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Hawker Hunter Crash at Shoreham Airshow

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Old 3rd Apr 2016, 08:25
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Upon reflection, it occurred to me that some more detail of the evidence given to the Court of Appeal by the Chief Inspector AAIB might be of interest to those concerned about the aviation safety implications:

The sole objective of an AAIB investigation is to determine the circumstances and causes of an accident (or incident) and make safety recommendations, if necessary with a view to the preservation of life and the avoidance of accidents and incidents in the future.

Anything that undermines the AAIB’s ability to obtain truthful information promptly would be detrimental to public safety and so contrary to the public interest.

If AAIB reports were frequently admitted into evidence in litigation there is the possibility that this would deter some people who were able to assist from doing so in the future. Witnesses may perceive a risk of their being called to give evidence or even made defendants to subsequent legal proceedings.

Witness cooperation may be less forthcoming. If witnesses have to be summoned to give evidence (only rarely necessary now) the quality of their evidence may be of less value.

Witnesses are likely to be more guarded in what they say. They may refer or be advised to refer to their employer organisation before dealing with the AAIB. Those organisations would likely refer the matter to their legal advisers to consider how evidence given might affect future litigation. This would slow down the progress of an investigation with a potential impact on the quality of any evidence, and could delay the development and formulation of any safety recommendation.

The regular admission of reports in evidence is likely to lead to requests for the underlying material since parties may argue that they need access to the underlying records to test the report’s findings and conclusions.

Organisations may not be prepared to provide information anonymously and in confidence if there is a risk it can be used against them or for commercial gain.

The volunteering of information may dry up. Whistleblowers may remain silent.

In addition, investigators may have to mention to those concerned that any report is admissible in civil proceedings, which would likely restrict the free flow of information; they may be driven to the use of compulsory powers; and they may write reports with a view to having to defend them in court rather than maximising safety benefits.

They may feel that any conclusions would have to be provable to the civil standard and that they would need to corroborate and track evidential chains to a much greater extent than is current practice. Reports may be drafted in such a way as to minimise the possibility of blame being inferred.

In addition appearances in court would increase the workload of inspectors and reduce time available for actual investigation.

There could, also, be an adverse effect on the public’s perception of the independence and remit of the AAIB since investigations would be perceived as prepared with a view to the possibility of future litigation and not therefore objective.

The AAIB is likely to be drawn into litigation and asked its opinion on liability.

International airline bodies, pilots’ unions and aviation manufacturers would advise their members to be cautious about what they say to the AAIB.
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Old 3rd Apr 2016, 09:43
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Heliport

I DO understand the issues - but it never ceases to amaze me how the legal profession manages to encourage action after action in the same case - trial, appeal, appeal to higher courts, appeals to the ECJ, Judicial Review, start again with a slightly different action.............. "Eminent Council believes you have a case" etc etc

Just the other day a very senior Judge was bewailing the fact that csaes that went to arbitration might not be subject to legal review later.

To be blunt it often appears that the legal system exists to keep cases running until the plaintiffs cash runs out

Dickens was right
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Old 3rd Apr 2016, 10:22
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The RAeS seminar referred to was actually a mixture of opinion. That might not be totally surprising because one assumes the seminar was organized to produce a balanced perspective.

The seminar highlighted that the use of the accident investigator reports in the UK varies across mature aviation nations and there is no clear consensious (in fact I think there was mirth on the lawyers side that they in fact argue the points around this issue depending upon which side of the argument they find themselves on case by case..) and secondly that the focus of thinking was with commercial aviation.

Arguments that concern themselves with pilot unions, employers, witnesses from other parts of the same organization, whistleblowers, airline bodies, aviation manufacturers, cockpit voice and flight data recorders are almost exclusively the domain of commercial air transport; as is the thinking that surrounds initiatives such as ‘Just Culture’.

So to relate that to a GA environment and then suggest that people might not understand wider aviation safety issues is probably quite arrogant because actually almost none of the thinking around this process unambiguously address that sector.

Not least of which is the fact that when a piece of engineering work has been done by the AAIB it surely makes good sense to be able to take point of fact from their work rather than having to fund a secondary investigation that, as Prof. Braithwaite suggested in his presentation, should inevitably come to the same conclusions.

