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Shoreham Airshow Crash Trial

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Shoreham Airshow Crash Trial

Old 23rd Dec 2022, 08:47
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Putting aside the human factors element, the inquest and the criminal prosecution, this event does highlight the fine line between wanting to see old aircraft fly and the way in which we can maintain them and keep them airworthy, doesn't it?

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

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

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

Hard to see a way to fix this, given the disparity of different types, their increasing age, and the inevitable loss in old maintenance and repair skills.
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Old 23rd Dec 2022, 09:35
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Thanks Bob - and tucumseh and agrajag. I reckon we are all thinking on fairly similar lines: I mulled this again last night. The serviceability errors/failures/oversights were - like the inadequacies in pilot oversight and continuation training, indicative of an attitude, a team that really wasn't operating fully to the standards required for the task. Their operation was apparently 'safe enough' for long enough to perhaps lull people into false assurance. Of course I'm saying that with hindsight, which is always easy.

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

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

Agrajag - the comments you made about ageing and loss of experienced people are very apt. Its depressing that similar styles of incident and accident re-occur throughout engineering and throughout human activities and operations of all sorts. The loss of 'team learnings' as natural turnover occurs is a challenge everywhere. For us gnarly old types there is an element of frustration when we see or hear of the same old errors happening,and for the new young characters there is exasperation sometimes when we mutter 'oh, no again!'. If only there was a simple way to transfer all the old, hard won, lessons into new heads easily !
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Old 23rd Dec 2022, 09:44
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AJ :-
Hard to see a way to fix this, given the disparity of different types, their increasing age, and the inevitable loss in old maintenance and repair skills.
The problem isn't the different types, their age, or skills, it is rather the incompetence of the Regulatory Authorities involved, and the reluctance of Air Accident Investigators to draw attention to that incompetence. The regulatory incompetence of the MOD/MAA features in the many airworthiness related fatal accident threads that litter the PPRuNe military aviation forum. That incompetence stems from the deliberate plundering of hitherto ring fenced Air Safety budgets in the late 80s (to fund a disastrous AMSO policy of cost savings by divesting itself of spares holdings that would then have to be bought in at much higher cost). RAF VSOs in turn rid themselves of experienced and knowledgeable airworthiness engineers who would not bend to illegal orders to suborn the airworthiness regulations, replacing them with untrained and ignorant non-engineers who would happily comply.

Thus corporate memory was lost and the long march to a totally dysfunctional UK Military Airworthiness system commenced. The Sea King, Chinook, Hercules, Nimrod, Tornado, Hawk fleets all suffered airworthiness related fatal accidents as featured in this forum. That the CAA assumed that an ex 1950s RAF jet should still be assured of its airworthiness by the RAF when on the civilian register speaks volumes of how out of touch it was with its military equivalent, and hence of its own incompetence. As tuc continually tells us the solution is simple, implement the mandatory regulations! If the CAA had done so this aircraft would not have been granted civilian registration, let alone been carrying out an air display on that fateful day.
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Old 23rd Dec 2022, 09:47
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Originally Posted by BEagle View Post
From the AAIB report:

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

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

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

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

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

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

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


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

Savings at the expense of safety?
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Old 23rd Dec 2022, 09:56
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Originally Posted by Chugalug2 View Post
AJ :-


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

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

Originally Posted by _Agrajag_ View Post
... whether the skills and knowledge of the regulators themselves are adequate . . .
I think we all know there are weaknesses with regulators, and that these will most probably worsen with time, for a variety of reasons, not least being that running an effective regulatory regime is very costly.
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Old 23rd Dec 2022, 10:18
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AJ :-
I think we all know there are weaknesses with regulators, and that these will most probably worsen with time, for a variety of reasons, not least being that running an effective regulatory regime is very costly.
and that is the fundamental lesson to learn from Shoreham, just as it is with the UK Military Airworthiness Related Fatal Accidents that account for well over 100 avoidable deaths and the loss of much national treasure and potential Air Power, and many of which can be read about here in this very forum. The aircrews and engineers involved were the victims of regulatory incompetence no matter what part they themselves played in these tragedies. Time a spotlight was shone into the murky corridors and offices from which this scandal emerged. Nothing short of total reform of the Military Air Regulation and Accident Investigation system will suffice, with a basic requirement that they be independent of each other and of the operator (ie of the MOD). It would appear that much the same is called for of Civilian Regulation, but this is a Military Forum so I'll leave it there...
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Old 23rd Dec 2022, 10:52
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Originally Posted by _Agrajag_ View Post
Putting aside the human factors element, the inquest and the criminal prosecution, this event does highlight the fine line between wanting to see old aircraft fly and the way in which we can maintain them and keep them airworthy, doesn't it?

