Shoreham Airshow Crash Trial

[chevvron]

Without wading through 750 pages, was he using a 'g' suit?.
I ask because on my one Hunter flight my pilot pulled though a loop and I 'greyed' out at 5.5g; he had a 'g' suit, I didn't.
Before you ask we were at about 15,000ft.

[DaveReidUK]

Without wading through 750 pages, was he using a 'g' suit?.

Yes, he was.

[_Agrajag_]

Without wading through 750 pages, was he using a 'g' suit?.
I ask because on my one Hunter flight my pilot pulled though a loop and I 'greyed' out at 5.5g; he had a 'g' suit, I didn't.
Before you ask we were at about 15,000ft.


Not sure, but he should have been aware of the benefit of the anti-G straining manoeuvre (a.k.a "grunt and squeeze") I would have thought. I'm far from being fit and current, but didn't I even notice 4.5g during a bit of fun and games with an aero friend a year or so ago during a birthday treat flight, and its a couple of decades since I'd flown in anything with any sort of performance. It was only afterwards when he commented that we'd pulled about 4.5g in the final loop of the series. I was a bit surprised, to be honest, as it didn't feel close to that. We're alll very different though. I well remember watching a bloke go completely nuts in the hypobaric chamber when his mask was taken off, Took four of us to hold him down whilst the instructor got him back on 100% O2. That was at only 25,000ft, I think. He looked fine when he first took his mask off, doing sums on a pad like a good un, then just completely freaked out.

[airsound]

dastocks, you suggest that ;one of the fundamental duties of a FDD (Flight Display Director) would be to monitor the display as it is happeningYes it is one of his fundamental duties. But another is conducting mandatory briefings of display participants. There is more than one briefing during the day. That was what Rod Dean was doing when the crash happened. His absence was also prolonged by having to consider the possibility of programme changes because of forecast crosswinds outside historic aircraft limits. Incidentally (pedant hat on) - it's Flying Display Director, not Flight Display Director! (pedant hat doffed)

But the Flying Control Committee (FCC) has the duty of monitoring the whole display, whether the FDD is present or not. None of the FCC was present at the inquest when Rod Dean was giving evidence, but he said that the FCC had noticed the low entry height and the strange performance of the first half of the loop: they had discussed a STOP call, but decided that it would be too much of a distraction to the pilot at what was clearly a very busy moment, he said.

I don't believe any of the FCC is due to give evidence. Indeed, the chairman has died since the show.

airsound

[dastocks]

... the FCC had noticed the low entry height and the strange performance of the first half of the loop: they had discussed a STOP call, but decided that it would be too much of a distraction to the pilot at what was clearly a very busy moment, he said.

Thanks for the clarification. I don't think this was covered by the AAIB investigation and it didn't come out in any of the reporting from the criminal trial so it's been nagging for a long time.

[Thoughtful_Flyer]

Thanks for the clarification. I don't think this was covered by the AAIB investigation and it didn't come out in any of the reporting from the criminal trial so it's been nagging for a long time.

It is difficult to see how a "discussion" which ultimately didn't lead to any action was relevant to either.

In any case how could they possibly have discussed it and made a stop call in time? One person making that call on their own judgement might just conceivably have been possible but I fail to see how a group of people could have discussed it quickly enough.

[ShyTorque]

This was an extremely tragic event and understandably the aftermath is immense and far reaching and will linger on for many years.

But as far as the cause goes, it appeared to me, from the first video I saw, was that the aircraft was simply flown beyond its capabilities in that the speed chosen for a loop was more akin to that of a Jet Provost or a light single prop aircraft, rather than a swept wing fast jet (both of which were also flown by the pilot). If he had admitted that he made a mistake this would have caused far less anguish all round.

[H Peacock]

If he had admitted that he made a mistake this would have caused far less anguish all round.

Spot on ST; a simple hand up “Sorry, I screwed up!” rather than all the baloney to ‘find’ an alternative theory! It’s made it all so much worse for the friends and relatives of the unfortunate victims.

[KrisKringle]

It seems like a lot of people 'screwed up' or at least failed to perform their roles to an adequate standard: regulatory, supervisory, management and administration. If any of these roles had been performed diligently, an accident would not have been a tragedy.

[dastocks]

It is difficult to see how a "discussion" which ultimately didn't lead to any action was relevant to either.

In any case how could they possibly have discussed it and made a stop call in time? One person making that call on their own judgement might just conceivably have been possible but I fail to see how a group of people could have discussed it quickly enough.

All I was interested in was a bit more detail on whether a stop call could have been made and why it wasn't.

There might be a lesson to be learned about the display monitoring process because it would seem there are cases where an effective stop call can't be a group decision.

[dervish]

If he had admitted that he made a mistake this would have caused far less anguish all round.

My understanding is he DID admit a mistake, his point being he didn't know why as he could not recall. It was the others who have not yet admitted their mistakes.

[Thoughtful_Flyer]

It seems like a lot of people 'screwed up' or at least failed to perform their roles to an adequate standard: regulatory, supervisory, management and administration. If any of these roles had been performed diligently, an accident would not have been a tragedy.
Exactly ^^^^

A pilot in a single engine plane is one human being. As such there is always the possibility of a mistake or incapacity and if that happens sometimes the consequences can be catastrophic. In other circumstances the same mistake or incapacity may lead to either no damage at all or be confined to the plane itself and / or its pilot.

There are many circumstances around this tragedy that could have been avoided with better planning and also other failings that could potentially have led to a different accident.

For example, as a reaction to this incident, the centre of the airshow display point at Duxford has been moved further from the M11 and the public road that passes the end of the runway at Old Warden is now closed during flying displays. Had similar measures been in place at Shoreham there would have be fewer (if any) casualties.

[_Agrajag_]

Hasn't this always been the case with flight safety? The "I learned about flying from that" series in Air Clues was partly intended to gently highlight that chains of events lead to accidents, all it takes to prevent an accident is one link in the chain to be broken.

Accident reports are full of findings where a sequence of failings led to the accident, often just preventing one of those would have prevented it, or at least lessened its severity.

Who can honestly hold up there hand and say they have never made an error?

I clearly remember two, either of which could have killed me or caused the loss of the aircraft, but by good fortune everyone else had been diligent and so none of the "holes in the Swiss cheese" lined up on those sorties. No one has yet invented the infallible human being, or the perfectly trained one, come to that.

[DaveReidUK]

For example, as a reaction to this incident, the centre of the airshow display point at Duxford has been moved further from the M11 and the public road that passes the end of the runway at Old Warden is now closed during flying displays. Had similar measures been in place at Shoreham there would have be fewer (if any) casualties.

Closing the A27 (as opposed to the unclassified road that runs past Old Warden) would have been hugely disruptive.

[Thoughtful_Flyer]

Closing the A27 (as opposed to the unclassified road that runs past Old Warden) would have been hugely disruptive.

Maybe so. It is not exactly popular with some of the the locals at Old Warden. Particularly as it is seven or eight times a year!

However, if an objective risk assessment says the road needs to be closed for an airshow to take place there are only two options. Close it (if that is possible) or don't hold the airshow at that venue.

Obviously there might be a compromise in some circumstances by excluding certain types of aircraft, restricting their display routine and / or moving the centre point as at Duxford. Duxford has also been to great lengths and expense to stop "freeloaders" assembling and watching from the so called "naughty fields" on the south side of the runway.

Over the years at Duxford there have been several fatal accidents at airshows. They have involved crashes close to the M11, on both sides of the road. Any of these could have been a Shoreham situation. The M11 has also been closed as a result of a model jet aircraft crashing close to the road and setting fire to the cornfield!

Obviously you cannot eliminate all risks. A lot has been done following terrible accidents at Farnborough (and other venues) in the past to protect spectators within the venue. That is all good but to my mind the highest priority must be to protect those who are not involved. If you go to spectate motor racing you are extensively warned that it is dangerous and that you are accepting an element of risk. Fair enough but with airshows and I suppose air races etc the danger extends well outside the venue.

[KrisKringle]

Closing the A27 (as opposed to the unclassified road that runs past Old Warden) would have been hugely disruptive.

Correct. However, the traffic lights at the junction were supposed to be at continuous green, with the side road closed off, to keep the traffic flowing, not backed up in a queue with a needless red light right under the 230m display line. Although the risk assessment was weak, this was a stated area of concern but, for some reason between the organisers and the council, this action to switch the lights to continuous green during the flying display did not occur as it had in previous years.

This and many other deficiencies mentioned in the AAIB report, and in some of the expert statements made at the Old Bailey (I did attend for a few days), underscore a poorly regulated, organised, supervised, managed and administrated event. Sadly, these were not reported in the press with the focus on the pilot's f-up which, in the end, sadly killed 11 people.

[Asturias56]

https://www.bbc.co.uk/news/uk-england-sussex-64040265Shoreham air crash victims unlawfully killed, coroner concludesEleven men who died when a jet crashed on a dual carriageway during an air show were unlawfully killed, a coroner has concluded.

The men died when a Hawker Hunter plane crashed on the A27 in West Sussex as it carried out a stunt at the Shoreham Airshow on 22 August 2015.

The pilot, Andrew Hill, was cleared of manslaughter by gross negligence (https://www.bbc.co.uk/news/uk-england-47495885). Coroner Penelope Schofield said the plane crashing was "a result of the manner in which it was flown".
A series of errors was serious enough to reach a conclusion, on the balance of probabilities, that the men had been killed as a result of gross negligence manslaughter, she told the inquest in Horsham. The victims played "no part" in causing their own deaths, the West Sussex coroner added.

A number of the victims' family members were present and in tears as the conclusion was delivered. Ms Schofield said: "Eleven innocent lives were cruelly lost, lives that were cut too short.
This huge loss will be borne by their families for the rest of their lives."

Mr Hill has always maintained he has no recollection of the crash. His defence at his trial in 2015 argued he had been suffering from "cognitive impairment". An Air Accidents Investigation Branch (AAIB) inquiry concluded that the crash could have been avoided and was caused by pilot error when Mr Hill flew too low and too slowly while carrying out a manoeuvre. All 21 safety recommendations made by the AAIB were accepted by the Civil Aviation Authority (CAA).

They included a review into whether changes should be made to the minimum distance required between the public and display aircraft, and a review of guidance for air show organisers, including how they carry out risk assessments.

[uxb99]

https://www.bbc.co.uk/news/uk-england-sussex-64040265Shoreham air crash victims unlawfully killed, coroner concludesEleven men who died when a jet crashed on a dual carriageway during an air show were unlawfully killed, a coroner has concluded.

The men died when a Hawker Hunter plane crashed on the A27 in West Sussex as it carried out a stunt at the Shoreham Airshow on 22 August 2015.

The pilot, Andrew Hill, was cleared of manslaughter by gross negligence (https://www.bbc.co.uk/news/uk-england-47495885). Coroner Penelope Schofield said the plane crashing was "a result of the manner in which it was flown".
A series of errors was serious enough to reach a conclusion, on the balance of probabilities, that the men had been killed as a result of gross negligence manslaughter, she told the inquest in Horsham. The victims played "no part" in causing their own deaths, the West Sussex coroner added.

A number of the victims' family members were present and in tears as the conclusion was delivered. Ms Schofield said: "Eleven innocent lives were cruelly lost, lives that were cut too short.
This huge loss will be borne by their families for the rest of their lives."

Mr Hill has always maintained he has no recollection of the crash. His defence at his trial in 2015 argued he had been suffering from "cognitive impairment". An Air Accidents Investigation Branch (AAIB) inquiry concluded that the crash could have been avoided and was caused by pilot error when Mr Hill flew too low and too slowly while carrying out a manoeuvre. All 21 safety recommendations made by the AAIB were accepted by the Civil Aviation Authority (CAA).

They included a review into whether changes should be made to the minimum distance required between the public and display aircraft, and a review of guidance for air show organisers, including how they carry out risk assessments.

What effect does this have on the outcome? What's the point in this ruling?

[pasta]

What effect does this have on the outcome? What's the point in this ruling?
From the Sky News report at https://news.sky.com/story/eleven-men-who-died-in-2015-shoreham-airshow-plane-crash-were-unlawfully-killed-coroner-rules-12772021:
Following the conclusion, Sarah Stewart, partner at law firm Stewarts, who represented a number of families in the disaster, said: "The families we represent would like to thank the senior coroner for her thorough investigation."The bereaved families have waited more than seven years to reach this point and, although the senior coroner's conclusion will not ease the pain of their loss, their voices have been heard."
If it helps the families of the victims in some way, that seems like sufficient justification.

[_Agrajag_]

Does the change in the double jeopardy law have any impact?

Might it now be possible for Andrew Hill to face a re-trial, on the basis of the findings by the coroner?

I'm not sure that anything would be gained from doing so, in terms of true justice. Nothing changes the fact that these innocent people were killed, nor that human error was the cause of their death. Very sad as events like these are, I'm never really sure that prolonged legal action ever really makes anyone feel any better about the tragic outcome, other than the results from an inquest. I suspect that the same will be true for other tragic events involving the loss of life. Grenfell Tower springs to mind, and with no wish to go off-topic I strongly suspect that none of those guilty of errors and deliberate corner cutting will face criminal charges.

[Yellow Sun]

Does the change in the double jeopardy law have any impact?

Might it now be possible for Andrew Hill to face a re-trial, on the basis of the findings by the coroner?

The following should help clarify the situation:

Ms Schofield ( the coroner) said that although she recorded a narrative verdict of unlawful killing, it did not "detract from the fact" Mr Hill was acquitted in a criminal court in 2019.

​​​​​​​YS

[_Agrajag_]

The following should help clarify the situation:



​​​​​​​YS


Many thanks, I had missed that.

[Easy Street]

The standard of proof for all Coroner's Court decisions, including unlawful killing, has been 'the balance of probabilities' since a Supreme Court judgement (https://www.supremecourt.uk/cases/docs/uksc-2019-0137-judgment.pdf) in November 2020. Conversely Mr Hill's acquittal reflects the higher test of 'beyond reasonable doubt' applicable to criminal proceedings. What this verdict does is confirm that it was more likely than not Mr Hill's fault that the bystanders were killed, and that he very likely owes his freedom to his lawyers and the 'cognitive impairment' argument authored by his non-AvMed qualified paediatrician friend, which the jury evidently considered as having introduced reasonable doubt at his criminal trial.

[H Peacock]

I believe that the vast majority of people who have flown ac similar to the Hunter or flown a relatively dynamic routine at an Airshow will opine that AH’s ‘mishandling’ was indeed the root cause of this tragedy; the Coroner has obviously agreed, so this does bring some closure to the friends and relatives of the people that died as a direct result of AH’s avoidable error(s).

[Pozidrive]

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.

It isn't "non-standard", think of it as a flexible process. Coroners cover everything from an elderly person dying after a fall, the Shoreham case discussed here, through to the really big ones - Hillsborough, Lockerbie etc. All done within the same standards and procedures, and it works very well.

[biscuit74]

What effect does this have on the outcome? What's the point in this ruling?

The Coroner is obliged to rule on what, in her opinion was the underlying cause or causes. That she has now done.
This gives some clarity to the victims' relatives and friends, unlike the rather poorly handled criminal trial. This verdict seems to accord with the views of quite a number of people with appropriate & relevant aviation experience, sadly.

It is, I think, quite feasible that civil prosecution(s) of Mr Hill could follow, perhaps either to try to get fuller acknowledgement from him or for damages. Not necessarily very useful, but possible.

[KrisKringle]

The Coroner is obliged to rule on what, in her opinion was the underlying cause or causes. That she has now done.
This gives some clarity to the victims' relatives and friends, unlike the rather poorly handled criminal trial. This verdict seems to accord with the views of quite a number of people with appropriate & relevant aviation experience, sadly.

It is, I think, quite feasible that civil prosecution(s) of Mr Hill could follow, perhaps either to try to get fuller acknowledgement from him or for damages. Not necessarily very useful, but possible.

The criminal trial may not have been the verdict that many biased by news snippets and rumour wanted to hear but 'poorly handled' it was not. I get it, we want someone to pin all the blame for a tragedy, that is human nature, and the pilot who ultimately caused the crash is the obvious person. This coroner's verdict saves the complexity of investigating those that set up an unsafe environment for which only a public enquiry could have the time and resources to explore.

However, If you mean 'poorly handled' is listening to a broad range of experts and witnesses under cross-examination by the UK's best QCs in front of an impartial judge and jury then I would suggest you views of the criminal trial is bizarrely warped. Did this coroner seek a broad range of SMEs with different analyses and opinions and did she, or the lawyers represented, cross examine them? Did she only seek those experts who had a purpose to hide their own (or their organisation's) deficiencies which set up the inevitable tragedy? I don't know as I've only read news snippets.

[H Peacock]

Come on KK; the Hunter crashed because the loop was mishandled!

Dreadfully unfortunate where it crashed, and I understand the desire by some to blame the Display organiser, but if the manoeuvre had been properly flown then the accident wouldn't have happened!

[KrisKringle]

Come on KK; the Hunter crashed because the loop was mishandled!

Dreadfully unfortunate where it crashed, and I understand the desire by some to blame the Display organiser, but if the manoeuvre had been properly flown then the accident wouldn't have happened!

Come on HP. Of course, the manouvre was mishandled but also misconceived, so it crashed. That was the pilot's error and mistake and so indicative of a lack of oversight and supervison. But it seems as if you are insinuating this was a safe venue / event? An accident on the liveside of a display should never lead to a tradgedy. I could list all the accidents and nearmisses at Shoreham Airshow (some reported and some not) but I do need to get some sleep.

[safetypee]

The more this discussion considers 'cause' and 'blame' the less opportunity there is to learn.

The emotion of death distracts. Consider a different outcome, just a few feet one way or the other, or higher, then the tabloid headlines would be 'hero remains in aircraft to avoid the road', …
This discussion would be reframed; luck, good judgement, etc.

We overlook the effects and power of outcome bias and frame of reference for the event - how we wish to see it opposed to the actors viewpoint within the event, at that time.

Either side of a fatal event or not there is opportunity to learn; we must take this opportunity. Avoid 'human error' (cause, blame), and look for the how and what to learn.


https://cimg6.ibsrv.net/gimg/pprune.org-vbulletin/800x600/hindsight_101_e88a102025b51c9c34d5270d99d601e3e8c737db.jpg

[Just This Once...]

All valid points but if Mr Hill had ploughed into this junction in a lorry, at the wrong speed and in the wrong lane, we would not bat an eyelid at the thought of him being prosecuted and found guilty. He was not found guilty of course because of a new medical phenomena that nobody had heard of before, or since.

[Bob Viking]

AH’s defence team went to great lengths at his criminal trial to have him found not guilty because nobody could prove that cognitive impairment had not happened. The coroner stated that there was no evidence of impairment due to G forces. That is a very interesting clash of legal standpoints.

I realise it is probably too late for anything else to happen now but if I were a family member of the deceased I would still not feel that justice has been done.

We could argue about this until our dying days but the bottom line is that an inexperienced and under qualified individual was doing low level aerobatics at a venue that was unsuitable (at least unsuitable for an inexperienced and under qualified pilot).

I was not at the trial and I have not been through everything with a fine toothed comb but I have watched the videos in the public domain. That aircraft was being flown until impact.

I understand that there are those that still wish to defend AH and all credit to you. But there are those of us that have enough experience of flying jets to still know that a clever legal defence cannot change facts.

BV

[_Agrajag_]

AH’s defence team went to great lengths at his criminal trial to have him found not guilty because nobody could prove that cognitive impairment had not happened. The coroner stated that there was no evidence of impairment due to G forces. That is a very interesting clash of legal standpoints.

I realise it is probably too late for anything else to happen now but if I were a family member of the deceased I would still not feel that justice has been done.

We could argue about this until our dying days but the bottom line is that an inexperienced and under qualified individual was doing low level aerobatics at a venue that was unsuitable (at least unsuitable for an inexperienced and under qualified pilot).

I was not at the trial and I have not been through everything with a fine toothed comb but I have watched the videos in the public domain. That aircraft was being flown until impact.

I understand that there are those that still wish to defend AH and all credit to you. But there are those of us that have enough experience of flying jets to still know that a clever legal defence cannot change facts.

