350 KIAS with full power gives an apex height and airspeed that both are significantly greater than the minima required to complete the second half of a loop safely. The fact that a big engine single seat version has more thrust and so, for the same entry conditions, will apex higher and faster is totally irrelevant. If full T7 power is maintained throughout a looping manoeuvre entered at 350 KIAS at the accident atmospheric and mass conditions and the exit height is the same as entry height then the exit airspeed will be greater than that at entry ie. the aircraft will have gained energy overall. Therefore, as stated in the AAIB report, a Hunter T7 can fly a bent loop perfectly safely if it is entered at 350 KIAS with full power.

[sittingstress]

As a non-flying type please can the term "CI" in the context of this thread be explained to me.

Sorry for the interruption.

[AndoniP]

As a non-flying type please can the term "CI" in the context of this thread be explained to me.

Sorry for the interruption.

Cognitive Impairment. Basically something the defence put forward as the reason for the crash that the prosecution couldn't disprove. Hadn't happened to him before though.

[Bravo Alpha One]

This dreadfuI event puzzles and disturbs me. I cannot claim any expertise in fast jet aerobatics, but I have had experiences that I wonder might be relevant.
Naturally, experienced pilots speculate that if the accident pilot had become impaired it may have been due to G, or to some sort of oxygen deprivation. However, if I have read things correctly the fatal manoeuvre went wrong right rom the start, way before the onset of G.
There is something else that can do that; a Transient Ischaemic Attack (TIA) - (https://www.nhs.uk/conditions/transient-ischaemic-attack-tia/). This often referred to as a mini-stroke. A TIA is caused by a very small blood clot blocking a small artery in the brain causing various symptoms similar to stroke; the clot then dissolves (if you're lucky) to leave no trace.
I have seen three people suffer from this, their main symptom was confusion and the only one that was actually diagnosed at the time was a friend who crashed his car. He said he had no idea what had happened, he was totally confused, and so investigations were commenced soon after the event thus revealed the cause.

[RetiredBA/BY]

That is a very sound suggestion.

23 years ago I lost my licence after suffering what was initially diagnosed In hospital as a TIA, although the immediate thoughts of my wife, a nurse, and my sister, a doctor, was that I had suffered a mini stroke.,

In fact, after extensive diagnoses it was ascribed to Transient Global Amnesia, part of my brain, the left temporal lobe dealing with memory, had simply shut down. I woke up, became normally aware, in hospital about 12 hours after the onset having no recollection of the hours between onset but full memory of all before that. Although CAA removed my licence, an ATPL as I was a 75/76 captain at the time, as the risk of recurrence was considered unacceptable, I was eventually granted a PPL and gliding instructor’s certificate. Little is known about TGA because it us a rare occurrence and not considered life threatening unless you are a pilot, surgeon or train driver, I was told by my distinguished neurologist !

So, based on personal experience I would suggest TIA or TGA, (was anyone in the AAIB even aware of its existence ?) and about which I learned a lot is far more likely, in my opinion based on that experience, than cognitive impairment, something I never heard of in my entire flying career.

Perhaps the fact that little is known or understood about TGA is one reason its possibility was not raised in the investigation. I dont think the possibility could be discounted., but the likely remaining evidence of TGA can be a slightly abnormal EEG trace.

[Caramba]

Cognitive Impairment. Basically something the defence put forward as the reason for the crash that the prosecution couldn't disprove. Hadn't happened to him before though.

That is a rather cynical view, if I may say. Cognitive impairment is a well known condition (Look it up - Google will suffice) and the only wrinkle here is that of the context in which it is being used. Several contributors here seem strongly of the opinion that it doesn’t exist, is irrelevant. Consider it possible that you may be mistaken. The brain is intensely metabolically active, needing both oxygen and glucose, which arrive via various arteries. Any diminution in blood flow will have some effect - the problem is measuring the effect whilst manoeuvring in flight. But consider the combination of “low level” G, and abnormal head position as a consequence of opto kinetic cervical reflex (which is also now recognised as existing). It is well know that tilt or rotation of the head can cause impingement of various bits of cervical vertebrae on carotid or vertebral arteries. There is a clever Finnish study which demonstrated a 30% reduction in cerebral blood flow after manoeuvres at 5G in a Hawk, despite g-suits, straining. So it is quite feasible that some low level G, abnormal head position, a hot day, all conspire to produce a brain that is temporarily impaired. The phenomenon needs proper study, and not to be dismissed without consideration.
As for expert opinion - when I was a medical student, surgeons did all sorts of clever operations to reduce the acid secretion that led to ulcers. Now we know the ulcers are caused by an infection and treat it with antibiotics. All that expert opinion was just wrong.

Caramba

[megan]

Diagnosis, with due deference to RetiredBA/BY experience, Transient Global Amnesia equals Cognitive Impairment. I'd imagine difficult to prove post event.

[Bob Viking]

The issue that many posters have, myself included, is not just about whether or not some form of CI took place.

Our concern is more about how AH was adjudged to have been so experienced an aviator that only an incident of CI could explain his poor flying in the lead up to the crash.

As many of us have pointed out, 40 hours on type in 5 years and a FJ experience base of 1500 (ish) hours from twenty years previously (plus a few JP hours in the intervening period - which by the way had been proven to apex at a very similar height to the accident sortie) does not, in the opinion of many current and former FJ operators, make an experienced pilot. Not in terms of flying low level aerobatics in a FJ anyway.

I know I keep banging the same drum but I have checked my logbook and I have accrued 40 hours Hawk in the last 6 weeks and I still wouldn’t fly low level aerobatics. I think an experienced aviator should be able to recognise their own weaknesses.

The fact that flying hours in privately owned jets are a precious commodity should not dictate the amount of practice a pilot gets. My view would be that if you can’t afford it, don’t do it. Even if your business model relies on display fees.

The presence of CI on the day is effectively conjecture (though it is of course a potential explanation) and rests on the assertion that there could be no other explanation for the mistakes made. Many of us believe that lack of experience, currency and recency (on type) could be just as likely an explanation.

Our views, though, are obviously irrelevant to the outcome of the court case since the CI defence won the day.

BV

[Just This Once...]

Agree with BV.

[Caramba]

BV, I totally accept that - to use a cycling analogy - I am merely an enthusiastic amateur whereas as you and many others here are Bradley Wiggins.

However, there have been many comments dismissing CI as a possible cause of the tragedy. My point is that it warrants proper investigation, not least because it might provide an explanation for previous apparently inexplicable accidents that have claimed the lives of highly experienced and capable aviators.

To use and extend Treble One’s analogy, if I heard clip clopping outside, I might surmise it it was a horse (common around here), but really all I know is that it sounds like a large ungulate - but if I wanted to be sure I’d have to go and look.

Caramba

[EXFIN]

I am also inclined to agree with BV. Additionally, with the JP at Southport and the ‘stop’ call, would this be down to CI?

[POBJOY]

I find the 'clip clop' syndrome very interesting but if I lived in a tower block it would also be highly questionable.
I trust that the coroners search for an answer will be able to be understood by the relatives, and rather more in line with the evidence as described in the AAIB report.
I feel that the case as tried was going to be difficult to prove, and did not actually deal with the issues that most people feel existed.
It was wrong to lay the blame on one person when in fact the failure was much wider, and the case as tried rather closed the book on the larger picture.

[Hot 'n' High]

.................................

The presence of CI on the day is effectively conjecture (though it is of course a potential explanation) and rests on the assertion that there could be no other explanation for the mistakes made. Many of us believe that lack of experience, currency and recency (on type) could be just as likely an explanation.

Our views, though, are obviously irrelevant to the outcome of the court case since the CI defence won the day.

BVAgreed BV - and Pobjoy as you've just posted above! I do find it faintly amusing reading all the arguments re the finding of the Court Case and what people believe may (or may not) have actually happened. IMHO, we’ll never square this one off as no-one, maybe not even AH, knows what happened and why. Just because a Court decides that, on the balance of probability, something happened in a certain way actually has no bearing at all on whether it actually happened or not in that way.

Over the years, my view of the so called UK “legal system” has become very cynical – it’s all ultimately a game, played by highly paid legal buffs at all levels (my apologies to Legalapproach - and other “legal-beagle” PPRuNers – I’ll assume you are all exceptions!!), many of whom talk utter rubbish but talk such rubbish with such conviction that, if you didn’t know otherwise, you’d believe them (again, apologies to Legalapproach et al – who will now be building effigies of H ‘n’ H no doubt ……. it will explain the stabbing pains I will shortly experience!! :uhoh:). Actually, the deriving of the truth of any matter is often impossible – it’s all down to who argues the best.

I once gave evidence at a hearing which, subsequently, went to appeal and so the decision was struck off on a legal technicality. The appeal was heard by a senior Judge who simply reviewed the written evidence and hearing transcript. I was given a copy of his findings which stated the legal basis for the decision being overturned. No problem; the hearing panel screwed up in their treatment of the plaintiff (or whatever they are called in a hearing) and so the plaintiff got off on a technicality in how the hearing was run. That was the sole basis for the appeal and that was the grounds upon which it was overturned. Fair do's! While not present at the part of the hearing where things had gone wrong, I actually felt quite sorry for the plaintiff and their treatment by the panel - as portrayed in the findings of the Appeal.

I then read on – to be utterly shocked to see where my evidence alone was singled out by the Judge, which the Judge then stated was not the reason the case had been overturned, but was, in his opinion, “so unbelievable that it is unlikely to have happened in the way described”. I other words, a senior Judge had gone down in print accusing me of lying! I was not named but, to all of those involved and who received the Appeal findings, I was known. In fact, the Judge seems to have gone beyond his remit in reviewing the case, a fact he basically admitted to before his "accusation"!

