Hawker Hunter Crash at Shoreham Airshow
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"Just culture"doesn't mean prosecution if you make a mistake, it means a proper investigation should be made and no blame attached unless deliberate violations are proven to have taken place. I have made mistakes and had reports raised against me. The interview procedure was to find out why I had made that mistake and try to stop it happening again. And Nutty, the CAA follow the EASA rule that if you certify work, it is done in accordance with specific maintenance documentation. Certainly is the policy of my companies engineering management, they never condon pick and choosing the way of doing tasks outside the manuals instructions. I have grounded aircraft because I do not have the right bolt and the company have always never put pressure on me to use illegal alternates.
I see the Hunter and airshows as an easy target with few users, driven by a press, yes it is a tragedy people died and everyone from the pilot down, myself included, if they could right that wrong, they would.
BUT you do not get a knee jerk reaction as this elsewhere , refuse trucks are still in Scotland collecting rubbish, Ferries still sailing across the Channel from Zeebrugge, Airliners still flying over the Alps. True we learnt from these things, but sad as it is, financial implications rule the roost.
BUT you do not get a knee jerk reaction as this elsewhere , refuse trucks are still in Scotland collecting rubbish, Ferries still sailing across the Channel from Zeebrugge, Airliners still flying over the Alps. True we learnt from these things, but sad as it is, financial implications rule the roost.
The formal enquiry is well worth a read for students of organisational safety.
Jwscud
Herald of Free Enterprise is constantly cited by MoD when discussing the need to re-introduce the concept of managing safety, so in that sense I believe it a very fair analogy. MoD safety management was run in a "shockingly unsafe manner from top to bottom", albeit with a few exceptions where some staff refused to commit offences. RAF Cranwell recommended that students read the report, but not too openly as at the time (1990s) it contradicted RAF policy.
Herald of Free Enterprise is constantly cited by MoD when discussing the need to re-introduce the concept of managing safety, so in that sense I believe it a very fair analogy. MoD safety management was run in a "shockingly unsafe manner from top to bottom", albeit with a few exceptions where some staff refused to commit offences. RAF Cranwell recommended that students read the report, but not too openly as at the time (1990s) it contradicted RAF policy.
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BUT you do not get a knee jerk reaction as this elsewhere , refuse trucks are still in Scotland collecting rubbish, Ferries still sailing across the Channel from Zeebrugge, Airliners still flying over the Alps. True we learnt from these things, but sad as it is, financial implications rule the roost.
However, comparing the events that Nut has cited to Shoreham is particularly bone headed. He has compared activities from which people gain real tangible benefits, e.g. refuse collection, travel, transport (people, food, goods etc) with an airshow. Yes, leisure activities are important too, but in this case (and others), it seems more about an individual satisfying his lust for flying with doing it an airshow somehow legitimising the risk or more likely, helping to fund it. What many on here seem to forget is that in assessing risk, the benefits gained from taking the risk need to be considered. Airshows provide entertainment. The activities that Nut uses as a comparison provide far, far more.
Leisure activities and entertainment are a vital part of life by the way, but when one persons entertainment exposes others to risk, then that person has to think very carefully about the consequences if things go wrong, because individuals can and should be held to account.
S-D
What many on here seem to forget is that in assessing risk, the benefits gained from taking the risk need to be considered.
S-D
I was looking at it from the viewpoint of assessing risks and developing risk mitigation plans, while being allowed to proceed with the activity. If the probability of occurrence is 100% (a certainty) and the impact or outcome is not what you wish, then one is not permitted to proceed until you've reduced the certainty to "only" a risk. Perhaps not a great example in this case, but whenever initiating an upgrade programme the probability (after about 1992) of not having a valid safety case was 100% (as it was not policy), so one had to first let a risk reduction contract to create one or resurrect the lapsed one, before being allowed to commit more money. That's what I meant by certainty. You don't proceed knowing it exists. Apply, for example, to Nimrod MRA4. There was a "no go" situation, mandated by Secy of State, 16 years before the fleet was scrapped.
I was looking at it from the viewpoint of assessing risks and developing risk mitigation plans, while being allowed to proceed with the activity. If the probability of occurrence is 100% (a certainty) and the impact or outcome is not what you wish, then one is not permitted to proceed until you've reduced the certainty to "only" a risk. Perhaps not a great example in this case, but whenever initiating an upgrade programme the probability (after about 1992) of not having a valid safety case was 100% (as it was not policy), so one had to first let a risk reduction contract to create one or resurrect the lapsed one, before being allowed to commit more money. That's what I meant by certainty. You don't proceed knowing it exists. Apply, for example, to Nimrod MRA4. There was a "no go" situation, mandated by Secy of State, 16 years before the fleet was scrapped.
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In a way the question being asked here is has an AAIB report ever been used as the basis for a prosecution? If the AAIB find there was a material failing and publish such, the CPS decide to prosecute, the AAIB staff can be called as expert witnesses, so no conflict of interest.
This is what Sydney Dekker says about " Just Culture".
"A just culture is meant to balance learning from
incidents with accountability for their consequences."