BV

This is really just an illustration as to how our legal system works, and why it should (in my view) continue to work this way. To be found guilty the jury need to be convinced "beyond all reasonable doubt". It is the prosecution's job to do that. In the criminal hearing the defence introduced enough "reasonable doubt" for the jury to remain unconvinced that the prosecution had made a strong enough case. That is how it should be - if we lower that standard then we risk more people being wrongly convicted.

The flaw with the height of the bar we have fixed in place before someone can be convicted is that some of the guilty walk free. I think we all know this and see this every day in our courts, even if most cases don't make the headlines as this one did. Nothing that Andrew Hill's defence team did was ruled as being wrong or unlawful: had it been, the judge could have intervened to resolve any points of law involved (with the jury out of the court whilst this happened). The judge was content for the evidence of impairment to be heard, and that evidence most probably swung the verdict.

I'm sure there are lots of detailed legal points surrounding both the competence of expert witnesses and whether an expert witness may be biased.

The question this case raises is whether the defence expert witness was competent. My instinctive feeling is that he may have been a very good doctor, and well-qualified, but that he lacked experience of aero-medicine, and that may not have been made clear to the jury.

[Asturias56]

Folks - we're going back to the original arguments. I don't think any one has changed their minds - whatever conclusion you, personally came to won't chnage

I suggest we don't refight the same issues at enormous length.

[Bob Viking]

On the contrary. I think we’re all a little more free to say what we really think now. That luxury was not afforded to us previously.

While I’m on the subject don’t you think it’s a bit weird that someone who, by his own admission, is neither ex or current military nor an aviator would hang about in this forum trying to discourage chat about a subject of great interest to ex and current military aviators and non aviators alike?

Or should this forum fully degrade into somewhere to discuss BBQs and nothing else?

BV

[downsizer]

On the contrary. I think we’re all a little more free to say what we really think now. That luxury was not afforded to us previously.

While I’m on the subject don’t you think it’s a bit weird that someone who, by his own admission, is neither ex or current military nor an aviator would hang about in this forum trying to discourage chat about a subject of great interest to ex and current military aviators and non aviators alike?

Or should this forum fully degrade into somewhere to discuss BBQs and nothing else?

BV

Pretty much there are we not?

[Thoughtful_Flyer]

The Coroner is obliged to rule on what, in her opinion was the underlying cause or causes. That she has now done.
This gives some clarity to the victims' relatives and friends, unlike the rather poorly handled criminal trial. This verdict seems to accord with the views of quite a number of people with appropriate & relevant aviation experience, sadly.

It is, I think, quite feasible that civil prosecution(s) of Mr Hill could follow, perhaps either to try to get fuller acknowledgement from him or for damages. Not necessarily very useful, but possible.

There may be civil claims for damages but there cannot be a "civil prosecution". Very rarely there can be a "private prosecution" but not in this case. With very few exceptions, which wouldn't apply here, you cannot be prosecuted again having been found not guilty by a jury.

[safetypee]

Although the difference in our industry between safety and legal process is narrowing (society in general); discussions should avoid intermixing the views.

One view learns, or should learn; the other punishes, then claims to have learnt.

[Thoughtful_Flyer]

Does the change in the double jeopardy law have any impact?

Might it now be possible for Andrew Hill to face a re-trial, on the basis of the findings by the coroner?



No and no.

For the reasons stated in my post above.

[Treble one]

The 'beyond reasonable doubt' factor was the key to the accquital in the criminal trial of course. Whether the supposed cognitive impairment met that criteria can certainly be argued, but obviously the jury thought so.

[Squat switch]

The legal process has had its say whether you agree with the outcome or not. Only AH may have the full facts, regardless he will have to live with events of the day for the remainder of his time.

[tucumseh]

As a non-pilot I am in no position to comment on airmanship; and won’t, except to repeat something said before, that the pilot fully admitted he screwed up, but didn’t know why. Hence his defence, which I can’t comment on either.

But there is no way the Coroner conducted a thorough investigation. She was hidebound by the restrictive High Court ruling regarding the AAIB report, making the scope of her Inquest very narrow. She could take no account of the prior negligence set out in the report. There is no ‘balance’ to her ‘balance of probabilities’ test, as mitigating evidence was not allowed to be heard. Hers is judicial truth, not the actual truth. One needs the latter to prevent recurrence, which is meant to be one of her primary aims.

As an engineer I’d like to see a comprehensive Inquiry into why the pilot was given an aircraft that had no valid airworthiness or serviceability certification, and was not fit for purpose. Any engineer reading the AAIB report will tell you one thing. That aircraft should not have been flying. The state of the fuel pump diaphragm alone tells you that.

Perhaps the RAF (not MoD) could have offered as a witness a member of its Hunter Design Authority team? Sarcastic? Yes. But fundamental. What complete **** allowed that premise through the certification process?

[DaveReidUK]

As a non-pilot I am in no position to comment on airmanship; and won’t, except to repeat something said before, that the pilot fully admitted he screwed up, but didn’t know why. Hence his defence, which I can’t comment on either.

But there is no way the Coroner conducted a thorough investigation. She was hidebound by the restrictive High Court ruling regarding the AAIB report, making the scope of her Inquest very narrow. She could take no account of the prior negligence set out in the report. There is no ‘balance’ to her ‘balance of probabilities’ test, as mitigating evidence was not allowed to be heard. Hers is judicial truth, not the actual truth. One needs the latter to prevent recurrence, which is meant to be one of her primary aims.

Which of the alternative verdicts available to a Coroner do you think she should have delivered ?

[biscuit74]

The criminal trial may not have been the verdict that many biased by news snippets and rumour wanted to hear but 'poorly handled' it was not. I get it, we want someone to pin all the blame for a tragedy, that is human nature, and the pilot who ultimately caused the crash is the obvious person. This coroner's verdict saves the complexity of investigating those that set up an unsafe environment for which only a public enquiry could have the time and resources to explore.

However, If you mean 'poorly handled' is listening to a broad range of experts and witnesses under cross-examination by the UK's best QCs in front of an impartial judge and jury then I would suggest you views of the criminal trial is bizarrely warped. Did this coroner seek a broad range of SMEs with different analyses and opinions and did she, or the lawyers represented, cross examine them? Did she only seek those experts who had a purpose to hide their own (or their organisation's) deficiencies which set up the inevitable tragedy? I don't know as I've only read news snippets.


What I read of the trial suggested that some of the 'expert' testimony was dubious at best - and didn;t seento be challenged satisfactorily. That is all I meant. The whole thrust of the defence was flimsy, but a good (and probably expensive!) lawyer ensured that just enough doubt was sown in the minds of those concerned with making the decision. That is the job of the defence lawyer; its up to the prosecution - or the judge if felt necessary - to deal with that.

I think Bob Viking's posts sum it up well.

[biscuit74]

There may be civil claims for damages but there cannot be a "civil prosecution". Very rarely there can be a "private prosecution" but not in this case. With very few exceptions, which wouldn't apply here, you cannot be prosecuted again having been found not guilty by a jury.

Thanks, Thoughtful Flyer. My error. A civil claim, of course.

[mopardave]

Does his defence of cognitive impairment not open the door for this "defence" to be trotted out for all sorts of (thinking RTC's) scenario's now? I can't imagine the relatives have some sense of "closure".......more a sense of injustice! His very skilled defence team won........doesn't mean it's the right verdict!

[Pozidrive]

Does his defence of cognitive impairment not open the door for this "defence" to be trotted out for all sorts of (thinking RTC's) scenario's now? I can't imagine the relatives have some sense of "closure".......more a sense of injustice! His very skilled defence team won........doesn't mean it's the right verdict!

It already happens. Similar "defences" have been used for years, transient physical or medical problems, one-off mechanical defects that can't be traced. It's all part of the legal game.
.

[Pozidrive]

....As an engineer I’d like to see a comprehensive Inquiry into why the pilot was given an aircraft that had no valid airworthiness or serviceability certification, and was not fit for purpose. Any engineer reading the AAIB report will tell you one thing. That aircraft should not have been flying. The state of the fuel pump diaphragm alone tells you that....

The report did open a can of worms on the maintenance of ageing aircraft. I haven't heard any details, I haven't looked, but I'd hope the CAA has been having a bit of a crack-down.

[tucumseh]

Which of the alternative verdicts available to a Coroner do you think she should have delivered ?

Dave, I think 'open' is perhaps the obvious one, given her court being denied sufficient evidence. She was in a very difficult position, as she knew of the serious failings exposed by the AAIB. Her finding might initially please the bereaved, but they'll soon be frustrated. I'd hazard a guess the underlying failings have not been explained to them in any detail. A quirk of our legal system that allows the entire population to read the evidence, yet not allow it heard in court.

But discussing only the final act, in the face of accepted evidence the aircraft should not have flown, flies in the face of all proper investigative protocols and natural justice. As I said, the aims of the Inquest could not be met, therefore the entire process was tainted. I suppose she could have followed the lead of (for example) the previous NW Wales Coroner, by simply refusing to hold a mandatory Inquest. The Chief Coroner allowed that, so why not here? Politics I'm afraid.

[megan]

The link may give those interested in UK pilot prosecution matters a bit of background.

https://core.ac.uk/download/pdf/147637712.pdf

[DaveReidUK]

Dave, I think 'open' is perhaps the obvious one, given her court being denied sufficient evidence. She was in a very difficult position, as she knew of the serious failings exposed by the AAIB. Her finding might initially please the bereaved, but they'll soon be frustrated. I'd hazard a guess the underlying failings have not been explained to them in any detail. A quirk of our legal system that allows the entire population to read the evidence, yet not allow it heard in court.

I disagree. An open verdict would have been entirely inappropriate.

The Coroner's responsibility is basically to establish how the deceased came by their death(s). In this case 15 people died as a result of an aircraft impacting the ground. That fact remains undisputed whether or not the scope of the inquest is widened to consider the chain of events and causal factors that led to the event - Coroners are not expected and do not need to be accident investigators,

[ehwatezedoing]

The 'beyond reasonable doubt' factor was the key to the accquital in the criminal trial of course. Whether the supposed cognitive impairment met that criteria can certainly be argued, but obviously the jury thought so.
Well, that his judgement was impaired one way or another is hard to deny. You don't voluntary launch yourself into a loop without room to recovery unless you have suicidal tendency. So, without going too deep into the argument I can understand why it leaned towards that kind of result at the end.

My point of view only.

[charliegolf]

Coroners are not expected and do not need to be accident investigators,

Dave, my understanding is that coroners do indeed have investigatory resources available to them, to support their findings. I believe they have experienced serving police officers seconded to them.

CG

[tucumseh]

I disagree. An open verdict would have been entirely inappropriate.

The Coroner's responsibility is basically to establish how the deceased came by their death(s). In this case 15 people died as a result of an aircraft impacting the ground. That fact remains undisputed whether or not the scope of the inquest is widened to consider the chain of events and causal factors that led to the event - Coroners are not expected and do not need to be accident investigators,

Dave

I respect your opinion.

The Coroner's responsibility also includes making recommendations to prevent recurrence. They are not expected to re-investigate unless, for example, there was an obvious deficiency in the original investigation. This is the argument that persists in so many military accidents/Inquests, as military investigations are nothing of the kind. This was reiterated a year ago in the Coroner's decision in the Jon Bayliss case, where she ruled the MAA was not independent and had omitted much from the official report. It is why all Coroners have investigators, who are very often retired senior police detectives. They came to the fore in the Bayliss case by tracking down evidence MoD denied the existence of.

Many of the same issues arose here, with those who investigated allowed to judge their own case. Especially, the serious certification failures noted but not explained by the AAIB (itself a deficiency) were put to the CAA, who were allowed to judge their own case. But the Coroner was not allowed to 'go there', it taking a High Court ruling to stop her. So, the question remains. Given, as you say, the aircraft crashing caused the deaths, why was it flying when the AAIB report set out why it should not?

[Easy Street]

Well, that his judgement was impaired one way or another is hard to deny. You don't voluntary launch yourself into a loop without room to recovery unless you have suicidal tendency. So, without going too deep into the argument I can understand why it leaned towards that kind of result at the end.

My point of view only.

Responsibility for this accident extends beyond the mishandling of the loop. The very fact that AH was conducting LL aerobatics at such a constrained site raises, in my view, other issues of culpability: both of himself and the show organisers. Putting yourself, or someone else in a position where an involuntary error brought on by lack of currency or experience could easily prove fatal is just as much a culpable misjudgment as knowingly entering a loop too low. You wouldn't expect a junior surgeon (or their employing hospital) to be able to plead 'temporary medical impairment' as a defence to a fatal error in a non-emergency surgical procedure which was attempted despite it being outside the individual's capability, even if they had got away with it on previous occasions.

[Chugalug2]

Now that the coroner has issued her finding all should be clear. A terrible tragedy occurred at Shoreham which has been the subject of an Accident Investigation, A High Court verdict and a ruling, and a Coroner's finding. No stone has been left unturned by our legal and investigative institutions and we may be confident that all has been revealed and appropriate action taken. Or is this simply another example of the protecting of public bodies, be they County Councils or Air Regulators and Investigators? Not unexpectedly the focus has returned to the pilot, but is that sufficient? As tuc points out, the aircraft should not have been flying at all, let alone carrying out aerobatic manoeuvres over a backed up and congested major road. Am I alone in feeling a distinct sense of unease about how this has all now seemingly finished up, after so called due process?

[PoacherNowGamekeeper]

https://www.bbc.co.uk/news/uk-england-sussex-64040265Shoreham air crash victims unlawfully killed, coroner concludesEleven men who died when a jet crashed on a dual carriageway during an air show were unlawfully killed, a coroner has concluded.

The men died when a Hawker Hunter plane crashed on the A27 in West Sussex as it carried out a stunt at the Shoreham Airshow on 22 August 2015.

The pilot, Andrew Hill, was cleared of manslaughter by gross negligence (https://www.bbc.co.uk/news/uk-england-47495885). Coroner Penelope Schofield said the plane crashing was "a result of the manner in which it was flown".
A series of errors was serious enough to reach a conclusion, on the balance of probabilities, that the men had been killed as a result of gross negligence manslaughter, she told the inquest in Horsham. The victims played "no part" in causing their own deaths, the West Sussex coroner added.

A number of the victims' family members were present and in tears as the conclusion was delivered. Ms Schofield said: "Eleven innocent lives were cruelly lost, lives that were cut too short.
This huge loss will be borne by their families for the rest of their lives."

Mr Hill has always maintained he has no recollection of the crash. His defence at his trial in 2015 argued he had been suffering from "cognitive impairment". An Air Accidents Investigation Branch (AAIB) inquiry concluded that the crash could have been avoided and was caused by pilot error when Mr Hill flew too low and too slowly while carrying out a manoeuvre. All 21 safety recommendations made by the AAIB were accepted by the Civil Aviation Authority (CAA).

They included a review into whether changes should be made to the minimum distance required between the public and display aircraft, and a review of guidance for air show organisers, including how they carry out risk assessments.
21 Safety Recommendations? 31, actually.

[tucumseh]

21 Safety Recommendations? 31, actually.

It's not so much the number of recommendations but:

(a) How many were already mandated, and,
(b) The CAA's response to some of them, revealing an alarming incompetence or lack of corporate knowledge.

In other words, the same as any MoD report.

This has all been done to death, but the one example that might interest military pilots and engineers is the CAA response to safety recommendation 2015-044, of 8 April 2016. It's complete nonsense, ignoring the concept of (e.g.) the Difference Data Manual and modification procedures/classification.

The HSE made exactly the same mistake in the Sean Cunningham case. The Difference Data Manual is what proves Martin-Baker provided the information on seat servicing that MoD and the HSE claimed had not been provided. The AAIB's Shoreham report contains multiple references to the same manuals that the HSE denied the existence of. As the HSE contributed a significant proportion of the AAIB report, it must know this, so offering even more evidence that it knowingly lied to the M-B trial judge. Linkages....

[DaveReidUK]

21 Safety Recommendations? 31, actually.

I assume that the BBC reference is to the original 21 Safety Recommendations made in the 2015/2016 AAIB Special Bulletins following the accident.

A further 11 were made in the 2017 Aircraft Accident Report, making 32 in total.

[Thoughtful_Flyer]

Does his defence of cognitive impairment not open the door for this "defence" to be trotted out for all sorts of (thinking RTC's) scenario's now? I can't imagine the relatives have some sense of "closure".......more a sense of injustice! His very skilled defence team won........doesn't mean it's the right verdict!

It doesn't mean it was the wrong verdict either.

The jury, selected at random, who unlike you heard all the evidence did not consider the case proved beyond reasonable doubt. That is not guilty and the end of the matter.

[Bob Viking]

I may be wrong and I haven’t checked through every post but there is something that jumps out to me from this thread and chats at work. That is the fact that the most sceptical cohort when it comes to the CI defence are fast jet pilots. What does that tell you? The jury may have heard all the evidence but I’m willing to bet that very few of them understood the rigours of manoeuvring under G and could probably have been convinced that AH saw fairies if a doctor had suggested it.

Proof beyond reasonable doubt was a very high bar and probably impossible to achieve. It doesn’t exonerate him though.

BV

[Treble one]

Well, that his judgement was impaired one way or another is hard to deny. You don't voluntary launch yourself into a loop without room to recovery unless you have suicidal tendency. So, without going too deep into the argument I can understand why it leaned towards that kind of result at the end.

My point of view only.

Fair enough. Just wondering when the CI began and ended? It had certainly ended just before impact when it seems like AH was pulling like mad to avoid collision with the ground (wing rock)? It just seems that The CI occurring at some specific part of the accident manoeuvre, when there was no evidence of any previous CI during the flight, or even during his career (I believe?), is rather a lot of holes lining up in some cheese at a rather inopportune moment?

[Timmy Tomkins]

I suppose this saga highlights the drawbacks of prosecutions following accidents crashes. The need to protect oneself in court doaoes not encourage a "mea culpa this is how I screwed up" statement.

[DaveReidUK]

The need to protect oneself in court does not encourage a "mea culpa this is how I screwed up" statement.

You could equally argue that it does.

Pleading guilty at the earliest opportunity gets you a third off any custodial sentence, and the sentence itself will take account of any mitigating factors, including contrition on the part of the defendant.

[biscuit74]

Well, that his judgement was impaired one way or another is hard to deny. You don't voluntary launch yourself into a loop without room to recovery unless you have suicidal tendency. So, without going too deep into the argument I can understand why it leaned towards that kind of result at the end.

My point of view only.

The obvious snag with that argument is that no-one (except the seriously mentally disturbed) takes off deliberately intending to have an accident, yet accidents happen. Most of them due to our human errors and mis-perceptions.

Far too many pilots have hit the ground due to errors in apparently simple maneouvres. 'Cognitive impairment' in every case, or simple mis-judgements plus possible lack of currency, lack of adequate oversight and inadequate practice - especially of the 'get-out' manoeuvres? I understans tucumseh's very valid points, but the serviceability of the aircraft is likley a red herring. More than that - if the aircraft was not performing satisfactorily, all the more reason and justification for an early abandonment of the maneoeuvre. It is hard when it is in public view becasue you feel reputation is on the line, but if safety really matters.it is the right action.

That said, clearly that was a successful effort by the defence to cloud the issue.

[mopardave]

It doesn't mean it was the wrong verdict either.

The jury, selected at random, who unlike you heard all the evidence did not consider the case proved beyond reasonable doubt. That is not guilty and the end of the matter.

Oh, well that's alright then. Not the end of the matter for the families.

[alfred_the_great]

I suppose this saga highlights the drawbacks of prosecutions following accidents crashes. The need to protect oneself in court doaoes not encourage a "mea culpa this is how I screwed up" statement.

A Just Safety Culture does not remove the ability to hold people (criminally) accountable.

[Bob Viking]

Tucumseh will doubtless explain it much better than me but I think you may have misunderstood his point slightly. His point is not that the aircraft was not functioning correctly. It is more about the fact that it should not have been flying from a legal standpoint.

Think of it like driving without an MOT. Your car will function perfectly well without the certificate but if you were to crash, your insurance is completely invalid.