I complained about the fact a person, a senior Judge no less, had chosen to accuse me of lying (tho, cleverly, he didn’t directly state that!) without providing me with an opportunity to defend myself. My argument was not what had been said, but the fact it was said when the Judge had no idea what had happened and that I had no opportunity to defend my reputation and he had now gone on record stating what he did. Both the JCIO and JACO basically stated that a Judge can say whatever he/she wants and told me to “run along"! Now, that’s what I call “justice”! Yer, right! “Rules for one but not the other”! I wrapped my hand in at that point realising that, with such an incestuous system, I’d get nowhere. Truth is irrelevant; the Judges opinion is absolute! :ugh:

So all this talk about what happened is fairly futile given the legal system we operate. Of course, what happens next to air displays depends both on the legal outcome as well as the findings of the Coroner in due course. It will be a mix of people/organisations covering their 6 o’clocks as well as sensible, practical, “useful” changes. Hopefully, at the end of the day, a “balanced good” will come out of the various decisions made as a result of the Court Case and the Coroner but, as for actually what happened on that fateful day in skies over Shoreham – we will never know for sure. The best the poor people so dreadfully affected by that day can do is pick out the bones at the end of this process and draw their own conclusions. Far from ideal but that's the best to be hoped for.

From a rather tired, cynical, H ‘n’ H who hopes he never ends up in Court now I know that, often, the truth is simply an “annoying technicality” to be considered but, ultimately, that it's the game that counts! :(

[RetiredBA/BY]

Diagnosis, with due deference to RetiredBA/BY experience, Transient Global Amnesia equals Cognitive Impairment. I'd imagine difficult to prove post event.


Perhaps, I simply dont know. I can clearly see some parallels between TGA and CI but are they are the same thing ?

If they are the same, then I find it strange that during investigations of my TGA by two very highly qualified neurologists, I never heard the term, Cognitive impairment. Medically, I will leave it at that.

Having again reviewed the video, and video only, of the Southport JP display and stop, I have to conclude that the low level roll was extremely, dangerously, badly flown. I base that opinion on about 1000 hours instructing on the JP, refresher students and other QFIs.

[airsound]

Bob Viking
Many of us believe that lack of experience, currency and recency (on type) could be just as likely an explanation But as you will have seen from the Conclusions of the AAIB report(a) Findings

Operational aspects

1. The pilot was licensed and authorised in accordance with the requirements existing at the time of the accident to operate the Hawker Hunter at flying displays.

2. It was the pilot’s fifth aerobatic display in a Hunter during the 2015 season and the only public display he carried out that day. He met the recency requirements specified in CAP 403.
Also, from the Prosecution's 53-page opening handout which I referred to in post #5898. Mr Hill had been flying the Hawker Hunter since 2011 and held an Aircraft Type Rating Exemption (ATRE) for the Hawker Hunter Jet aircraft from June 2011. This covered him to fly the Hunter, a Jet Provost Mk 1-5 and Strikemaster aircraft. The required certification had been renewed as required and was valid at the time of the Shoreham display.

13. Mr Hill also held a European Union Class 1 Medical Certificate with no limitations, issued on 20 January 2015. It is clear that Mr Hill had all the necessary permits and authorisations to perform the planned aerobatic display and that he was medically fit to fly the Hawker Hunter at the Shoreham Air Show.

14. Several witnesses know Mr Hill and we expect he will be described as a highly competent and experienced pilot. Rod Dean (Sp.1), the flying director at Shoreham knew him and also knew the other man who used to pilot the Hunter, Chris Heames. Mr Dean describes Andy Hill as a competent and professional display pilot with whom he was completely comfortable. Chris Heames, Andy Hill’s friend and Chief Pilot of this aircraft who recruited Mr Hill as co-pilot describes him as an extremely competent and skilful pilot (Heames Sp.11). Other witnesses may describe him in similar terms.


So neither the AAIB, nor the Prosecution, support your view. Indeed, the Prosecution charge relied on AH's being suitably experienced and qualified to fly the display – inexperience cannot equate to negligence.

You are, of course, entitled to differ in your opinion. But are you restricting your view to the pages of PPRuNe? Some might think that you have a moral obligation to express that view to the coroner. I am aware from the hearing two weeks ago that unsolicited communications have been received, and are being taken into account. And, august as PPRuNe is, I doubt it forms part of the Coroner's reading.

airsound

[Thud105]

An excellent post from Hot ‘n’ High. All too often, as we have seen on this very thread, people conflate ‘The Law’ with ‘Justice’ – and they are very different things. Any lawyer worth his vast fees can walk into a courtroom knowing full well that his client is guilty, quite possibly of a vile, heinous crime, and still do their very best to help their client avoid ‘Justice’ by careful manipulation of ‘The Law’. My two cents on this sorry saga? To paraphrase Sherlock Holmes, when you have eliminated the impossible, whatever remains, however unpalatable, must be the truth.

[Timelord]

As I said in a previous post ; On the day, he screwed up. That is not because of a hitherto unheard of medical condition, but nor is it criminal negligence. It is a result of being a human being. The whole of aviation safety is based around the acceptance that human beings make mistakes, so a system has evolved to minimise them of training, assessment, monitoring and supervision.. In my view it is that system that failed in this case.

[airsound]

Caramba....there have been many comments dismissing CI as a possible cause of the tragedy. My point is that it warrants proper investigation, not least because it might provide an explanation for previous apparently inexplicable accidents that have claimed the lives of highly experienced and capable aviators.Caramba’s point surely goes to the heart of accident investigation, the purpose of which is to prevent similar accidents happening in the future. It became clear during the trial that research into CI was in short supply.

I’m sure we can all think of examples of those ‘inexplicable accidents’ - and in many of those cases the pilot died. I suspect that the research that was done on CI for the Old Bailey trial might never have been done had AH died.

So, now that the subject has been well and truly raised, should we not be taking advantage and investing in further research that might explain some things that were previously inexplicable?

airsound

[EXFIN]

Mandatory cameras in the cockpit as a start with a live feed to the display director? Cheaper than fitting an ADR/FDR, would it though have shown evidence of CI in the Shoreham case, a head nod perhaps?

[LOMCEVAK]

Mandatory cameras in the cockpit as a start with a live feed to the display director? Cheaper than fitting an ADR/FDR, would it though have shown evidence of CI in the Shoreham case, a head nod perhaps?
GoPro from the cockpit was shown in court, albeit thankfully stopped before the impact. Those in court were able to see what movements and inputs were made by AH. I am not a medical expert so it would be inappropriate for me to comment upon whether or not the content of this video demonstrated signs of CI.

Just because a Court decides that, on the balance of probability, something happened in a certain way actually has no bearing at all on whether it actually happened or not in that way] I believe that with a manslaughter charge such as the one that is being discussed here the verdict has to be based upon 'beyond reasonable doubt' rather than a 'balance of probability' (legalapproach please correct me if I am wrong).

[POBJOY]

As I said in a previous post ; On the day, he screwed up. That is not because of a hitherto unheard of medical condition, but nor is it criminal negligence. It is a result of being a human being. The whole of aviation safety is based around the acceptance that human beings make mistakes, so a system has evolved to minimise them of training, assessment, monitoring and supervision.. In my view it is that system that failed in this case.

Absolutely agree 100% with the above, and this is why the trial did not get to the root cause. The quite correct not quilty verdict effectively closed the book on the bigger picture, which was the real elephant in the room. My power flying world started when airshows were not subject to legal requirements or authorisations but participants were expected to attend the Air Show brief (on site) and failure to do this meant you did not display. In the case of the large civilian operations like the Air Fair at Biggin Hill there was always at least one designated person to oversee the flying in addition to ATC or commentary people. Participants were stopped, warned, and not invited back if they failed to comply with the on the day requirements. When DA's came about it was intended that you had to demonstrate your actual display to a satisfactory standard in the display machine, and various limits were also included that were part of the authorisation. The system was required whether you flew a turbulent, warbird, or jet, and formalised what was already in place with most organisations/teams that provided air show acts.
The UK air show tradition has a long history, and has provided much pleasure to the public with a very wide ranging variety of events ranging from simple charity type non airfield locations to the huge multi national shows such as IAT. These replaced the former military events RAF and RN At Homes which were hugely popular, and attracted massive crowds with hundreds of our military aircraft of the day, and were themselves a legacy of the world famous pre war Hendon shows. I mention this as air shows are part of our heritage and of considerable interest to all and we should not see their demise due to allowing a control system to degrade.

[Bob Viking]

I hope you don’t mind me continuing the conversation but it genuinely fascinates me.

I have a few other thoughts.

Firstly the lack of research into CI may well be something that should be rectified. From the defence point of view that was probably a good thing of course. A little understood phenomenon is a perfect way to sew seeds of doubt into the minds of a jury. I realise that sounds like I am accusing them of Machiavellianism but I am just pointing out how a legal defence works in reality.

I have been reading a lot today about the series of handling errors put forward by Dr Jarvis and the assumed level of experience of AH. Presumably Dr Jarvis was told that AH was experienced by people who were effectively on his side or believed that the total of 14000 hours were all relevant. I agree that is an awful lot more hours than I have but then my FJ total is more than double AH’s (and very recent) and I’m still telling you that I dispute the ‘experienced’ claim. I’m not a doctor but I do understand flying.

If Dr Jarvis had been convinced that AH was not the highly experienced aviator he was led to believe I wonder if his conclusions would have been the same?

My final thought for now, because I have to go out, is regarding the assertion that the aircraft was not under control as it descended from the loop.

Here is where I will bow to the knowledge of Hunter pilots. Surely to pull through from a loop that has apexed at 2800’ actually requires incredible skill and concentration. Any lack of consciousness or awareness would surely have resulted in a vertical ground impact rather than a (miraculously) survivable almost level attitude?

I can only put this accident into Hawk terms but I know that if I were to apex 1500’ lower than intended and continued the manoeuvre I would be incredibly lucky to complete the second half before ground impact. I can’t imagine a Hunter is markedly different in that regard.

I know you and I are never likely to agree on this (yes I know you sat in court and I fully understand my thoughts really don’t matter in the grand scheme of things) but I think we can both accept that in any court case an innocent verdict does not mean that the complete truth has been presented and accepted.

Please don’t take any of this personally but, as you can see, some of us are having a hard time accepting the stated course of events.

BV

[just another jocky]

But as you will have seen from the Conclusions of the AAIB report Also, from the Prosecution's 53-page opening handout which I referred to in post #589 So neither the AAIB, nor the Prosecution, support your view. Indeed, the Prosecution charge relied on AH's being suitably experienced and qualified to fly the display – inexperience cannot equate to negligence.

airsound

I went through a similar system to get my DA on the Hunter T7. Albeit with a lot of years flying fast jets (though none of it flying low level aerobatics), it took me 3 trips to go solo in the Hunter (an aircraft I had never flown before) and a further 4 to get my low level DA. At the time I was naïve enough to just go along with it as I believed I was safe and circumspect about what I attempted and the manoeuvres we planned for our displays were all very 'safe' with no nose low commits as we weren't experienced enough.

