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Shoreham Airshow Crash Trial

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Shoreham Airshow Crash Trial

Old 27th Mar 2019, 06:42
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Onceapilot

Now, I do not know you but, this is absolute bread and butter info to a FJ pilot and you should know it.
Interesting, then, that RAFCAM were unaware of it and it has never been part of any anti-G training. Where do pilots pick up this bread and butter knowledge of potential sub A-LOC impairment, because it's not part of the syllabus?
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Old 27th Mar 2019, 07:22
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Originally Posted by Legalapproach
Interesting, then, that RAFCAM were unaware of it and it has never been part of any anti-G training. Where do pilots pick up this bread and butter knowledge of potential sub A-LOC impairment, because it's not part of the syllabus?
Where do we pick it up? Every time we trained under G from early aerobatics on elementary trainers, through maximum possible rate turns at basic and advanced flying training, and onto air combat training at the front line. It may not have been taught at RAFCAM or given a name, but the understanding that even ‘simple’ things are more difficult while under G and the need to make appropriate allowance are things that a fast jet pilot recognises as a straightforward consequence of having passed the training, let alone having survived a career spanning thousands of hours. Failure to meet performance standards (eg height, speed, fuel awareness, quality of tactical decision-making), whether or not G-induced, is a common reason for application of remedial action up to and including withdrawal from flying duties. BV can provide a QFI’s perspective, but for me as a former front-line instructor, would a G-induced cognitive impairment excuse an individual from the professional consequences that might follow? Absolutely not.

I get that this wooliness leaves space for a legal argument and acquittal in a court of law. Fine. But that has no bearing on the judgement of the court of professional opinion. This forum is part of the latter, so LW50, your point is irrelevant. Views expressed here have no consequence for AH as a citizen, but we are entitled to hold them irrespective of the legal position.

Last edited by Easy Street; 27th Mar 2019 at 09:04.
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Old 27th Mar 2019, 08:49
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Originally Posted by Legalapproach
Onceapilot



Interesting, then, that RAFCAM were unaware of it and it has never been part of any anti-G training. Where do pilots pick up this bread and butter knowledge of potential sub A-LOC impairment, because it's not part of the syllabus?
More interesting, it seems to me that a basic reality of the physical and mental effects of flying FJ type aircraft in a dynamic envelope is being misunderstood or misrepresented?

OAP

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Old 27th Mar 2019, 09:40
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Extremely well put EA and OAP. It is always difficult to get across to the uninitiated what the training is like to be able to fly and fight a FJ. It is that type of innate knowledge that frankly sorts the men from the boys!
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Old 27th Mar 2019, 10:08
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Easy Street et al

Ah yes, the court of opinion that hasn't heard any of the evidence. I have done my best to try and encapsulate the medical position and to try and inform the debate but with limited success. We are all (well some of us) familiar with the more recognisable effects of G and how to combat it. I've experienced A-LOC 'grey out' as it was termed in my day and I could detect it at the time, but we weren't talking about grey out, blackout (or even red out).

The issue of CI in AH's case was a form of hypoxia. Remember the trip to North Luffenham and being put in the altitude Chamber? Remember being tasked to count down from 100 subtracting in 7's, coming off the oxygen, carrying on, oxygen back on and only then noting the gibberish on the clip board? One of the difficulties with hypoxia is the subject not being aware of it at the time. Possible symptoms - feeling of euphoria, sense of confidence?

Onceapilot
Misunderstood or misrepresented - by whom? By the highly respected experts who gave evidence? If you have have read the expert reports (from both sides) and have heard the evidence, please point out the misrepresentations (assuming you are confident that you are not libeling the medical experts by suggesting deliberate misrepresentation on oath) because I would be fascinated to know how we got it so wrong and Pprune gets it so right.
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Old 27th Mar 2019, 10:25
  #326 (permalink)  
 
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I am surprised that the low level of g being talked about that would induce blood pooling in the chest cavity would be enough to inflate g pants at all, never mind enough to constrict the diaphragm. Is there rigorous experimental evidence from an operational environmental or is it a theory? I don't believe I ever noticed this effect but my wife tells me that I am insensitive.
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Old 27th Mar 2019, 10:41
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The court of opinion has many thousands of hours flying high performance aircraft. Jurys can be easily flumoxed by selected technical evidence. Hypoxia, he should have been so lucky to be so high. Didn’t I read that AH had been a QFI and responsible for teaching RAF pilots aerobatics?
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Old 27th Mar 2019, 11:11
  #328 (permalink)  
 
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My thoughts

I’ve thought long and hard about what I think regarding this event. My thoughts are thus:

If the jury ruled that AH suffered from CI after listening to hours of evidence then who am I to argue? I will still admit to not fully understanding it based on what has been explained on here.