In that context why not use details of an AAIB report, where those same details would become apparent were another investigation be engaged by some other body?

Of course you might argue that the other body might not be granted the same access to certain material of evidence but that would just lead to having an official AAIB report publishing certain facts that then become the elephant in the room and contradictory to this:

‘Anything that undermines the AAIB’s ability to obtain truthful information promptly would be detrimental to public safety and so contrary to the public interest.’

Surely it is also detrimental to public safety and contrary to public interest if there is no consequence to identifiable issues?
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Old 3rd Apr 2016, 22:13
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Pittsextra

The platform speakers at each session of the seminar were selected for their specialist knowledge in relevant fields and to generate debate. SOP.
The audience was not. The seminar was open to anyone, including non-members.
I spoke from the floor in two of the sessions.
Did you offer your opinion(s)?

I think there was mirth on the lawyers side that they in fact argue the points around this issue depending upon which side of the argument they find themselves on case by case.
Lawyers were free to express their personal opinions at the seminar.
When engaged in court proceedings they are under a professional duty to represent their client's interests to the best of their skill and ability. That includes relying upon any point of law which assists their client even if they happen to disagree with that law. Their personal views are wholly irrelevant when acting in a professional capacity. They would immediately be told very firmly by the Judge not to express personal opinions if they were silly enough to try.
the focus of thinking was with commercial aviation.
That is not correct.
The controversial Court of Appeal decision which was widely discussed at the seminar (and which I explained above) arose from the crash of a privately owned Tiger Moth flown by a PPL.
The focus was upon the implications for aviation safety.
The CA decision applies to both private and commercial aviation.


Many people, including some aviators, do not understand the wider aviation safety issues. Some can be encouraged to consider the wider issues; others are unwilling or unable to do so.
You are, of course, free to regard either or both of those assertions as "probably quite arrogant".
Some may think there is an irony in you accusing anyone of arrogance, even of the 'probably quite' variety.

Non-contentious information extracted from aviation accident reports has been used in civil proceedings for at least 40 years to my knowledge.
That is not the issue which the Court of Appeal had to decide, and was not the topic of the seminar.

Two separate issues arise from the Court of Appeal's decision.
  • Fairness in civil proceedings.
  • Whether it will hamper future accident investigations and, in consequence, diminish the ability of the AAIB to make safety recommendations – for the reasons submitted by the Chief Inspector AAIB which I summarised above. Some of his points apply to commercial aviation; others apply to all aviation.
The first is primarily of interest to people involved in civil proceedings, voluntarily or otherwise, and their lawyers.
The second should be of concern to anyone concerned about aviation safety.

.

Last edited by Flying Lawyer; 3rd Apr 2016 at 23:18.
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Old 3rd Apr 2016, 23:46
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Originally Posted by Flying Lawyer

AAIB reports are hearsay, not direct evidence.
  • They are anonymized documents - the authors are not named.
  • Opinions are expressed by un-named individuals whose expertise (or lack of) is not known.
  • The risk that juries will attach too much weight to the opinions of unknown AAIB inspectors simply because they are AAIB inspectors. They are generally very good but, in common with the rest of us, they are not infallible.

Any reason why AAIB inspectors should be anonymous? Surely they are all professionals who are capable of explaining their findings and opinions - effectively an expert witness role.
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Old 4th Apr 2016, 11:38
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My experiences of lawyers in safety - accident investigation (not AAIB, but in support of them and investigations worldwide), was that the legal views before and after an accident differed significantly. Not a change amongst the same people, but in the roles undertaken by different groups.
Proactive advice, safety orientated, was invaluable; seeking to avoid accidents or understand and learn from events to improve safety; the classic, but not exactly the same view of separating investigation and law.
Reactive involvement was restrictive, cumbersome, and in rare instances devious to the point of influencing investigations.
These views reflect learning without blame – aviation safety, or alternatively punishment and retribution within the law. ‘Oil and water’, unfortunately the slippery oil was usually on top; thus you require a good detergent for a clean balanced view.