Was that enough to then fly within striking distance of 000's of people, plus those outside the fence who were just going about their daily business? In hindsight, I think not. When you compare what I did to what an RAF pilot will have to go through to get a DA, on a type they're already current on and the gulf is huge, perhaps more than huge. And of course once they have a DA, it's only for the manoeuvres they are cleared to do whereas I was then cleared to fly any manoeuvre I chose at the time.

AH was current and fit in terms of the regs at the time, that doesn't mean it was safe, at least in my opinion. The system failed those victims and their families

[GeeRam]

Firstly the lack of research into CI may well be something that should be rectified. From the defence point of view that was probably a good thing of course. A little understood phenomenon is a perfect way to sew seeds of doubt into the minds of a jury. I realise that sounds like I am accusing them of Machiavellianism but I am just pointing out how a legal defence works in reality.


Yep.
I served on a jury over 30 years ago, where the defence team did a similar thing and utterly confused and brain-numbed most of the jury, who had been given enough 'seeds of doubt'....to bring a not guilty verdict despite the hard evidence presented.
As pointed out in other posts, its all a 'game' played by legal teams.

As pointed out the system failed as much as AH did.
As per AAIB report, that was only his 5th Hunter display that season, and given Shoreham was Sept and thus pretty much near the end of the display season, yet the system thought that was adequate for a FJ display DA when you have less that 40 hrs on type, is.......well......

[LOMCEVAK]

Surely to pull through from a loop that has apexed at 2800’ actually requires incredible skill and concentration. Any lack of consciousness or awareness would surely have resulted in a vertical ground impact rather than a (miraculously) survivable almost level attitude?

I can only put this accident into Hawk terms but I know that if I were to apex 1500’ lower than intended and continued the manoeuvre I would be incredibly lucky to complete the second half before ground impact. I can’t imagine a Hunter is markedly different in that regard.

BV, there is data supporting your assumption in the AAIB report. The aeroplane had to be flown at maximum instantaneous turn performance (light buffet) throughout the pull through to achieve that radius. Assuming that the aircraft was trimmed in pitch at the pull-up point, this would have required a significant (but easily applied) aft stick force and displacement throughout the manoeuvre. There are a couple of extra significant considerations.
First, analysis of the external videos showed that at some point in the manoeuvre the flaps were selected from 1 notch to 2.
Secondly, during the last quarter of the manoeuvre when about 30 degrees nose down the aircraft entered wing rock which would have been caused by a further aft stick input increasing angle of attack past the maximum value ie. the aircraft was pulled into an accelerated stall. This would actually have increased the height loss slightly but was, in my opinion, a totally instinctive control input and did indicate to me that the pilot was aware of the aircraft's flightpath with respect to the ground.

Your comparison with the Hawk is interesting because the Hunter is actually a lot easier to fly in situations such as this. It has a progressive increase in buffet intensity as AoA is increased compared to the Hawk as so is much easier for maintaining maximum instantaneous turn at all airspeeds.

[beardy]

I know you and I are never likely to agree on this (yes I know you sat in court and I fully understand my thoughts really don’t matter in the grand scheme of things) but I think we can both accept that in any court case an innocent verdict does not mean that the complete truth has been presented and accepted.

The verdict was not guilty of the charges brought against him, not that of innocence.

[Caramba]

Beardy - the trial was in England; AH was found not guilty of the charges against him. There is no “not proven” verdict south of the border, and, technically, no court declares someone innocent.

Because of the “not guilty” verdicts, AH was acquitted and thereby absolved of the charges. Sounds like innocent to me.

Caramba

[Odanrot]

BV, there is data supporting your assumption in the AAIB report. The aeroplane had to be flown at maximum instantaneous turn performance (light buffet) throughout the pull through to achieve that radius. Assuming that the aircraft was trimmed in pitch at the pull-up point, this would have required a significant (but easily applied) aft stick force and displacement throughout the manoeuvre. There are a couple of extra significant considerations.
First, analysis of the external videos showed that at some point in the manoeuvre the flaps were selected from 1 notch to 2.
Secondly, during the last quarter of the manoeuvre when about 30 degrees nose down the aircraft entered wing rock which would have been caused by a further aft stick input increasing angle of attack past the maximum value ie. the aircraft was pulled into an accelerated stall. This would actually have increased the height loss slightly but was, in my opinion, a totally instinctive control input and did indicate to me that the pilot was aware of the aircraft's flightpath with respect to the ground.

Your comparison with the Hawk is interesting because the Hunter is actually a lot easier to fly in situations such as this. It has a progressive increase in buffet intensity as AoA is increased compared to the Hawk as so is much easier for maintaining maximum instantaneous turn at all airspeeds.
There is also the fact that the Hawk behaves as a straight wing aeroplane whereas the Hunter a swept wing aeroplane, and therein lies the difference.
In a Hawk max CL comes as you achieve light buffet, pulling through this does not increase CL but actually reduces it, a straight wing characteristic. In the Hunter light buffet gives optimum CL for hard manoeuvring, but not max CL, that is achieved by continuing to pull into heavier buffet, ie wing rock, but with an unacceptable increase in drag, So, While you can get more out of the wing if you hold deeper buffet for any length of time, the loss of speed, ie energy, negates the CL advantage gained earlier.
To me this explains the wing rock In the last quarter of the loop and the fact that he didn’t tent peg. Whether or not AH was aware of this is irrelevant as most people put in this position would pull harder. Had he been in a Hawk and missed his gate height by a similar margin and not flown an escape manoeuvre he would have arrived at ground level in a steep dive, but the Hunter achieved a nose up attitude at impact albeit still descending.
He knew he was in the s.... and tried to do something about it !!! But decided not to eject.

[RetiredBA/BY]

Whatever he decided an ejection in the last quarter of the loop was almost certain death.

MB. say, in those seats, you need a height of at LEAST 10 % of your ROD to survive.

He did not have that height.

He had no option but to pull to, or through, the buffet to obtain Max Cl.

The video shows max or near max, elevator deflection which suggest he was pulling hard, a natural instinct if you are about to hit the ground !

[beamer]

I still find it surprising that so many people cannot accept the idea that, on the day, a pilot made an unintentional mistake with tragic consequences.

[Odanrot]

I still find it surprising that so many people cannot accept the idea that, on the day, a pilot made an unintentional mistake with tragic consequences.
Where do you get the idea that anyone here feels that his “mistake” was anything other than unintentional? The discussion is about possibilities of how it happened and being discussed by professional pilots (some retired) who have thousands of hours flying Hunters and other fast jets.

[beardy]

Beardy - the trial was in England; AH was found not guilty of the charges against him. There is no “not proven” verdict south of the border, and, technically, no court declares someone innocent.

Because of the “not guilty” verdicts, AH was acquitted and thereby absolved of the charges. Sounds like innocent to me.

Caramba
In that case we shall have to disagree on the term 'innocent'

[Hot 'n' High]

.......

I believe that with a manslaughter charge such as the one that is being discussed here the verdict has to be based upon 'beyond reasonable doubt' rather than a 'balance of probability' (legalapproach please correct me if I am wrong).

I should have put "Just because a Court decides that, on the balance of probability, something happened in a certain way actually has no bearing at all on whether it actually happened or not in that way." :ok: H 'n' H trying to sound "intelligent" backfires on him yet again!!! You'd think I'd learn.......! :}

However, my error does not detract from the heart of my Post, which was put far better than I did by Thud105 a few posts up and that is that the legal-beagles "still do their very best to help their client avoid ‘Justice’ by careful manipulation of ‘The Law’" (which is even their Duty so I believe - as a laybod I hasten to add) and by GeeRam that, from their own experience, has observed a case where "........ the defence team ........ utterly confused and brain-numbed most of the jury, who had been given enough 'seeds of doubt'....to bring a not guilty verdict despite the hard evidence presented.".

Quite what was/was not applicable to the Case under discussion in this Thread I know not, nor care, as it changes nothing in the Case in question, nor will it change the way legal things are run in the future (particularly given my experience with my Judge-"friend" and others I've met who are in the legal world) - just that my faith in Justice generally being done within the UK legal system is, well, virtually zero! As POBJOY says, "and this is why the trial did not get to the root cause" - the "players" only looked at what suited them in terms of the basis for the prosecution and the subsequent defence. As just another jockey said, "The system failed those victims and their families". Actually, that's "systems" - the Aviation one and the Legal one!

I'm not sure what the mathematical term is for a graph with two peaks, one at either end and a smattering in the middle (a Camel Curve maybe? I'm sure several PPRuNers will know). If you took a straw poll here, today, based on all that is known, observed, guessed or derived by some other means, with "Totally professionally executed display written off by a CI event" through to "A series of intentionally flown deviations (which did not, I hasten to add, have the intent to crash the jet - just to produce an ace display)" I'd expect something like a Camel Curve to emerge.

Ah well, I've had my say - I'll slink back and await that effigy of H 'n' H to be constructed by Legalapproach - clearly, La was busy doing other things yesterday so no stabbing pains ..... yet!!!! :ooh:

[Legalapproach]

H'n'H

She who must be obeyed has me decorating the hall so up a ladder yesterday. In any event it will be, like the key cross-examination question, when and where you least expect it. I'm just biding my time.

And to clarify, by hall I mean the bit behind the front door where we hang the coats and dog leads, not Hall as in Legal Towers before any of you b****** start going on about vast fees. Vast fees? - we were on legal aid.

[Hot 'n' High]

H'n'H
............

And to clarify, by hall I mean the bit behind the front door where we hang the coats and dog leads, not Hall as in Legal Towers before any of you b****** start going on about vast fees. Vast fees? - we were on legal aid.

No probs Leags, and sorry I'm such a cynic in such matters. I'll expect the stabbing pains once you've had a chance to construct an effigy of moi now you have been released from hard labour. My front door has taken 2 weeks now due to inclement Wx! I share your pain!