I sat through two BFM sorties today and whilst exposed to prolonged G I don’t believe my faculties to have been adversely affected in any way.

If we are to state that AH is an ‘experienced FJ operator’ then I think we need to define what we mean by that. The elder statesmen of this forum regularly pour scorn on the youngsters who have far less hours than they accrued during their service careers.

AH had 1500 FJ hours (800 of which were on the JP) and left the RAF 21 years before the accident. There was then a 9-10 year gap before he started flying JPs again.

I wouldn't argue for a second if someone said he was an experienced JP pilot. With 14000 total flying hours we can all agree he is also an experienced pilot. The bit I take issue with is that most of his flying was either so distant or on a completely unrelated type to the Hunter.

I stated earlier I have a fair amount of current Hawk experience but I wouldn’t go and fly low level aerobatics tomorrow without an appropriate work up (or work down depending on how you look at it).

I apologise if this is not the Pprune approved opinion but it is mine.

I can accept that AH was not criminally negligent. I also accept that the CAA bear a lot of blame for allowing the regulations as they were. As an ‘experienced FJ operator’ though I question why he felt suitably qualified and current to fly those manoeuvres.

The upshot, for me personally, is that I would not take my family to an air show with these old Warbirds displaying as things stand. I’m all for flying them as a hobby (I wouldn’t do it but I understand why others want to) and even performing flypasts but until I know something has changed markedly then my family and I will not partake.

Rip me to shreds if you must but you can’t change my opinion.

BV

Edited to add: Capt Scribble, you don’t need to be at altitude to suffer from hypoxia. Hypoxia is a deficiency in the amount of Oxygen reaching the tissues. That can be for many reasons. Altitude is just the one that we, as pilots, are most familiar with.

Last edited by Bob Viking; 27th Mar 2019 at 11:33.
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Old 27th Mar 2019, 11:52
  #329 (permalink)  
 
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BV,

I totally agree with all that you state. I would like to add that there is no way that a "check out" in a JP should qualify one to fly a Hunter.

Any pilot who is disciplined and professional who performs aerobatics (at any height, let alone low level) sets and learns gate heights and speeds for the whole display. They are written on a knee board and if low level engraved on ones mind. Even if one was suffering from the effects of "hypoxia" these numbers would be almost the last to go from ones memory. As stated previously, a fast jet pilot is trained so that his/her mind can still prioritise even when operating under duress. Operating under g forces, the effects of, and how to counter them were all taught in the RAF since the Meteor. Just because the USAF discovered gLoc in the late 70s and we learnt from them does not mean that there was not such training previously.

Is it possible that the supposed "hypoxia" was caused by hyperventilation due to anxiety. Was AH over-breathing and thus filling his lungs with Carbon Dioxide? Was he dumped with the Shoreham display (a difficult venue for a fast jet) at a late stage and he was not able to say No. The downwind takeoff and track taken prior to the display are not necessarily the actions of one in total control! Even so, if properly trained and qualified he should have been able to over come the situation that he put himself in. The accident was avoidable!
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Old 27th Mar 2019, 14:38
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I seem to recall flying straight and level achieved around 1G. Running-in to a display and not being at or above the minimum entry speed at or before pitching into the vertical is a decision made in the most benign of circumstances. I am struggling to see how or why this action could be impaired by any G-related physiological effects.

Originally Posted by Bob Viking
I can accept that AH was not criminally negligent. I also accept that the CAA bear a lot of blame for allowing the regulations as they were. As an ‘experienced FJ operator’ though I question why he felt suitably qualified and current to fly those manoeuvres.
I can only agree that the CAA's lax or incoherent regulation played a part in this incident but we don't blame the police if they fail to identify and stop a bad driver before a car crash. This pilot will have known that he was attempting something that the RAF would have never authorised him to do - fly an unfamiliar fast jet at a public display with just a handful of hours on type. Even in his day job his employer would not allow him to operate any aircraft type with such poor currency.

