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-   -   Shoreham Airshow Crash Trial (https://www.pprune.org/military-aviation/619209-shoreham-airshow-crash-trial.html)

Easy Street 27th Mar 2019 22:12

airsound

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.

212man 28th Mar 2019 09:14


Originally Posted by Easy Street (Post 10431817)


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.

DODGYOLDFART 28th Mar 2019 09:58

Just to add a further thought to Easy Street's comments about being "maxed out". Please excuse the slight divergence form the main thread.

It is worth considering what happened to a Red Arrows pilot (Jon Egging) at the Bournemouth Air Show back in I think 2011. He died following a formation break to land. If I remember correctly the following C of I attributed at least some of the cause to possibly pulling too much G (up to 6G+) in trying to avoid flying over the built up part of Bournemouth and consequently became maxed out or CI to use the latest vernacular. For those that don't know, flying over that part of Bournemouth particularly in circuit or at low level is almost a hanging offence and I guess this was at the forefront of the Eggmans mind at that time.

I am not trying to relate the Bournemouth accident to the Shoreham and AH but just pointing out that even current military display pilots can run into trouble from time to time.

Bob Viking 28th Mar 2019 10:20

DODGYOLDFART
 
To give my reply some context I am a Bournemouth lad who has used the airport multiple times in both Hawk and Jaguar. I also knew Eggman and read the report with interest as we all did.

I think it would be fair to say there are quite a few inaccuracies in your post and you may wish to do more research and edit it accordingly.

For starters, Poole is miles away and not even a Jaguar would struggle to stay away from it during a break to land. If you understood the RAFAT break you’d know what profile they were flying and local geography had nothing to do with it.

As for the cause of Eggmans crash it was ALOC/GLOC related. From what I’m beginning to understand this CI phenomenon is different to GLOC. I don’t think we should confuse the two.

That was as polite as I could make it.

BV

DODGYOLDFART 28th Mar 2019 10:33

BV I am happy to stand corrected due to your superior knowledge of the area. However as you admit it was ALOC/GLOC related and according to the trial so was AH's hypoxia or whatever his form of CI was.

Bob Viking 28th Mar 2019 10:48

DODGYOLDFART
 
Without wishing to read the entire report again and, since I have not read the court transcripts, I will trust that you are correct on the CI vs ALOC/GLOC issue.

I personally had not made a connection between the Bournemouth and Shoreham events. I see more similarities with the Car Fest event and Shoreham to be honest.

I will leave it there since I don’t want to drag this too far off topic.

BV

airsound 28th Mar 2019 11:30

Easy Street, BV and andrewn.

I don't necessarily disagree with the general sense of your responses to my two posts. But I would like to point out that I was mostly writing about what took place at Court 8 at the Central Criminal Court (the Old Bailey) between 16 January and 8 March 2019.

I do believe that the ramifications of this case have hardly started, and I was aware, E Street, of the military interest in CI that you mention.

The next significant happening will probably be the inquest. At the moment, the West Sussex Senior Coroner, Penelope Schofield, plans to hold a case management hearing on the afternoon of 8 April 2019. I understand it is not expected to last longer than that day. At that stage, she may reveal the start date for the full hearing, and also whether this will be an Article 2 Inquest (in which a state organisation may be implicated).

airsound

Evalu8ter 29th Mar 2019 10:51

BV - "I see more similarities with the Car Fest event and Shoreham to be honest."

100%

Ex-mil FJs are expensive to operate - even more so than a SEP Warbird (with the exception of acquisition cost & hull cost insurance). Therefore, selected pilots fly few hours with irregular currency. Perhaps its time for a more stringent look at "who flies what" in front of the public. By all means, if you have the money and can afford the training, take your Spitfire, P51 or JP up for a dance amongst the clouds at Medium Level (which is 500ft and above in my terms…). I am, however, very nervous when I see the same set of names dynamically displaying lots of different aircraft with relatively low hours on each in front of the public. Yes, I appreciate that this could cause issues and the increased costs might remove popular aircraft from public display, but there's nowt to stop the larger operators restricting their pilots to a couple of types to display, and rotating every couple of years. It might encourage the training and selection of new pilots, and prevent the "he's a great bloke, everybody likes/rates him, he's got thousands of hours - I'm sure he'll be fine displaying the Gnat/JP/Hunter/T33 with less than enough hours for a Prog Check on an OCU spread out over 3 years…." oh, and of course, no simulator to practise emergencies in. The Boultbee Spitfire simulator initiative is to be applauded, and, IMHO, should be something that Insurance companies start to insist that pilots conduct recurrent training in, including emergencies at various stages of their display. sequence...

