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Shoreham Airshow Crash Trial

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Shoreham Airshow Crash Trial

Old 7th Jul 2020, 19:44
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That is a very sound suggestion.

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

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

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

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

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Old 7th Jul 2020, 23:01
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Originally Posted by AndoniP View Post
Cognitive Impairment. Basically something the defence put forward as the reason for the crash that the prosecution couldn't disprove. Hadn't happened to him before though.
That is a rather cynical view, if I may say. Cognitive impairment is a well known condition (Look it up - Google will suffice) and the only wrinkle here is that of the context in which it is being used. Several contributors here seem strongly of the opinion that it doesnít exist, is irrelevant. Consider it possible that you may be mistaken. The brain is intensely metabolically active, needing both oxygen and glucose, which arrive via various arteries. Any diminution in blood flow will have some effect - the problem is measuring the effect whilst manoeuvring in flight. But consider the combination of ďlow levelĒ G, and abnormal head position as a consequence of opto kinetic cervical reflex (which is also now recognised as existing). It is well know that tilt or rotation of the head can cause impingement of various bits of cervical vertebrae on carotid or vertebral arteries. There is a clever Finnish study which demonstrated a 30% reduction in cerebral blood flow after manoeuvres at 5G in a Hawk, despite g-suits, straining. So it is quite feasible that some low level G, abnormal head position, a hot day, all conspire to produce a brain that is temporarily impaired. The phenomenon needs proper study, and not to be dismissed without consideration.
As for expert opinion - when I was a medical student, surgeons did all sorts of clever operations to reduce the acid secretion that led to ulcers. Now we know the ulcers are caused by an infection and treat it with antibiotics. All that expert opinion was just wrong.

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Old 8th Jul 2020, 02:11
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Diagnosis, with due deference to RetiredBA/BY experience, Transient Global Amnesia equals Cognitive Impairment. I'd imagine difficult to prove post event.
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Old 8th Jul 2020, 03:24
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Caramba

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

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

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

I know I keep banging the same drum but I have checked my logbook and I have accrued 40 hours Hawk in the last 6 weeks and I still wouldnít fly low level aerobatics. I think an experienced aviator should be able to recognise their own weaknesses.

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

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

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

BV

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Old 8th Jul 2020, 07:09
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Agree with BV.
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Old 8th Jul 2020, 07:55
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BV, I totally accept that - to use a cycling analogy - I am merely an enthusiastic amateur whereas as you and many others here are Bradley Wiggins.

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

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

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Old 8th Jul 2020, 08:43
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I am also inclined to agree with BV. Additionally, with the JP at Southport and the ‘stop’ call, would this be down to CI?
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Old 8th Jul 2020, 09:05
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I find the 'clip clop' syndrome very interesting but if I lived in a tower block it would also be highly questionable.
I trust that the coroners search for an answer will be able to be understood by the relatives, and rather more in line with the evidence as described in the AAIB report.
I feel that the case as tried was going to be difficult to prove, and did not actually deal with the issues that most people feel existed.
It was wrong to lay the blame on one person when in fact the failure was much wider, and the case as tried rather closed the book on the larger picture.
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Old 8th Jul 2020, 09:06
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Originally Posted by Bob Viking View Post
.................................

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

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

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

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

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

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

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

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

From a rather tired, cynical, H ‘n’ H who hopes he never ends up in Court now I know that, often, the truth is simply an “annoying technicality” to be considered but, ultimately, that it's the game that counts!
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Old 8th Jul 2020, 09:13
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Originally Posted by megan View Post
Diagnosis, with due deference to RetiredBA/BY experience, Transient Global Amnesia equals Cognitive Impairment. I'd imagine difficult to prove post event.

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

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

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


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Old 8th Jul 2020, 10:37
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Bob Viking
Many of us believe that lack of experience, currency and recency (on type) could be just as likely an explanation
But as you will have seen from the Conclusions of the AAIB report
(a) Findings

Operational aspects

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

2. It was the pilotís fifth aerobatic display in a Hunter during the 2015 season and the only public display he carried out that day. He met the recency requirements specified in CAP 403.
Also, from the Prosecution's 53-page opening handout which I referred to in post #589
8. Mr Hill had been flying the Hawker Hunter since 2011 and held an Aircraft Type Rating Exemption (ATRE) for the Hawker Hunter Jet aircraft from June 2011. This covered him to fly the Hunter, a Jet Provost Mk 1-5 and Strikemaster aircraft. The required certification had been renewed as required and was valid at the time of the Shoreham display.