I think we can all agree that Shoreham was a disaster on a personal level for so many people, a disaster for the air show scene - tho with benefits in highlighting a load of areas which need reviewing - and an utter disaster for AH himself as he has to live with this for the rest of his days. Summary? A right mess!

Let's just hope genuine progress is made, taking everything into account as hard as that may be. At least that will be a fitting epitaph for those who have sadly paid the ultimate price. Cheers, H 'n' H

[Dan Winterland]

John Derry aircraft exceeding its design limits

The DH110 design had one major flaw in the straight tailplane which would suffer from compressability before the mainplane - a bit of a disaster for stability at high Mach numbers. In service, the MNO of the Sea Vixen was subsonic. Dan Griffiths, while displaying the last airworthy Sea Vixen had some thoughts on the matter.

https://vintageaviationecho.com/flying-the-sea-vixen/

[wonderboysteve]

The DH110 design had one major flaw in the straight tailplane which would suffer from compressability before the mainplane - a bit of a disaster for stability at high Mach numbers.

Was that definitely the case? I hasten to add that I don't know in the case of the Sea Vixen, but a straight tailplane would not inherently suffer from compressability issues before the mainplane, if it had a thickness to chord ratio that was sufficiently lower. The greater lift curve slope of the straight tailplane versus the swept wing would help to maintain manouvre margin with increasing Mach number. I read through the article but couldn't see a reference specifically to the tailplane suffering as opposed to the mainplane.

[Dan Winterland]

Was that definitely the case? I hasten to add that I don't know in the case of the Sea Vixen, but a straight tail-plane would not inherently suffer from compressability issues before the main-plane, if it had a thickness to chord ratio that was sufficiently lower. The greater lift curve slope of the straight tailplane versus the swept wing would help to maintain manouvre margin with increasing Mach number. I read through the article but couldn't see a reference specifically to the tailp-lane suffering as opposed to the main-plane.

I recall reading about it elsewhere some time ago, but I don't recall where. A straight plan-form can be sufficient for high speed flight if the fineness ratio is high - as in the F104. longitudinal stability at high speed is a favourite interview question - "why do airliners have greater sweep on the tail-plane compared to the wing?" (The 747 has the same sweep on both, but gets round it with a greater fineness ratio). But looking at a picture of the Sea-vixen, there does seem to be a bit of camber on the tail-plane. The tail design went through several changes and although the DH110 achieved supersonic flight in testing, in service it was limited to a very low M0.92 considering it's role.

Dan talks about pitch stability at the extremities of the range in his article and attributes much of this to elevator gear changing. But an ex-colleague who flew them mentioned the dreadful high speed handling of the Sea Vixen. It was so powerful, you could get to VMne very quickly and it was easy to exceed. My friend scared himself several times and remarked that he was glad when the Phantom came along as he considered it far safer and that he was 'on borrowed time'. If you consider the F4 to be safe, then that says something about the aircraft you were flying before! And the statistic of some 40% of the fleet lost in accidents also says something.

[wonderboysteve]

DW - thanks for your response! I'll PM as this is far from topic.

[TC_LTN]

A very interesting read;

https://publicapps.caa.co.uk/modalapplication.aspx?appid=11&mode=detail&id=9876

[Training Risky]

A very interesting read;

https://publicapps.caa.co.uk/modalapplication.aspx?appid=11&mode=detail&id=9876

Yes indeed!

From this excerpt below, it appears that AH's defence of cognitive impairment has been disproven:

"9.60 There is no evidence to suggest that cognitive effects can be demonstrated at low levels of G force when experienced for the short period of time associated with aerobatic displays. The overwhelming weight of available scientific evidence does not show any demonstrable, practical and meaningful cognitive impairments under +4 Gz that would point to impaired flight safety."

"9.61 The Review Team has concluded that there is no identifiable risk of cognitive impairment in civil pilots experiencing G forces at levels, and for durations recorded by accident investigators as having been experienced by the Shoreham pilot."

"9.62 This review makes a number of recommendations for the CAA to consider. The recommendations are weighted towards improving the safety of flights where aerobatic manoeuvres are undertaken as these are the flights where levels of G above +2 Gz are likely to be experienced and physiological effects could be encountered. The focus has been on safety improvement."

"9.63 None of the recommendations are considered to be urgent safety recommendations." (Really!! I am sure the Shoreham families may disagree?)

So according to this report, he just entered the loop too low and slow and didn't realise it until too late.

[just another jocky]

A very interesting read;

https://publicapps.caa.co.uk/modalapplication.aspx?appid=11&mode=detail&id=9876

"The overwhelming weight of available scientific evidence does not show any demonstrable, practical and meaningful cognitive impairments under +4 Gz that would point to impaired flight safety."

[Ridger]

Versus:

"In the absence of direct evidence there remains the possibility that some aspects of pilot performance could be affected at levels of +Gz lower than those associated with effects on vision and consciousness, though these may only relate to longer durations of exposure. It is not possible to state from the data available whether any of the impairments would have occurred at much shorter durations than those reported in the literature".

"Few studies have been undertaken on higher mental functions with low G force. In part this is due to the difficulty of accurately measuring these functions in a +Gz environment. Varied study designs, methodologies, differences in choice and experience of participants, individual differences between participants and levels of Gz have been employed in studies and this lack of consistency makes comparisons challenging"

[just another jocky]

"There is no evidence to support the existence of cognitive effects prior to a level of G where grey out or blackout affects vision."

"A considerable number of international aviation organisations were contacted, for the purpose of this review, to ask for any information or concerns they may have been aware of relating to cognitive impairment with G force. No respondents described cases that fitted the criteria of acceleration-induced cognitive impairment at relatively low G force. The RAF Centre of Aviation Medicine informed the review that following consultation with international colleagues and experts ‘no consulted expert or organization recognises the existence of a low-G impairment syndrome’ and that ‘the total unanimity and unambiguous nature of expert opinion and long-term international experience offers significant reassurance’"

Does that make the report confusing and/or contradictory then?

[falcon900]

At the risk of sounding cynical, is asking the CAA to look for the evidence not a bit like putting the fox in charge of the chicken coop?
Given their responsibilities before and after the incident, it would have been more than a tad embarassing to discover evidence corroborating the existence of CI which they had hitherto failed to discover, Ditto the RAF, so with all due respect, I am reading the report with a very large pinch of salt.
If there is a real desire to find out the state of scientific / medical knowledge on the topic, there needs to be an independent person / body conducting the search, ie one which can express an opinion without the risk of incriminating itself or its own past inaction.

[DODGYOLDFART]

I guess we can continue to bat the ball back and forth on the subject of G induced CI for ever but I wonder what conclusion the Coroner will come to when the Inquest is resumed? For sure a conclusion needs to be reached for the sake of the casualties and their relatives and that is part of the Coroners remit.

[pasta]

Does that make the report confusing and/or contradictory then?
I don't think so. My interpretation is that they were unable to find any evidence for G-induced cognitive impairment, but can't prove that it doesn't exist.

It's very hard to prove that something doesn't exist.

[Ridger]

The RAF Centre of Aviation Medicine informed the review that following consultation with international colleagues and experts ‘no consulted expert or organization recognises the existence of a low-G impairment syndrome’ and that ‘the total unanimity and unambiguous nature of expert opinion and long-term international experience offers significant reassurance With all due respect to RAFCAM, that statement absolutely does not offer reassurance, let alone at a significant level! They might as well say that because no-one has ever seen a blue chicken, then blue chickens don't exist!

If there is a real desire to find out the state of scientific / medical knowledge on the topic, there needs to be an independent person / body conducting the search, ie one which can express an opinion without the risk of incriminating itself or its own past inaction

Completely agree - the report has attempted to draw a conclusion from a review of opinions and research examples which either didn't assess cognitive performance by intent, or were not able to assess cognitive performance to the level that the report required. If the regulator wants to take this seriously, then they should motivate some actual research in a centrifuge, not a lit review.

[tucumseh]

At the risk of sounding cynical, is asking the CAA to look for the evidence not a bit like putting the fox in charge of the chicken coop?
Given their responsibilities before and after the incident, it would have been more than a tad embarassing to discover evidence corroborating the existence of CI which they had hitherto failed to discover, Ditto the RAF, so with all due respect, I am reading the report with a very large pinch of salt.
If there is a real desire to find out the state of scientific / medical knowledge on the topic, there needs to be an independent person / body conducting the search, ie one which can express an opinion without the risk of incriminating itself or its own past inaction.

Agreed. I wonder if this will now become the focus of the Inquest, in an attempt to divert from awkward questions. Such as, a Permit to Fly predicated on the RAF (not MoD) being the Aircraft Design Authority. Step forward Hunter PT Leader, and tell us all about your safety case.

[just another jocky]

At the risk of sounding cynical, is asking the CAA to look for the evidence not a bit like putting the fox in charge of the chicken coop?
Given their responsibilities before and after the incident, it would have been more than a tad embarassing to discover evidence corroborating the existence of CI which they had hitherto failed to discover, Ditto the RAF, so with all due respect, I am reading the report with a very large pinch of salt.
If there is a real desire to find out the state of scientific / medical knowledge on the topic, there needs to be an independent person / body conducting the search, ie one which can express an opinion without the risk of incriminating itself or its own past inaction.
Who would you suggest (or perhaps who would be acceptable)?

[orca]

I agree that the aircraft needs to be demonstrably safe to operate, just as everyone else probably (hopefully) agrees it needs to be operated safely.
I fear that the families’ search for definitive answers will never end - but I know where I fall on the ‘camel curve’ mentioned above.

[falcon900]

Who would you suggest (or perhaps who would be acceptable)?
More or less anyone apart from the CAA.......
There will be others better placed than me to suggest specific names, but for me the key issues are independence and objectivity.
For the record, I am not saying the CAA are wrong, it is just that they have a lack of independence, indeed to the point where they might even have a conflict of interest.

[just another jocky]

More or less anyone apart from the CAA.......
There will be others better placed than me to suggest specific names, but for me the key issues are independence and objectivity.
For the record, I am not saying the CAA are wrong, it is just that they have a lack of independence, indeed to the point where they might even have a conflict of interest.

You may be right, doesn't mean their report is incorrect, and the quote from RAFCAM and other, "international aviation organisations" is fairly damning. Are they not independent and objective enough? If not, I'm beginning to wonder who would satisfy.