BV

[tucumseh]

BV. Couldn't have said it better. I'd add that there is an obligation to address issues and factors that, while they may not have contributed directly to a particular accident, were nevertheless identified as failings (and in this case violations) and may cause or contribute to recurrence.

That obligation is seldom met. In this case, as I said, those responsible were permitted to judge their own case; and guess what......

Biscuit is correct when saying:

"The obvious snag with that argument is that no-one takes off deliberately intending to have an accident, yet accidents happen. Most of them due to our human errors and mis-perceptions."

The pilot was charged with gross negligence manslaughter. The prosecution therefore had to prove a degree of intent to disregard or be indifferent to obvious risks. Very difficult I suggest. But it is quite easy to demonstrate against others, if for example they have been warned as to the effect of their illegal actions, and they persist.

As for aircraft serviceability - it wasn't, on many counts. The reason I mentioned the buggered fuel pump was that there were two distinct 'atypical power reductions' during the final manouevre, and it could not be demonstrated who or what caused these. Peel back one layer (the incorrect servicing instructions) and you come to the invalid permit to fly, which says the RAF is responsible for maintaining these.

[BEagle]

From the AAIB report:

The investigation identified a degraded diaphragm in the engine fuel control system, which could no longer be considered airworthy. However, the engine manufacturer concluded it would not have affected the normal operation of
the engine.

[_Agrajag_]

Putting aside the human factors element, the inquest and the criminal prosecution, this event does highlight the fine line between wanting to see old aircraft fly and the way in which we can maintain them and keep them airworthy, doesn't it?

Ex-military types seem to be covered by a patchwork of bits of different regulatory regimes. Many operate under Permits to Fly, but with a varying basis for who holds responsibility for airworthiness, who regulates the specialists skills of inspectors, who assesses the technical competence of those that maintain them, whether the skills and knowledge of the regulators themselves are adequate, etc.

We all know about skills fade with time. We all know that there is knowledge that is key to flight safety but that isn't written down clearly, but passed by word of mouth (shouldn't be the case but it has always been thus). Couple that with the pressure to get aircraft like this airworthy and performing in front of many thousands of people that very much want to see them fly, and fly at the edge of their safe envelope, and it seems inevitable that there are likely to be airworthiness issues. I know these didn't seem to contribute in this case, but it has highlighted them.

I remember talking with one of the engineers at Goodwood that helped look after ML407, years ago. He mentioned that there were a handful of people that had the knowledge and understanding to keep aircraft like that airworthy, and that if anything happened to them then there was a fair chance that they would be grounded, at least here in the UK. No one wants that, but it seems to me that keeping older types flying at displays is very much reliant on the deep pockets of a few enthusiasts and the committent of many more who freely give their time to both learn about and help to look after this small and varied fleet.

Hard to see a way to fix this, given the disparity of different types, their increasing age, and the inevitable loss in old maintenance and repair skills.

[biscuit74]

Thanks Bob - and tucumseh and agrajag. I reckon we are all thinking on fairly similar lines: I mulled this again last night. The serviceability errors/failures/oversights were - like the inadequacies in pilot oversight and continuation training, indicative of an attitude, a team that really wasn't operating fully to the standards required for the task. Their operation was apparently 'safe enough' for long enough to perhaps lull people into false assurance. Of course I'm saying that with hindsight, which is always easy.

But I'm also saying it reflecting on my own experiences, when in a somewhat different engineering environment we - my team - also failed. Fortunately not fatally, but very expensively. When we carried out a full investigation and after action review - I was deputy team leader - we realised that we had allowed urgent operational pressures, time constraints and commercial pressures, plus some equipment shortcomings, to slowly erode our normal safe way of working. At first all went well because we had enough additional protections in place, and good people involved. That masked our reduction in safe practice and we became (in effect) complacent at out new lower level of safe operation. (Normalisation?) (And of course some up the management line took this to show that we had been overly cautious hitherto!) Eventually the holes lined up and we were very lucky to get away with just a costly lesson. I had the cold shudders quite a few nights after that, thinking about what could have happened, how many people could have died - because of my (our) concentration on the wrong things.

Looking at this accident, I wonder. If the team had stepped back and looked dispassionately at themselves, could they have realised that neither the engineering nor the flying operation was as tightly controlled as it needed to be? Hindsight is wonderful !

Agrajag - the comments you made about ageing and loss of experienced people are very apt. Its depressing that similar styles of incident and accident re-occur throughout engineering and throughout human activities and operations of all sorts. The loss of 'team learnings' as natural turnover occurs is a challenge everywhere. For us gnarly old types there is an element of frustration when we see or hear of the same old errors happening,and for the new young characters there is exasperation sometimes when we mutter 'oh, no again!'. If only there was a simple way to transfer all the old, hard won, lessons into new heads easily !

[Chugalug2]

AJ :-
Hard to see a way to fix this, given the disparity of different types, their increasing age, and the inevitable loss in old maintenance and repair skills.

The problem isn't the different types, their age, or skills, it is rather the incompetence of the Regulatory Authorities involved, and the reluctance of Air Accident Investigators to draw attention to that incompetence. The regulatory incompetence of the MOD/MAA features in the many airworthiness related fatal accident threads that litter the PPRuNe military aviation forum. That incompetence stems from the deliberate plundering of hitherto ring fenced Air Safety budgets in the late 80s (to fund a disastrous AMSO policy of cost savings by divesting itself of spares holdings that would then have to be bought in at much higher cost). RAF VSOs in turn rid themselves of experienced and knowledgeable airworthiness engineers who would not bend to illegal orders to suborn the airworthiness regulations, replacing them with untrained and ignorant non-engineers who would happily comply.

Thus corporate memory was lost and the long march to a totally dysfunctional UK Military Airworthiness system commenced. The Sea King, Chinook, Hercules, Nimrod, Tornado, Hawk fleets all suffered airworthiness related fatal accidents as featured in this forum. That the CAA assumed that an ex 1950s RAF jet should still be assured of its airworthiness by the RAF when on the civilian register speaks volumes of how out of touch it was with its military equivalent, and hence of its own incompetence. As tuc continually tells us the solution is simple, implement the mandatory regulations! If the CAA had done so this aircraft would not have been granted civilian registration, let alone been carrying out an air display on that fateful day.

[tucumseh]

From the AAIB report:


Thanks Beagle. That's what I was saying above. "....an obligation to address issues and factors that, while they may not have contributed directly to a particular accident, were nevertheless identified as failings.........".

Rolls Royce: "The fuel pump governor diaphragm.... showed significant signs of distress. The degradation of the rubber on both faces of the convolution, due to the effects of age, loss of flexibility and chemical interaction with fuel have resulted in a diaphragm that has exceeded the known predictable functional capability of the design. Whilst the diaphragm had not failed, its continued integrity would be severely affected by the degraded condition of the rubber both above and below the “Tide-Mark”."

The AAIB said: "The engine manufacturer concluded it would not have affected the normal operation of the engine". Nowhere in their published reports do Rolls Royce say this.

"Exceeded the known predicable functional capability" is difficult to reconcile with "would not have affected....." Where does the truth lie? Somewhere in between? The answer is very difficult, and that is why you build defences and mandate periodic inspections. You don't ignore such a violation. You jump on it and withdraw approvals until it's fixed.

I find it incomprehensible that every Hunter operator the AAIB spoke to claimed not to understand the effects of fuel degradation. The AAIB, as usual, is too polite. It cites the Air Publication that spells it out, but does not comment on the apparent inability of any operator to understand plain English. For example, the following was not undertaken:

"In addition, ground run every 30 days and repeat application of anti-corrosion inhibiting fluid to compressor. If the engine is not to be ground run, drain engine oil, inhibit fuel system, apply anti-corrosion paper. Grease the control and inlet guide vane ram linkages".

This was a 'requirement', and hence mandated. The AAIB cites numerous violations in the 3 years preceding the accident. What actions have been taken to prevent recurrence? The CAA did publish a directive in 2016, but it merely repeated what the operator was meant to have done. What is invisible is any sanction over the failure to do this properly in the first place (while signing to say it HAS been done), and lack of oversight.


There's pages of this stuff, so may I suggest people look at the report, starting at page 63.

Savings at the expense of safety?

[_Agrajag_]

AJ :-


The problem isn't the different types, their age, or skills, it is rather the incompetence of the Regulatory Authorities involved, and the reluctance of Air Accident Investigators to draw attention to that incompetence. The regulatory incompetence of the MOD/MAA features in the many airworthiness related fatal accident threads that litter the PPRuNe military aviation forum. That incompetence stems from the deliberate plundering of hitherto ring fenced Air Safety budgets in the late 80s (to fund a disastrous AMSO policy of cost savings by divesting itself of spares holdings that would then have to be bought in at much higher cost). RAF VSOs in turn rid themselves of experienced and knowledgeable airworthiness engineers who would not bend to illegal orders to suborn the airworthiness regulations, replacing them with untrained and ignorant non-engineers who would happily comply. Thus corporate memory was lost and the long march to a totally dysfunctional UK Military Airworthiness system commenced. The Sea King, Chinook, Hercules, Nimrod, Tornado, Hawk fleets all suffered airworthiness related fatal accidents as featured in this forum. That the CAA assumed that an ex 1950s RAF jet should still be assured of its airworthiness by the RAF when on the civilian register speaks volumes of how out of touch it was with its military equivalent, and hence of its own incompetence. As tuc continually tells us the solution is simple, implement the mandatory regulations! If the CAA had done so this aircraft would not have been granted civilian registration, let alone been carrying out an air display on that fateful day.


That's exactly why I included this in my post that you refer to:

... whether the skills and knowledge of the regulators themselves are adequate . . .


I think we all know there are weaknesses with regulators, and that these will most probably worsen with time, for a variety of reasons, not least being that running an effective regulatory regime is very costly.

[Chugalug2]

AJ :-
I think we all know there are weaknesses with regulators, and that these will most probably worsen with time, for a variety of reasons, not least being that running an effective regulatory regime is very costly.

and that is the fundamental lesson to learn from Shoreham, just as it is with the UK Military Airworthiness Related Fatal Accidents that account for well over 100 avoidable deaths and the loss of much national treasure and potential Air Power, and many of which can be read about here in this very forum. The aircrews and engineers involved were the victims of regulatory incompetence no matter what part they themselves played in these tragedies. Time a spotlight was shone into the murky corridors and offices from which this scandal emerged. Nothing short of total reform of the Military Air Regulation and Accident Investigation system will suffice, with a basic requirement that they be independent of each other and of the operator (ie of the MOD). It would appear that much the same is called for of Civilian Regulation, but this is a Military Forum so I'll leave it there...

[Thoughtful_Flyer]

Putting aside the human factors element, the inquest and the criminal prosecution, this event does highlight the fine line between wanting to see old aircraft fly and the way in which we can maintain them and keep them airworthy, doesn't it?

Ex-military types seem to be covered by a patchwork of bits of different regulatory regimes. Many operate under Permits to Fly, but with a varying basis for who holds responsibility for airworthiness, who regulates the specialists skills of inspectors, who assesses the technical competence of those that maintain them, whether the skills and knowledge of the regulators themselves are adequate, etc.

We all know about skills fade with time. We all know that there is knowledge that is key to flight safety but that isn't written down clearly, but passed by word of mouth (shouldn't be the case but it has always been thus). Couple that with the pressure to get aircraft like this airworthy and performing in front of many thousands of people that very much want to see them fly, and fly at the edge of their safe envelope, and it seems inevitable that there are likely to be airworthiness issues. I know these didn't seem to contribute in this case, but it has highlighted them.

I remember talking with one of the engineers at Goodwood that helped look after ML407, years ago. He mentioned that there were a handful of people that had the knowledge and understanding to keep aircraft like that airworthy, and that if anything happened to them then there was a fair chance that they would be grounded, at least here in the UK. No one wants that, but it seems to me that keeping older types flying at displays is very much reliant on the deep pockets of a few enthusiasts and the committent of many more who freely give their time to both learn about and help to look after this small and varied fleet.

Hard to see a way to fix this, given the disparity of different types, their increasing age, and the inevitable loss in old maintenance and repair skills.

I would largely agree but put it somewhat stronger and also ask the unwelcome / unthinkable question....

Is it really possible, both technically and economically, to keep these types of historic aircraft airworthy in civilian hands?

Even if the answer to that is yes then is it economically possible for a pilot, however skilled they may have been in the past, to get sufficient hours on the aircraft to be safe to conduct high energy manoeuvres in it at a public display?

Occasionally a very rich owner may be able to solve some of these issues with their cheque book but even that assumes that technicians and pilots with the required skills can be hired.

[_Agrajag_]

I would largely agree but put it somewhat stronger and also ask the unwelcome / unthinkable question....

Is it really possible, both technically and economically, to keep these types of historic aircraft airworthy in civilian hands?

Even if the answer to that is yes then is it economically possible for a pilot, however skilled they may have been in the past, to get sufficient hours on the aircraft to be safe to conduct high energy manoeuvres in it at a public display?

Occasionally a very rich owner may be able to solve some of these issues with their cheque book but even that assumes that technicians and pilots with the required skills can be hired.

I think the issue of getting enough hours in is key, especially for single seat A/C. I've noticed that some of the operators of two seat types are offering jollies to members of the public with deep pockets, and presumably that both raises funds to keep them flying and also maintains currency for the pilots. It also brings with it a whole can of worms about carrying what amounts to fare paying passengers in aircraft that were neither designed nor certified for such use. It's not really a satisfactory way to keep these old aircraft, the maintainers and their crews operational. They get all passengers to sign a disclaimer, but I do wonder how valid that would turn out to be if it was ever tested following an accident.

I would hate to see the loss of historic aircraft being displayed, but the way the world is changing and becoming more litigious, together with the ageing of the fleets, the fading skills and the poor state of airworthiness regulation it's hard to see how privately operated historic aircraft can be kept flying. Be a great shame to see them grounded. We gave a very good friend an 80th birthday gift of a jolly in a Harvard, a type he'd flown in action in Kenya in the early 50's. Really made his day, and as he said to his (rather concerned) wife when signing the disclaimer before the flight, "I've done pretty well to get to 80, this aircraft didn't manage to kill me 50 years ago when I was being shot at so it's not likely to now, is it?". He was right, it didn't, but sadly the "big C" did a couple of years later.

[Chugalug2]

TF :-
Is it really possible, both technically and economically, to keep these types of historic aircraft airworthy in civilian hands?
The pertinent word is 'keep'. There is no reason to believe that any ex-military aircraft is airworthy unless the records accompanying it prove it to be so. The appropriate records for example of one type were found to be so much sodden pulp, stored as they were in a shed with a collapsed roof. Even if they were intact and readable I doubt they would have been of any use, because airworthiness is a matter of continuous record and audit. Break that process of continuation and airworthiness is lost, as was shown in the scandal of the ACO Gliders. Those that managed to fly again had to be fully dismantled and rebuilt IAW with the regs. Just doable with such simple airframes (though even then scarcely economic), but with a FJ? Forget it, keep them in museums for future generations to see unless they are indeed airworthy and can be proved to be so. Good luck with that!

[GeeRam]

This seems to be going off at somewhat of a tangent, in terms of references to older piston types, which is not very relevant to Shoreham?
There's more chance of keeping a piston type airworthy, the skills are not being lost, and many of the main operators are passing on the knowledge to younger people already. The issue as ever is owners with deep enough pockets to restore and operate them.....and they are getting fewer, but with established maintainence operators like Air Leasing, ARC, Air Legends, and TFC of course, although TFC's fleet is ever reducing with SG's increasing age. Afterall, BBMF are contracting out their winter deep maintainence work to these operations now.

The subject when talking about post-war historic jets however, is effectively a non-subject now post Shoreham, as there are very few left now because of the post-Shoreham CAA changes, meaning owners have sold or grounded them having been unable to sell them. Other than a few JP's and the single(?) L39 that's all there is, flying in civvie hands and there's not likely to be any more than that now.

[typerated]

AJ :-


and that is the fundamental lesson to learn from Shoreham, just as it is with the UK Military Airworthiness Related Fatal Accidents that account for well over 100 avoidable deaths and the loss of much national treasure and potential Air Power, and many of which can be read about here in this very forum. The aircrews and engineers involved were the victims of regulatory incompetence no matter what part they themselves played in these tragedies. Time a spotlight was shone into the murky corridors and offices from which this scandal emerged. Nothing short of total reform of the Military Air Regulation and Accident Investigation system will suffice, with a basic requirement that they be independent of each other and of the operator (ie of the MOD). It would appear that much the same is called for of Civilian Regulation, but this is a Military Forum so I'll leave it there...

Ahhhh are you sure that Airworthiness is THE lesson from Shoreham?
Ill give you a clue - NO! Even if the Hunter was legally unairworthy, it was not the reason for the crash- not even peripherally!

The unasked question about Shoreham is could it happen again? Are UK airshows any safer since the CAA review?
https://publicapps.caa.co.uk/docs/33/CAP%201400%20MAY16.pdf
My personal feeling is the answer is - Not really.

[dervish]

The unasked question about Shoreham is could it happen again? Are UK airshows any safer since the CAA review?
https://publicapps.caa.co.uk/docs/33/CAP%201400%20MAY16.pdf
My personal feeling is the answer is - Not really.

Just looking at the above posts the question of recurrence and preventing it HAS been asked. It's just not been answered adequately. But I agree with your conclusion!


.

[POBJOY]

Ahhhh are you sure that Airworthiness is THE lesson from Shoreham?
Ill give you a clue - NO! Even if the Hunter was legally unairworthy, it was not the reason for the crash- not even peripherally!

The main Issue with Shoreham was the lack of implementation of the existing rules/guidance at the time, starting with the Display authorisation and continuing to the lack of actual Display control on the day. There was enough 'potential control' in the system, but it was not heeded, and that includes the suitability of the location for a machine that needed 'space' to position for the short crowd line, and having to avoid so many built up area's.
The only 'safe' option has already happened since the event, with the drastic reduction in the smaller displays due cost, and some of the larger ones moving to a 'sea front' location. One thing for sure as Dallas has shown is that Pilot awareness will always be a major factor, and multiple layers of rules do not protect against poor planning and control on the day.

[DaveReidUK]

Ahhhh are you sure that Airworthiness is THE lesson from Shoreham?
Ill give you a clue - NO! Even if the Hunter was legally unairworthy, it was not the reason for the crash- not even peripherally!

Interestingly the NTSB (though not the AAIB) demarcates its analysis of findings after an accident into 3 categories:
Probable Cause/s
Contributory Factor/s
Other Factor/s

While that last category might appear to be a contradiction in terms (a factor that didn't contribute to the event/outcome), it's a useful repository for findings such as the state of the Hunter's fuel pump diaphragm.

[Chugalug2]

Ahhhh are you sure that Airworthiness is THE lesson from Shoreham?
Ill give you a clue - NO! Even if the Hunter was legally unairworthy, it was not the reason for the crash- not even peripherally!

The unasked question about Shoreham is could it happen again? Are UK airshows any safer since the CAA review?
https://publicapps.caa.co.uk/docs/33/CAP%201400%20MAY16.pdf
My personal feeling is the answer is - Not really.
I suspect that we are in violent agreement about UK airshows. My point about airworthiness is that it is the sine qua non of aviation. Without it, no matter how well maintained, no matter how well flown, an aircraft is fatally compromised and looking for a place to have its accident. As to the Shoreham tragedy, it shares with Mull the dubious distinction of killing large numbers of people who had nothing to do with the maintaining or operating of the aircraft. It also shares the scandal of an accident investigation that chose not to delve deeply into gross regulatory failings that were known about.

Both investigations were compromised by not considering all the evidence available. That is a scandal that casts doubt upon the findings and 'the reason for the crash'. There was a time when Air Accident Investigations, be they civil or military, were thorough and turned over all the stones to determine the cause. The Comet tragedies being a case in point. They were unairworthy, and the reason they were was proved and remedial action taken. My own fleet, the HP Hastings, was grounded for months following the Little Baldon disaster. They were unairworthy and extensive remedial action taken, even though they were out of service a mere few years later. Now we have question marks hanging over whole military fleets, and manufacturers fitted up to cover the incompetence of the regulatory authority. I'd say that's a big lesson to take on board, no matter who or what was responsible for Shoreham. Wouldn't you?