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

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

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

Hard to see a way to fix this, given the disparity of different types, their increasing age, and the inevitable loss in old maintenance and repair skills.
I would largely agree but put it somewhat stronger and also ask the unwelcome / unthinkable question....

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

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

Occasionally a very rich owner may be able to solve some of these issues with their cheque book but even that assumes that technicians and pilots with the required skills can be hired.
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Old 23rd Dec 2022, 11:37
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Originally Posted by Thoughtful_Flyer View Post
I would largely agree but put it somewhat stronger and also ask the unwelcome / unthinkable question....

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

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

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

I would hate to see the loss of historic aircraft being displayed, but the way the world is changing and becoming more litigious, together with the ageing of the fleets, the fading skills and the poor state of airworthiness regulation it's hard to see how privately operated historic aircraft can be kept flying. Be a great shame to see them grounded. We gave a very good friend an 80th birthday gift of a jolly in a Harvard, a type he'd flown in action in Kenya in the early 50's. Really made his day, and as he said to his (rather concerned) wife when signing the disclaimer before the flight, "I've done pretty well to get to 80, this aircraft didn't manage to kill me 50 years ago when I was being shot at so it's not likely to now, is it?". He was right, it didn't, but sadly the "big C" did a couple of years later.
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Old 23rd Dec 2022, 11:47
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TF :-
Is it really possible, both technically and economically, to keep these types of historic aircraft airworthy in civilian hands?
The pertinent word is 'keep'. There is no reason to believe that any ex-military aircraft is airworthy unless the records accompanying it prove it to be so. The appropriate records for example of one type were found to be so much sodden pulp, stored as they were in a shed with a collapsed roof. Even if they were intact and readable I doubt they would have been of any use, because airworthiness is a matter of continuous record and audit. Break that process of continuation and airworthiness is lost, as was shown in the scandal of the ACO Gliders. Those that managed to fly again had to be fully dismantled and rebuilt IAW with the regs. Just doable with such simple airframes (though even then scarcely economic), but with a FJ? Forget it, keep them in museums for future generations to see unless they are indeed airworthy and can be proved to be so. Good luck with that!
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Old 23rd Dec 2022, 11:57
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This seems to be going off at somewhat of a tangent, in terms of references to older piston types, which is not very relevant to Shoreham?
There's more chance of keeping a piston type airworthy, the skills are not being lost, and many of the main operators are passing on the knowledge to younger people already. The issue as ever is owners with deep enough pockets to restore and operate them.....and they are getting fewer, but with established maintainence operators like Air Leasing, ARC, Air Legends, and TFC of course, although TFC's fleet is ever reducing with SG's increasing age. Afterall, BBMF are contracting out their winter deep maintainence work to these operations now.

The subject when talking about post-war historic jets however, is effectively a non-subject now post Shoreham, as there are very few left now because of the post-Shoreham CAA changes, meaning owners have sold or grounded them having been unable to sell them. Other than a few JP's and the single(?) L39 that's all there is, flying in civvie hands and there's not likely to be any more than that now.
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Old 24th Dec 2022, 05:14
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Originally Posted by Chugalug2 View Post
AJ :-


and that is the fundamental lesson to learn from Shoreham, just as it is with the UK Military Airworthiness Related Fatal Accidents that account for well over 100 avoidable deaths and the loss of much national treasure and potential Air Power, and many of which can be read about here in this very forum. The aircrews and engineers involved were the victims of regulatory incompetence no matter what part they themselves played in these tragedies. Time a spotlight was shone into the murky corridors and offices from which this scandal emerged. Nothing short of total reform of the Military Air Regulation and Accident Investigation system will suffice, with a basic requirement that they be independent of each other and of the operator (ie of the MOD). It would appear that much the same is called for of Civilian Regulation, but this is a Military Forum so I'll leave it there...
Ahhhh are you sure that Airworthiness is THE lesson from Shoreham?
Ill give you a clue - NO! Even if the Hunter was legally unairworthy, it was not the reason for the crash- not even peripherally!

The unasked question about Shoreham is could it happen again? Are UK airshows any safer since the CAA review?
https://publicapps.caa.co.uk/docs/33...00%20MAY16.pdf
My personal feeling is the answer is - Not really.

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Old 24th Dec 2022, 07:23
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Originally Posted by typerated View Post
The unasked question about Shoreham is could it happen again? Are UK airshows any safer since the CAA review?
https://publicapps.caa.co.uk/docs/33...00%20MAY16.pdf
My personal feeling is the answer is - Not really.
Just looking at the above posts the question of recurrence and preventing it HAS been asked. It's just not been answered adequately. But I agree with your conclusion!


.


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Old 24th Dec 2022, 08:11
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Will Airshows be safer !!!!