[TC_LTN]

More or less anyone apart from the CAA.......
There will be others better placed than me to suggest specific names, but for me the key issues are independence and objectivity.
For the record, I am not saying the CAA are wrong, it is just that they have a lack of independence, indeed to the point where they might even have a conflict of interest.

Let’s remember, as disclosed during a Pre Inquest Review, it was Andy Hill that initiated the request for the CAA and AAIB to investigate the phenomena in the first place. On the basis of these requests, the Coroner elected to delay the inquest until the reports were delivered.

[Just This Once...]

Let’s remember, as disclosed during a Pre Inquest Review, it was Andy Hill that initiated the request for the CAA and AAIB to investigate the phenomena in the first place.

Presumably Bob Massingbird will be representing Andy Hill again.

[falcon900]

The point I am trying to make is simply that the CAA (and to a lesser extent the RAF) are not objective or independent. In so far as the CAA has a general regulatory role, it has in my view a meaningful conflict of interest.
Were its investigations to unearth a body of credible evidence in support of CI, the obvious and immediate question becomes why had they not carried out these investigations before, leading to questions as to whether they were properly and proactively discharging their duties. It is a short journey from there to the question of whether the accident could have been avoided if the CAA had discharged its responsibilities diligently. Given that the evidence would have been unearthed by the CAA themselves, it would be pretty difficult for them to escape the conclusion that they had not.
On the other hand, a perfunctory cast around in places where they knew there was no evidence, and a factually correct statement that they had found no evidence........
Independence and the avoidance of actual or apparent conflicts of interest are basic and obvious requirements, and in their absence, I'm afraid the outcomes of the investigation are seriously compromised. IMHO

[Chugalug2]

falcon900 :-
Independence and the avoidance of actual or apparent conflicts of interest are basic and obvious requirements, and in their absence, I'm afraid the outcomes of the investigation are seriously compromised. IMHO

Absolutely right, falcon! Whatever the rights and wrongs of this terrible tragedy, your statement should be nailed above the entrance of every Regulator and Investigator, whether civil or military. Partiality doesn't work in aviation, it just leads to more accidents, more deaths. It is far too prevalent these days!

[POBJOY]

The CAA are NOT an independent input into this whole scenario, simply because 'they' were the controlling authority for most of the issues that conspired in one way or another to 'enable' this accident.
There is no doubt it was an accident, but more to the point 'was it preventable'.
One thing for sure is the least culpable part was the aircraft itself which demonstrated up to impact its ability to maintain control as far as was possible.
The requirements of both display pilot authority, and actual display location 'oversight' are both CAA regulated to the point that designated persons have a responsibility in both cases.There is no doubt that the CI input clouded the issue to the point that that relatives are still left to wonder 'who/what was responsible', and what could have been done to prevent it.The day in question was hot and that itself is always a factor in reducing performance of both aircraft and engine, however display limits are designed to allow a margin for error and the CAA require a display director to oversee operations and call a stop to proceedings if required.Whilst the original charges should never had been implemented equally the decision to proceed with the intended vertical display manoeuvre from a lower than authorised height should have prompted a reaction from the display director, and this was before any possible G factors.
So !, have any lessons been learnt that contribute towards this happening again !!, of course they have, but in the main they did so because of forums like this, not because of a trial that failed to highlight the root cause of the situation.
Whether the Coroner will be influenced in all of this rather depends on anyone who is able to offer evidence that 'de clouds' the questionable CI input, and looks at how the systems in place at the time were followed.

[tucumseh]

One thing for sure is the least culpable part was the aircraft itself which demonstrated up to impact its ability to maintain control as far as was possible..

Yet the aircraft was not airworthy or serviceable, and operating under a fundamentally flawed permit to fly. And the pilot was not told this.
However, I agree with the general points you make.

[just another jocky]

......I'm afraid the outcomes of the investigation are may be seriously compromised. IMHO

My edit, otherwise I agree.

Doesn't mean they're wrong, especially when they include the opinions of overseas expertise.

[WB627]

POBJOY - That is a great post and says just about says all that needs to be said.

I am not an aviation professional, but I have been reading aviation accident reports since 1968; I was 11 years old, RAF crew room used by my Dad, AEF VR pilot. The human factors are the most interesting and I missed my vocation in life. Sadly the one thing I have learnt over the years, is that lessons are still not learnt.

[POBJOY]

Yet the aircraft was not airworthy or serviceable, and operating under a fundamentally flawed permit to fly. And the pilot was not told this.
However, I agree with the general points you make.

TUC My comment was referring to the point that the 'aircraft itself' did not cause or was part responsible for the incident notwithstanding any issues re its permit. In fact it only proved what a fine machine it was and how sound the design was even when pushed beyond what was reasonable for the conditions. However it 'was grounded', and one has to assume this action was taken in order to 'create the impression' that the stable door has been closed even though that particular horse had never 'bolted'. One has to remember that safety rules regarding airshows were originally drawn up to protect crowds attending such events, and the Pilots briefings were always quite clear on such basic items as not flying over the crowd or turning 'towards' the crowd line. These rules were very much airfield related, but could include the wider scope of areas to avoid whilst positioning. However these rules did not replace the overall conditions as per the ANO which applied to aircraft operations in general,and include many public safety issues as the norm. What Shoreham highlighted (if it needed highlighting) was that some display locations were unsuitable for some aircraft that required a larger positioning space to cope with a short crowd line and nearby built up areas. The other factor is the 'off airfield' areas that attract collections of people watching the display but are not part of the 'display safety regulations', and although on paper covered by the ANO in fact should be part of the overall display organisation 'planning' to mitigate any potential issues that this may cause. As to the actual Shoreham incident itself we are left with a public that have not really been given an honest appraisal of all the facts, and the effective loss of a hugely popular display scene overall.

[falcon900]

My edit, otherwise I agree.

Doesn't mean they're wrong, especially when they include the opinions of overseas expertise.
The problem is, when you dont know whether the investigation is compromised or not, then it absolutely IS compromised.

[Easy Street]

Can someone explain to me what motivation the CAA might have for wanting to influence the findings of further investigation into CI? There does not seem to be an obvious equivalent to the “protect the retired Air Marshals” allegation associated with Mull, etc. The CAA’s regulation of display supervision has already been discredited; what else could it be hoping to protect? A finding of CI would surely take attention *away from* airworthiness matters, if indeed there is anything to be diverted from.

As for the RAF, a finding of CI’s existence would actually be quite convenient to very senior leadership in implementing its vision for uncrewed platforms. So not sure what institutional motivation is being implied there either.

[flighthappens]

Can someone explain to me what motivation the CAA might have for wanting to influence the findings of further investigation into CI? There does not seem to be an obvious equivalent to the “protect the retired Air Marshals” allegation associated with Mull, etc. The CAA’s regulation of display supervision has already been discredited; what else could it be hoping to protect? A finding of CI would surely take attention *away from* airworthiness matters, if indeed there is anything to be diverted from.

As for the RAF, a finding of CI’s existence would actually be quite convenient to very senior leadership in implementing its vision for uncrewed platforms. So not sure what institutional motivation is being implied there either.

Agree with this. CI being real would be a convenient excuse to CAA “oh, we didnt know about this CI, it explains everything, nothing else to see here” (sweeps regulatory issues under carpet).

looking at the credentials of the panel - 3x Profs, 1x Doctors and a couple of other professionals - who have worked in the UK, Aus, US and NZ, I have no reason to doubt their relevant professionalism or experience. They are also displaying willing to put their name to the report, so if there was contrary evidence they would be discredited immediately.

It starts looking like parts of the US unwillingness to look at science in the face if Covid-19 because it doesn’t suit their narrative.

[POBJOY]

A Coroner is required to 'explore facts' to determine the probable cause of any 'unnatural death. One would assume they are 'independent' and able to use whatever information is available to come to a decision. The use of CI by the defendants team was part of a 'legal' process to show doubt on the prosecutions case which was in itself was poorly constituted, and probably not the correct charge to have been made.
A Coroner has the opportunity to look at the 'facts' and engage with information from outside independent bodies to assist in a fair inquiry.
I suspect that a Coroner will be very wary of being influenced by 'clouding issues' and more interested in exploring how this sad and tragic accident happened in what is supposed to be a highly regulated regime. It may well be that the more basic details of the situation will be explored in greater detail, and a honest and reasonable cause attributed to this accident.

[falcon900]

Can someone explain to me what motivation the CAA might have for wanting to influence the findings of further investigation into CI? .

If the investigation discovered that there was clear and available evidence that CI existed which predated Shoreham, then there would be an inference that a diligent regulator would have sought to address it in regulations for pilot medicals and or airshow display rules. As the CAA had done neither, there would be a clear basis for an allegation of negligence.
All hypothetical obviously, and as I have said already, I am not saying that CI does exist, or that the CAA report is incorrect. Simply that the CAA had such an obvious and significant conflict of interest that they were arguably the worst people to be carrying out the investigation as, however thorough they were, suspicion would remain.

[POBJOY]

[QUOTE=Easy Street;10941581]Can someone explain to me what motivation the CAA might have for wanting to influence the findings of further investigation into CI? There does not seem to be an obvious equivalent to the “protect the retired Air Marshals” allegation associated with Mull, etc. The CAA’s regulation of display supervision has already been discredited; what else could it be hoping to protect? A finding of CI would surely take attention *away from* airworthiness matters, if indeed there is anything to be diverted from.

If you remove all the issues of a 'trial' and merely investigated how this accident happened under a CAA regulated system, it would throw up many items that were less than satisfactory, and certainly did not even follow the system as envisaged by the authority. The common factor in all this was the authority itself therefore the CI input if nothing else was a convenient distraction from the rather more relevant route of how the system itself was implemented. Having been provided with a suitable 5/8 of cloud cover in court, increasing this only diverts attention away from more tangible evidence. Who benefits from that !!. Mistakes/Errors happen so the original CPS case was not appropriate, and should not have singled out the Pilot. Let us hope that the Coroner looks at the wider picture.

[DODGYOLDFART]

In these somewhat difficult times does anyone know if a new date for a resumed inquest has yet been set?

[skridlov]

https://www.westsussex.gov.uk/news/shoreham-airshow-crash-inquest-postponed-until-february-2022/

[CAEBr]

The coroner due to hold inquests into the deaths at Shoreham air crash has lost her High Court bid to obtain video footage from the pilot's cockpit.