My understanding of the above is the learning from to avoid repetition purpose of air accident investigation balanced with holding all those responsible for the accident thorough the system of justice.
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Thanks Chronus for raising the thread, I hadn't realised SD had posted a load of sh*te and it gives me a chance to reply.
Some as already mentioned have been addressed as examples on here, so I see know point in addressing this as it has already been covered in using the ferry disaster as an example.
So you are in effect saying that those that died at Shoreham due to it being an "entertainment" are not relevant in the real wide world where those that got mowed down by a bin Lorry are, because the bin Lorry was carrying out "tangible benefits" which of course are allowed to continue because there is a financial and commercial factors at work.
You also point out it was all the fault of someone with a lust for flying that is the primary cause, how then can you then explain the continuing ban and financial implications on the owners of Hunter aircraft, whose assets are now virtually worthless, even though that wasn't the primary cause of the accident and may have complied with all the legislation and requirements in place. Dustbin lorries were not removed from instant service across the UK until the inquiry was concluded, why was the Hunter?
And so should everyone else, sadly in some cases it still hasn't happened, Bhopal is a classic case.
I am surprised this post hasn't attracted adverse comments before now, because the analogies that Nutloose has made or some of the most crass I have seen. Tic, you are right in the Herald is a much studied example, as are Piper Alpha, Kings Cross etc. And indeed these massive failures were in the main what led to the sea change in safety management in the UK.
However, comparing the events that Nut has cited to Shoreham is particularly bone headed. He has compared activities from which people gain real tangible benefits, e.g. refuse collection, travel, transport (people, food, goods etc) with an airshow. Yes, leisure activities are important too, but in this case (and others), it seems more about an individual satisfying his lust for flying with doing it an airshow somehow legitimising the risk or more likely, helping to fund it. What many on here seem to forget is that in assessing risk, the benefits gained from taking the risk need to be considered. Airshows provide entertainment. The activities that Nut uses as a comparison provide far, far more.
You also point out it was all the fault of someone with a lust for flying that is the primary cause, how then can you then explain the continuing ban and financial implications on the owners of Hunter aircraft, whose assets are now virtually worthless, even though that wasn't the primary cause of the accident and may have complied with all the legislation and requirements in place. Dustbin lorries were not removed from instant service across the UK until the inquiry was concluded, why was the Hunter?
Leisure activities and entertainment are a vital part of life by the way, but when one persons entertainment exposes others to risk, then that person has to think very carefully about the consequences if things go wrong, because individuals can and should be held to account.
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Nutloose. You have absolutely no idea what you are talking about, that much is clear by your posts and your replies. There is little point in writing a lengthy reply to your post, because to be honest, this whole discussion is beyond you. You have completely misunderstood what I wrote and then also misrepresented it.
Fortunately, most other posters on this forum have the wit that you lack to understand the concepts involved here.
So, my apologies for the bluntness, but stick to what you know about fella - kicking chocks!
S-D
Fortunately, most other posters on this forum have the wit that you lack to understand the concepts involved here.
So, my apologies for the bluntness, but stick to what you know about fella - kicking chocks!
S-D
Last edited by salad-dodger; 21st Jul 2016 at 21:46.
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Really and your experience is?
Mine is an EASA and CAA licensed engineer for 25 plus, Chief Engineer, Camo and previously a Nominated Engineer for the last 15 - 20 years + and prior to that ex RAF Engineer with a total of 40 plus years, covering fighters, both Civilian and military jet, and piston engine ex military, along with Helicopter and airliner, business and piston experience, along with several hundred types on my licences.
I await with baited breath your qualifications.
Mine is an EASA and CAA licensed engineer for 25 plus, Chief Engineer, Camo and previously a Nominated Engineer for the last 15 - 20 years + and prior to that ex RAF Engineer with a total of 40 plus years, covering fighters, both Civilian and military jet, and piston engine ex military, along with Helicopter and airliner, business and piston experience, along with several hundred types on my licences.
I await with baited breath your qualifications.
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Are you aware what a Camo is actually responsible for and does?
Why did you edit your post twice, the first to remove your experience of 20 years as a safety engineer on aircraft, ATM machines and some rail work plus a masters? Something you should be proud off, And then to remove your begrudging exceptance of the facts to have another pop at me.
Curious behaviour.
As I said, if the pilot is to blame, why is the Hunter still grounded, that for me is a major question, after all prior to the incident they would have been maintained in accordance with a maintenance and servicing schedule approved by the CAA, if they are now grounded because of failings within that schedule, then surely part of the problem must be the CAA in itself, who authorised and approved it. If it had been ignored then yes, but are they really trying to say every operator simply ignored their own approvals, which I highly doubt.
.
Why did you edit your post twice, the first to remove your experience of 20 years as a safety engineer on aircraft, ATM machines and some rail work plus a masters? Something you should be proud off, And then to remove your begrudging exceptance of the facts to have another pop at me.
Curious behaviour.
