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Shoreham Airshow Crash Trial

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Shoreham Airshow Crash Trial

Old 22nd Dec 2022, 08:03
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Originally Posted by tucumseh
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,
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Old 22nd Dec 2022, 08:16
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Originally Posted by 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.
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.
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Old 22nd Dec 2022, 08:27
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Originally Posted by DaveReidUK
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
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Old 22nd Dec 2022, 08:39
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Originally Posted by DaveReidUK
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?
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Old 22nd Dec 2022, 10:08
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Originally Posted by ehwatezedoing
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.
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Old 22nd Dec 2022, 10:47
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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?
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Old 22nd Dec 2022, 12:27
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Originally Posted by Asturias56
https://www.bbc.co.uk/news/uk-england-sussex-64040265

Shoreham air crash victims unlawfully killed, coroner concludes

Eleven 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. 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.
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Old 22nd Dec 2022, 13:11
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Originally Posted by PoacherNowGamekeeper
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....
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Old 22nd Dec 2022, 13:23
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Originally Posted by PoacherNowGamekeeper
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.
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Old 22nd Dec 2022, 13:34
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Originally Posted by 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!
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.

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Old 22nd Dec 2022, 13:54
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TF

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
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Old 22nd Dec 2022, 15:06
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Originally Posted by ehwatezedoing
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?
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Old 22nd Dec 2022, 15:21
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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.
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Old 22nd Dec 2022, 16:47
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Originally Posted by Timmy Tomkins
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.
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Old 22nd Dec 2022, 19:15
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Originally Posted by ehwatezedoing
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.
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Old 22nd Dec 2022, 19:29
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Originally Posted by Thoughtful_Flyer
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.


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Old 22nd Dec 2022, 19:54
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Originally Posted by 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.
A Just Safety Culture does not remove the ability to hold people (criminally) accountable.
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Old 22nd Dec 2022, 19:54
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Biscuit74

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
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Old 23rd Dec 2022, 05:32
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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.
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Old 23rd Dec 2022, 08:12
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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.
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