BBC report here (https://www.bbc.co.uk/news/uk-england-sussex-60267730)

[Hebog]

TUC My comment was referring to the point that the 'aircraft itself' did not cause or was part responsible for the incident notwithstanding any issues re its permit.

I think you will find the aircraft itself had restrictions on aeros placed by a maintenance organisation. It had a major issue which has not been mentioned by the CAA or the AAIB. This major issue may have resulted in the flying controls being compromised. The failure would most likely happen under high G.
Therefore did the CAA carry out a proper inspection of the aircraft and it records at all. Did the AAIB have the full maintenance records for the aircraft going back at least 10 years prior and if the failure had happened would it have been realised and identified in the wreckage. Were all the records proved to the AAIB.
Also remember the AAIB sometimes ask maintenance companies that may have been involved with the maintenance of the aircraft for help an assistance during investigations. Surely this is a conflict of interest by the AAIB.

Personally I think too much was placed on pilot error / judgement and trying to prove this. More investigation into the pre flight condition of the aircraft, maintenance carried out or not carried out and reported problems should have been looked into more detail and the impact these could have had on the aircraft and the reason for the pilots response or non response.

[[email protected]]

Personally I think too much was placed on pilot error / judgement and trying to prove this. Who was it made a mess of the manoeuvre? The engineers? The CAA? No, it was the bloke with his hands on the controls.

[Hebog]

Yes he had his hand on the controls but if say those controls had been restricted due to a failure in the aircraft structure and the lack of engine power and despite anything he did the aircraft wouldn't have responded as expected by the pilot.

[Bob Viking]

Using any of the numerous videos of the accident that are available publicly, please tell us (with the benefit of your extensive experience of flying military jets or investigating jet accidents) at what stage you think the jet exhibited any signs of a control restriction or control failure.

It is entirely possible that you have discovered something that the combined minds of the AAIB failed to consider. My money is on something else though. Something that the AAIB did have on their list.

BV

[tigerfish]

I am not a pilot but have operated Police Helicopters for many years. For me the Important factor comes from the soundtrack of one of the commentators at the Airshow who said that he thought the Pilot doing the loop was a bit low - And that was said before the crash!

TF

[LOMCEVAK]

I think you will find the aircraft itself had restrictions on aeros placed by a maintenance organisation. It had a major issue which has not been mentioned by the CAA or the AAIB. This major issue may have resulted in the flying controls being compromised. The failure would most likely happen under high G.
Therefore did the CAA carry out a proper inspection of the aircraft and it records at all. Did the AAIB have the full maintenance records for the aircraft going back at least 10 years prior and if the failure had happened would it have been realised and identified in the wreckage. Were all the records proved to the AAIB.
Also remember the AAIB sometimes ask maintenance companies that may have been involved with the maintenance of the aircraft for help an assistance during investigations. Surely this is a conflict of interest by the AAIB.

Personally I think too much was placed on pilot error / judgement and trying to prove this. More investigation into the pre flight condition of the aircraft, maintenance carried out or not carried out and reported problems should have been looked into more detail and the impact these could have had on the aircraft and the reason for the pilots response or non response.
Could you please give some indication as to the nature of what compromised the flying controls? There may well have been an issue but it did not degrade the flying qualities of the aircraft on that sortie. There was sufficient elevator authority available to maintain the aircraft at an angle of attack that gave maximum instantaneous turn performance/pitch rate throughout the manoeuvre and enabled the aircraft to be pulled into an accelerated stall before impact. Wings level was maintained during the downward portion of the manoeuvre and there was no evidence of any sideslip. Therefore, although you may have some information that indicates a potential problem there is no evidence to show that the performance of the aeroplane was affected in any way whatsoever.

[Bob Viking]

I know it’s been said on here before but I would like to reiterate that being low before the pull up would have had no bearing on the accident whatsoever. Anyone can stretch a loop upwards by relaxing the pull on the way up if necessary.

If the commentary states he looked low at the top then that commentator had a very keen eye and was absolutely correct.

BV

PS. LOMCEVAK I was hoping you’d jump in. I knew you’d say it better than me.

[LOMCEVAK]

Post this and the publication of CAA CAP1724 it is still permitted to commence an aerobatic manoeuvre from flypast height minima so long as the aircraft is no more than 30 degrees nose up on climbing through the minimum aerobatic height, and AH was above his flypast minima when he pulled up for this manoeuvre.

[Cat Techie]

I think you will find the aircraft itself had restrictions on aeros placed by a maintenance organisation. It had a major issue which has not been mentioned by the CAA or the AAIB. This major issue may have resulted in the flying controls being compromised. The failure would most likely happen under high G.
Therefore did the CAA carry out a proper inspection of the aircraft and it records at all. Did the AAIB have the full maintenance records for the aircraft going back at least 10 years prior and if the failure had happened would it have been realised and identified in the wreckage. Were all the records proved to the AAIB.
Also remember the AAIB sometimes ask maintenance companies that may have been involved with the maintenance of the aircraft for help an assistance during investigations. Surely this is a conflict of interest by the AAIB.

Personally I think too much was placed on pilot error / judgement and trying to prove this. More investigation into the pre flight condition of the aircraft, maintenance carried out or not carried out and reported problems should have been looked into more detail and the impact these could have had on the aircraft and the reason for the pilots response or non response.

I think you have little understanding of the maintenance of any aircraft as well! If there was any restriction by a maintenance inspection on the aircraft especially being an ex military Permit to Fly aircraft, the CAA regulations state that the maintenance recording should follow the service recording for the aircraft in military service. Thus if there was any limitations by a maintenance inspection that restricted the scope of handling of the aircraft such as high energy manoeuvres should have been recorded in the F703 limitations red pages of the F700 tech log. BV would have known such as some of his Jaguars flown had limitations on MTOM and landing weight. G limitations on some airframes as well due to high fatigue life. Pilot signs the tech log to say he is happy to take the aircraft in the condition it is in and will consider the limitations is part and parcel of his operation of the airframe. If it had maintenance limitations, the engineers should legally have recorded it, he should have known them from reading the tech log AND should have abided by it. If you are an engineer involved in knowing about such and not recording it, I would quite happily hang, draw and quarter if you did not record such detail. The CAA do not do inspections on aircraft, they empower A8-23 or A8-24 orgs to do such under audit and proof of competency of the engineering staff employed by such. I must admit reading and hearing of the standard that the CAA will allow people to hold certifying positions in such A8 companies shocks me (I am an unrestricted B1 CAA AML type rated and current holder that has C cert rights as well). I know the AAIB inspector that did investigate the accident as lead and and on hearing of his involvement on the case, I mentioned the name of the pilot. We were sitting with two FJ pilots in the conversation and the way their lips curled with the name mentioned said it all. Both have done Hunter instruction time and multi thousand hour FJ logged hours. 2+2 =4 unlike your 5.

[JMVR]

I am not a pilot but have operated Police Helicopters for many years. For me the Important factor comes from the soundtrack of one of the commentators at the Airshow who said that he thought the Pilot doing the loop was a bit low - And that was said before the crash!

TF

That did not happen.

[airsound]

I can't see this posted anywhere else - and I'm not even sure this is the right place for it, since the 'Trial' finished in 2019.

But anyway, the Inquest is finally due to start on Wednesday 30 November at County Hall North (Parkside), Horsham. It's expected to last till 20 December.

If Mods think a new thread would be more appropriate, I'm sure they'll make the appropriate arrangements!

airsound

[T28B]

I can't see this posted anywhere else - and I'm not even sure this is the right place for it, since the 'Trial' finished in 2019.

But anyway, the Inquest is finally due to start on Wednesday 30 November at County Hall North (Parkside), Horsham. It's expected to last till 20 December.

If Mods think a new thread would be more appropriate, I'm sure they'll make the appropriate arrangements!

airsound
Let's keep it here. Thanks for keeping an eye on that. :ok:

[Asturias56]

It needs to be kept up to date but can we avoid revisiting every aspect that has been flogged to death on here in the past

[Thoughtful_Flyer]

It needs to be kept up to date but can we avoid revisiting every aspect that has been flogged to death on here in the past

Indeed.

Also respect that fact that a jury who, unlike everybody on here heard all the evidence, unanimously found the pilot not guilty on all charges.

[Thoughtful_Flyer]

https://www.bbc.co.uk/news/uk-england-sussex-63813366

[Asturias56]

A coroner has apologised to the families of 11 men who were killed in the Shoreham Airshow tragedy for their seven-year wait for answers.

West Sussex senior coroner Penelope Schofield expressed her "deepest regret" that the ordeal endured by relatives of those who died had been "added to" by delays to the inquest.

The men died when a plane taking part in a display in August 2015 crashed into the A27. A further 13 people were injured. The pilot of the Hawker Hunter plane, Andrew Hill, was charged with 11 counts of manslaughter by gross negligence but found not guilty on all counts in March 2019. He maintains he has no recollection of the crash.

The inquest was originally opened on 2 September 2015 but adjourned in 2018 due to the criminal trial of Mr Hill. The inquest resumed in March 2019 after the trial, but hearings set for September 2020 were adjourned due to the pandemic.

[Thoughtful_Flyer]

The Coroner also explained that the high court had refused her request for access to the cockpit video. The reasons are explained in the greatest detail in the following judgement.....

https://www.bailii.org/ew/cases/EWHC/QB/2022/215.html

It also transpires that the police had, contrary to a court order, retained copies of the video!

"The Chief Constable, represented by Mr Downs, has apologised to the Court for the failure to abide by the terms of the order of this court; and has provided assurances in evidence that processes have now been put in place to ensure that such a breach does not occur in the future."

[tucumseh]

It also transpires that the police had, contrary to a court order, retained copies of the video!

"The Chief Constable, represented by Mr Downs, has apologised to the Court for the failure to abide by the terms of the order of this court; and has provided assurances in evidence that processes have now been put in place to ensure that such a breach does not occur in the future."



I wonder if the Coroner will write to the Home Secretary expressing a ‘matter of concern’ over this unseemly trend?