[idle bystander]

and fly at the edge of their safe envelope

About the last thing I want to see, if you don't mind

[_Agrajag_]

About the last thing I want to see, if you don't mind


I don't either, but there are a lot of paying punters that go to air shows to see aircraft performing dynamic manoeuvres, and those punters are a significant revenue stream that helps keep those aircraft flying. If air shows are forced to only fly parade laps then I rather think that visitor numbers will reduce. For example, ask many air show punters what they consider to be the best part of the Red's display and they will likely say the opposition pair. The risk is not from flight dynamics, but the high closing speed and apparent close proximity looks very dramatic from the ground (and even more so from the cockpit video footage).

The Shoreham crash would not have happened if the Hunter has been restricted to flying just a relatively safe parade lap, Even though the loop, as planned, rather than as executed, was not a particularly dynamic manoeuvre, it was intended to increase the appeal of the aircraft to the audience, I'm sure, and keeping the audience happy is what keeps them coming back.

The same is true of every air show. Take Farnborough, as another example. Many of the big civil aircraft taking part are being shown off by the manufacturers, and perform dynamic manoeuvres that they are most probably never going to perform in service. I'll lay money that some of them are close to the edge of the safe flight envelope and almost certainly outside the manufacturers in-service operating envelope. The risks are low, but they do these dynamic manoeuvres to make their aircraft stand out and grab the attention of the media.

Apparent risk attracts punters, be it to air shows or many other events, even TV shows. It seems to be a inherent part of human nature to want to view things that look risky.

[The Nip]

Doesn’t the Pilot have the final say on whether everything is in order? I hope RAF and ex RAF Pilots have the knowledge and experience to ensure that everything is in order.
When they turn up in the morning, whether at the location of the display or not, they will go through all the required paperwork. Their own paperwork and licenses will be checked as well?
But, the final say would be the Pilot? Or does a nice big paycheque somehow speed things along?

[Mike51]

Doesn’t the Pilot have the final say on whether everything is in order? I hope RAF and ex RAF Pilots have the knowledge and experience to ensure that everything is in order.
When they turn up in the morning, whether at the location of the display or not, they will go through all the required paperwork. Their own paperwork and licenses will be checked as well?
But, the final say would be the Pilot? Or does a nice big paycheque somehow speed things along?
Nice big paycheque for flying vintage aircraft at airshows? Not outside the Vulcan boondoggle I’m afraid.

[tucumseh]

Interestingly the NTSB (though not the AAIB) demarcates its analysis of findings after an accident into 3 categories:
Probable Cause/s
Contributory Factor/s
Other Factor/s

While that last category might appear to be a contradiction in terms (a factor that didn't contribute to the event/outcome), it's a useful repository for findings such as the state of the Hunter's fuel pump diaphragm.

Indeed, and an observation made many times about AAIB reports, which are often difficult to read. Case in point.

MoD Service Inquiries are structured like this (Causal, Contributing, Aggravating and Other Factors, and Observations). Importantly, the rules state that ALL must be addressed. They seldom are.

In the vast majority of cases the Factors and Observations are recurring and, as stated by Pobjoy, the Recommendations amount to 'implement mandated policy'. Here, that failure is a Causal Factor, as the aircraft shouldn't have been flying. ('Failure' is kind. It was flat refusal and more deserving of a gross negligence manslaughter charge than the pilot).

If one can be certain the fuel pump (in this case) did not contribute, then by all means put it in 'Other Factors'. But, actually, it is but one of many pointers to the greater failings - refusal to maintain airworthiness and failure of independent oversight. It could be said this is also a Casual Factor. Authorities usually argue against this, but only because their default starting point is that airworthiness has always been maintained. They would be better assuming it is never maintained. Here it was not, and the CAA knew it, so the fuel pump violation simply becomes supporting evidence to a Causal Factor.

[Mogwi]

Apparent risk attracts punters.

When I started display flying (nearly 50 years ago) I was told that the trick was to make the easy look difficult, the difficult look impossible and never to attempt the impossible!

Mog

[safetypee]

Agra, Farnborough "I'll lay money that some of them ('big civil aircraft') are close to the edge of the safe flight envelope and almost certainly outside the manufacturers in-service operating envelope."
You would loose your money; excepting some pitch / bank limits.

Farnborough flying is (was - getting old) tightly controlled being overseen by a flight control committee - test pilots or similar professionals. The committee updates the overall risk assessment based on previous and similar shows.
For all public displays, each pilot, aircraft, has to be approved for all options of good / bad weather routines, usually two flights. Individual pilots would have a 'mentor' of relevant experience according to type. Preflight briefings discuss the flight mechanics of manoeuvres and how they relate to operational performance, and for new aircraft what has been tested so far. Each display would be assessed by 3 or more of the committee.

Debriefings for practices, approval, and show-day displays are held in private, generally one to one. In some cases suggestions for change are made.
Very rarely, specific manoeuvres would not be approved.

[_Agrajag_]

Doesn't flying an aircraft outside the pitch or bank limits constitute flying "outside the manufacturers in-service operating envelope", as I wrote?

Not that long ago I flew a type with a placard limitation that read "Not to exceed 60° angle of bank" and my assumption was that it was unsafe to pull a tighter turn than that. I'm sure the aircraft would probably have been OK at a bit over 60°, but if I'd pulled it a bit tighter and then had it fall out of the sky I'm damned sure that the AAIB would have included my failure to stay within the safe operating envelope as the primary cause of the subsequent crash.

I also fully accept that in modern times Farnborough was a very well regulated flying programme. However, let's not forget that a significant part of the tightening up of air show safety came after the 1952 DH.110 crash, that killed the pilot, flight test observer and twenty nine spectators. That accident was a consequence of the aircraft being pitched up too hard after a high speed (supersonic) dive, causing the aircraft to disintegrate in mid-air.

[BEagle]

That accident was a consequence of the aircraft being pitched up too hard after a high speed (supersonic) dive, causing the aircraft to disintegrate in mid-air.

Not so! The accident was caused because the wing had only 64% of the ultimate strength required in the design due to an erroneous estimate of the allowable stress at that point. The intended manoeuvre would not have caused a catastrophic failure had the wing design not been faulty.

John Derry was subsequently absolved of any blame for the accident.

Nevertheless, pre-1952 Fanrborough was something of a free for all. However, by 1953 the Farnborough Airfield Commandant had wisely introduced a new set of rigidly enforced safety rules.

[_Agrajag_]

Not so! The accident was caused because the wing had only 64% of the ultimate strength required in the design due to an erroneous estimate of the allowable stress at that point. The intended manoeuvre would not have caused a catastrophic failure had the wing design not been faulty.

John Derry was subsequently absolved of any blame for the accident.

Nevertheless, pre-1952 Fanrborough was something of a free for all. However, by 1953 the Farnborough Airfield Commandant had wisely introduced a new set of rigidly enforced safety rules.


Many thanks for the clarification.

I can easily understand how early flying displays became a bit of a free for all. Weren't the earliest of air shows little more than flying circuses? Easy to see how a "keeping the paying punters happy" culture could evolve.

[PoacherNowGamekeeper]

I assume that the BBC reference is to the original 21 Safety Recommendations made in the 2015/2016 AAIB Special Bulletins following the accident.

A further 11 were made in the 2017 Aircraft Accident Report, making 32 in total.
Possibly a correct assumption, I can't recall exactly.

31 for the CAA then I think.

[Diff Tail Shim]

This seems to be going off at somewhat of a tangent, in terms of references to older piston types, which is not very relevant to Shoreham?
There's more chance of keeping a piston type airworthy, the skills are not being lost, and many of the main operators are passing on the knowledge to younger people already. The issue as ever is owners with deep enough pockets to restore and operate them.....and they are getting fewer, but with established maintainence operators like Air Leasing, ARC, Air Legends, and TFC of course, although TFC's fleet is ever reducing with SG's increasing age. Afterall, BBMF are contracting out their winter deep maintainence work to these operations now.

The subject when talking about post-war historic jets however, is effectively a non-subject now post Shoreham, as there are very few left now because of the post-Shoreham CAA changes, meaning owners have sold or grounded them having been unable to sell them. Other than a few JP's and the single(?) L39 that's all there is, flying in civvie hands and there's not likely to be any more than that now.
Still quite a few with PtFs including the Gnats and Hunters not in the hands of HHA. G-INFO tells you all.

[Mike51]

No Hunters operating under Permits since Shoreham.

[Mogwi]

Standby for another type close to my heart in the near future also 😊

Mog

[Diff Tail Shim]

No Hunters operating under Permits since Shoreham.
Check on INFO confirms your statement.

[Diff Tail Shim]

Standby for another type close to my heart in the near future also 😊

Mog
Time will tell. The money is there, with the spares and I believe the backroom staff. When the maintenance provider is always asking for suitable people are available to do the work required, that does makes me wonder.

[Big Pistons Forever]

The root cause of this accident was a wholly unfit for purpose CAA regulatory regime for airshows. This airplane would never have been allowed to fly in a North American Airshow because the display area was not big enough and even if it was big enough the pilot would not have been eligible because his display authorization was obtained flying a 180 hp homebuilt not a jet.

[H Peacock]

BPF: I accept that under different regulations the outcome cound have been very different, likewise had the Hunter been deemed non-airworthy and not been flown that fateful day. But the root cause was simply a mishandled loop!

[Big Pistons Forever]

But the root cause was simply a mishandled loop!

That wasn’t the root cause it was the result of the root cause. If the display area had been properly sized he would not have crashed in an area full of people on a road. Secondly if he had been properly evaluated for his display authorization, he likely would not have been allowed to fly this category of aircraft, especially given his previous airshow history.

[typerated]

That wasn’t the root cause it was the result of the root cause. If the display area had been properly sized he would not have crashed in an area full of people on a road. Secondly if he had been properly evaluated for his display authorization, he likely would not have been allowed to fly this category of aircraft, especially given his previous airshow history.

Surely cart before horse?
If the loop if flown safely it does not matter who is stood where on the ground.

[alfred_the_great]

That wasn’t the root cause it was the result of the root cause. If the display area had been properly sized he would not have crashed in an area full of people on a road. Secondly if he had been properly evaluated for his display authorization, he likely would not have been allowed to fly this category of aircraft, especially given his previous airshow history.

and if he was a competent pilot he’d have realised the display area was too small, and he wouldn’t be trying to fly that category of aircraft.

his was an entirely discretionary activity that day, and he had no need to walk out to the aircraft.

[Blackfriar]

I don't either, but there are a lot of paying punters that go to air shows to see aircraft performing dynamic manoeuvres, and those punters are a significant revenue stream that helps keep those aircraft flying. If air shows are forced to only fly parade laps then I rather think that visitor numbers will reduce. For example, ask many air show punters what they consider to be the best part of the Red's display and they will likely say the opposition pair. The risk is not from flight dynamics, but the high closing speed and apparent close proximity looks very dramatic from the ground (and even more so from the cockpit video footage).

The Shoreham crash would not have happened if the Hunter has been restricted to flying just a relatively safe parade lap, Even though the loop, as planned, rather than as executed, was not a particularly dynamic manoeuvre, it was intended to increase the appeal of the aircraft to the audience, I'm sure, and keeping the audience happy is what keeps them coming back.

The same is true of every air show. Take Farnborough, as another example. Many of the big civil aircraft taking part are being shown off by the manufacturers, and perform dynamic manoeuvres that they are most probably never going to perform in service. I'll lay money that some of them are close to the edge of the safe flight envelope and almost certainly outside the manufacturers in-service operating envelope. The risks are low, but they do these dynamic manoeuvres to make their aircraft stand out and grab the attention of the media.

Apparent risk attracts punters, be it to air shows or many other events, even TV shows. It seems to be a inherent part of human nature to want to view things that look risky.
Hasn't every manufacturer done this? E.g. barrel-rolling the Vulcan in 1955?
A few pilots have done stuff that was "risky" too. Belfast International Airport's first Airshow in 1985(?) when the BMA scheduled DC-9 from London Heathrow did a low fly-by, wheels up, down the runway centre-line with normal fare-paying passengers on board. The Air Bridge Merchantman Captain wanted to do a low fly-by/pull up with two engines off.

[DaveReidUK]

That wasn’t the root cause it was the result of the root cause.

As with many if not most accidents, as soon as one starts to talk about "the root cause", one risks oversimplifying what happened to the point of meaninglessness.

[Capt Scribble]

In the usual analysis of accidents, there is always a 'root cause' which cascades other factors that build the consequences of the accident. Regulation did not cause this accident, it might have prevented it, but a mishandled loop was the direct cause of the aircraft hitting the ground. Everyone has expressed their views on why the mishandling occurred, and a court has accepted one explanation, but the exact reason will never be proven.

[falcon900]

Having followed this thread from the outset, and made a few contributions along the way, it does strike me that we are now reaching a point where there is significant degree of consensus around the key points:
- The regulators failed dramatically. This aircraft should not have been flying, this pilot should not have been flying it, and they should not have been attempting to fly this display. Prioritise these any way you like, but had the existing regulations been effectively applied to any one of them, we would not have had this incident.
- The investigation has not provided a convincing or ( in my view at least) credible outcome. For example, The apparent power deficit during the fateful climb and the evidence regarding the fuel pump diaphragm were staring them in the face, yet they chose to ascribe a conclusion to Rolls Royces analysis which Rolls Royce themselves had avoided.
Also, how come the traffic lights weren’t set to Green as had been mandated? If the traffic hadn’t been queuing, it seems highly likely that fewer lives would have been lost. Why is this not properly developed as a theme?
- The Coroners conclusion regarding the victims being “unlawfully killed” verges on the Kafka-esque. A moments consideration of the facts by primary school pupils would lead to that conclusion. Leaving aside there isn’t a verdict of being “lawfully killed” , the tragic victims obviously did nothing to warrant what transpired. Ignoring some of the directly pertinent evidence to arrive at such an arcane verdict does little to enhance the credibility of the process, and I fear will provide little enduring comfort for the relatives of the deceased.

The existing system could and should have prevented this incident, and made its consequences less severe. None of those who presided over or were directly responsible for the failure to implement it have been held to account. I’m sure the various changes which have been introduced can make things safer still, but ONLY IF THEY ARE ACTUALLY APPLIED. Where does the confidence that they will be come from?

[Big Pistons Forever]

Job 1 for people who plan airshows, run airshows, and fly in airshows is to not to kill anyone on the ground. Epic failure at all levels led to horrific and preventable fatalities.

Falcon 900 has articulated the challenge for future airshows. Talking about loop geometry may explain how this accident happened but won’t prevent the next accident.

[beardy]

Leaving aside there isn’t a verdict of being “lawfully killed”
​​​​
Point of information : in the correct circumstances that verdict can be given. I know because it was decided by the coroner's jury of which I was foreman.

[biscuit74]

That wasn’t the root cause it was the result of the root cause. If the display area had been properly sized he would not have crashed in an area full of people on a road. Secondly if he had been properly evaluated for his display authorization, he likely would not have been allowed to fly this category of aircraft, especially given his previous airshow history.

Encapsulates the matter very well, especially the last sentence - thanks BPF. That is not only a matter for those supposed to be overseeing, but also for the pilot. More ego than competence, demonstrably. Many of us have been there or close to that, at some point, fortunately generally without tragic consequences.
Sadly, probably a lesson all directly concerned have now learned, or at least realised as relevant.

[STUPREC]

More ego than competence, demonstrably.
Really? I know AH. Egotistical he is not.

[melmothtw]

Also, how come the traffic lights weren’t set to Green as had been mandated? If the traffic hadn’t been queuing, it seems highly likely that fewer lives would have been lost. Why is this not properly developed as a theme?

Surely the lights could not have been set to green for everyone. If not the cars that were hit, then other cars would have been queing in the immediate vicinity of the crash. Guessing this is why this hasn't been developed as a theme.

[GeeRam]

Surely the lights could not have been set to green for everyone. If not the cars that were hit, then other cars would have been queing in the immediate vicinity of the crash. Guessing this is why this hasn't been developed as a theme.

I would say its more likely that it might not have reduced the number of casualties, as they were all from the cars stationary at the red lights on the westbound carriageway, and thus the traffic on the eastbound carrieageway were also being held on the red, further to the west of the impact point, and thus the eastbound carriageway was free of traffic when the impact occured.
Had the lights been set to full time green, it would have thus been for both carriageways and thus there would have been flowing traffic on both carriageways, which might have meant less, or possibly even more with traffic flow in both directions. As such its an unknown variable, so can't be taken as a factor.

[melmothtw]

I would say its more likely that it might not have reduced the number of casualties, as they were all from the cars stationary at the red lights on the westbound carriageway, and thus the traffic on the eastbound carrieageway were also being held on the red, further to the west of the impact point, and thus the eastbound carriageway was free of traffic when the impact occured.
Had the lights been set to full time green, it would have thus been for both carriageways and thus there would have been flowing traffic on both carriageways, which might have meant less, or possibly even more with traffic flow in both directions. As such its an unknown variable, so can't be taken as a factor.

Well yes, but also that the lights could not all be set to green for the very reason lights were needed there in the first place.

[GeeRam]

Well yes, but also that the lights could not all be set to green for the very reason lights were needed there in the first place.

Well, not really, the two side roads either side of that junction were closed to traffic because of the airshow, so there was therefore no need for them, so that's why the lights were supposed to be set to full time green for the duration, so as to not have static traffic being held on the westbound carriageway, and thus under the display area, which is why people are saying because of this there could have been less casualties. However as pointed out the eastbound traffic was being held at the lights as well so was therefore traffic free at time of impact, and therefore it can't be certain that there would thus have been less casualties. Its a possibility not a certainty.

[falcon900]

Indeed, but yet further evidence of the fact that what the various existing rules and regulations had prescribed was not being carried out. Prescribing yet more rules and regulations is especially pointless where the existing ones can be ignored with impunity it seems.
what about those responsible for allowing that aircraft to fly? What about those responsible for allowing it to embark on that display? And yes, what about the person who failed to implement the mandated condition for the traffic lights? Why are they all being given a free pass?

[Asturias56]

"Why are they all being given a free pass?"

Because it would open up th can of worms referred to be several posters on here . Who ever was fingered would immediately drag in all the old cases where things were swept under the carpet as evidence of the culture and processes ACTUALLY in place rather than the ones laid down in the law and regs

[DaveReidUK]

And yes, what about the person who failed to implement the mandated condition for the traffic lights? Why are they all being given a free pass?

Because, as has been pointed out by several posters, there is no way to determine whether the lights were a contributory factor towards the number and/or type of fatalities/injuries.

[Chugalug2]

Having followed this thread from the outset, and made a few contributions along the way, it does strike me that we are now reaching a point where there is significant degree of consensus around the key points:
- The regulators failed dramatically. This aircraft should not have been flying, this pilot should not have been flying it, and they should not have been attempting to fly this display. Prioritise these any way you like, but had the existing regulations been effectively applied to any one of them, we would not have had this incident.
- The investigation has not provided a convincing or ( in my view at least) credible outcome. For example, The apparent power deficit during the fateful climb and the evidence regarding the fuel pump diaphragm were staring them in the face, yet they chose to ascribe a conclusion to Rolls Royces analysis which Rolls Royce themselves had avoided.
Also, how come the traffic lights weren’t set to Green as had been mandated? If the traffic hadn’t been queuing, it seems highly likely that fewer lives would have been lost. Why is this not properly developed as a theme?
- The Coroners conclusion regarding the victims being “unlawfully killed” verges on the Kafka-esque. A moments consideration of the facts by primary school pupils would lead to that conclusion. Leaving aside there isn’t a verdict of being “lawfully killed” , the tragic victims obviously did nothing to warrant what transpired. Ignoring some of the directly pertinent evidence to arrive at such an arcane verdict does little to enhance the credibility of the process, and I fear will provide little enduring comfort for the relatives of the deceased.