Originally Posted by typerated View Post
Ahhhh are you sure that Airworthiness is THE lesson from Shoreham?
Ill give you a clue - NO! Even if the Hunter was legally unairworthy, it was not the reason for the crash- not even peripherally!
The main Issue with Shoreham was the lack of implementation of the existing rules/guidance at the time, starting with the Display authorisation and continuing to the lack of actual Display control on the day. There was enough 'potential control' in the system, but it was not heeded, and that includes the suitability of the location for a machine that needed 'space' to position for the short crowd line, and having to avoid so many built up area's.
The only 'safe' option has already happened since the event, with the drastic reduction in the smaller displays due cost, and some of the larger ones moving to a 'sea front' location. One thing for sure as Dallas has shown is that Pilot awareness will always be a major factor, and multiple layers of rules do not protect against poor planning and control on the day.

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Old 24th Dec 2022, 08:15
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Originally Posted by typerated View Post
Ahhhh are you sure that Airworthiness is THE lesson from Shoreham?
Ill give you a clue - NO! Even if the Hunter was legally unairworthy, it was not the reason for the crash- not even peripherally!
Interestingly the NTSB (though not the AAIB) demarcates its analysis of findings after an accident into 3 categories:
Probable Cause/s
Contributory Factor/s
Other Factor/s

While that last category might appear to be a contradiction in terms (a factor that didn't contribute to the event/outcome), it's a useful repository for findings such as the state of the Hunter's fuel pump diaphragm.
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Old 24th Dec 2022, 08:25
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Originally Posted by typerated View Post
Ahhhh are you sure that Airworthiness is THE lesson from Shoreham?
Ill give you a clue - NO! Even if the Hunter was legally unairworthy, it was not the reason for the crash- not even peripherally!

The unasked question about Shoreham is could it happen again? Are UK airshows any safer since the CAA review?
https://publicapps.caa.co.uk/docs/33...00%20MAY16.pdf
My personal feeling is the answer is - Not really.
I suspect that we are in violent agreement about UK airshows. My point about airworthiness is that it is the sine qua non of aviation. Without it, no matter how well maintained, no matter how well flown, an aircraft is fatally compromised and looking for a place to have its accident. As to the Shoreham tragedy, it shares with Mull the dubious distinction of killing large numbers of people who had nothing to do with the maintaining or operating of the aircraft. It also shares the scandal of an accident investigation that chose not to delve deeply into gross regulatory failings that were known about.

Both investigations were compromised by not considering all the evidence available. That is a scandal that casts doubt upon the findings and 'the reason for the crash'. There was a time when Air Accident Investigations, be they civil or military, were thorough and turned over all the stones to determine the cause. The Comet tragedies being a case in point. They were unairworthy, and the reason they were was proved and remedial action taken. My own fleet, the HP Hastings, was grounded for months following the Little Baldon disaster. They were unairworthy and extensive remedial action taken, even though they were out of service a mere few years later. Now we have question marks hanging over whole military fleets, and manufacturers fitted up to cover the incompetence of the regulatory authority. I'd say that's a big lesson to take on board, no matter who or what was responsible for Shoreham. Wouldn't you?
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Old 24th Dec 2022, 09:32
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and fly at the edge of their safe envelope
About the last thing I want to see, if you don't mind
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Old 24th Dec 2022, 10:57
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Originally Posted by idle bystander View Post
About the last thing I want to see, if you don't mind

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

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

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

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

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Old 24th Dec 2022, 11:18
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Doesn’t the Pilot have the final say on whether everything is in order? I hope RAF and ex RAF Pilots have the knowledge and experience to ensure that everything is in order.
When they turn up in the morning, whether at the location of the display or not, they will go through all the required paperwork. Their own paperwork and licenses will be checked as well?
But, the final say would be the Pilot? Or does a nice big paycheque somehow speed things along?
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Old 24th Dec 2022, 11:20
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Originally Posted by The Nip View Post
Doesnít the Pilot have the final say on whether everything is in order? I hope RAF and ex RAF Pilots have the knowledge and experience to ensure that everything is in order.
When they turn up in the morning, whether at the location of the display or not, they will go through all the required paperwork. Their own paperwork and licenses will be checked as well?
But, the final say would be the Pilot? Or does a nice big paycheque somehow speed things along?
Nice big paycheque for flying vintage aircraft at airshows? Not outside the Vulcan boondoggle Iím afraid.
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Old 24th Dec 2022, 11:28
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Originally Posted by DaveReidUK View Post
Interestingly the NTSB (though not the AAIB) demarcates its analysis of findings after an accident into 3 categories:
Probable Cause/s
Contributory Factor/s
Other Factor/s

While that last category might appear to be a contradiction in terms (a factor that didn't contribute to the event/outcome), it's a useful repository for findings such as the state of the Hunter's fuel pump diaphragm.
Indeed, and an observation made many times about AAIB reports, which are often difficult to read. Case in point.

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

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

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