In the Jon Bayliss case (Red Arrows Hawk XX177, 2018), the police’s retention of Jon’s iPhone was only revealed when MoD’s QC misled the court, claiming MoD had it and it was damaged beyond any data retrieval. (Which is very specific, and he was briefed beforehand as he answered immediately). The Coroner didn’t believe a word and demanded to know the details. MoD had to admit it didn’t have it, and her investigators tracked it down in plod HQ. All data was retrieved. The same claim (outright lie) was made about Jon’s GoPro, yet 24 videos of the day in question and 89 images were retrieved.

In the Mull of Kintyre case, the families still await the return of personal electronic devices and watches. It will be clear to any followers what the latter might reveal, given MoD lied about the entire timeframe. The police have exercised their right to ‘neither confirm nor deny’ possession, citing ongoing terrorism risks. Similarly MoD, who say evidence in an ongoing (!) investigation cannot be returned.

Given this failure to disclose, one wonders how the pilot can receive a fair hearing in any future civil case. Or indeed anyone affected by an accident where the police have at some point held primacy and been allowed to trouser key evidence at will.

[Asturias56]

I'm afraid you can't trust the police to tell the truth all the time

[_Agrajag_]

I'm afraid you can't trust the police to tell the truth all the time

My experience once was that you cannot always trust the AAIB to do the same, either. I attended an inquest many years ago, where the evidence given by the AAIB contradicted that in their report, significantly so, despite their witness being the author of the report. I spoke with the Coroner's Officer at the end of the end and pointed this out, to be told that the Coroner had disallowed the AAIB report from being used as evidence. I have no idea why, or whether the disparity between the report and the evidence given made any difference to the findings by the jury, but it's stuck in my mind as being an example of how bias, perhaps unconscious bias, may change with time and impact the weight applied to events. Not suggesting this is wrong, it may well be that there was additional evidence found after the report was issued, but it did puzzle me as to why the report hadn't been amended, and why the Coroner chose to make the report inadmissible as evidence. I'm not a lawyer though, so it may be that this is normal.

This was pre-internet, so I don't think anyone picked up on it and the media didn't seem to spot it, either. Nowadays "trial be media", or by discussion on the internet, seems to be the way everything is judged. I am not convinced this is commensurate with real justice, and I am equally sure that it is of no comfort to the unfortunate victims.

[DaveReidUK]

Worth summarising the range of verdicts open to a coroner:

accident
industrial disease
natural causes
open verdict
suicide
unlawful killing

[_Agrajag_]

Worth summarising the range of verdicts open to a coroner:

accident
industrial disease
natural causes
open verdict
suicide
unlawful killing


That helps, thanks. The sad case I listened to was an accident, and ruled as such by the jury, so in all probability the significant difference between the cause as given in the AAIB report and the cause as given by the AAIB investigator giving evidence didn't matter. Still seemed odd to me that the report wasn't amended to reflect the two different causes they presented.

[beardy]

Worth summarising the range of verdicts open to a coroner:

accident
industrial disease
natural causes
open verdict
suicide
unlawful killing
As I understand the instruction given to me when I was a juror in a coroner's court the only decisions that can be made are :

Who died
Where they died and
How

BUT, the coroner can then construct a narrative based on the evidence.

The coroner decides who to call to give evidence and the jury can ask questions of the witnesses, the answers form part of the evidence. Cue the coroner leading the jury.

[tucumseh]

To be fair to the AAIB inspectors, their perception over time often changes with the emergence of evidence that has been concealed from them; especially on military accidents where they are only permitted to report on the evidence from the scene. Compare their report from any military accident with that of Shoreham and the differences are obvious. But Shoreham's lacks much critical analysis, so for example omits an assessment of why the Airworthiness Approval Note was predicated on the RAF being Hunter Design Authority; which it isn't, and never was. Therefore, it is unclear who exactly was responsible for many of the violations the AAIB reported. And to be clear, none of this would be apparent to the pilot.

In a civilian accident it is less likely that entire parts of the report will be withheld - for example, we have yet to see the AAIB report on the avionics from Chinook ZD576, which MoD and government has consistently refused to release even to Ministers. And the Inspector was prevented from giving any evidence to any Inquiry. So, we had a situation that his Senior Inspector's evidence to the MoK review in 2011 was quite different than that to the Fatal Accident Inquiry in 1996, which in turn differed from the official report. Not so much contradictory, but more expansive based on what he now knew; especially about the avionics. But yes, the problem is the official reports (MoD, AAIB, CAA) are never updated, so simply quoting the AAIB report at the current Inquest would be very misleading. Most importantly, its report cannot be used to used to apportion blame or liability, at it would be 'against the purposes for which the investigation was undertaken'. This was the subject of a court ruling on Shoreham, where Sussex Police unsuccessfully applied to disclose protected material.

This makes the Coroner's job very difficult, because he/she needs to be able to separate cause of accident and cause of death (accepting one usually leads to the other). It is common for Coroners to conflate the two - see the Bayliss case, where she completely ignored her remit to establish cause of death.

I wonder if the Shoreham Coroner will make the same ruling as the Bayliss Coroner? Witnesses are not to answer questions about events that occurred before they took up their current post. Shuffle a few people around just before the Inquest opens, and proceedings become farcically brief.

[_Agrajag_]

To be fair to the AAIB inspectors, their perception over time often changes with the emergence of evidence that has been concealed from them; especially on military accidents where they are only permitted to report on the evidence from the scene. Compare their report from any military accident with that of Shoreham and the differences are obvious. But Shoreham's lacks much critical analysis, so for example omits an assessment of why the Airworthiness Approval Note was predicated on the RAF being Hunter Design Authority; which it isn't, and never was. Therefore, it is unclear who exactly was responsible for many of the violations the AAIB reported. And to be clear, none of this would be apparent to the pilot.

In a civilian accident it is less likely that entire parts of the report will be withheld - for example, we have yet to see the AAIB report on the avionics from Chinook ZD576, which MoD and government has consistently refused to release even to Ministers. And the Inspector was prevented from giving any evidence to any Inquiry. So, we had a situation that his Senior Inspector's evidence to the MoK review in 2011 was quite different than that to the Fatal Accident Inquiry in 1996, which in turn differed from the official report. Not so much contradictory, but more expansive based on what he now knew; especially about the avionics. But yes, the problem is the official reports (MoD, AAIB, CAA) are never updated, so simply quoting the AAIB report at the current Inquest would be very misleading. Most importantly, its report cannot be used to used to apportion blame or liability, at it would be 'against the purposes for which the investigation was undertaken'. This was the subject of a court ruling on Shoreham, where Sussex Police unsuccessfully applied to disclose protected material.

This makes the Coroner's job very difficult, because he/she needs to be able to separate cause of accident and cause of death (accepting one usually leads to the other). It is common for Coroners to conflate the two - see the Bayliss case, where she completely ignored her remit to establish cause of death.

I wonder if the Shoreham Coroner will make the same ruling as the Bayliss Coroner? Witnesses are not to answer questions about events that occurred before they took up their current post. Shuffle a few people around just before the Inquest opens, and proceedings become farcically brief.


I can understand the AAIB views changing over time, but have a bit of a problem with the reports not being amended to reflect that. These reports are largely about learning from experience, so we all understand errors and problems that have occurred in the past and are better able to try and eliminate them in the future. If we have AAIB reports being used as reference material that are in error, then that dilutes their effectiveness, to the point where people may die in future because the wrong cause is given in the report. That seems to me to fly in the face of one key reason as to why we put so much time and effort into investigating the cause of accidents. Makes me wonder quite why the policy of not amending reports exists.

[Easy Street]

The Coroner also explained that the high court had refused her request for access to the cockpit video. The reasons are explained in the greatest detail in the following judgement.....

https://www.bailii.org/ew/cases/EWHC/QB/2022/215.html



Thank you for posting the link to the High Court judgement. I have read it in full, and would encourage all interested in the case to do so for its crucial exploration of the "cognitive impairment" issue and the background to the "academic" medical paper which proposed the existence of such a phenomenon. Indeed I am surprised it was not commented on here when first published in February - perhaps because it is inconvenient to the arguments of the most active posters on this matter?

If I may be so bold as to summarise: "The paper produced by Mr Hill's friend Dr Mitchell, a paediatrician with no professional expertise or standing in matters of aviation medicine, may have introduced enough doubt to the minds of the trial jury to avert criminal conviction of Mr Hill. However it is not remotely credible as a basis on which to question the AAIB's findings. The principle of non-disclosure of cockpit recordings must not be undermined merely to allow the Coroner to re-investigate a matter which does not need to be re-investigated".

Which says it all, really.

[Iheardthat]

I can understand the AAIB views changing over time, but have a bit of a problem with the reports not being amended to reflect that. These reports are largely about learning from experience, so we all understand errors and problems that have occurred in the past and are better able to try and eliminate them in the future. If we have AAIB reports being used as reference material that are in error, then that dilutes their effectiveness, to the point where people may die in future because the wrong cause is given in the report. That seems to me to fly in the face of one key reason as to why we put so much time and effort into investigating the cause of accidents. Makes me wonder quite why the policy of not amending reports exists.

There is no such policy. Have you looked at the AAIB Monthly Bulletins for October and November? As a newb I cannot paste a link so you will have to search manually through the website www.AAIB.com. While not used every month, Addenda and Corrections is a standing agenda item and both these bulletins include changes to published reports.

[_Agrajag_]

There is no such policy. Have you looked at the AAIB Monthly Bulletins for October and November? As a newb I cannot paste a link so you will have to search manually through the website www.AAIB.com. While not used every month, Addenda and Corrections is a standing agenda item and both these bulletins include changes to published reports.

Thanks. I have just checked back to the report in question. It has not been amended as far as I can tell and still gives the cause for the accident that is contrary to the evidence given by the AAIB investigator who gave evidence to the Coroner's Court. As I mentioned, the disparity almost certainly didn't change the jury's verdict, but it does mean that anyone reading that report today would still be mislead as to the accident cause. The issue in question was whether witness marks from a control cable were indicative of the cause, or whether they were incidental and caused by airframe damage during the break up of the aircraft. The report states they are incidental, the investigators evidence in court stated they were causal.

[Thoughtful_Flyer]

As I understand the instruction given to me when I was a juror in a coroner's court the only decisions that can be made are :

Who died
Where they died and
How

BUT, the coroner can then construct a narrative based on the evidence.