If AAIB reports are admissible (civil law), then why not allow 'anonymous' text of research / books, particularly for human factors to be considered.
Investigation reports are often restricted in identifying ‘real’ facts. The industry is increasingly safe and most accidents relate to human behaviour. There are few 'facts'; reports rarely speculate on human behaviour and even in nonfatal accidents pilots may not know why a particular course of action was taken – the subconscious mind.
Investigation reports will always be open to interpretation, not only individual experiences and expertise, but also as to how rules and regulatory advice is (should have been) interpreted – hindsight, after the fact.

Consider an accident similar to this thread. A pilot is cleared to 100ft for fly pasts, but the general rules require vertical manoeuvres to complete by 500ft; how might the rules be interpreted during an aerobatic sequence, transitioning from the vertical to a level flypast; what is complete.
Before an event this could be a matter of judgement, the regulatory process has accepted that the pilot is qualified, experienced, current, etc; but after an event - a failure of judgement where rules could be reinterpreted by investigators, regulators, and legal argument. I stress that the more reputable investigators are well versed in hindsight – regulators much less so; lawyers - may depend on objective / aviation context – human factors – but then I am biased.

Thus the ‘success’ of judgement is always after the fact, either error, blame, or a unique opportunity to learn because this involves the same mental process of judgement – the everyday method of learning.
The difference between before and after might only be a few feet in altitude; I suspect that there will be many ‘expert’ witnesses with such experience.

Other thoughts:-
“A just culture depends on who draws ‘the line’, not where the line is.” (Dekker)

http://www.safer.healthcare.ucla.edu...lPrimerDoc.pdf

The emperor’s new clothes.
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Old 4th Apr 2016, 13:11
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FL - my reflection upon the RAeS event was just that. I reflect my view, nothing more. You may have a different view / different focus. Ultimately if there was a clear and consistent view I guess there would have been no seminar...

The Moth case was an interesting introduction to the subject but actually my summary of the same is that the outcome had wider points of debate than merely the use of AAIB material in a court of law. Not least the fact that a reports content may reflect safety recommendations that are subsequently of dispute in court.

One also wonders if events are in debate if interested parties raised points pre-final report.

Or you can turn it around and in the case of the Moth I'm not sure how flight safety is compromised if one agrees that control restriction was the primary issue and that had been reported definitively in an AAIB report.
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Old 4th Apr 2016, 13:53
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Any reason why AAIB inspectors should be anonymous?
I, too, am puzzled. I've just had cause to read an AAIB report. The introduction (by the senior engineering inspector) begins, "I am Mr .........." and all his colleagues who contributed are similarly named. Their expertise is listed. Has this changed recently?
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Old 4th Apr 2016, 13:58
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Airworthiness / safety is “none of my or the Society's business”. (Chief Executive, RAeS 5 October 2011)

Has this changed recently?
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Old 4th Apr 2016, 19:10
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alf5071h

A very interesting post.
There's force in what you say.

These views reflect learning without blame – aviation safety, or alternatively punishment and retribution within the law.
That, I agree, is an important issue in terms of aviation safety.
Public opinion, understandably and perhaps instinctively, favours the latter.
Informed opinion is divided. 'Informed' in this context being those who are aware of the pros and cons and have objectively considered the competing arguments.


Pittsextra
No useful purpose will be served by my repeating the arguments about why flight safety is likely to be compromised if AAIB reports are used for a purpose for which they are not intended.
See the submissions by the Chief Inspector AAIB in post 1490 above.


tucumseh
Airworthiness / safety is “none of my or the Society's business”. (Chief Executive, RAeS 5 October 2011)
I have read that claim elsewhere – by only one person. He/she also put only a part as a direct quote.
The sentence read as a whole is so obviously not correct that I wonder if the part not in quotes is the writer's interpretation of what the CEO said.

I have no axe to grind. Although I have been a Fellow of the RAeS for about 14 years, I have never been involved in its affairs. My contact has been limited to attending the occasional lecture, giving a keynote address at a Flight Operations Group conference and attending a couple of seminars. I don't know nor, as far as I can recall, have I ever met the CEO.
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Old 4th Apr 2016, 19:47
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FL - I hear the concern I just think in a GA context they are overplayed as the majority of issues raised relate to commercial operations. Cockpit voice, FDRs, pilot unions, whistle blowers and 'organisational lawyers' seem consistent with that.