KenV 29th Mar 2019 15:29


Originally Posted by Evalu8ter (Post 10433305)
BV - "I see more similarities with the Car Fest event and Shoreham to be honest."

100%

Ex-mil FJs are expensive to operate - even more so than a SEP Warbird (with the exception of acquisition cost & hull cost insurance). Therefore, selected pilots fly few hours with irregular currency. Perhaps its time for a more stringent look at "who flies what" in front of the public. By all means, if you have the money and can afford the training, take your Spitfire, P51 or JP up for a dance amongst the clouds at Medium Level (which is 500ft and above in my terms…). I am, however, very nervous when I see the same set of names dynamically displaying lots of different aircraft with relatively low hours on each in front of the public. Yes, I appreciate that this could cause issues and the increased costs might remove popular aircraft from public display, but there's nowt to stop the larger operators restricting their pilots to a couple of types to display, and rotating every couple of years. It might encourage the training and selection of new pilots, and prevent the "he's a great bloke, everybody likes/rates him, he's got thousands of hours - I'm sure he'll be fine displaying the Gnat/JP/Hunter/T33 with less than enough hours for a Prog Check on an OCU spread out over 3 years…." oh, and of course, no simulator to practise emergencies in. The Boultbee Spitfire simulator initiative is to be applauded, and, IMHO, should be something that Insurance companies start to insist that pilots conduct recurrent training in, including emergencies at various stages of their display. sequence...

So may I ask, what part of the Shoreham tragedy was caused by a lack of time/experience in type by the pilot? Or even contributed to it? I personally see nothing. And I don't see how the above handwringing measures would have altered the outcome one iota.


jindabyne 29th Mar 2019 20:46

Time to knock it off Mods?

orca 29th Mar 2019 21:27

Why? Many of us would be interested in the simple yes/no answer to the question posed.

DB6 29th Mar 2019 21:47

From what I have seen of the Southport incident it was a roll, not a loop, that caused puckering.

beardy 29th Mar 2019 21:49

Having established that Andy Hill is not guilty of the charges levelled against him, where does the buck stop?

T28B 30th Mar 2019 02:41

For jindabyne:
The discussion is in touch. So no, "knock it off" is not the correct call.
Carry on, please keep it professional.

Homelover 30th Mar 2019 13:29


Originally Posted by KenV (Post 10433507)
So may I ask, what part of the Shoreham tragedy was caused by a lack of time/experience in type by the pilot? Or even contributed to it? I personally see nothing. And I don't see how the above handwringing measures would have altered the outcome one iota.

Err, probably the crashing part?

LOMCEVAK 30th Mar 2019 14:05


Originally Posted by airsound (Post 10431481)
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.

I would like to postulate reasons for three of these errors listed above:
- Continuing the turn beyond the appropriate inbound track. We do not know precisely what point on the display line AH planned to point towards. From the height and distance that he was from the display line the sightline angle was very shallow and he may not have had a full perspective of the runway. Similarly, judgement of the required pull-up point is difficult and is a purely visual assessment and that is one of the biggest potential errors in flying this manoeuvre. There is a great deal of scope for all of us to make an error with judging this aspect of such a manoeuvre.
- Pitch oscillations. This reference was to immediately after rolling out of the turn prior to the pull-up when about 2 cycles of a very low amplitude pitch oscillation occurred. This is a normal open loop Hunter response, and if anyone wishes I am quite happy to give a full explanation.
- Incorrect roll in the vertical. In this manoeuvre, the required roll angle will always be different every time that you fly it due to the angle off the display line, distance from the display line and on/off crowd wind component. There are no visual cues that you can use when the roll angle required is small; you make the input with partial aileron by cadence alone and there is a great tendency to 'over-roll', especially if, during the pull-up, you realise that you have pulled up too soon and try to roll through more than the angle required for the heading change in order to displace and exit on the display line.

All of the above potential error mechanisms may occur without cognitive impairment. With respect to a rule based ejection option, this would have included rolling wings level then pulling to a level or slightly nose high pitch attitude which is the same as an escape manoeuvre. However, no competent display pilot would ever consider that ejection should be an option at the apex of a loop when the gate height has not been achieved and, therefore, I contend that ejection would never be a rule-based action in this situation.