As you say BV, most of us would not consider attempting such a display even when current on type. Unfortunately a few pilots had convinced themselves that the lack of civil regulation was a green light to undertake anything they were personally prepared to do.
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Old 27th Mar 2019, 14:54
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Originally Posted by Dominator2
Is it possible that the supposed "hypoxia" was caused by hyperventilation due to anxiety. Was AH over-breathing and thus filling his lungs with Carbon Dioxide? Was he dumped with the Shoreham display (a difficult venue for a fast jet) at a late stage and he was not able to say No. The downwind takeoff and track taken prior to the display are not necessarily the actions of one in total control! Even so, if properly trained and qualified he should have been able to over come the situation that he put himself in. The accident was avoidable!
Avoidable? Yes, certainly. Essentially all accidents are avoidable/preventable. But that was not the point in the trial. The point in the trial was: did the failure to avoid/prevent the accident rise to the level of a crime? Specifically, did that failure constitute criminal negligent manslaughter? After hearing all the evidence, the jury clearly and unanimously said no. The rest is moot. And pointless.

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Old 27th Mar 2019, 14:58
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I sat through the seven-odd weeks of the case (apart from three days in the middle), and I have contemporaneous notes of most of the proceedings.

There were two pieces of evidence that particularly struck me, over many days of detailed offerings.

The first was from one of the ‘first responders’ who attended AH as he lay beside the wreckage of the Hunter cockpit. AH was at death’s door - indeed his life was only saved by the timely introduction of a needle into his lung. He was speaking, although not particularly coherently. But, according to the evidence of Mark Durham, AH said he had “at some point blacked out in the air”. Although this was not an actual ‘death bed statement’, it could be considered to have a similar status, since he was, effectively, about to die.

The second piece of evidence that seemed particularly significant to me, was offered by the defence ‘human factors’ expert witness, Dr Stephen Jarvis. He adduced seven, eight, or possibly even twelve, piloting errors in the 23 seconds leading up to the aircraft’s arrival at the apex of the accident manoeuvre (the bent loop). They included:
  • Unexplained power reduction.
  • Continuing the turn beyond the appropriate inbound track.
  • Failure to notice low speed.
  • Pitch oscillations.
  • Incorrect roll in the vertical.
  • After, the apex, the failure to eject. That would have been a rule-based action, from his training.
Dr Jarvis did not include the failure to conduct an escape manoeuvre as one of his errors, because he said that was not his area of expertise.

Also not mentioned in his evidence, but clearly visible in the cockpit GoPro camera footage, was the fact that the aircraft was lined up on the road, apparently intentionally, during its final descent. Why would any pilot in his right mind do that, unless he was under the impression that he was lining up on a runway?

Dr Jarvis pointed out that one type of accident is an accumulation errors, which are not independent. In this case he was unable to find any relationship between the errors. The chances of that happening, he said, were astronomically improbable. That makes them very difficult to explain - other than by some degree of cognitive impairment.

He was asked about the possibility of this all being due to “extremely bad piloting”. He couldn’t accept that. AH was a very experienced and expert pilot, he said. Bad piloting didn’t fit, when he made ten or more errors in 23 seconds. “He’s in front of an audience, he’s on peak performance, [and] gash, complacent behaviour doesn’t fit.”

It may be worth reminding ourselves that AH has no memory of anything from Thursday 20 August 2015 (two days before the crash) to when he came round from his induced coma, in hospital, the following week. His amnesia was medically attested to by Legalapproach in his post #132, when Legalapproach also pointed out that the prosecution had not sought to discredit the amnesia. So in all of AH’s three and a half days in the witness box, he was not able to describe at first hand anything that happened during the accident flight or its immediate preparation.

Bearing in mind that the jury (of eleven people) came to a unanimous verdict after about seven hours of consideration, it seems clear that they accepted the defence arguments over the prosecution’s. Who are we to disagree with that?

Incidentally, the reason for there being eleven jurors, rather than twelve, was that, on 29 January, one juror fell ill and was taken to hospital by ambulance. She was excused further jury service.