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

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

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

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

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Old 8th Jul 2020, 11:35
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An excellent post from Hot ‘n’ High. All too often, as we have seen on this very thread, people conflate ‘The Law’ with ‘Justice’ – and they are very different things. Any lawyer worth his vast fees can walk into a courtroom knowing full well that his client is guilty, quite possibly of a vile, heinous crime, and still do their very best to help their client avoid ‘Justice’ by careful manipulation of ‘The Law’. My two cents on this sorry saga? To paraphrase Sherlock Holmes, when you have eliminated the impossible, whatever remains, however unpalatable, must be the truth.
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Old 8th Jul 2020, 12:01
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As I said in a previous post ; On the day, he screwed up. That is not because of a hitherto unheard of medical condition, but nor is it criminal negligence. It is a result of being a human being. The whole of aviation safety is based around the acceptance that human beings make mistakes, so a system has evolved to minimise them of training, assessment, monitoring and supervision.. In my view it is that system that failed in this case.
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Old 8th Jul 2020, 13:18
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....there have been many comments dismissing CI as a possible cause of the tragedy. My point is that it warrants proper investigation, not least because it might provide an explanation for previous apparently inexplicable accidents that have claimed the lives of highly experienced and capable aviators.
Carambaís point surely goes to the heart of accident investigation, the purpose of which is to prevent similar accidents happening in the future. It became clear during the trial that research into CI was in short supply.

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

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

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Old 8th Jul 2020, 13:25
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Mandatory cameras in the cockpit as a start with a live feed to the display director? Cheaper than fitting an ADR/FDR, would it though have shown evidence of CI in the Shoreham case, a head nod perhaps?
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Old 8th Jul 2020, 14:40
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Originally Posted by EXFIN View Post
Mandatory cameras in the cockpit as a start with a live feed to the display director? Cheaper than fitting an ADR/FDR, would it though have shown evidence of CI in the Shoreham case, a head nod perhaps?
GoPro from the cockpit was shown in court, albeit thankfully stopped before the impact. Those in court were able to see what movements and inputs were made by AH. I am not a medical expert so it would be inappropriate for me to comment upon whether or not the content of this video demonstrated signs of CI.

Just because a Court decides that, on the balance of probability, something happened in a certain way actually has no bearing at all on whether it actually happened or not in that way]
I believe that with a manslaughter charge such as the one that is being discussed here the verdict has to be based upon 'beyond reasonable doubt' rather than a 'balance of probability' (legalapproach please correct me if I am wrong).
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Old 8th Jul 2020, 14:44
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DA history

Originally Posted by Timelord View Post
As I said in a previous post ; On the day, he screwed up. That is not because of a hitherto unheard of medical condition, but nor is it criminal negligence. It is a result of being a human being. The whole of aviation safety is based around the acceptance that human beings make mistakes, so a system has evolved to minimise them of training, assessment, monitoring and supervision.. In my view it is that system that failed in this case.
Absolutely agree 100% with the above, and this is why the trial did not get to the root cause. The quite correct not quilty verdict effectively closed the book on the bigger picture, which was the real elephant in the room. My power flying world started when airshows were not subject to legal requirements or authorisations but participants were expected to attend the Air Show brief (on site) and failure to do this meant you did not display. In the case of the large civilian operations like the Air Fair at Biggin Hill there was always at least one designated person to oversee the flying in addition to ATC or commentary people. Participants were stopped, warned, and not invited back if they failed to comply with the on the day requirements. When DA's came about it was intended that you had to demonstrate your actual display to a satisfactory standard in the display machine, and various limits were also included that were part of the authorisation. The system was required whether you flew a turbulent, warbird, or jet, and formalised what was already in place with most organisations/teams that provided air show acts.
The UK air show tradition has a long history, and has provided much pleasure to the public with a very wide ranging variety of events ranging from simple charity type non airfield locations to the huge multi national shows such as IAT. These replaced the former military events RAF and RN At Homes which were hugely popular, and attracted massive crowds with hundreds of our military aircraft of the day, and were themselves a legacy of the world famous pre war Hendon shows. I mention this as air shows are part of our heritage and of considerable interest to all and we should not see their demise due to allowing a control system to degrade.
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Old 8th Jul 2020, 14:54
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Airsound

I hope you donít mind me continuing the conversation but it genuinely fascinates me.

I have a few other thoughts.

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

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

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

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

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

I can only put this accident into Hawk terms but I know that if I were to apex 1500í lower than intended and continued the manoeuvre I would be incredibly lucky to complete the second half before ground impact. I canít imagine a Hunter is markedly different in that regard.

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

Please donít take any of this personally but, as you can see, some of us are having a hard time accepting the stated course of events.

BV
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Old 8th Jul 2020, 15:05
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Originally Posted by airsound View Post
But as you will have seen from the Conclusions of the AAIB report Also, from the Prosecution's 53-page opening handout which I referred to in post #589 So neither the AAIB, nor the Prosecution, support your view. Indeed, the Prosecution charge relied on AH's being suitably experienced and qualified to fly the display – inexperience cannot equate to negligence.

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

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

AH was current and fit in terms of the regs at the time, that doesn't mean it was safe, at least in my opinion. The system failed those victims and their families
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Old 8th Jul 2020, 15:13
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Originally Posted by Bob Viking View Post
Firstly the lack of research into CI may well be something that should be rectified. From the defence point of view that was probably a good thing of course. A little understood phenomenon is a perfect way to sew seeds of doubt into the minds of a jury. I realise that sounds like I am accusing them of Machiavellianism but I am just pointing out how a legal defence works in reality.
Yep.
I served on a jury over 30 years ago, where the defence team did a similar thing and utterly confused and brain-numbed most of the jury, who had been given enough 'seeds of doubt'....to bring a not guilty verdict despite the hard evidence presented.
As pointed out in other posts, its all a 'game' played by legal teams.

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


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