You highlighted the Rogers v Hoyle case. Im unclear how this case supports the fear of uncooperative witness or pilot statements to the AAIB.

Surely here the pilot expressed a view of control restriction at the time and maintained that view later, it's just the AAIB report (as I read it) perhaps placed different emphasis. Likewise the AAIB had no real motivation for placing any emphasis on anything they didn't believe to be factual, yet we can all read their views.

Just as witness statements as reflected in the AAIB report would unlikely change as I'm not entirely sure what the consequence for them was either way?

So that isn't really supportive of a view that has a pilot - in trying to be helpful to the AAIB - subsequently hanging himself with his own statement; which is I think one colloquial summary of one fear.

The point being that if you replayed the interaction of pilot and AAIB saying nothing arguably would be worse than maintaining a consistent view as was done. If anything the greater risk to using AAIB reports in this manner is that challenges to the points raised has the potential to damage long term credibility and their validity.
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Old 4th Apr 2016, 19:51
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An interesting topic, the AAIB evidence being used in court.

I know of one case where the AAIB almost certainly came to an incorrect conclusion regarding the cause of a fatal accident involving an aerobatic biplane.

The accident was of direct interest to me because the deceased was a friend of mine and I had flown in the actual aircraft (in the same seat as himself) on the flight immediately previous to the accident. It occurred over the same area, carrying out the same type of aerobatic manoeuvres....with the subsequent deceased pilot in the other seat. I was also at the departure airfield waiting for the aircraft to return - which it never did.

I later spoke at length with the badly injured, second occupant of the aircraft. This person told me precisely what had happened and how control of the aircraft had been lost. The conclusion of the AAIB was quite different to what I was told.

Last edited by ShyTorque; 8th Apr 2016 at 17:21.
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Old 4th Apr 2016, 20:05
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I used to accept whatever the AAIB published, after all, they have no reason to lie and must surely be professional enough to get it right.... well.... not any more.

Looking through accident reports and finding errors of fact, not opinion, in the situations that I do know about, makes me doubt all of the others.

Why is it that when someone points out errors, the AAIB don't correct the report?
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Old 4th Apr 2016, 22:48
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Why is it that when someone points out errors, the CAA don't correct the report?
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Old 4th Apr 2016, 22:59
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Pittsextra

You highlighted the Rogers v Hoyle case.
I referred to the appeal in that case because it produced a significant and far-reaching decision.
I'm unclear how this case supports the fear of uncooperative witness or pilot statements to the AAIB.
That is because you persist in focusing upon the facts/circumstances (as you see them) of the particular accident and associated report. If you could stop doing that all should become clear.
I just think in a GA context they are overplayed as the majority of issues raised relate to commercial operations. Cockpit voice, FDRs, pilot unions, whistle blowers and 'organisational lawyers' seem consistent with that.
That is demonstrably not true.
You have, in an attempt to support your argument, selected just a few items from the list of AAIB objections summarised in post 1490.

  • The use of the AAIB report as evidence in the Rogers v Hoyle case is of importance only to the parties.
You appear to think it made no difference in the circumstances of that case. The experienced specialist lawyers on both sides thought it did. On the basis that almost anything is possible, I suppose it's possible that you could be right and all the lawyers were wrong. I leave you to reflect upon how likely that is.
  • The circumstances of the accident which led to the civil claim were not relevant to the Court of Appeal's decision, nor were the contents of the AAIB report. That is because the Court was considering and deciding a point of legal principle.
The detailed judgment explaining the decision is more than 11,000 words long. The facts of the accident took up 52 of those words. (The introductory paragraph.) I haven't checked but, from recollection, I don't think it contained any reference to the contents of the report. I would not expect it to because the Court decided a point of legal principle.
  • The importance of the Court of Appeal's decision is that it applies to all civil cases in which a party seeks to use an AAIB report as evidence - not just to the case of Rogers v Hoyle.
It has been described by some legal commentators using legal jargon as a 'landmark' decision for that reason. It was. Unless there are exceptional circumstances, judges now have to allow entire AAIB reports to be used as evidence in civil cases.
  • The AAIB stance.
Neither the AAIB nor anyone else suggested that all the AAIB objections applied in the Rogers v Hoyle case.
For some reason, you fail to grasp that the AAIB did not simply object to the use of its report as evidence in the particular case. It was opposed, for the reasons summarised in post 1490, to its reports being adduced as evidence in court proceedings - whether relating to commercial aviation or GA accidents.
ie The potential detrimental effect upon future air accident investigations.