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Old 27th Mar 2019, 15:29
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Dominatior 2: “Is it possible that the supposed "hypoxia" was caused by hyperventilation due to anxiety. Was AH over-breathing and thus filling his lungs with Carbon Dioxide?”
Hyperventilation will not, cannot fill anybody’s lungs with carbon dioxide. There is damn all carbon dioxide in the atmosphere, even in these climate warming times. Hyperventilation leads to a reduction of arterial CO2, which in turn leads to a decrease in cerebral blood flow. That’s why you start feeling a bit dizzy when you blow up an air bed. So if AH was hyperventilating, it might contribute to cerebral hypoxia but nothing to do with CO2.

Bob Viking - what a sensible balanced post.

Legalapproach - keep trying! You are doing a good job. BTW is it possible, can I get a transcript of the judge’s and prosecution’s summing up? For my interest and education. Thanks.

Airsound: you were there, you know what a load of cobblers the press coverage was, and I agree totally with your comments.

Caramba


Last edited by Caramba; 27th Mar 2019 at 15:32. Reason: Adding comment
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Old 27th Mar 2019, 18:29
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Hi airsound,

Thank you for your post. Can you tell us how it was established that the pilot was both expert and experienced and which criteria were used?

I wasn’t present and haven’t read the proceedings (or very much of the open press coverage tbh) but there seems to be the ‘expert opinion’ that something must have been wrong because the pilot’s perceived status ruled out other explanations. Just wondering how that status was established and tested.

Thanks in advance for any light shed.
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Old 27th Mar 2019, 19:34
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Originally Posted by airsound
Bearing in mind that the jury (of eleven people) came to a unanimous verdict after about seven hours of consideration, it seems clear that they accepted the defence arguments over the prosecution’s. Who are we to disagree with that?
We are professional aviators who are expected to understand and learn from tragedies such as this. I also don't doubt the independence, professionalism or experience of the AAIB and their report is sobering. I would be concerned if AH was presented as a skilled or experienced Hunter pilot - he was not. I would count someone such as LOMCEVAK as a highly skilled and experienced Hunter pilot and he didn't achieve that status with a handful of sorties.

AH 'qualified' after 3hrs 25min flying the Hunter. By the time of the crash 4 years later he had amassed 19hrs 25min total time displaying the Hunter, including transits, with an average of just 5 sorties per year. It was the only fast jet he had flown since leaving the RAF 11 years earlier, after completing just 1 frontline tour and with no RAF display experience.
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Old 27th Mar 2019, 20:40
  #336 (permalink)  
 
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the defence ‘human factors’ expert witness, Dr Stephen Jarvis ... adduced seven, eight, or possibly even twelve, piloting errors in the 23 seconds leading up to the aircraft’s arrival at the apex of the accident manoeuvre (the bent loop). They included:
  • Unexplained power reduction.
  • Continuing the turn beyond the appropriate inbound track.
  • Failure to notice low speed.
  • Pitch oscillations.
  • Incorrect roll in the vertical.
  • After, the apex, the failure to eject. That would have been a rule-based action, from his training.
Dr Jarvis did not include the failure to conduct an escape manoeuvre as one of his errors, because he said that was not his area of expertise.

Also not mentioned in his evidence, but clearly visible in the cockpit GoPro camera footage, was the fact that the aircraft was lined up on the road, apparently intentionally, during its final descent. Why would any pilot in his right mind do that, unless he was under the impression that he was lining up on a runway?

Dr Jarvis pointed out that one type of accident is an accumulation errors, which are not independent. In this case he was unable to find any relationship between the errors. The chances of that happening, he said, were astronomically improbable. That makes them very difficult to explain - other than by some degree of cognitive impairment.

He was asked about the possibility of this all being due to “extremely bad piloting”. He couldn’t accept that. AH was a very experienced and expert pilot, he said. Bad piloting didn’t fit, when he made ten or more errors in 23 seconds.
This is readily explained by the condition known in the military aviation profession as being ‘maxed out’, or stretched beyond the limits of mental capacity. Most often seen in student pilots, its recurrence is a common reason for suspension, whether in initial training or under carefully supervised conditions on postgraduate courses such as the Qualified Weapons Instructor Course. Many a current and capable second- or third-tour aviator with greater ability than AH has failed the latter by becoming ‘maxed out’ despite operating at what most would consider peak performance. The condition is typically suppressed outside the training environment by the application of a process known as ‘flying supervision’, which begins with regulations setting out minimum qualification and currency requirements and upon which a layer of professional judgement is applied, culminating in a signature authorising a particular sortie. Even the most experienced and expert military aviators are limited in what they are permitted to do when outside of currency stipulations, in part because of the risk of making errors and mistakes while ‘maxed out’.