The existing system could and should have prevented this incident, and made its consequences less severe. None of those who presided over or were directly responsible for the failure to implement it have been held to account. I’m sure the various changes which have been introduced can make things safer still, but ONLY IF THEY ARE ACTUALLY APPLIED. Where does the confidence that they will be come from?
Excellent post, f900. Shoreham has been treated, like other airworthiness associated fatal air accidents in this forum, as separate and unique. What tuc terms 'stovepiping'. In reality of course it's just the same old same old. A Regulator fails in its primary purpose of ensuring that the aircraft within its purview are airworthy. An Air Accident Investigator fails to hold that Regulator to account when evidence confirms that the aircraft involved in the accident was not airworthy. In this case it seems it even fabricated evidence to show that an unairworthy component fitted to the unairworthy aircraft played no part in the accident. Who guards the guardians? Oh, and just to keep the lid on things it gets a High Court ruling that prevents the Coroner from raising issues stemming from the AAIB Report. The rot is spreading....

[DaveReidUK]

In this case it seems it even fabricated evidence to show that an unairworthy component fitted to the unairworthy aircraft played no part in the accident.

And your evidence that it did play a part is ... ?

[pulse1]

DR, I don't think that Chug is saying that the fuel pump did play any part in the accident. It seems that he is suggesting that evidence was fabricated to minimise the chances of the accident being laid at that door. Guarding the guardians.

[DaveReidUK]

DR, I don't think that Chug is saying that the fuel pump did play any part in the accident. It seems that he is suggesting that evidence was fabricated to minimise the chances of the accident being laid at that door. Guarding the guardians.

Ah, OK. But either way it's hardly a smoking gun pointing to evidence having been fabricated.

[Chugalug2]

Ah, OK. But either way it's hardly a smoking gun pointing to evidence having been fabricated.
Anecdotal evidence on this forum suggests that there might have been a reduction in engine power during the loop ascent. That may or may not have happened. If it did happen it might have been pilot input, conscious or otherwise, or it might have been a technical malfunction. The fuel pump was found to be compromised by RR but the AAIB said that RR didn't consider that to be relevant to its performance. RR said no such thing. It seems to me that the AAIB is now part of the problem and its investigation needs to be investigated. The High Court ruling ensured that the Coroner wasn't able to do that. Thus no smoking gun.

And your evidence that it did play a part is ... ? None whatsoever, just as we don't know if the positively dangerous Chinook Mk2 FADEC played a part in the deaths of 29 people on the Mull of Kintyre in 1994. What we do know is that both aircraft were unairworthy, a fact that both investigations preferred to pass over.

[Timelord]

I am just beginning to look back with some nostalgia on the days when “Pilot error” was all that needed to be said about an accident.

[falcon900]

Because, as has been pointed out by several posters, there is no way to determine whether the lights were a contributory factor towards the number and/or type of fatalities/injuries.

The point is not whether you or I with the benefit of 20/20 hindsight consider the lights made a difference. The point is that someone before the incident conducted a risk evaluation which determined that it was important that they were set to Green, and the display was authorised on the basis that they would be. You might be right that there was no incremental loss of life as a result of there being a queue of traffic for the aircraft to plough into ( good luck arguing that one) but it remains the case that a condition precedent was not fulfilled, and nobody has been taken to task.

[bvcu]

interesting read and theory about fuel pump. BUT read the report , the aircraft was not airworthy in the first place so shouldnt have been flying. Approved by CAA so there the problem lies. If airworthy then the other factors could be relevant . Info all in AAIB report findings.

[DaveReidUK]

You might be right that there was no incremental loss of life as a result of there being a queue of traffic for the aircraft to plough into ( good luck arguing that one)

I didn't say that at all - reread my post.

I said that there was no way to determine whether or not that had been the case.

[pasta]

interesting read and theory about fuel pump. BUT read the report , the aircraft was not airworthy in the first place so shouldnt have been flying. Approved by CAA so there the problem lies. If airworthy then the other factors could be relevant . Info all in AAIB report findings.
If the aircraft had been airworthy but all other circumstances been the same, would the incident still have happened, with the same results? In my view it probably would have done, so whilst the airworthiness issues are serious and warrant further action, I don't think you can say they were the root cause.

[BEagle]

pasta - absolutely correct. The manoeuvre was flown from below the planned entry height, 40KIAS below the planned entry speed and with less than full power. The apex gate was not achieved, but the manoeuvre could still have been aborted at that point.

What isn't known is WHY these errors were made.

[dastocks]

The point is not whether you or I with the benefit of 20/20 hindsight consider the lights made a difference. The point is that someone before the incident conducted a risk evaluation which determined that it was important that they were set to Green, and the display was authorised on the basis that they would be. You might be right that there was no incremental loss of life as a result of there being a queue of traffic for the aircraft to plough into ( good luck arguing that one) but it remains the case that a condition precedent was not fulfilled, and nobody has been taken to task.
Looking at the AAIB report it is clear that the risk assessments applied to the road junction only considered the following:
1. Road traffic risks to vehicles entering/leaving the airport area - this junction is the only means of access for most vehicles (there is a very narrow and height restricted road access to the south of the airport)
2. Road traffic risks to "secondary spectators" who were known to gather at the junction.

I'm not certain of the exact traffic conditions at the time of the accident but it is likely that westbound traffic was very slow moving all the way back from the roundabout at North Lancing and onto the flyover to the east of the airport. This is the route to/from my office and it's what I see in the afternoons when I am going home eastbound through the junction.

The main reasons for setting the traffic lights to be green during an airshow would be:
1. to stop eastbound traffic from tailing back to the North Lancing roundabout, aggravating the congestion there
2. with right turns prohibited and the other road closures in place they would not be required except (possibly) to control traffic leaving the airshow.

[tucumseh]

If the aircraft had been airworthy but all other circumstances been the same, would the incident still have happened, with the same results? In my view it probably would have done, so whilst the airworthiness issues are serious and warrant further action, I don't think you can say they were the root cause.

I think you need to look at it slightly differently. If the airworthiness regulations had been implemented correctly, the accident would not have happened because the aircraft would not have been flying. Ergo, that failure to implement is a root cause.

If, for example, the regulations had been implemented the pilot would have had an up-to-date set of Flight Reference Cards (not those from April 1974), the engineers would have had up-to-date tech pubs, and the fuel pump would have been serviceable. Perhaps the Master Airspeed Indicator and G-Meter would have been serviceable? Maybe the various missing instruments would have been fitted?

The CAA certification stated that the RAF was responsible for the underpinning process, with permission to fly predicated on this. They were not, AND NEVER HAVE BEEN, which is a complete howler. It has never been made clear who was. Some may opine that none of this had a direct bearing on the accident flight (I'm not so sure), but such gross failures are indicative of systemic and wider failings - which the AAIB report lists in excruciating detail. (Little wonder the pilot and Coroner wanted it read out in court, and the CAA did not). There's obviously someone in the loop who decided not to bother doing their job, or was told this mandate would be waived. And the CAA allowed this, with their mandated audit 7 months overdue.

Mr Hill admitted he screwed up, but couldn't explain it. Time for others to be equally honest. They don't need to explain, because we already know.

[DaveReidUK]

I think you need to look at it slightly differently. If the airworthiness regulations had been implemented correctly, the accident would not have happened because the aircraft would not have been flying. Ergo, that failure to implement is a root cause.

True - inasmuch as the root cause of every airborne accident is the fact that the aircraft was flying at the time ...

[pasta]

True - inasmuch as the root cause of every airborne accident is the fact that the aircraft was flying at the time ...
Exactly. If (hypothetically) a pilot's car was untaxed and uninsured, you couldn't say the root cause of an accident involving that pilot was the police's failure to impound his car, thereby enabling them to drive to the airfield and fly the aircraft. That's despite the fact that the tax and insurance status of the pilot's car might well say something about their attention to detail and their attitude to regulation.

tucumseh makes some very good points, there were clearly massive airworthiness failings, but it appears that this accident probably happened before the airworthiness issues had a chance to cause a different one.

[tucumseh]

True - inasmuch as the root cause of every airborne accident is the fact that the aircraft was flying at the time ...

Which is precisely why all investigations must confirm, as a matter of urgency, that the aircraft was legally permitted to fly. Almost everything else flows from that. If it wasn't, the reasons why tell the investigator so much.

In military accidents this is the role of the Service Inquiry engineer. In civilian accidents, the AAIB. The latter are pretty good at it; although in this case they didn't go too far, but said enough to identify the culprits. The former simply don't bother, and it is left to the public to investigate. The 'final act' syndrome.


"The root causes of most accidents are usually deficiencies in systems, whether these are systems for management, design, certification, maintenance, and/or operation".

(Tony Cable, Senior Investigator Air France Concorde, PanAm Lockerbie, Chinooks ZD576 and ZA721, etc, etc.).

Shoreham has root causes in all these domains. In only one has legal action been taken.

[dervish]

In military accidents this is the role of the Service Inquiry engineer. In civilian accidents, the AAIB. The latter are pretty good at it; although in this case they didn't go too far, but said enough to identify the culprits. The former simply don't bother, and it is left to the public to investigate. The 'final act' syndrome.

Spot on. And I know you've said this repeatedly and understand it, but one is independent and the other is judging its own case.

[Busta]

The 1955 Vulcan performed an aileron roll.

Nothing matters very much, most things don't matter at all, will try and make the F4 TDPU this year!

T+9

[dagenham]

South Today News reporting this morning that Hill has started proceedings asking for a judicial review of the coroner’s verdict.

[ORAC]

Link to BBC report above.

https://www.bbc.co.uk/news/uk-england-sussex-64503147

Shoreham air crash: Pilot seeks judicial review of inquest verdict

[Asturias56]

Many would suggest he'd be better off staying quiet

[falcon900]

Many would suggest he'd be better off staying quiet

Many undoubtedly would, and I can easily imagine that the relatives of the victims might be among them, but there is definitely unfinished business here, and there might at least be some saying it is brave of AH to push to have the full picture exposed to daylight.

[Timelord]

Does the Coroner’s verdict render him liable to be pursued through the civil courts by the relatives where, I believe, the verdict is on balance of probability rather than beyond reasonable doubt? If so, that is probably his motive for pushing for a judicial review.

[Raikum]

Does the Coroner’s verdict render him liable to be pursued through the civil courts by the relatives where, I believe, the verdict is on balance of probability rather than beyond reasonable doubt? If so, that is probably his motive for pushing for a judicial review.

No the coroner's verdict is completely irrelevant to any issue in civil proceedings where, as you say, the proof required is on a balance of probabilities rather than the higher criminal standard. I assume, possibly wrongly, that the civil case (s) have already been settled.

[Asturias56]

Ms Schofield said that although she recorded a narrative verdict of unlawful killing, it did not "detract from the fact" Mr Hill was acquitted in a criminal court in 2019.

It is not yet clear on what grounds Mr Hill is asking for the review.

The coroner will be given the opportunity to respond, and then it will be up to the High Court to decide whether to hear the case.

[tucumseh]

Many undoubtedly would, and I can easily imagine that the relatives of the victims might be among them, but there is definitely unfinished business here, and there might at least be some saying it is brave of AH to push to have the full picture exposed to daylight.

I think this a fair view. I can't see how 'unlawful killing' can be justified when so much evidence about the failings of others was not allowed to be heard in court, and the CAA was allowed to judge its own case when confronted with further evidence. Oh, and RAF, just how many people do you have working in your Hunter Design Authority Directorate?

[Asturias56]

"RAF, just how many people do you have working in your Hunter Design Authority Directorate?"

lots of course - but its SECRET covered by the Act as it could be of use to a Foreign Power - you'll just have to trust us....................

[tucumseh]

"RAF, just how many people do you have working in your Hunter Design Authority Directorate?"

lots of course - but its SECRET covered by the Act as it could be of use to a Foreign Power - you'll just have to trust us....................

To be fair, when asked the question about this MoD confirmed neither it nor the RAF had ever been Hunter DA. That is, the accident aircraft's Airworthiness Approval Note, reproduced in the AAIB report, was based on a false premise. Which is rather important, as airworthiness facilitates serviceability. G-BXFI was neither.

Perhaps a greater reason why MoD and especially the HSE would not want this discussed in detail, is that the same AAN cites the MoD documentation that disproves the allegation against Martin-Baker in the Sean Cunningham case. And the HSE was a major contributor to the AAIB report. That is called prosecutorial misconduct.

[Chugalug2]

Perhaps a greater reason why MoD and especially the HSE would not want this discussed in detail, is that the same AAN cites the MoD documentation that disproves the allegation against Martin-Baker in the Sean Cunningham case. And the HSE was a major contributor to the AAIB report. That is called prosecutorial misconduct.
Indeed, tuc. If you listen very carefully you can hear a rustling sound from inside the tin. If we just open the lid then all will be revealed...

[dagenham]

To be fair, when asked the question about this MoD confirmed neither it nor the RAF had ever been Hunter DA. That is, the accident aircraft's Airworthiness Approval Note, reproduced in the AAIB report, was based on a false premise. Which is rather important, as airworthiness facilitates serviceability. G-BXFI was neither.

Perhaps a greater reason why MoD and especially the HSE would not want this discussed in detail, is that the same AAN cites the MoD documentation that disproves the allegation against Martin-Baker in the Sean Cunningham case. And the HSE was a major contributor to the AAIB report. That is called prosecutorial misconduct.

tuc, so is it being alleged that the shoreham verdict is on some way linked to the cover up with mb?

[tucumseh]

Dagenham

tuc, so is it being alleged that the shoreham verdict is on some way linked to the cover up with mb?



The evidence to the Shoreham Coroner in October 2019 highlighted the linkages, and this (I UNDERSTAND) was put to the CAA and AAIB. I have not seen their replies. However, I KNOW that it was put to MoD and the HSE. As I said, MoD correctly wholly refuted the accuracy of the Airworthiness Approval Note, putting the CAA on the spot. The matter was not raised in court, but if there is a judicial review.....

The HSE have confirmed they did not point out these anomalies reported (without comment) by the AAIB. Nor did they disclose to the M-B Judge that the Airworthiness Approval Note completely destroyed their case against M-B. This led to a complaint of prosecutorial misconduct, but the Lincs Chief Constable ruled that the HSE could judge their own case. I do not have the HSE's reply - they refuse to release it - but the extracts quoted by the Chief Constable make it clear he was lied to. Informed of this, and given irrefutable written and video evidence, both he an his Police and Crime Commissioner are content to let matters lie.

As a different department in the HSE had dealt with Shoreham, after the Andy Hill trial the head of the HSE was notified again of the exculpatory evidence in the M-B case, and asked if they would now review it and advise the Judge and police (the latter also being under an obligation to review it). They declined to comment. As at least 12 factors were then repeated in Jon Bayliss's death in 2018, my opinion is that M-B must take some blame there. Rolling over protected MoD, leaving it free to continue its violations. But their actions pale compared MoD and the HSE.

I hope that helps. To offer more is difficult, as the matter is sub judice in that a police investigation by another force is ongoing, and Lincs Police and Coroner should be getting a knock on the door soon. But the above is in the public domain. It's a case of reading up on the cases and drawing the linkages. Which is what the authorities never do.

[Asturias56]

I think Tuc and Chug are pointing to the fact that the systemic failings here stretch back a very long time - and TBH seem to continue into the foreseeable future unless someone cleans the stables.

[steamchicken]

Link to BBC report above.

https://www.bbc.co.uk/news/uk-england-sussex-64503147

Shoreham air crash: Pilot seeks judicial review of inquest verdict

Didn't he get away with it?

[OvertHawk]

Didn't he get away with it?


He's challenging the Inquest verdict - not the criminal trial verdict!

[ShyTorque]

There’s an old saying: “The longer you hold onto a hot coal, the more it burns”.

[KrisKringle]

There’s an old saying: “The longer you hold onto a hot coal, the more it burns”.

While we're on the subject of old sayings...

...“You can tell a lot about the author by what they write"

[_Agrajag_]

Inquests are odd. I gave evidence at one years ago. The cause of death was bleedin' obvious. Self-inflicted death by the idiocy of the the deceased. The coroner bent over backwards to ignore the obvious and make out the deceased idiot hadn't been reckless and stupid. Recorded a narrative verdict that absolved the deceased from the massive contribution he made towards his death. I came away convinced that the system was rigged to make the relatives feel better, not uncover the truth.

Can't comment on the Hunter inquest. I wasn't there. Sounds to me as if the coroner felt the victims needed someone to blame to make them feel better. Easy to blame the pilot. Far harder to place blame fairly on all the organisations that were grossly negligent.

Off topic, but I'm certain we will see the same with Grenfell.

[charliegolf]

Agra, where are you on the moon landings and JFK?

On the topic... if you take it all the way back, and the Hunter were not invented, this would not happened*. What I'm saying, is that people seem to want to show that the flying aspect was the tip of a larger sh1tberg; and AH is taking the fall. Or have I got that wrong. I've never done a loop, but I have learned that there's an entry speed and a minimum height needed to complete one. Have I got that wrong too? The pilot had neither (AAIB).

CG

*facetious of course...

[tucumseh]

if you take it all the way back, and the Hunter were not invented, this would not happened*. What I'm saying, is that people seem to want to show that the flying aspect was the tip of a larger sh1tberg; and AH is taking the fall. Or have I got that wrong. I've never done a loop, but I have learned that there's an entry speed and a minimum height needed to complete one. Have I got that wrong too? The pilot had neither (AAIB).

CG

*facetious of course...

I don’t think your first question is facetious at all. I don’t know the proper legal answer, but ‘proximity’ is a common test. It’s why Inquiries are required to determine root causes. A factor is considered a root cause if its removal from the problem-fault sequence would have prevented the undesirable outcome. It would be reasonable (I believe) to reject the invention of the Hunter as a root cause; but the accident aircraft not being airworthy, serviceable, or fit for purpose, and the pilot not being told this, passes any proximity test.

The AAIB report did say he got it wrong, and the pilot admitted that. The question the Coroner was not allowed to ask (by High Court order), was WHY? The pilot could not explain it, and a defence of Cognitive Impairment was advanced, and was successful at his trial. I cannot comment on that, as I’m not medically trained. But without answering that question it could be argued the Coroner went too far with her decision.

There‘s been a lot of criticism here about this defence, but little about the RAF advancing self-inflicted CI as a root cause of a high profile fatal accident a few years before, which tended to divert from more obvious root causes. Such as, the aircraft was not airworthy, serviceable or fit for purpose, and the pilot not being told this.

[Timelord]

It’s one of those irregular verbs as coined by “ Yes, minister”

I suffered CI
You made a mistake
He was grossly negligent

[mike rondot]

The AAIB report did say he got it wrong, and the pilot admitted that.

No he didn't, he pleaded Not Guilty and his artful brief got him off on the novel defence of a brain fart that baffled the brain(s) of the jury.
Your endless arguments about airworthiness indicate that you might not understand the difference between serviceability and airworthiness, and give me the impression that you are apologising for the pilot and attempting to shift the blame for the fatalities onto others.
In case you did not know, the captain of an aircraft is responsible for deciding whether the aircraft is serviceable and fit to continue on its planned flight. If he decides it is not serviceable, he always has the immediate option of discontinuing his mission and landing at the nearest suitable airfield. All other arguments about airworthiness or maintenance or management are irrelevant and serve only to fog the primary issue. This captain decided to continue with his routine when inverted at the top of a looping manoeuvre.

[tucumseh]

No he didn't, he pleaded Not Guilty and his artful brief got him off on the novel defence of a brain fart that baffled the brain(s) of the jury.
Your endless arguments about airworthiness indicate that you might not understand the difference between serviceability and airworthiness, and give me the impression that you are apologising for the pilot and attempting to shift the blame for the fatalities onto others.
In case you did not know, the captain of an aircraft is responsible for deciding whether the aircraft is serviceable and fit to continue on its planned flight. If he decides it is not serviceable, he always has the immediate option of discontinuing his mission and landing at the nearest suitable airfield. All other arguments about airworthiness or maintenance or management are irrelevant and serve only to fog the primary issue. This captain decided to continue with his routine when inverted at the top of a looping manoeuvre.

It is sometimes better to read the facts.

The pilot pleaded not guilty to gross negligence manslaughter. He admitted the errors in the manouevre, but couldn't explain them except for the CI defence. These are quite different issues and it is disingenuous to conflate them.

You criticise me for 'endless' arguments. Two things must then be true:

1. Given my arguments have been proven valid in legal reviews and in courts, but the failings are still recurring, then those responsible are still not doing their job, but still making false declarations that they are. Do you have a similar pop at those responsible for that? If not, please tell us why. If you have, I'd be interested in their reply.

