A sincere question: In the UK is it really the coroner's job to determine "why" a person died as opposed to "how"? I ask because in another thread about aerotoxic syndrome another coroner made some scathing conclusions about air quality in airliners having contributed to a person's death. That sounded odd to an American's ears.

UK Coroners Duties
 

Ken,

The paragraph below is lifted from a government document given to relatives of a deceased:


When a death is reported to a coroner, he or she:
• firstly establishes whether an investigation is required;
• if yes, investigates to establish the identity of the person who has died; how, when, and where they died; and any information required to register the death; and
• uses information discovered during the investigation to assist in the prevention of other deaths where possible.

Hope this helps. Google is your friend.

ACW

Thanks for that, including your Google admonition.

That last item (uses information discovered during the investigation to assist in the prevention of other deaths where possible) is interesting from an American's perspective. So if an aircraft performing at an air show is determined to be the cause of death, the coroner could (rule? suggest? require? recommend? I'm not sure of the correct term here) that air shows be banned? If so, I now better understand the coroner's meaning in her use of the word "fearless".

My concern is really that the adjective is inappropriate.

Full and thorough investigation would suffice.

Fearless implies that the coroner has already decided that there maybe a need to be aggressive or confrontational with the sources or evidence or those involved in the incident. I see no evidence so far to suggest the coroner will not get full co-operation to get to the bottom of this incident.

Is there some reason you think the coroner needs to start out all guns blazing and being fearless? Or could they approach the investigation dispassionately with an open mind and diligently find out the truth?

If I was unfortunate enough to be involved in this tradegy, I'd want the coroner to conduct the investigation without any apparent "I'll show them" bias from the outset. I'd want neutrality and the truth.

The phase fearless creates the impression the coroner "already knows best" and may decide they can interpret expert testimony accordingly. In my view that's where a previous coroner went rather wrong in another high profile aviation case.

I maybe reading too much into it, but it has already created the wrong impression in my mind, and I suspect I am not alone. Even if there is nothing behind it, the choice of words was in my view poor.

"Fearless" may not apply to the coroner's first two responsibilities. It may apply only to the third, which is to "assist in the prevention of other deaths where possible." If that means banning flight displays, making such a ruling in the face of opposition that would almost certainly be loud and powerful would seem to require more than a little fearlessness. And if given the chance, I would join an anti-ban chorus.

Ken,
While in no way referring to this specific case, my understanding is that UK coroners have the power to write a report to any party or organisation in the interest of preventing future deaths. In my very limited layman's experience, however, coroners are very reluctant to take this course of action unless there is no doubt that a death could and should have been prevented. In this case, I think that - in theory at least - there will be 11 inquests. (I imagine that would also apply in the US?)

JFZ90,
Assuming the coroner's remarks have not been misreported, I entirely agree with your sentiments in this case.

Ken, an English or Welsh Coroner is a judicial post, usually occupied by a lawyer.

CPS: Coroners

What is a Coroner?

Coroners are independent judicial officers, appointed by the local authority, and are either doctors or lawyers responsible for investigating the cause of deaths.

What does a Coroner do?

Coroners inquire into the causes and circumstance of a death under section 5 of the Coroners and Justice Act 2009; inquiries are directed solely to ascertain:

• who the deceased was;
• how, when and where the deceased came by his or her death; and,
• the particulars (if any) required by the Births Deaths and Registrations Act 1953 to be registered concerning the death.

Lots more in the link....

Ken, it is my understanding that the coroner can not order or require a subsequent course of action but that to so ignore such a finding would be germane should such avoidable deaths occur in future. A change in procedure is more likely to be instigated by a Government Department or Agency.

As an example, a death on a fast road might result in a recommendation for a lower speed limit. The relevant council will show that the speed limit in force met the existing rules. The Highways Agency will then consider whether the rule should be changed (Government money involved) or recommend (local money involved).

The legislation re inquests in England and Wales is, as one would expect, fiendishly complicated to us laymen, and the Rules and Guidance to Coroners (most of whom, by the way, seem to have started out in medicine and gained legal qualifications later) seem to have undergone much review and amendment in the last decade.

However, I may be able to shed a little more light on what used to be described as "Guidance for Coroners on ... Rule 43: Coroner reports to prevent future deaths." The legislation that included Rule 43 has been superseded by the recent implementation of the Coroners and Justice Act 2009. Here is a relevant extract:

Coroners and Justice Act 2009 (c. 25)
Schedule 5 — Powers of coroners

[Page 147]
Action to prevent other deaths
7 (1) Where—
(a) a senior coroner has been conducting an investigation under this Part
into a person’s death,
(b) anything revealed by the investigation gives rise to a concern that
circumstances creating a risk of other deaths will occur, or will continue to exist, in the future, and
(c) in the coroner’s opinion, action should be taken to prevent the
occurrence or continuation of such circumstances, or to eliminate or
reduce the risk of death created by such circumstances,
the coroner must report the matter to a person who the coroner believes may have power to take such action.
(2) A person to whom a senior coroner makes a report under this paragraph
must give the senior coroner a written response to it.
(3) A copy of a report under this paragraph, and of the response to it, must be sent to the Chief Coroner.


Hope this helps, in addition to the info provided by PN and ORAC above.

CS, in other words the buck is very firmly passed up the line until someone takes responsibility for action or inaction.

Special Bulletin S3/2015 published:
AAIB Bulletin 3/2015
SPECIAL
https://twitter.com/aaibgovuk/status/639793440436449281


See the PDF at
https://assets.digital.cabinet-offic...015_G-BXFI.pdf
as published this Friday 4 September 2015.

SF, thank you for that.

You can sign up for email alerts each time the AAIB publish anything on their web site.

https://www.gov.uk/government/email-...on-branch.atom

I have to agree with JFZ90 re the comments about the coroners terminology. Legal expression should be expressionless and neutral, unless it is being used to make an argument, for or against, or post judgement being reached. Maybe a minor point, but it struck me too when I read it.

moving on...

The interim report will ad fuel to the speculation no doubt, to the chagrin of some. Nevertheless, for me the relevant authorities seem to be doing a good, timely and expeditious job. Some scenarios, if not fully ruled out, are looking ever more unlikely.

I'm no lawyer, but my understanding is that inquests in the US are quite different. First of all, this falls under the jurisdiction of state governments, not the federal government, and so it varies by state. Here (Texas), if a qualified medical examiner determined the cause of death and signed the death certificate, an inquest may often not be required at all. If the cause of death was due to some unlawful action (assault, etc) or due to a legal omission (criminal negligence), then an inquest is generally required. And one inquest can cover more than one dead individual. (for example, three people who are killed in a single plane crash would result in a single inquest.) But coroners here have neither the responsibility nor the authority to make recommendations about how to prevent future such deaths. Those are policy decisions that get handled differently here.

Putting the tragedy of this incident to one side, it's mildly amusing to watch the PPRuNe glitterati giving insight to flying, display flying, military flying, accident investigation, aviation authority legislation, government policy and now, the Coroners court and its reach and responsibility. On another forum, they've already started awarding medals...

hmm a figure with a vertical and rolling component....

There is comment in the Guardian about the Interim report, attributed to David Learmount, operations and safety editor at Flight Global.

Shoreham airshow crash plane working normally, interim report suggests | UK news | The Guardian

In the news today, top of loop was 2600 ft at 100kts, fine in a BAe Bulldog, even Neil McCarthy, PPL JP3 and Hunter (?) display pilot, has stated it was a bit low and slow.

Apparently no defects in the AAIB report, so I guess the pilot screwed up, despite his experience.