He’s in front of an audience
Widely known in professional circles, and most especially in the display world, as one of the *very* highest risk factors for poor decision-making and self-induced pressure, while performing and even on the ground beforehand. Evidence: B-52 Fairchild AFB 1994, C-17 Elmendorf AFB 2010, Tucano Linton-on-Ouse 2009, plenty of other case studies, and the enormous quantity of military regulation that existed to control flypasts, role demonstrations and displays even before the Shoreham accident.

he’s on peak performance
Not a barrier to becoming 'maxed out', see my QWI course example above. More significantly, the statement is way beyond the bounds of credibility given AH's currency and experience on type.

gash, complacent behaviour doesn’t fit
A straw man argument in relation to the sequence of errors recounted. AH could have been doing his very best at that point in the occurrence. The key to our profession is not putting pilots in a place where their best is not good enough.

I am being deliberately tongue-in-cheek with all of this because I can’t think of many sortie profiles more likely to stretch a pilot beyond the limit of their mental capacity than a low-level aerobatic display at a tricky venue with patchy currency and less than 20 hours on type. Frankly I find it astonishing that a human factors expert would offer the pilot's supposed 'experienced and expert' status as an absolute barrier to poor performance, given countless historical examples of 'experienced and expert' pilots performing very poorly indeed.

Originally Posted by legalapproach
Easy Street et al

Ah yes, the court of opinion that hasn't heard any of the evidence. I have done my best to try and encapsulate the medical position
Few, if any on here are disputing the verdict duly reached in court of law; perhaps that makes our discussion off-topic given the word 'trial' in the thread title. However you should be unsurprised to learn that the verdict and medical position have been examined carefully by military authorities, as the outcome could be taken to infer that the military is unaware of the potential for CI at relatively low G, which would be a significant issue for legally-accountable aviation duty holders. So you'll have to take it as read that some of us may be more informed on the medical position than you think. Your statement of that position was enough to prevent the criminal standard of proof from being reached, but I'm afraid it won't wash with the majority here.

Last edited by Easy Street; 27th Mar 2019 at 23:20.
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Old 27th Mar 2019, 20:52
  #337 (permalink)  
 
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Great post BV - hope you dont mind if I give my own thoughts in line below...

Originally Posted by Bob Viking
If we are to state that AH is an ‘experienced FJ operator’ then I think we need to define what we mean by that.

Why does that need defining? If your point is "was he experienced enough to be flying that aircraft that day at an airshow" then per the CAA display flying rules and regs of the day he either met or exceeded all the criteria laid down related to experience, currency and competency.

Originally Posted by Bob Viking
AH had 1500 FJ hours (800 of which were on the JP) and left the RAF 21 years before the accident. There was then a 9-10 year gap before he started flying JPs again.

I wouldn't argue for a second if someone said he was an experienced JP pilot. With 14000 total flying hours we can all agree he is also an experienced pilot. The bit I take issue with is that most of his flying was either so distant or on a completely unrelated type to the Hunter.
You make some salient, but obvious, points. The question, in my mind, is why was the environment so permissive that it allowed (you could almost say encouraged) AH and others to display high performance vintage jets in a public environment with such appalingly low levels of overall flying time, type experience and/or currency? If you want a real eye-opener look at the flying hrs table in the AAIB report (P.68/69) for the Carfest Gnat crash. I should add, with respect to the deceased, that like AH he was in full compliance with the rules and regs of the day....

Originally Posted by Bob Viking
I stated earlier I have a fair amount of current Hawk experience but I wouldn’t go and fly low level aerobatics tomorrow without an appropriate work up (or work down depending on how you look at it).