2. As you say 'endless', that implies you have read some of my posts, which will have revealed I know the difference between attaining and maintaining airworthiness, serviceability, and fitness for purpose; and how to do all four in practice; and on both aircraft and equipment. I can only infer, therefore, you believe it acceptable that the accident aircraft should not have been flying, but was declared airworthy, etc. If you do not think that a mitigating factor, even if the pilot were found guilty, then you are entitled to your opinion.

I have never commented on the airmanship aspects of the flight. I am in no position to. But I certainly do not think it reasonable that Mr Hill should have been expected to know, for example, that his master airspeed indicator and g-meter were unserviceable, and the fuel pump diaphragm rotted, if this was not declared to him. And how many pilots here can honestly say they could look at the Airworthiness Approval Note (reproduced by the AAIB) and realise that it was based on an entirely false premise (a premise that was NEVER true, even when in military service), and so there could be no airworthiness or serviceability audit trail? I'd hazard a guess very few. Similarly, the CAA and MoD didn't spot it; and if the AAIB did, they didn't say anything, yet pointed out other reasons why it wasn't airworthy. Have you written to the regulator to ask why they issued such an Approval Note, and if they have checked others to see if it's a widespread cockup?

There have been many threads here over the years that have revealed the same thing. Chinook ZD576. Nimrod XV230. Tornado ZG710. Sea Kings XV650 & 704. Hawk XX177. Hercules XV179. Not one of them airworthy, to varying degrees, yet false declarations made to the pilots that they were. (The Sea Kings were the closest, and ironically that is the only one where the Board of Inquiry spelt it out in detail). Only in the Chinook case is it known the aircraft captain suspected as much, but was in no position to prove it. In EACH case others met their duty and reported the failures, but their concerns were rejected. Have you had a pop at those who decided to lie to aircrew and passengers, or those who knew but did not report it? Their names are known in each case. Write to them and again let us know what they say. I'm not sure they'll give you the courtesy of a reply, as I do.

[Jwscud]

I think the elephant in the room is not so much airworthiness as display safety. It being an entirely foreseeable event that an aircraft crash on its display line, appropriate mitigations were not in place. AH is responsible as the commander for the handling and the aircraft crashing. He was not in any way responsible for Shoreham Airshow’s planning and risk assessment that allowed him to be displaying over a major road. IMO these are the individuals and offices who should have faced far more scrutiny from the coroner.

[Lordflasheart]

...
Oh dear ... here we go again ...

If anyone should actually wish to read any of the technical arguments supporting Tucumseh's posts above, might I recommend some learned books authored by David Hill (who I presume is no relation to Andy Hill)

"Breaking the Military Covenant - Who speaks for the Dead ?" "Red 5" (the death of F/Lt Sean Cunningham) and "A Noble Anger - the Manslaughter of Corporal Jonathan Bayliss" are among his titles readily available as €-books from the usual place.

While I could not for myself claim that what David Hill writes is 100% true or accurate (because I do not have the technical knowledge and intelligence required to make such a claim) his books are eminently readable, should any of the nay-sayers and apologists be so inclined.

It requires IMHO only a little aviation and technical knowledge to make sense of the author's reasoning and his eloquent and compelling claims of deliberate and knowing misfeasance by government offices and officers, who always seem to avoid having to account for their misdeeds and the resulting loss of life. I doubt if he would write such damning stuff if he wasn't reasonably sure of his facts.

It's really quite depressing to realise that this shameful and sleazy escapism continues even now, which suggests they're all in the culture, jointly and severally covering their past, present and future backsides.

LFH

[tucumseh]

I think the elephant in the room is not so much airworthiness as display safety. It being an entirely foreseeable event that an aircraft crash on its display line, appropriate mitigations were not in place. AH is responsible as the commander for the handling and the aircraft crashing. He was not in any way responsible for Shoreham Airshow’s planning and risk assessment that allowed him to be displaying over a major road. IMO these are the individuals and offices who should have faced far more scrutiny from the coroner.

Indeed, and the AAIB was equally scathing about the CAA. The airworthiness aspect didn't need much scrutiny. It was cut and dried. The display aspects were more difficult, and I think airsound mentioned earlier that one key chap has passed away. But in any case, as both questions arose from the AAIB report, the court order prevented the Coroner from going there. It is that inability to discuss the main evidence that makes me nervous about placing sole blame on the pilot.

[DaveReidUK]

A factor is considered a root cause if its removal from the problem-fault sequence would have prevented the undesirable outcome.

That implies, presumably, that in a classical Swiss Cheese accident model, a single event can have multiple root causes. Or do I misunderstand ?

[DaveJ75]

That implies, presumably, that in a classical Swiss Cheese accident model, a single event can have multiple root causes. Or do I misunderstand ?

Go on Dave - give us the answer!

[Chugalug2]

No he didn't, he pleaded Not Guilty and his artful brief got him off on the novel defence of a brain fart that baffled the brain(s) of the jury.
Your endless arguments about airworthiness indicate that you might not understand the difference between serviceability and airworthiness, and give me the impression that you are apologising for the pilot and attempting to shift the blame for the fatalities onto others.
In case you did not know, the captain of an aircraft is responsible for deciding whether the aircraft is serviceable and fit to continue on its planned flight. If he decides it is not serviceable, he always has the immediate option of discontinuing his mission and landing at the nearest suitable airfield. All other arguments about airworthiness or maintenance or management are irrelevant and serve only to fog the primary issue. This captain decided to continue with his routine when inverted at the top of a looping manoeuvre.
Quite why you feel compelled to deliver this ad hominem attack on someone who knows more than any here (please step forward if I have it wrong) about UK Military Airworthiness and the scandal of it being subverted by RAF VSOs and since covered up by succeeding VSOs I have no idea. As someone else who has indulged in endless argument over these matters I suppose I am on your little list too, or worse still that I do not rate inclusion. Either way, please take your abuse elsewhere.

I can only surmise that you (and those who chose to endorse your rant) feel that any airworthiness shortcomings in the aircraft might diminish the pilot's shortcomings that were involved in this tragedy. tuc has always distanced himself from discussions of airmanship, not only in this thread but in the too many other airworthiness related accident threads in this forum. His speciality is airworthiness, and your condescending dig that he doesn't understand the difference with that and serviceability simply undermines any argument that you may have to offer. I wonder if you know the difference yourself? You say a pilot is responsible for deciding if the aircraft is serviceable for the planned flight. How, other than to carry out his checks, external and internal, and by studying the F700? In reality he is placing his trust in those who signed off/deferred known defects and declared the a/c serviceable. Unfortunately, he has no such resources to turn to for its airworthiness. He has to place blind faith in those who are responsible that it is. That faith has been betrayed over and over again, witness the list in tuc's post.

You feel led to believe that tuc, and those who are in agreement with him, are apologists for the pilot. Why, by pointing out that the aircraft was unairworthy and should have never been cleared to fly by the CAA? That is the point he makes (and I), and no amount of personal attacks can change that. Perhaps you are an apologist for the RAF VSOs who carried out the attacks on UK Military Air Safety, and of other RAF VSOs who have managed the cover up since. If I say that your posts give me the impression that you are, does that justify me saying so? No? Then don't do so either.

You can think what you like about the airmanship, or lack of it, involved in this tragedy. As an ex FJ you have a better grasp of that than I anyway. By attacking the very notion that airworthiness, or lack of it, is irrelevant to the accident leads me to query the professionalism to which this site is dedicated (it's the first P in PPRuNe!).

[Timelord]

I don’t really understand this argument.

Was the aircraft airworthy……… No
Did the pilot screw up……………Yes
Would the pilot still have screwed up in an airworthy and serviceable aircraft……Probably

Surely all of the above can be true?

[DaveReidUK]

Go on Dave - give us the answer!

By definition, asking whether you have misunderstood something is not a question you can answer yourself. :O

[KrisKringle]

I don’t really understand this argument.

Was the aircraft airworthy……… No
Did the pilot screw up……………Yes
Would the pilot still have screwed up in an airworthy and serviceable aircraft……Probably

Surely all of the above can be true?

No it can't. Maybe this will help you understand.

Was the aircraft airworthy………No
Did the pilot screw up……………Maybe if he was cognitively alert; but not if he was suffering a physiological episode
Would the pilot still have screwed up in an airworthy and serviceable aircraft……Maybe

It's an assumption that their was no link. We just don't know.

No bloods were tested post accident, so we don't even know if a possible physiological event was generated by the many undocumented and hidden faults of the machine.

I would really like the in-cockpit GoPros to be released. They would be telling. Until then, lazy assumptions, blame culture and emotion will prevail.

As stated before, do I 'think' he screwed up - I vehemently did. After watching the evidence in court, it convincingly opened my mind that the pilot's cognitive function wasn't right: 'the lights were on but no-one was at home'.

[dervish]

By definition, asking whether you have misunderstood something is not a question you can answer yourself. :O

Surely by mentioning the classic swiss cheese model the question was rhetorical and required no reply!?

[DaveReidUK]

Surely by mentioning the classic swiss cheese model the question was rhetorical and required no reply!?

Quite so.

But my namesake did ask ...

[Gordomac]

Steered from R&N, here, by David. Very late into the discussion so apologies if I am off track a bit.

Media reports where I reside suggest that the latest furore is about the judgement made that the pilot was guilty of "unlawfull killing". It is that element that the pilot sought appeal against and,it seems, won.

Again, apologies if my take of local reporting is off kelter but if I got it right, it moves the discussion into much deeper, specific, legal argument.

[DaveReidUK]

Steered from R&N, here, by David. Very late into the discussion so apologies if I am off track a bit.

Media reports where I reside suggest that the latest furore is about the judgement made that the pilot was guilty of "unlawfull killing". It is that element that the pilot sought appeal against and,it seems, won.

Again, apologies if my take of local reporting is off kelter but if I got it right, it moves the discussion into much deeper, specific, legal argument.

I think you're mixing up two different things:

The pilot was found not guilty of gross negligence manslaughter in a criminal trial. Clearly he is not appealing against that verdict.

Following the trial, the coroner's inquest into the deaths of the 11 men reached a verdict of unlawful killing. An inquest does not determine culpability, so there is no scope for appealing against a verdict, but the pilot is seeking a judicial review of the inquest process. AFAIK, it's not yet clear on what grounds the JR is being sought.

[beardy]

WHY is a judicial review being sought and WHO is funding it? Genuine question, could it be insurance related?

[DaveReidUK]

WHY is a judicial review being sought and WHO is funding it? Genuine question, could it be insurance related?

None of the above has yet been announced, though it's reasonable to assume that the pilot may not be comfortable with some of the coroner's findings:

https://cimg6.ibsrv.net/gimg/pprune.org-vbulletin/860x2000/extract_from_shoreham_coroner_s_judgement_a9a25f84c8f6cbc391 503142d3d47d37e0cd75d3.jpg

[dagenham]

Thank you everyone for trying to answer my question. I follow the logic tuc is laying out and expanded upon by others.

hypothetically, if there is a situation where airworthiness is an issue and the pilot in charge screws up through nothing to do with airworthiness, are we not advocating that this is airworthiness related rather than both being discrete events that at some point do need to be brought together but only once route cause has been established … correlation not being causality, or am I again missing something?

is there a risk, that the many issues raised on airworthiness ( quite rightly too ) start to deflect on other important issues?

[DaveReidUK]

is there a risk, that the many issues raised on airworthiness ( quite rightly too ) start to deflect on other important issues?

No, I don't think there is any confusion over what was the primary cause (in NTSB-speak) of the accident.

[tucumseh]

Thank you DaveReidUK for posting that extract from court papers. It raises a number of interesting points illustrating the power of a Coroner, and which perhaps go some way to answering a few of the questions above.

The High Court ruled that the AAIB report could not be used in a criminal trial (even though everyone had it, and the prosecution proceeded based on it); but it could be used by the Coroner, who is not permitted to apportion blame (although that’s unavoidable in some circumstances). Here, the Coroner has used it to make what is effectively a criminal judgment. I wonder if that is why the pilot is thinking about a judicial review?

But while not claiming to understand the ins and outs of the legal system, it troubles me that the Coroner, despite being notified of many errors and anomalies in the report, continued to regard it as factual. The High Court ruling prevented anyone introducing evidence of these errors or arguing against the report at the Inquest. To make sure, the pilot was not allowed to be a witness, the Coroner ruling this on 22 June 2022. Specifically, she said:

‘However it seems to me that any matter that Mr Hill, the pilot, might address in his evidence is already covered by the AIIB [sic] investigation and I do not propose that he should be called to give evidence to the inquests’.

Which is plainly rubbish, as he’d be mad not to point out the errors, or at least submit that the Coroner could not cite the report until corrected, and the true implications of what it revealed were made clear. Again, I wonder if the pilot considers this as an abuse of power or somehow tainting the proceedings?

Who benefited from this ruling? The CAA, certainly. And the AAIB would be spared the embarrassment of its errors. Also, MoD’s flawed g calculations would not be discussed. When you can refute something like that, then it’s not difficult to see how reasonable doubt was raised at trial.

[tucumseh]

hypothetically, if there is a situation where airworthiness is an issue and the pilot in charge screws up through nothing to do with airworthiness, are we not advocating that this is airworthiness related rather than both being discrete events that at some point do need to be brought together but only once route cause has been established … correlation not being causality, or am I again missing something?

is there a risk, that the many issues raised on airworthiness ( quite rightly too ) start to deflect on other important issues?

ANY anomaly uncovered in an investigation MUST be fully investigated and resolved, regardless of suspected impact on the investigation in hand. And must be reported in the official investigation report. This is widely ignored and leads to recurrence (which is a factor to be considered when looking at gross negligence or corporate manslaughter).

Plainly, one must be absolutely sure the anomaly (in your example, airworthiness) was NOT a causal factor. This has not been confirmed here, as the entire issue has been swept under the carpet.

The CAA made a basic error, in turn affecting all airworthiness and maintenance activities. There could be no valid safety argument. The investigator MUST ask if this occurred before, is it still happening, and what is the regulator doing to correct its error? Only after this work is complete can one form a final judgment on the direct effect on the current accident. On Shoreham, that work has not yet commenced, probably because it would reveal recurrence; in turn risking future occurrences. Who benefits?

Here, I would argue, those who attend an air show rather assume (if they even think about it) that the aircraft they're watching are airworthy, serviceable and fit for purpose. It could be said they enter into a contract with the organisers to this effect, who in turn rely upon the CAA, the operator, and, ultimately, the pilot. Too many think 'ultimately' means only the pilot can be at fault. That chain of responsibility was definitely broken by the organisers, CAA and operator before the pilot entered the aircraft. I can't comment on his actions, as I'm not a pilot. He's been cleared, the others have not yet been investigated.

[Easy Street]

The High Court ruled that the AAIB report could not be used in a criminal trial. ... Here, the Coroner has used it to make what is effectively a criminal judgment. I wonder if that is why the pilot is thinking about a judicial review?

A finding of unlawful killing is not effectively a criminal judgment. On this occasion, Wiki (https://en.m.wikipedia.org/wiki/Unlawful_killing) explains perfectly well enough why:

"In R (on the application of Maughan) v Her Majesty's Senior Coroner for Oxfordshire[3] (https://en.m.wikipedia.org/wiki/Unlawful_killing#cite_note-3) the Supreme Court clarified that the standard of proof for suicide and unlawful killing in an inquest is the civil standard of the balance of probabilities and not the criminal standard of beyond reasonable doubt."

Hill's defence managed to introduce reasonable doubt, but IMHO not balance of probabilities doubt. He will just have to get used to life in the legal no-man's land in between. Next question: civil action by the families, and against whom...

[dervish]

Thanks for those two posts tuc. I couldn’t work out why the coroner allowed the AAIB report when it was prohibited in the high court. I see now. She referred to it, but was not allowed to hear evidence about it? She’s on thin ice if she knew it was wrong in any way or showed up other failings she didn't mention.

[Chris Scott]

None of the above has yet been announced, though it's reasonable to assume that the pilot may not be comfortable with some of the coroner's findings:
[...]

Thanks for that, Dave. I'm new to this thread and the post-inquest discussion, but am curious about the following extract you've included from H.M. Coroner's findings:
"40. [Mr Hill's] flying was exceptionally bad in several aspects such that I am satisfied, applying the threshold as described in Misra, that this was, on the balance of probabilities, so far a departure from the standards to be expected that it meets the high threshold for the final element of gross negligence manslaughter, and I shall be reflecting that finding within my narrative conclusion."

Many of us have seen the result of misjudgement and/or negligence by a pilot that has led to an accident which had the potential to harm third parties. As a layperson, it seems to me that any proposal of gross negligence on the part of a pilot flying alone has to address the fact that (s)he is usually the party most likely to suffer any serious consequences. Therefore, I'm wondering if a finding of gross-negligence manslaughter can be applied in this case. Did the coroner have any evidence that Mr Hill made a deliberate attempt to impact the public road, rather than open spaces nearby?

If that question has been answered previously on this thread, please accept my apologies.

[Gordomac]

Thanks David. Headline grab and junior reporting referred to the "Shoreham Air disaster pilot" being found not guilty "upon appeal".The reporter got mixed up and I got totally confused by entering the debate chamber late (!)

Subsequent posts here confirm my view of very interesting legal debate.. A "balance of probabilities" could often lead to a "beyond reasonable doubt" concluding act. I submit. Sorry. Watching too much Judge Judy in retirement from Airline piloting. I'll stop me there.

I have little doubt. though, that Hill did not set out, that fateful day to kill himself or kill innocent bystanders. His actions appear to have been negligent and resulted in accidental loss of life.. I agree with Peers who concluded that he was not guilty of "unlawful killing".

[Chugalug2]

Can this country do nothing right? All that an air accident report (civil or military) is required to do is state the result of a fully comprehensive unbiased and objective investigation into an aircraft accident. Plainly this one didn't. That error is then compounded by it being treated as holy writ and protected from challenge in court but then used by the coroner, despite her being denied consideration of evidence of it being flawed. These proceedings were about as just as the scandal of the Mull's kangaroo court.

So, the canker that has blighted military air safety for so long is now infecting its civil counterpart it would seem. The primary purpose of air accident investigation is to prevent recurrence. Not only has this one failed spectacularly in that, it has almost guaranteed recurrence by protecting the civil regulator from the result of its own negligence. The negligence will continue unhindered unless it is exposed. All that is missing is the continuous cover up protecting its military counterpart's gross negligence. Then the curse will be complete.

[Raikum]

I think it would be a good move for people to read the Misra case to which the coroner referred. Its not that difficult to understand for non-lawyers.
The key is in para 66 where the Court of Appeal said as follows:
"....The jury concluded that the conduct of each appellant in the course of performing his professional obligations to his patient was "truly exceptionally bad"...."
You can read it here https://www.casemine.com/judgement/uk/5a8ff7b360d03e7f57eb152b

[tucumseh]

A finding of unlawful killing is not effectively a criminal judgment.



Easy Street...... I think you probably realise I know the different standards of proof. I said 'effectively', because the Coroner mentioned the (criminal) gross negligence manslaughter test (e.g. ‘exceptionally bad’). (See DaveReidUK’s post). The same words are used in both courts. In many ways, a distinction without a difference. (Edit - Raikum got in first!).

Strictly speaking, post-trial there wasn’t any need for an Inquest. The Coroner gave various reasons why she was holding one, but was not allowed to address the key question of WHY the aircraft was being flown the way it was. That was determined at trial but, as you say, against a different standard. She wanted to ask, but was stopped by the High Court.

At that point the Inquest could never meet its stated aims, especially if held under Article 2. We know what she said the basis of her finding was, but it was a poor basis given she KNEW the AAIB report she relied upon was wrong/flawed/incomplete, and that others had made serious errors.

Despite what others have said (above), the pilot admitted his errors (which I’ll take his word for as I can’t explain them, and when doing so he was referring to a GoPro video that has never been released) - errors that took place in a very short period of time, each compounding the next. But others committed errors and even offences over a much longer period, knew it, didn’t correct them, continued, and then fought for them not to be disclosed.

[DaveReidUK]

I agree with Peers who concluded that he was not guilty of "unlawful killing".