As I said, if the pilot is to blame, why is the Hunter still grounded, that for me is a major question, after all prior to the incident they would have been maintained in accordance with a maintenance and servicing schedule approved by the CAA, if they are now grounded because of failings within that schedule, then surely part of the problem must be the CAA in itself, who authorised and approved it. If it had been ignored then yes, but are they really trying to say every operator simply ignored their own approvals, which I highly doubt.
.
Last edited by NutLoose; 22nd Jul 2016 at 03:49.
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I watched a display today, normally, like everyone else, I'm close to the scene of the crime but today I was 5 miles away.
First time I've watched a display from a distance in a long, long time, and it was eye opening, not for the lack of vis of the low level action but the singular and deeply striking moment (for me) was watching the pilot pulling the nose down through the vertical and the vv and alpha going way past the direction the cab was actually going at that instant.
Awesome.
JATK sd.
First time I've watched a display from a distance in a long, long time, and it was eye opening, not for the lack of vis of the low level action but the singular and deeply striking moment (for me) was watching the pilot pulling the nose down through the vertical and the vv and alpha going way past the direction the cab was actually going at that instant.
Awesome.
JATK sd.
Last edited by glad rag; 21st Jul 2016 at 22:59.
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Nutloose, you are right, I took my post down as to be honest, I couldn't be arsed to continue with it. But seeing as you have regurgitated some of it, I had better correct you.
Over 30 years in aviation, including aircraft engineering, support and operations, safety and airworthiness. Most of the aircraft stuff is military, but some civil. ATM*, including Airports, Air Traffic (radars/displays/comms/NavAids, AGL etc) in the terminal and enroute environments, working with both airport operators and equipment suppliers large and small. A little rail work for a bit of diversification and a few other other niche areas.
Oh yes, and a Bachelors in Engineering and a Masters in Safety.
Yes, I know what a CAMO is, I work with them all the time, and chief engineers and many other flavours of engineers, aircrew, controllers, and support staff.
*ATM - Air Traffic Management. Sorry, but I used it thinking someone with such experience in aviation would understand that I was not referring to cash machines
The subject we are discussing, safety and risk assessment, I do it for a living. Have done for over 20 years. I can point you in the direction of some decent training if you like. A key part of the role is knowing one's limitations. When I want to know exactly how a system operates, I ask an expert in that system, sometimes the OEM. When I want to know how an aircraft is operated, I ask the crew, or sometimes a TP. When I want to know how a controller reacts to situations, I ask controllers. I stick to the safety engineering aspects of all that.
Not claiming to have all the answers by the way, but I do have very many questions.
S-D
Over 30 years in aviation, including aircraft engineering, support and operations, safety and airworthiness. Most of the aircraft stuff is military, but some civil. ATM*, including Airports, Air Traffic (radars/displays/comms/NavAids, AGL etc) in the terminal and enroute environments, working with both airport operators and equipment suppliers large and small. A little rail work for a bit of diversification and a few other other niche areas.
Oh yes, and a Bachelors in Engineering and a Masters in Safety.
Yes, I know what a CAMO is, I work with them all the time, and chief engineers and many other flavours of engineers, aircrew, controllers, and support staff.
*ATM - Air Traffic Management. Sorry, but I used it thinking someone with such experience in aviation would understand that I was not referring to cash machines
The subject we are discussing, safety and risk assessment, I do it for a living. Have done for over 20 years. I can point you in the direction of some decent training if you like. A key part of the role is knowing one's limitations. When I want to know exactly how a system operates, I ask an expert in that system, sometimes the OEM. When I want to know how an aircraft is operated, I ask the crew, or sometimes a TP. When I want to know how a controller reacts to situations, I ask controllers. I stick to the safety engineering aspects of all that.
Not claiming to have all the answers by the way, but I do have very many questions.
S-D
Last edited by salad-dodger; 22nd Jul 2016 at 09:59.
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Just to clarify a small misunderstandng in your display story Glad Rag:
The "vv" IS where the cab is going. That's why pilots use it as a reference. In very high AoA manoeuvres the VV sits at the bottom of the HUD flashing to inform the pilot that the real vector is out of the field of view and cannot be used. So, it's the LFD (and chord line) above the vv (or flight path) in the manoeuvre you describe.
Not that it really matters, as I don't believe the Hunter has that sort of set up.
The "vv" IS where the cab is going. That's why pilots use it as a reference. In very high AoA manoeuvres the VV sits at the bottom of the HUD flashing to inform the pilot that the real vector is out of the field of view and cannot be used. So, it's the LFD (and chord line) above the vv (or flight path) in the manoeuvre you describe.
Not that it really matters, as I don't believe the Hunter has that sort of set up.
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*ATM - Air Traffic Management. Sorry, but I used it thinking someone with such experience in aviation would understand that I was not referring to cash machines
Nutlike if you read the interim report from AAIB you'll realise why the Hunter is still grounded. The two mk58's flying on the military register are because they can access ejection seat cartridges which civil registered can't at the moment. The T7/8's probably won't fly again in the UK because of the engine inspection requirement. As the operator recently told me , why do an expensive inspection if you can't carry out repairs , there are no approved facilities for the Avon 122 , but there are for the 200 series so the the MK58's and F6/9's are sustainable.