I can accept that AH was not criminally negligent. I also accept that the CAA bear a lot of blame for allowing the regulations as they were.
That's a fair viewpoint and I personally believe rules and regulations, although not a substitute for commonsense, are there for a reason - usually to try and prevent the worst excesses of human nature (fallibility) from spilling over. But for any rules/regs to be effective in preventing whatever they are meant to prevent they need to be appropriate at the outset, kept under regular review, be open to change as circumstances dictate, and be enforced consistently. Unfortunately, in my opinion, the CAA display flying regs in place at the time of the Shoreham tragedy failed most of those key tests.

Originally Posted by Bob Viking
As an ‘experienced FJ operator’ though I question why he felt suitably qualified and current to fly those manoeuvres
Questioning why AH got in the cockpit that day to fly those manoeuvres in that way in that plane is a bit like asking why somebody that mowed down a child was driving at 30mph past a school at 8.30am or 3.30pm. With our sensible head many of us would recognise that it's inappropriate but in many areas its still legal to do it, so some of us take advantage of it. It's human nature to be overly confident in our own abilities and generally have an overly optimistic view of possible impacts and consequences. And when we are confident we are fully compliant with the laws of the day that makes the decision making process a whole lot easier. Unfortunately what seems so obvious to some is often completely overlooked by others - back again I am afraid for the onus to be on the rules and regs to be fit for purpose.

Originally Posted by Bob Viking
The upshot, for me personally, is that I would not take my family to an air show with these old Warbirds displaying as things stand. I’m all for flying them as a hobby (I wouldn’t do it but I understand why others want to) and even performing flypasts but until I know something has changed markedly then my family and I will not partake.
So a personal recollection that I think I shared on here some time ago, so forgive me for repetition. I was at the Carfest event that the Gnat crashed at and saw it unfold first hand. I had a deep sense of foreboding the moment I saw the Gnat pair arrive in the overhead and ushered my wife and kids into a marquee whilst I stood outside and watched what I believed was a inappropriate display at an unsuitable venue in marginal weather conditions. I've read on here that others had a similar sense of unease as they saw AH pull up into the vertical at Shoreham. Not possible to turn back the clock, regrettably, but I do believe a LOT of lessons have now been learned (or re-learned) and that many of the factors that led to both these accidents have now been addressed, such as to make the chances of reoccurence substantially lower. I still regularly attend airshows and take my family with me occasionally.



Last edited by andrewn; 27th Mar 2019 at 21:07. Reason: edited for typo's
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Old 27th Mar 2019, 21:59
  #338 (permalink)  

 
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orca. You ask
Can you tell us how it was established that the pilot was both expert and experienced and which criteria were used?
Well, AH graduated from advanced FJ training at RAF Valley and became a ‘creamy’ - that’s to say, he was so good that the RAF ‘creamed’ him off as as a first tour instructor before sending him on to a frontline squadron. When he did go on, he was posted onto Harriers - an indication that he was amongst the top echelons of RAF pilots.

When he left the Air Force in 1995, having been an instructor in advanced combat manoeuvres and formation flying, he got his ATPL and flew for Virgin and BA, becoming a captain for BA.

But he also became a display pilot, flying the Extra 300, Bulldog and Vans RV-8. He became a light aircraft test pilot and taught aerobatics. He was part of a two-ship RV-8 team called the RV-8ors (geddit?), and did more than 300 displays with them. They were a very popular part of the display scene. AH also displayed the JP, and was eventually invited to display the Hunter. He was trained in that by the experienced and distinguished Hunter pilot, Chris Heames.

So I suggest that it was clear AH was ‘expert and experienced’ as a display pilot - although not, by military standards, as a Hunter display pilot. He was, though, fully qualified on the Hunter for CAA purposes.

It is also noteworthy that, at his trial, his defence team produced an extraordinary array of fourteen highly positive character references from distinguished pilots. The referees included:
  • A past leader of the Red Arrows,
  • A former director of the Empire Test Pilots’ School and subsequent founder of the ‘Ultimate High’ flight safety training organisation,
  • A Red Bull Air Race World Championship pilot,
  • A pilot to the royal families of the UK and Jordan who was also British National Aerobatic Champion and flew as a BA captain and a warbird pilot.