What other verdict that was available to the coroner should she have delivered ?

[Chris Scott]

I think it would be a good move for people to read the Misra case to which the coroner referred. Its not that difficult to understand for non-lawyers.

The key is in para 66 where the Court of Appeal said as follows:

"....The jury concluded that the conduct of each appellant in the course of performing his professional obligations to his patient was "truly exceptionally bad"...."

You can read it here https://www.casemine.com/judgement/uk/5a8ff7b360d03e7f57eb152b

The conduct of the medical clinicians in that case took place during a period of over 24 hours, during which they were able to confer with fellow doctors and the nursing staff who had first alerted one of them to concerning abnormalities in the patient's condition. Between them, they made a series of errors of omission.

No doubt lawyers, including coroners, may have to resort to studying case law to try and find what laypersons like myself might refer to as an analogy for the case they are considering.

However, I fail to see that the Misra case can be considered analogous to that of a lone display pilot, who has no more than a few seconds to identify any problem, consider whether an escape manoeuvre or other change of plan is required, and initiate it.

[tucumseh]

What other verdict that was available to the coroner should she have delivered ?


"An open conclusion will be reached where there is not enough evidence to reach any other conclusion".

That might be thought appropriate, especially given the evidence the Coroner was restricted to.


She could also have said:

"Accident / Misadventure....

Where deaths are truly 'accidental' in the sense that neither the acts causing death nor the consequences of those acts were intended."

(Unless anyone is claiming the pilot intended what happened).


As for:

"Unlawful killing

A conclusion of unlawful killing can essentially be returned in two circumstances:

(i) as a result of an unlawful act, such as an assault or murder; or

(ii) through gross negligence manslaughter."


This refers to intent, and the "conduct of the individual will always be considered against the background of all the relevant circumstances....".


And 'Misra', cited by the Coroner, also says:

"Mistakes, even very serious mistakes, and errors of judgment, even very serious errors of judgment, and the like, are nowhere near enough for a crime as serious as manslaughter to be committed".


My interpretation (because it is not clear cut, and I'm no expert) is that Unlawful Killing is unsafe given the Coroner was not allowed to explore 'the background of all the relevant circumstances' which the AAIB report referred to. Primarily, the failings of others whom the pilot (and deceased) relied upon.

[_Agrajag_]

I agree with your take on this, tucumseh . This ticks all the boxes for "misadventure". A pilot that made non-deliberate errors. An aircraft with a dubious airworthiness status. Display planners that thought it was OK to display so close to a busy main road. Nothing I've read suggests a deliberate act by the pilot. Careless certainly, and opportunities to avoid the accident were missed. Carelessness runs right through this tragic accident from several parties though.

One thing we've learned many times is that carelessness and complacency go hand in hand. This accident proves this, yet again.

[Asturias56]

The problem is that although there may well have been many careless people only one was flying the aircraft that day. And as has been pointed out - he only got off by invoking a unique medical condition that, shall we be generous, has many people baffled.

[_Agrajag_]

The problem is that although there may well have been many careless people only one was flying the aircraft that day. And as has been pointed out - he only got off by invoking a unique medical condition that, shall we be generous, has many people baffled.

The same could be said of the display planning. Had they not set things up so that the loop was very close to a major busy road then the pilot being careless may not have resulted in a lot of people being killed. From what I've read the airworthiness issues may not have contributed to this accident. They could easily have done though. Hard to find any aspect of the planning of this display, its execution on the day, or the airworthiness of the aircraft, that were up to snuff. The pilot's error was the critical one. That seems more by misfortune than judgement. The aircraft airworthiness and the display planning were an accident waiting to happen. To me that is indicative of a culture of carelessness.

Many of us have seen this before. When there's a lack of discipline and sound leadership it's inevitable that complacency and carelessness result in safety standards dropping. Who here hasn't seen this happen? I have, for sure. In a very different environment. The case I remember is where the culture of "get the job done" meant that it had become "custom and practice" to ignore "inconvenient" safety procedures. This level of complacency had built up over years. No one really noticed it. Leadership by example was non-existent. The key thing was keep things running by fair means or foul. I have a strong feeling that this air show had fallen into the same trap. Been running for years and was the perfect breeding ground for complacent attitudes to set in across the board.

[Easy Street]

However, I fail to see that the Misra case can be considered analogous to that of a lone display pilot, who has no more than a few seconds to identify any problem, consider whether an escape manoeuvre or other change of plan is required, and initiate it.

Hill's failings can't be reduced to the single fateful mistake of continuing the loop. As has been recounted, he had made mistakes in previous displays and should have had some awareness of his own shortcomings of experience, training and currency as a result of them. He had days/weeks/months in which to realise that displaying a high performance swept wing aircraft in a confined site was not wise. The fact that regulations allowed him to reflects poorly indeed on the regulator, but it doesn't absolve Hill of primary responsibility.

As for whether the fateful action was 'intended', well of course he didn't intend to crash or kill people. But he did intend to fly the display while inadequately prepared (having not practised the requisite escape manoeuvre) and, excepting the remote possibility that he did so involuntarily while incapacitated, he did intend to continue the loop having entered low and apexed below gate height. Those actions alone might be judged to reach the balance of probabilities test for gross negligence manslaughter, and in that sense the Coroner had enough to reach her verdict.

[Cole Burner]

And as has been pointed out - he only got off by invoking a unique medical condition...

Are we sure about that? Does a jury actually give a reason for their verdict?

I think you are probably right, but unless you were on the jury - who knows? They may have just thought that the prosecution case was weak and such a nice chap couldn't possibly be guilty...

[Chris Scott]

Hill's failings can't be reduced to the single fateful mistake of continuing the loop. As has been recounted, he had made mistakes in previous displays and should have had some awareness of his own shortcomings of experience, training and currency as a result of them. He had days/weeks/months in which to realise that displaying a high performance swept wing aircraft in a confined site was not wise. The fact that regulations allowed him to reflects poorly indeed on the regulator, but it doesn't absolve Hill of primary responsibility.

As for whether the fateful action was 'intended', well of course he didn't intend to crash or kill people. But he did intend to fly the display while inadequately prepared (having not practised the requisite escape manoeuvre) and, excepting the remote possibility that he did so involuntarily while incapacitated, he did intend to continue the loop having entered low and apexed below gate height. Those actions alone might be judged to reach the balance of probabilities test for gross negligence manslaughter, and in that sense the Coroner had enough to reach her verdict.

You present a plausible argument, Easy Street, but haven't yet addressed the point I made in my first post (https://www.pprune.org/military-aviation/619209-shoreham-airshow-crash-trial.html#post11383959):
"As a layperson, it seems to me that any proposal of gross negligence on the part of a pilot flying alone has to address the fact that (s)he is usually the party most likely to suffer any serious consequences. Therefore, I'm wondering if a finding of gross-negligence manslaughter can be applied in this case. Did the coroner have any evidence that Mr Hill made a deliberate attempt to impact the public road, rather than open spaces nearby?"

If not, the fact that Mr Hill was the most likely victim of his own mistake surely distinguishes his culpability from that of the two clinicians in the so-called Misra case.

[Easy Street]

I don't understand where you're trying to go with that. Are you saying that Hill couldn't possibly be grossly negligent, because he was the one most likely to die if he crashed? That would fall down because negligent acts don't have to be intended: the legal definition of negligence is essentially 'failure to take proper care'. Aviation history is littered with examples of pilots who have died due to their own grossly negligent flying, so the self-preservation argument is of no value.

[Chris Scott]

I don't understand where you're trying to go with that. Are you saying that Hill couldn't possibly be grossly negligent, because he was the one most likely to die if he crashed? That would fall down because negligent acts don't have to be intended: the legal definition of negligence is essentially 'failure to take proper care'. Aviation history is littered with examples of pilots who have died due to their own grossly negligent flying, so the self-preservation argument is of no value.
No, we've already discussed the gross negligence part. Perhaps I should have highlighted my relevant sentence on "gross-negligence manslaughter". As a layman, I find it hard to contemplate that a manslaughter judgement could be applied to someone when there is no evidence that he was not aiming for an open space and that, in any case, he was the most likely victim of his own error of judgement. The latter could not possibly have applied in the so-called Misra case cited by Raikum above, which - IMHO - is a red herring.

[tucumseh]

I don't understand where you're trying to go with that. Are you saying that Hill couldn't possibly be grossly negligent, because he was the one most likely to die if he crashed? That would fall down because negligent acts don't have to be intended: the legal definition of negligence is essentially 'failure to take proper care'. Aviation history is littered with examples of pilots who have died due to their own grossly negligent flying, so the self-preservation argument is of no value.

There is a distinction between negligence and gross negligence. Negligence is commonly defined as ‘the inadvertent taking of an unjustifiable risk’. Whereas, gross negligence is ‘a conscious act or omission in disregard of a legal duty and of the consequences to another party’. (Ormerod D. Smith 8 Hogan’s Criminal Law (11th edition)). In other words, degree relates to appreciation of the risks involved, together with serious disregard or indifference to an obvious risk. The outcome (in this case death) is not a factor in determining degree.

Based on that definition, the Coroner's ruling is that the pilot made a conscious decision to fly the entire manouevre as he did. I wonder if the pilot would have accepted 'negligence'? That huge leap to 'gross negligence' forced a court case, and a defence which the prosecution couldn't refute.


It is seldom if ever mentioned that the Judge directed the jury on several points of evidence, specifically factual errors in the prosecution case. It wasn't a simple 'CI or not CI' question. Even if the CI defence had not been advanced, it is likely the same verdict would have been reached, as fundamental errors by the prosecution, and failure to disclose evidence, tends not to sit well when the test is 'beyond reasonable doubt'. Moreover, the pilot's acceptance of his error, and refusal to blame others, despite their CONSCIOUS acts of commission and omission, clearly went down well with the Judge.

Cognitive Impairment is not a 'unique medical condition'. Most people here should know that, if only from MoD advancing it in the Sean Cunningham case, both in the SI report and in court. The difference being, at Shoreham there was no claim it was self-induced.

[typerated]

There is a distinction between negligence and gross negligence. Negligence is commonly defined as ‘the inadvertent taking of an unjustifiable risk’. Whereas, gross negligence is ‘a conscious act or omission in disregard of a legal duty and of the consequences to another party’. (Ormerod D. Smith 8 Hogan’s Criminal Law (11th edition)). In other words, degree relates to appreciation of the risks involved, together with serious disregard or indifference to an obvious risk. The outcome (in this case death) is not a factor in determining degree.

Based on that definition, the Coroner's ruling is that the pilot made a conscious decision to fly the entire manouevre as he did. I wonder if the pilot would have accepted 'negligence'? That huge leap to 'gross negligence' forced a court case, and a defence which the prosecution couldn't refute.


It is seldom if ever mentioned that the Judge directed the jury on several points of evidence, specifically factual errors in the prosecution case. It wasn't a simple 'CI or not CI' question. Even if the CI defence had not been advanced, it is likely the same verdict would have been reached, as fundamental errors by the prosecution, and failure to disclose evidence, tends not to sit well when the test is 'beyond reasonable doubt'. Moreover, the pilot's acceptance of his error, and refusal to blame others, despite their CONSCIOUS acts of commission and omission, clearly went down well with the Judge.

Cognitive Impairment is not a 'unique medical condition'. Most people here should know that, if only from MoD advancing it in the Sean Cunningham case, both in the SI report and in court. The difference being, at Shoreham there was no claim it was self-induced.

Was it lack of airworthiness that caused the Cognitive Impairment ?

[DaveReidUK]

I don't understand where you're trying to go with that. Are you saying that Hill couldn't possibly be grossly negligent, because he was the one most likely to die if he crashed? That would fall down because negligent acts don't have to be intended: the legal definition of negligence is essentially 'failure to take proper care'.

Yes, that much is self-evident.

Bear in mind also that in the criminal trial gross negligence manslaughter was exactly what the pilot was indicted for, albeit the jury didn't agree that the prosecution had proved their case beyond reasonable doubt, i.e. to the standard of proof required in a criminal court.

[tucumseh]

Was it lack of airworthiness that caused the Cognitive Impairment ?

The two have never, as far as I know, been directly linked by anyone. You could say that training and authorisation to conduct the flight are related matters, as the safety of the air system as a whole would be affected. There will be criteria to satisfy in order to be authorised, which a pilot could better explain.

[Raikum]

The conduct of the medical clinicians in that case took place during a period of over 24 hours, during which they were able to confer with fellow doctors and the nursing staff who had first alerted one of them to concerning abnormalities in the patient's condition. Between them, they made a series of errors of omission.

No doubt lawyers, including coroners, may have to resort to studying case law to try and find what laypersons like myself might refer to as an analogy for the case they are considering.

However, I fail to see that the Misra case can be considered analogous to that of a lone display pilot, who has no more than a few seconds to identify any problem, consider whether an escape manoeuvre or other change of plan is required, and initiate it.

Of course the facts are different, but the issue in that case was whether those serial failures could be categorized as truly exceptionally bad, to which the answer was yes.
In this case the Coroner, asking herself the same question (as the law requires her to do), took the view that the pilot's actions or failures were, viewed objectively, truly exceptionally bad and concluded they were.
What you are doing is saying in your view they weren't which is fine; an opinion which you are of course entitled to hold. The Coroner, having heard and read all the evidence took a different view.
The irony of course is that it could be said that the pilot's legal advisors didn't disagree that the pilot's standard of flying was truly exceptionally bad and indeed used that categorization as evidence that other factors must have been in play: hence cognitive impairment.
All that said, I will be intrigued to see the what the grounds for the judicial review, or whatever it is now called, As they nailed their colours to the CI mast, I don't see how they can now argue that that the coroner got it wrong on how to judge the standard of their client's actions or failures.

[Chris Scott]

Thanks for the clarification, Raikum. And in particular your closing observation:
"The irony of course is that it could be said that the pilot's legal advisors didn't disagree that the pilot's standard of flying was truly exceptionally bad and indeed used that categorization as evidence that other factors must have been in play: hence cognitive impairment.
All that said, I will be intrigued to see the what the grounds for the judicial review, or whatever it is now called, As they nailed their colours to the CI mast, I don't see how they can now argue that that the coroner got it wrong on how to judge the standard of their client's actions or failures."

What about the manslaughter element of "gross-negligence manslaughter"? Does my argument above (https://www.pprune.org/military-aviation/619209-shoreham-airshow-crash-trial-48.html#post11384289) have any legal merit? If not, I suspect it would resonate with many lay people, nevertheless.

[Gordomac]

I did suggest that the discussion would develop into really interesting legal debate. It clearly has. David Reid asks what other conclusions might have been available to the Judge/coroner. Dunno. Not a Lawyer but no need for a reply as lots of posters offered answers.
I struggle with legal definition of stuff ,like,"Unlawful killing". Is that opposed to "Lawful killing" ? Tuc gives a suggestion that gross negligence can be tied to unlawful events.

It gets very involved in professional jargon but I stand by my view that HIll did not set out to kill himself or any innocent bystanders.Very tragic consequences , accidental, in my view, to a series of errors.

[Chugalug2]

Thread titles, on this forum at least, tend not to survive thread content, and later events and developments cause the discussion to move on. Thread drift perhaps, but tolerated by our esteemed mods and no more apparent than in that most celebrated thread of all, and now a sticky, that of obtaining an RAF Pilots Brevet in WWII. This one though seems obstinately to be obsessed with the trial that is the OP subject. I know little about legal process other than it be arcane and unpredictable but trying to rerun it in these pages seems to me to be bordering on the pointless.

The tragedy of Shoreham must never be repeated. There at least we are surely all in agreement. Aviation has a history of far too many fatal accidents, but each one is an opportunity to learn from in order to avoid repetition. There are many lessons to be learnt from Shoreham and professional aviators need to consider them all. Once again we find that many of the factors involved were not 'discovered' in the air accident investigation and it has fallen on others to expose them and seek formal consideration. That the 'authorities' seem reluctant to do so says more about our national institutions than it does about proper air accident investigation. The glaring shortfall on this occasion is a classic one, that of the relationship between Air Regulator and Accident Investigator. If ever there were proof of the necessity of a complete separation and independence of the two then it is here. Instead of hints and nudges of problems there needs to be outright condemnation of any regulatory negligence. It has been the curse of UK Military Aviation for over thirty years. It must not be allowed to infect our civil aviation as well.

The elephant in the room here isn't pilot CI, or even what he ate for breakfast. It is the fact that he was flying an ex-military FJ that was already unairworthy when it received its permit to fly and remained so until it crashed alongside the A27. Just as with Mull, the worst military example of this syndrome, we don't know if the lack of airworthiness caused the tragedy because, just like Mull, no-one felt disposed to seriously consider that. I find that to be the glaring omission in the subsequent investigations by the AAIB, the High Court, and the Coroner. That is a scandal in my view and will encourage repetition if not corrected.

[Raikum]

"What about the manslaughter element of "gross-negligence manslaughter"? Does my argument above (https://www.pprune.org/military-aviation/619209-shoreham-airshow-crash-trial-48.html#post11384289) have any legal merit? If not, I suspect it would resonate with many lay people, nevertheless."
Sorry my fault for sure but I'm not sure I quite understand the point you're making.. I should make it clear that I haven't read any of the transcripts, the AAIB report or anything else in any detail so I'm reluctant to comment on the facts of this ghastly affair. What does seem clear though is that the pilot messed up big time; hence the test 'truly exceptionally bad'. And sure he put his own neck on the line much like a driver indicted for the same offense but that, as per the facts in Misra,, is an irrelevance for a conviction.
I should add that though I was a lawyer in a past life (now gladly retired !), I never was involved in criminal cases so my knowledge is somewhat limited. Ironically though I was involved in a depressingly large number of medical negligence cases and one or two quite high profile aircraft accident cases.

[pasta]

What about the manslaughter element of "gross-negligence manslaughter"? Does my argument above (https://www.pprune.org/military-aviation/619209-shoreham-airshow-crash-trial-48.html#post11384289) have any legal merit? If not, I suspect it would resonate with many lay people, nevertheless.
It doesn't resonate with this lay person. A driver can be convicted of exactly the same offence, even though they didn't set out to have an accident at all, and were most likely to be the victim of any accident they did cause. Have a look at the CPS guidelines: https://www.cps.gov.uk/legal-guidance/road-traffic-charging

[DaveReidUK]

but I stand by my view that Hill did not set out to kill himself or any innocent bystanders.

I don't recall, nearly 1000 posts in, any contributor having suggested otherwise ...

[Two's in]

...The elephant in the room here isn't pilot CI, or even what he ate for breakfast. It is the fact that he was flying an ex-military FJ that was already unairworthy when it received its permit to fly and remained so until it crashed alongside the A27...

Well, there are two elephants in this particular room. The airworthiness is a foundation layer root cause, but quite how a pilot with limited currency/recency on a high performance jet can end up in a position of publicly displaying said jet should also be a question for the CAA. Of course, because there are two elephants it's almost a circus, so the CAA are eminently qualified to wade in at this point.

[Chugalug2]

Two's in, I agree entirely with your point about pilot currency and indeed with all the many shortfalls that litter this tragedy. All I'm trying to encourage is more awareness of every factor involved and of how they should all be dealt with to avoid recurrence. Simply concentrating on any pilot deficiency merely gives those others who failed in their duties a free pass and more importantly the certainty of similar failures in the future, particularly of Regulation in all its forms.

[Easy Street]

What about the manslaughter element of "gross-negligence manslaughter"? Does my argument above (https://www.pprune.org/military-aviation/619209-shoreham-airshow-crash-trial-48.html#post11384289) have any legal merit? If not, I suspect it would resonate with many lay people, nevertheless.

Intent, or its absence, is the difference between manslaughter and murder. Even lay people understand that, so your argument has no resonance whatsoever. Manslaughter very clearly means *unintentional* unlawful killing. Unintended actions can still be indictable where failure of a duty of reasonable care is involved, as it is with operating a vehicle or aircraft.

The fact that Hill didn't attempt to crash in an unoccupied area does not mean that he intended to kill the bystanders. (Had he tried to do something like that he certainly would have died). In the final stages he was taking the course of action most likely to avoid a crash, and very nearly succeeded; however the lack of intent to kill anyone else and the genuine effort to avoid crashing do not by themselves exclude manslaughter.