I don't wish to appear discourteous but I see no point in continuing exchanges with you. I have explained the implications of the decision as simply as I can. This post is my final attempt. If you are still unable to understand, so be it.




(Edit)

You haven't answered the question I asked earlier re the RAeS seminar:
I spoke from the floor in two of the sessions.
Did you offer your opinion(s)?
It was a perfect opportunity to have your opinions considered by many people with relevant expertise - legal and other, including a former AAIB Chief Inspector.

.

Last edited by Flying Lawyer; 4th Apr 2016 at 23:23.
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Old 4th Apr 2016, 23:20
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FL, I'd be interested to read your opinion regarding the situation I mentioned above. If that AAIB report had been used in evidence in court, it could have been entirely misleading but probably have been taken as correct and irrefutable and a miscarriage of justice would possibly have occurred. Obviously, someone such as myself would have learned of the miscarriage only after the event because I had no direct relevance to the case.
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Old 5th Apr 2016, 06:27
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Flying Lawyer

I have read that claim elsewhere – by only one person. He/she also put only a part as a direct quote.
The sentence read as a whole is so obviously not correct that I wonder if the part not in quotes is the writer's interpretation of what the CEO said.
First, a typo on my part - it was October 2012.

The context was the Chief Executive had been sent the written evidence to the Nimrod and Philip Reviews. In reply, he stated the content and subject was "none of my or the Society's business". The content was 100% safety/airworthiness related. The wider context was a number of Fellows expressing frustration at the CE vetoing letters refuting the MoD (and hence Society) line on the subject. Specifically, the members had noted, and wanted printed in the Society magazine, that MoD and Ministers (they named Adam Ingram) had been given advance warning of the systemic failures reiterated by Mr Haddon-Cave. This warning was given to Ingram over 18 months before the crash.

I'm sure, as you say, there is always scope for misinterpretation, or a poorly worded letter, but the Society's attitude toward the subject is well known, as is its overbearing attitude toward members who do not toe the line; especially on the likes of Mull of Kintyre.
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Old 5th Apr 2016, 06:40
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Tuc

I'm considering an experiment where people start threads on increasingly more random subjects and we time how long it will take you to turn it into a thread about your hobby horse and start twisting quotes to mean what you want them to mean rather than what the speaker meant.....
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Old 5th Apr 2016, 08:02
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Thanks for that Tourist.

I posted comments in response to others yet you do not make the same comment to them. You therefore personalise the matter.

The most important point you miss in your condemnation of those whose implement safety regulations is that, as a pilot, these things should be largely invisible to you. You need to appreciate that we would have no cause to discuss them if people employed to ensure your safety would do their jobs correctly. You target the messenger, but ignore the message.

You have been asked many times; if you disagree so much with the mandated regulations, please tell us which ones should be scrapped. If you have put your suggestions to the authorities, I'd be happy to compare notes and discuss their responses.
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Old 5th Apr 2016, 23:19
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tucumseh

After reading read your explanation, I looked again at what I had previously seen alleged in identical style by 'someone' on another aviation related website. (As mentioned in my original response to you.)

There was far more to the correspondence than merely sending the Chief Executive a copy of written evidence given to the Nimrod and Philip Reviews. If that had been all that happened then the CE's response would have been outrageous. It wasn't.

I now think misinterpretation of what the CE wrote (the possibility I suggested previously) is very mild – and certainly not the word I would use now.

This issue is way off topic so I'll leave it at that.
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