The referees spoke of AH’s high personal standards and his awareness of regulatory, operational and aircraft limits. One mentioned “his superior intellect [and his ability] to project ahead, identifying potential errors or hazardous situations and mitigating them.” Another spoke of his “threat error management”. Yet another said “Compared to his peers, AH’s ‘Situational Awareness’ was excellent.”

airsound

Last edited by airsound; 28th Mar 2019 at 07:37. Reason: Typo in AH RAF leaving date - should be 1995. Apologies
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Old 27th Mar 2019, 22:12
  #339 (permalink)  
 
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Had Lt Col Arthur 'Bud' Holland and Captain Jacob van Zanten survived their respective accidents and been put on trial, I'm sure their defence lawyers could have amassed dozens of general officers (in Holland's case) and senior captains and managers (in van Zanten's) who would have sung the praises of these outstandingly experienced and respected aviators. Whether that would have presented a true picture in court would rather depend on how much effort the prosecution spent establishing contrasting views from squadron commanders (Holland) and co-pilots (both), and whether it could protect its less 'prestigious' witnesses from attacks on their credibility. The truth behind both accidents would have been found in their evidence.

We have spent many years in aviation trying to get away from the notion of the infallible pilot. Medicine is just setting off on that journey with its consultants. It disappoints me to see the trend being reversed.

Last edited by Easy Street; 28th Mar 2019 at 00:18.
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Old 28th Mar 2019, 09:14
  #340 (permalink)  
 
Join Date: Oct 1999
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Originally Posted by Easy Street


This is readily explained by the condition known in the military aviation profession as being ‘maxed out’, or stretched beyond the limits of mental capacity. Most often seen in student pilots, its recurrence is a common reason for suspension, whether in initial training or under carefully supervised conditions on postgraduate courses such as the Qualified Weapons Instructor Course. Many a current and capable second- or third-tour aviator with greater ability than AH has failed the latter by becoming ‘maxed out’ despite operating at what most would consider peak performance. The condition is typically suppressed outside the training environment by the application of a process known as ‘flying supervision’, which begins with regulations setting out minimum qualification and currency requirements and upon which a layer of professional judgement is applied, culminating in a signature authorising a particular sortie. Even the most experienced and expert military aviators are limited in what they are permitted to do when outside of currency stipulations, in part because of the risk of making errors and mistakes while ‘maxed out’.



Widely known in professional circles, and most especially in the display world, as one of the *very* highest risk factors for poor decision-making and self-induced pressure, while performing and even on the ground beforehand. Evidence: B-52 Fairchild AFB 1994, C-17 Elmendorf AFB 2010, Tucano Linton-on-Ouse 2009, plenty of other case studies, and the enormous quantity of military regulation that existed to control flypasts, role demonstrations and displays even before the Shoreham accident.



Not a barrier to becoming 'maxed out', see my QWI course example above. More significantly, the statement is way beyond the bounds of credibility given AH's currency and experience on type.



A straw man argument in relation to the sequence of errors recounted. AH could have been doing his very best at that point in the occurrence. The key to our profession is not putting pilots in a place where their best is not good enough.

I am being deliberately tongue-in-cheek with all of this because I can’t think of many sortie profiles more likely to stretch a pilot beyond the limit of their mental capacity than a low-level aerobatic display at a tricky venue with patchy currency and less than 20 hours on type. Frankly I find it astonishing that a human factors expert would offer the pilot's supposed 'experienced and expert' status as an absolute barrier to poor performance, given countless historical examples of 'experienced and expert' pilots performing very poorly indeed.



Few, if any on here are disputing the verdict duly reached in court of law; perhaps that makes our discussion off-topic given the word 'trial' in the thread title. However you should be unsurprised to learn that the verdict and medical position have been examined carefully by military authorities, as the outcome could be taken to infer that the military is unaware of the potential for CI at relatively low G, which would be a significant issue for legally-accountable aviation duty holders. So you'll have to take it as read that some of us may be more informed on the medical position than you think. Your statement of that position was enough to prevent the criminal standard of proof from being reached, but I'm afraid it won't wash with the majority here.
Great post which I think resonates with many here. Having met Dr. Steven Jarvis and seen him presenting at conferences/workshops several times, I can say that he is a very dynamic and charismatic character (positively 'bounces' around the stage!) and it is easy to see how his evidence to a jury would be found to be very compelling.
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