[tucumseh]

Intent, or its absence, is the difference between manslaughter and murder. Even lay people understand that, so your argument has no resonance whatsoever. Manslaughter very clearly means *unintentional* unlawful killing.

The Sentencing Council says this:

'Manslaughter is a crime that can be broken down into two groups:

1. Voluntary manslaughter - where the offender INTENDED......
2. Involuntary manslaughter - where the offender DID NOT INTEND....'

(See above) I was citing in the first instance the difference between negligence and gross negligence:

"Negligence is commonly defined as ‘the inadvertent taking of an unjustifiable risk’. Whereas, gross negligence is ‘a conscious act or omission in disregard of a legal duty and of the consequences to another party’. (Ormerod D. Smith 8 Hogan’s Criminal Law (11th edition))."

Logically (so doesn't necessarily apply to the law) to pursue Gross Negligence Manslaughter, one must first satisfy the Gross Negligence criteria?

It's certainly a difficult area, and legal opinion differs greatly. But, from the above sources, it would seem the decision to prosecute the pilot for GNM followed a decision by the CPS (?) that there was intent of some kind. All complicated by the sentencing guidelines changing in 2018. My brain hurts.

[alfred_the_great]

Thread titles, on this forum at least, tend not to survive thread content, and later events and developments cause the discussion to move on. Thread drift perhaps, but tolerated by our esteemed mods and no more apparent than in that most celebrated thread of all, and now a sticky, that of obtaining an RAF Pilots Brevet in WWII. This one though seems obstinately to be obsessed with the trial that is the OP subject. I know little about legal process other than it be arcane and unpredictable but trying to rerun it in these pages seems to me to be bordering on the pointless.

The tragedy of Shoreham must never be repeated. There at least we are surely all in agreement. Aviation has a history of far too many fatal accidents, but each one is an opportunity to learn from in order to avoid repetition. There are many lessons to be learnt from Shoreham and professional aviators need to consider them all. Once again we find that many of the factors involved were not 'discovered' in the air accident investigation and it has fallen on others to expose them and seek formal consideration. That the 'authorities' seem reluctant to do so says more about our national institutions than it does about proper air accident investigation. The glaring shortfall on this occasion is a classic one, that of the relationship between Air Regulator and Accident Investigator. If ever there were proof of the necessity of a complete separation and independence of the two then it is here. Instead of hints and nudges of problems there needs to be outright condemnation of any regulatory negligence. It has been the curse of UK Military Aviation for over thirty years. It must not be allowed to infect our civil aviation as well.

The elephant in the room here isn't pilot CI, or even what he ate for breakfast. It is the fact that he was flying an ex-military FJ that was already unairworthy when it received its permit to fly and remained so until it crashed alongside the A27. Just as with Mull, the worst military example of this syndrome, we don't know if the lack of airworthiness caused the tragedy because, just like Mull, no-one felt disposed to seriously consider that. I find that to be the glaring omission in the subsequent investigations by the AAIB, the High Court, and the Coroner. That is a scandal in my view and will encourage repetition if not corrected.

the CAA and AAIB are separate and independent. I‘lol have to check, but I’m pretty sure his aircraft was on the civilian register.

[_Agrajag_]

the CAA and AAIB are separate and independent. I‘lol have to check, but I’m pretty sure his aircraft was on the civilian register.


It was operating under a Permit to Fly. Airworthiness was a dog's breakfast. The CAA knew SFA about the Hunter in terms of airworthiness. It was not certified, hence operating under a P t F. The MoD weren't much interested either. Both seem to have engaged in arse covering of the first order after the accident. Nothing to do with this accident, but highlights the general lack of competence when it comes to airworthiness of former military aircraft.

[alfred_the_great]

It was operating under a Permit to Fly. Airworthiness was a dog's breakfast. The CAA knew SFA about the Hunter in terms of airworthiness. It was not certified, hence operating under a P t F. The MoD weren't much interested either. Both seem to have engaged in arse covering of the first order after the accident. Nothing to do with this accident, but highlights the general lack of competence when it comes to airworthiness of former military aircraft.

well, then perhaps the military obvious answer is there shouldn’t be any civilians flying former military aircraft?

out of curiosity, who certified the spitfires flown by civvies? What’s the safety case?

[_Agrajag_]

well, then perhaps the military obvious answer is there shouldn’t be any civilians flying former military aircraft?

out of curiosity, who certified the spitfires flown by civvies? What’s the safety case?

Spitfires aren't certified either. They are all (except the BBMF I think) operated under a Permit to Fly. Loads of aircraft operate in the UK without any formal airworthiness certification, as such. A Permit to Fly isn't carte blanche to avoid all safety regulation. Just means there is no formal certificate of airworthiness for the type. Examples of types without certification are all ex-military types, microlights, home built aircraft, flying replicas, paramotors, balloons, some gliders, and probably a few others.

[alfred_the_great]

Spitfires aren't certified either. They are all (except the BBMF I think) operated under a Permit to Fly. Loads of aircraft operate in the UK without any formal airworthiness certification, as such. A Permit to Fly isn't carte blanche to avoid all safety regulation. Just means there is no formal certificate of airworthiness for the type. Examples of types without certification are all ex-military types, microlights, home built aircraft, flying replicas, paramotors, balloons, some gliders, and probably a few others.

and thus unsafe to fly.

[_Agrajag_]

and thus unsafe to fly.

A bit of paper doesn't magically make an aircraft safe. Aircraft are safe to fly when they are maintained and serviced properly. None of the aircraft produced during the war went through what we would now recognise as the sort of safety certification used in civil aviation. Come to that, none of the gliders used to give ATC cadets their first taste of flying were certified either.

Doesn't mean they were unsafe. Arguably the safety record for loads of uncertified aircraft proves beyond doubt that having an airworthiness certificate is a marginal benefit. Plenty of certified aircraft crash.

[Chugalug2]

the CAA and AAIB are separate and independent. I‘lol have to check, but I’m pretty sure his aircraft was on the civilian register.
So they say, ATG, but perhaps we should judge them by their actions rather than their claims. As AJ has pointed out, the CAA has been content to allow fleets of uncertified aircraft permits to fly. Unairworthy aircraft are an accident waiting to happen, putting one into the confines of Shoreham with crowds of unsuspecting spectators inside and outside its boundaries was foolhardy. That is not just with the wisdom of hindsight, it would always be foolhardy. It behoved the Regulator to assure itself that the aircraft was airworthy and the display safe, it behoved the investigator to point out its failure to do so. Independent, separate, or not, both failed in their duty. Why?

[megan]

and thus unsafe to flyIn the last 1,150 or so years since your days technology has advanced somewhat. :p

[dervish]

Arguably the safety record for loads of uncertified aircraft proves beyond doubt that having an airworthiness certificate is a marginal benefit. Plenty of certified aircraft crash.

A certificate must go hand in hand with a competent regulator. It is meant to provide confidence. If the regulator is incompetent what confidence can we have?

[Bob Viking]

I think we are all in broad agreement and just arguing similar points. From my personal perspective, the one body that could and should have regulated this whole sorry tale better is the CAA. Putting such an inexperienced (on type) pilot in the position of flying low level aerobatics for a huge crowd and over innocent bystanders was utter madness. The other points we can argue about until the cows come home.

BV

[_Agrajag_]

A certificate must go hand in hand with a competent regulator. It is meant to provide confidence. If the regulator is incompetent what confidence can we have?


Spot on, and in this case there wasn't a competent regulator. As it happens it most probably didn't play a role in this accident. The investigation has highlighted something known of for years and which has been kicked into the long grass. When an airworthiness authority disappears for an old type there doesn't seem to be a way to create a competent replacement.

[Dominator2]

Putting such an inexperienced (on type) pilot in the position of flying low level aerobatics for a huge crowd and over innocent bystanders was utter madness.

BV,

No one forced AH to fly this or any other display. The pilot must take the ultimate responsibility for accepting a display venue and adapting the display to suit the venue and conditions. If not able to do so the pilot should not "attempt" to fly the display.



That said, the whole "system" is totally lacking any effective control. If the CAA are responsible they must take control. With that comes responsibility. No hiding behind organisations, it comes down to individuals.


There can be no doubt that there are a few highly paid individuals within CAA who have not taken responsibility. As an observer it sounds as though there has been a lot of ducking and diving.


Tucumseh,

Whilst I agree with many of your questions about the airworthiness issues with some of these display aircraft they did not, as far as we know, effect this accident. As mentioned previously, when signing for an aircraft the Captain accepts that aircraft for the flight as planned. In doing so the Captain accepts responsibility. Despite all of the other distractions, AH was, IMHO, responsible for the outcome of this flight

[Chugalug2]

.
Whilst I agree with many of your questions about the airworthiness issues with some of these display aircraft they did not, as far as we know, effect this accident. As mentioned previously, when signing for an aircraft the Captain accepts that aircraft for the flight as planned. In doing so the Captain accepts responsibility. Despite all of the other distractions, AH was, IMHO, responsible for the outcome of this flight

Responsible for what? The airworthiness of the a/c? How is he supposed to know if it is anything other than fully airworthy? That is the default assumption that all pilots have to make unless they know to the contrary. By your reckoning the Captain of the ill fated Afghanistan Nimrod was responsible for the loss of his crew and its grossly unairworthy a/c when it spontaneously exploded after AAR. Utter rubbish. Your 'as far as we know' is at the very core of this argument. What we know now differs from what we were told by the accident report. That has to be considered formally, hopefully by Hill's JR.

[dervish]

Responsible for what? The airworthiness of the a/c? How is he supposed to know if it is anything other than fully airworthy? That is the default assumption that all pilots have to make unless they know to the contrary. By your reckoning the Captain of the ill fated Afghanistan Nimrod was responsible for the loss of his crew and its grossly unairworthy a/c when it spontaneously exploded after AAR. Utter rubbish. Your 'as far as we know' is at the very core of this argument. What we know now differs from what we were told by the accident report. That has to be considered formally, hopefully by Hill's JR.

Nailed it.

[dervish]

I think we are all in broad agreement and just arguing similar points. From my personal perspective, the one body that could and should have regulated this whole sorry tale better is the CAA.
BV

Agree about CAA. The AAIB report left them without a name, yet they are now working together, with MoD in tow. Someone please explain!

But broad agreement? There are people here making assertions that are factually inaccurate, who persist even when taken to the evidence.

[dagenham]

Nailed it.

actually no … the nimrod or mull have many parallels in terms of safety case / airworthiness, but there is still the issue that the accident could have been avoided or mitigated by appropriate manoeuvres …that where not an option in those instances….. so there are three issues here

1. airworthiness and sign off
2. accreditation and sign off
3. pilot actions and consequences or impediment to those by physiological events

all three are interconnected but has causality between been proven ?

everything cannot be lumped only into point 1…..

[dervish]

actually no … the nimrod or mull have many parallels in terms of safety case / airworthiness, but there is still the issue that the accident could have been avoided or mitigated by appropriate manoeuvres …that where not an option in those instances….. so there are three issues here

1. airworthiness and sign off
2. accreditation and sign off
3. pilot actions and consequences or impediment to those by physiological events

all three are interconnected but has causality between been proven ?

everything cannot be lumped only into point 1…..

I'm at a loss. Your post has nothing to do with Chugalug's or mine. He replied to a specific point made by someone else and was accurate, and nowhere implies "airworthiness and sign off" are the sole issues on Shoreham. By asking if causality between your 3 points has been proven, you are just repeating what he has already said and is true. I've read the accident report and it mentions all 3 but doesn't attempt to link them. That doesn't mean there is no link. It means the investigation was crap.

[dagenham]

I'm at a loss. Your post has nothing to do with Chugalug's or mine. He replied to a specific point made by someone else and was accurate, and nowhere implies "airworthiness and sign off" are the sole issues on Shoreham. By asking if causality between your 3 points has been proven, you are just repeating what he has already said and is true. I've read the accident report and it mentions all 3 but doesn't attempt to link them. That doesn't mean there is no link. It means the investigation was crap.

no argument to your last point ….

[Chugalug2]

actually no … the nimrod or mull have many parallels in terms of safety case / airworthiness, but there is still the issue that the accident could have been avoided or mitigated by appropriate manoeuvres …that where not an option in those instances….. so there are three issues here

1. airworthiness and sign off
2. accreditation and sign off
3. pilot actions and consequences or impediment to those by physiological events

all three are interconnected but has causality between been proven ?

everything cannot be lumped only into point 1…..
If you run out of argument then create a false one, is that it? No-one is saying that airworthiness should be considered alone. As Dervish has pointed out, I was merely answering D2's somewhat unique idea that having signed for it a pilot is responsible for the entire state of an aircraft including its airworthiness. Unless you share his view, I cannot see that we are in anything other than violent agreement, sorry! Indeed, the thread seems to have moved on from 'lumping' everything into point 3 of your list and now accepts that all three points are interconnected as your post states. Congratulations, we are as one!

[dagenham]

If you run out of argument then create a false one, is that it? No-one is saying that airworthiness should be considered alone. As Dervish has pointed out, I was merely answering D2's somewhat unique idea that having signed for it a pilot is responsible for the entire state of an aircraft including its airworthiness. Unless you share his view, I cannot see that we are in anything other than violent agreement, sorry! Indeed, the thread seems to have moved on from 'lumping' everything into point 3 of your list and now accepts that all three points are interconnected as your post states. Congratulations, we are as one!

chug I will now leave this mortal coil happy 😊

[Mike51]

https://www.bbc.co.uk/news/uk-england-sussex-65779379

[falcon900]

In many ways, for those most immediately involved in this case, this might be for the best, as no verdicts or judgements can alter what happened and its consequences on their lives. For those wondering about civil actions by the families, I suspect the terms of their compensation payments from the insurers will preclude this.
As for the larger issues, it would appear that the band plays on till the next time. All in all a very poor advert for our “system” whereby such a serious catastrophe can be pored over by so many for so long, and yet we end up with so many obvious inadequacies in the process followed. We all have our prejudices and pet theories about what actually happened that day, and why: I would have expected a much more coherent and cogent conclusion to have been reached by now, and would have been at ease with it whether it fitted my hypothesis or not had I been able to accept that a rational process had been followed. Rather than rational, the adjectives which spring to mind are arcane and machiavellian.

[Asturias56]

A spokesperson for the West Sussex, Brighton and Hove Coroner said: "Further to the High Court's decision to refuse permission for Mr Hill to proceed with the judicial review, Mr Hill has now advised that he will not be making a request for an oral hearing to challenge that decision."

Sarah Stewart, of law firm Stewarts, who acted for the majority of the families, said the relatives of the deceased could "continue their healing process in peace".

"The families look forward to putting this chapter firmly behind them, safe in the knowledge that their voices have finally been heard," she said.


Maybe we should lock this thread?

[Jet_Fan]

Mr Hill is now trying to get his licence back, which seems a trifle insensitive to little old me. I'm surprised there hasn't been a crowd founded, class action, civil case brought against Andy Hill by the bereaved. The burden of proof is lower in a civil action, so he could very well end up with a guilty verdict against his name.

He really should just try to fade into obscurity but his latest action, and the soon too be aired documentary about him, will ensure he remains newsworthy for some time to come.

[Thoughtful_Flyer]

Mr Hill is now trying to get his licence back, which seems a trifle insensitive to little old me. I'm surprised there hasn't been a crowd founded, class action, civil case brought against Andy Hill by the bereaved. The burden of proof is lower in a civil action, so he could very well end up with a guilty verdict against his name.

He really should just try to fade into obscurity but his latest action, and the soon too be aired documentary about him, will ensure he remains newsworthy for some time to come.

No he couldn't! You cannot be found "guilty" in a civil court. He might (or might not) be found liable in a civil capacity but as any liability would be met by his insurers it would no doubt be vigorously defended.

[dervish]

No he couldn't! You cannot be found "guilty" in a civil court. He might (or might not) be found liable in a civil capacity but as any liability would be met by his insurers it would no doubt be vigorously defended.

Is there a time limit on these things? If there was a civil case is he allowed to produce the evidence that wasn't permitted in the criminal case or inquest?

[DogTailRed2]

He won't fly at an airshow again. As for being tried in a civil court only on a different charge I would have thought.

[Asturias56]

This is a terrible mistake - the media will be writing as we speak and you can imagine the words they will use about him.................

[Jet_Fan]

This is a terrible mistake - the media will be writing as we speak and you can imagine the words they will use about him.................

Here's a link: https://www.itv.com/news/meridian/2023-12-28/parents-of-air-crash-victim-will-try-to-stop-pilot-getting-license-back

[Thoughtful_Flyer]

Is there a time limit on these things? If there was a civil case is he allowed to produce the evidence that wasn't permitted in the criminal case or inquest?

Yes and yes.

Normally six years (five if it had happened in Scotland)!

Different rules apply and a civil case is decided on the balance of probabilities. But, just because a tragedy happened and people died doesn't automatically mean that somebody must be liable.

In effect any case would be dealt with by the pilot's and the show organiser's insurance companies. They would weigh the cost of reaching a settlement against the costs and risks of defending the case. It would have little if anything to do with "guilt" but sadly some other posters' seem unable to understand that.

In a way it is a bigger version of a roof tile coming off your house and killing a passer by. If you had unreasonably neglected your roof and it was obvious to a average person that it was dangerous you could be liable and your insurance company would defend or settle the matter more or less as they see fit. If on the other hand you had taken reasonable care of your property and it was just "one of those unfortunate things" it is unlikely there would be any liability.

[Jet_Fan]

Yes and yes.

Normally six years (five if it had happened in Scotland)!

Different rules apply and a civil case is decided on the balance of probabilities. But, just because a tragedy happened and people died doesn't automatically mean that somebody must be liable.

In effect any case would be dealt with by the pilot's and the show organiser's insurance companies. They would weigh the cost of reaching a settlement against the costs and risks of defending the case. It would have little if anything to do with "guilt" but sadly some other posters' seem unable to understand that.

Liability, guilt, it's all the same in the court of public opinion.

Of course pilot error was found to be the cause in the official enquiry. Also, the inquest found that all the victims were unlawfully killed. There's no statute of limitations on capital crimes. And, putting aside civil action, anyone can bring a private prosecution against an individual for a criminal offence, within certain criteria.

[Thoughtful_Flyer]

Liability, guilt, it's all the same in the court of public opinion.

Of course pilot error was found to be the cause in the official enquiry. Also, the inquest found that all the victims were unlawfully killed. There's no statute of limitations on capital crimes. And, putting aside civil action, anyone can bring a private prosecution against an individual for a criminal offence, within certain criteria.

But, with very few exceptions (which do not apply here) you cannot be prosecuted again for the same offence. He was acquitted unanimously by the jury so that is the end of the (criminal) matter.

So that also rules out any private prosecution. In any case, the CPS can, at their absolute discretion, take over any private prosecution then discontinue it if they so please

Any civil claim must be brought within six years.

[Jet_Fan]

But, with very few exceptions (which do not apply here) you cannot be prosecuted again for the same offence. He was acquitted unanimously by the jury so that is the end of the (criminal) matter.

So that also rules out any private prosecution. In any case, the CPS can, at their absolute discretion, take over any private prosecution then discontinue it if they so please

Any civil claim must be brought within six years.

Six years of when? I would say from the date the criminal trial finished.

New evidence would have to emerge before a trail for the same offence could proceed. I did say within certain criteria.

The facts remain though, found liable by the official enquiry and the unlawful killing verdict of the inquest.

This isn’t over, imo.

[Fitter2]

Does a driver convicted of causing death by dangerous driving receive a lifetime driving ban? The emotions of those close to one of those killed in the crash are understandable, but have no bearing on Mr Hill’s wish to fly again; that is a matter for CAA licensing whether he meets all the requirements of the process.

[Jet_Fan]

Does a driver convicted of causing death by dangerous driving receive a lifetime driving ban? The emotions of those close to one of those killed in the crash are understandable, but have no bearing on Mr Hill’s wish to fly again; that is a matter for CAA licensing whether he meets all the requirements of the process.

Would you seek to fly again if it was you in this position? Legally, I’m not sure anything but a medical issue can stop him getting back in the air.