The coroner decides who to call to give evidence and the jury can ask questions of the witnesses, the answers form part of the evidence. Cue the coroner leading the jury.

It is relatively uncommon these days for an inquest to be held before a jury.

Unless there have been any changes that I am unaware of, this inquest will be heard by the coroner sitting alone.

https://www.westsussex.gov.uk/media/14348/shoreham_jury_ruling_2020.pdf

[airsound]

I can confirm that the Coroner, Ms Penelope Schofield, is holding this inquest without a jury.

airsound

[_Agrajag_]

I wonder why some inquests are held with a jury and most are not? The only one I've ever been to had a jury, although I wasn't convinced that their input was that useful. They were directed by the coroner as to the most likely verdict, so clearly that I rather think most of them took it as an instruction. They were only out for a very short time before coming back and delivering the verdict the coroner had pretty much told them to return (accidental death).

[treadigraph]

I went to an unexpected death inquest four years ago and was slightly surprised that the only people present were the coroner, a friend who provided a statement of the deceased's life and me as another friend. Three people... Statements from police and doctor were read out by the Coroner, but I had expected there to be a few more officials! Glad Pete and I went, otherwise the Coroner would have been on her own!

[beardy]

I wonder why some inquests are held with a jury and most are not? The only one I've ever been to had a jury, although I wasn't convinced that their input was that useful. They were directed by the coroner as to the most likely verdict, so clearly that I rather think most of them took it as an instruction. They were only out for a very short time before coming back and delivering the verdict the coroner had pretty much told them to return (accidental death).
Having been a juror at a coroner's inquest I may be able to shed a little light. The jury can ask questions that the coroner may not have the remit to pose. In my case the pertinent questions were about the administrative arrangements for the gold and silver commanders of a police force. Having been aired they became part of the coroner's narrative which exposed systemic weaknesses. Similarly health trust problems can be exposed by a jury. The narrative goes beyond the 'who, where and how' which is the coroner's verdict.

[tucumseh]

I wonder why some inquests are held with a jury and most are not? The only one I've ever been to had a jury, although I wasn't convinced that their input was that useful. They were directed by the coroner as to the most likely verdict, so clearly that I rather think most of them took it as an instruction. They were only out for a very short time before coming back and delivering the verdict the coroner had pretty much told them to return (accidental death).

The Coroners' Service says 'A Coroner will hold an Inquest with a Jury in certain circumstances such as when someone dies in prison or police custody or other state detention such as an immigration detention centre'. This differs significantly from other individual local Coroners' websites which add (e.g.) 'or in circumstances which may affect public health or safety'.

The former definition might explain the current case, but the latter would make it seem a candidate for a jury. Very confusing, but at the end of the day the bereaved rely on the integrity of individual Coroners. Sadly lacking in many of the cases discussed here (recent Hawks, Sea King ASaC), highly commendable in others (Hercules, Nimrod).

At the most recent one I attended, the Coroner had a WTF moment when the GP's report was read out, saying 'this 87-year old a woman...', and it was pointed out to her that the birth and marriage certificates said she was 57. She carried on, but in her decision said the GP's surgery was 'grossly incompetent' and had failed in its duty of care, prescribing the wrong medication. The GP involved quietly retired a few months later. If you want justice, might I suggest popping your clogs in Avon & Somerset.

[_Agrajag_]

Seems a curiously non-standard process to me. I'd always assumed that the way that Coroner's worked was the same everywhere, I had no idea there was so much apparent variation. Then again I've only ever been to one inquest, and only then because I had a personal interest in the accident, having seen it happen and been one of the first on scene. I, wrongly it seems, assumed they all worked in the same way, to the same standards and procedures.

[Chugalug2]

Seems a curiously non-standard process to me. I'd always assumed that the way that Coroner's worked was the same everywhere, I had no idea there was so much apparent variation. Then again I've only ever been to one inquest, and only then because I had a personal interest in the accident, having seen it happen and been one of the first on scene. I, wrongly it seems, assumed they all worked in the same way, to the same standards and procedures.
Give thanks that they don't AJ! As tuc says, some are exemplary in their duties, witness the Oxford Coroner informing the MOD that there is something wrong with their bloody aeroplanes! If they all sang from the same hymn sheet they would merely follow the lead of countless ministers, MPs, members of the HoL, Chief Constables, QCs, etc, etc, in not rocking the boat and sticking to the script. It is a +700-year-old institution that allows Coroners, if they so wish, to put their duty above all other considerations. BZ's to those who choose to do so!

[Thoughtful_Flyer]

I wonder why some inquests are held with a jury and most are not? The only one I've ever been to had a jury, although I wasn't convinced that their input was that useful. They were directed by the coroner as to the most likely verdict, so clearly that I rather think most of them took it as an instruction. They were only out for a very short time before coming back and delivering the verdict the coroner had pretty much told them to return (accidental death).

The coroner can direct the jury that certain verdicts are not appropriate in law, for the case before them, so cannot be used. Sometimes that can mean that only one verdict can reasonably be reached in which case it is not far short of a direction. However, if more than one verdict could reasonably be reached for a particular case, then jury should certainly not be steered as to which of those to return.

It is different from a criminal case where the judge can decide that the evidence on a particular charge is so weak that no reasonable jury could consider convicting. In that case he or she can direct the jury to acquit. What the judge can never do is direct the jury to convict!

[_Agrajag_]

Give thanks that they don't AJ! As tuc says, some are exemplary in their duties, witness the Oxford Coroner informing the MOD that there is something wrong with their bloody aeroplanes! If they all sang from the same hymn sheet they would merely follow the lead of countless ministers, MPs, members of the HoL, Chief Constables, QCs, etc, etc, in not rocking the boat and sticking to the script. It is a +700-year-old institution that allows Coroners, if they so wish, to put their duty above all other considerations. BZ's to those who choose to do so!


Wouldn't it be better if there was some attempt to get all coroners to strive to do things in the way that the best of them do, though? I can't help but feel a certain discomfort in knowing that there is such an apparent degree of variability in carrying out such a key role. I have to say that finding that out here has somewhat dented my faith in what I had assumed was a robust process.

[Thoughtful_Flyer]

The Coroners' Service says 'A Coroner will hold an Inquest with a Jury in certain circumstances such as when someone dies in prison or police custody or other state detention such as an immigration detention centre'. This differs significantly from other individual local Coroners' websites which add (e.g.) 'or in circumstances which may affect public health or safety'.

The former definition might explain the current case, but the latter would make it seem a candidate for a jury. Very confusing, but at the end of the day the bereaved rely on the integrity of individual Coroners. Sadly lacking in many of the cases discussed here (recent Hawks, Sea King ASaC), highly commendable in others (Hercules, Nimrod).

At the most recent one I attended, the Coroner had a WTF moment when the GP's report was read out, saying 'this 87-year old a woman...', and it was pointed out to her that the birth and marriage certificates said she was 57. She carried on, but in her decision said the GP's surgery was 'grossly incompetent' and had failed in its duty of care, prescribing the wrong medication. The GP involved quietly retired a few months later. If you want justice, might I suggest popping your clogs in Avon & Somerset.

Well you could apply that argument to any death, other than the driver, in a road traffic accident.

In the particular case we are discussing how wide would you spread the net? Just a few examples...

Was it an appropriate place to hold an airshow?
Was it only acceptable if the road have been closed?
Although apparently not the cause of this crash, was the aircraft maintained to an adequate standard to be considered safe to display?
Although licenced to conduct the flight were the requirements stringent enough?
Should there be a lower age limit, higher currency requirements, tighter medical requirements?
Should a civilian aircraft be allowed to fly with a live ejection seat (let alone one with expired cartridges)?
And so on.....

How much, if any, of this should be down to a coroner? Should there be a public inquiry? If so, who sets the terms of reference?

Where do you stop?

[tucumseh]

Well you could apply that argument to any death, other than the driver, in a road traffic accident.

In the particular case we are discussing how wide would you spread the net? Just a few examples...

Was it an appropriate place to hold an airshow?
Was it only acceptable if the road have been closed?
Although apparently not the cause of this crash, was the aircraft maintained to an adequate standard to be considered safe to display?
Although licenced to conduct the flight were the requirements stringent enough?
Should there be a lower age limit, higher currency requirements, tighter medical requirements?
Should a civilian aircraft be allowed to fly with a live ejection seat (let alone one with expired cartridges)?
And so on.....

How much, if any, of this should be down to a coroner? Should there be a public inquiry? If so, who sets the terms of reference?

Where do you stop?

Good questions. Let us know if any Coroner gives you a lucid reply! The Coroners' Guidelines offer little help.

[_Agrajag_]

The coroner can direct the jury that certain verdicts are not appropriate in law, for the case before them, so cannot be used. Sometimes that can mean that only one verdict can reasonably be reached in which case it is not far short of a direction. However, if more than one verdict could reasonably be reached for a particular case, then jury should certainly not be steered as to which of those to return.

It is different from a criminal case where the judge can decide that the evidence on a particular charge is so weak that no reasonable jury could consider convicting. In that case he or she can direct the jury to acquit. What the judge can never do is direct the jury to convict!


That is pretty much what happened. After several days of evidence, including two whole days from the AAIB alone, the Coroner ruled out all other options other than accidental death. He was right to do so, in my view, although the disparity between the AAIB evidence given in their report and the very different evidence presented in court caused me to feel slightly uncomfortable at the time. I assume this comes down to the Coroner only being concerned with whether that evidence materially changed the verdict, which I am sure it didn't.

[Thoughtful_Flyer]

Evidence seems to be touching upon some of the points I made in my previous post.....

https://www.bbc.co.uk/news/uk-england-sussex-63876398

[dastocks]

Evidence seems to be touching upon some of the points I made in my previous post.....

https://www.bbc.co.uk/news/uk-england-sussex-63876398

There is a little bit more here:
https://www.theargus.co.uk/news/23174115.shoreham-airshow-disaster-pilot-told-stop-loop/

I'm particularly interested in this quote:

"Mr Dean said he did not see the crash or the build up as he was at a meeting."

I would have thought that one of the fundamental duties of a FDD (Flight Display Director) would be to monitor the display as it is happening; if the FDD needs to be elsewhere this responsibility should be delegated?