There have been many comments on here regarding hours on type, currency and flying multiple types. A few points to ponder:
- Military display pilots, except for those involved with dedicated display teams such as RAFAT or BBMF, typically fly only one or occasionally two display seasons. Therefore, they have low overall display experience which is mitigated by flying rigidly defined sequences with a great deal of practise and stringent currency requirements. These mitigations are not necessary to the same extent for pilots who have decades of display experience on multiple types.
- Flying and displaying multiple types can be done safely but does require the pilot to have a robust philosophy and protocol for how they will refresh their competence. Under MAA (and precursor organisation) regulation pilots have maintained type currency on up to 9 widely different types of aircraft, including displaying some of them. What is interesting is that significantly different types are not a problem; it is types that are similar where cognitive errors tend to be made. The worst aspect is flying different airframes of a given type with some ASIs in KIAS and some in mph!
- An experienced display pilot can start displaying safely a new type on which he has few hours and with little practise or recency if the display sequence and the manoeuvres are appropriate ie. no pulling through the down vertical in looping manoeuvres, all rolls on a climbing line, no maximum AOA turns. I am happy to give examples.
- All of the above require two factors. First, a pilot with the requisite experience, ability and attitude. Please note that I am making no comment here about Shoreham but I am talking generically. Not all pilots and not all display pilots do have the required attributes, but those who do should not be prevented from flying displays which they are capable of doing safely just because other pilots cannot. Secondly, mentoring/supervision/training. Some pilots need more than others but these are essential aspects that are not always to the required standard.

Again, I will not make any comments about Shoreham specifically but mentoring and supervision need to be considered. However, I will raise one specific aspect regarding training and that is flying escape manoeuvres. At the time of the accident CAP403 did not require pilots to ever practise or demonstrate their ability to fly escape manoeuvres and AH stated that he had not done so. It was only required to be discussed under the 'Emergencies' aspect of DA issue. Thankfully, this is now a requirement for DA issue. Allied to this, an Aircrew Manual such as that for the Hunter will never cover in detail, if at all, how to fly these manoeuvres, especially at low IAS. This has to be an essential aspect of training, even if it is just a briefing on how to do so. The Hunter has outstanding handling qualities in this respect and the AAIB flying demonstrated that an escape manoeuvre could be flown safely at 80 KIAS without any abnormal skill. Any skill based activity is ~70% confidence, and if a pilot has never been briefed or practised an escape manoeuvre in a swept wing aircraft at an IAS significantly below the 1g stall speed then they may lack the confidence to do so for real when required.

Capt Scribble 30th Mar 2019 17:52

The fact that the escape manoeuvre had not been practised or demonstrated is yet another red herring. It is not possible for an RAF QFI who taught aerobatics not to know what to do when a vertical manoevre goes wrong. The argument suggests that an experienced low-level aerobatic pilot did not have the knowledge, and possibly skill, to safely escape his predicament if he did not make the ‘gate’ at the top of the loop. Not possible and I would consider it wreckless to pull up for loop without that knowledge.

Ridger 30th Mar 2019 22:04

Dear Lomcevak, I enjoyed your post - sounds like the case could have benefitted from your expertise as an expert witness (assuming you didn't indeed do so)

If you don't mind me asking, I am very interested in the cognitive aspects of these sort of activities You stated that some of the errors could occur without cognitive impairment and as you are clearly an expert in the field, could you help clarify some of the points you robustly made? Every day is a school day as they say!

[Similarly, judgement of the required pull-up point is difficult and is a purely visual assessment and that is one of the biggest potential errors in flying this manoeuvre.
There is a great deal of scope for all of us to make an error with judging this aspect of such a manoeuvre]. If, as you suggest, cognitive impairment wasn't necessarily present in this error, can you describe what aspects of the judging/visual assessment could cause an error?

[This is a normal open loop Hunter response, and if anyone wishes I am quite happy to give a full explanation]. Please do, this sounds unusual and interesting!

[during the pull-up, you realise that you have pulled up too soon and try to roll through more than the angle required for the heading change in order to displace and exit on the display line]. What cues would be used to inform the realisation that you'd pulled up too soon? If a pilot didn't realise they had pulled up soon, what would they need to do next?

[Any skill based activity is ~70% confidence] Please can you let me know what research produced that finding? I've never seen this statement before. For example, Fitts & Posners' 1967 three stage model of skill acquisition doesn't mention confidence at all. Obviously it's plausible confidence plays a role but I'm fascinated by a potential of 70%. Is the other 30% perception and judgement?

Sorry for the questions but I never pass up an opportunity to learn something new!

Lonewolf_50 31st Mar 2019 03:48


Originally Posted by Ridger (Post 10434603)
For example, Fitts & Posners' 1967 three stage model of skill acquisition doesn't mention confidence at all. Obviously it's plausible confidence plays a role but I'm fascinated by a potential of 70%. Is the other 30% perception and judgement? !

Was Fitts and Posners' work to do with aviation, or something else? We have a variety of skill sets that call for mastery or proficiency, particularly perishable skills, that also have currency requirements.
As an example, landing an aircraft on a naval ship at night.
Unless you know how to do it, have done it before (both are elements of confidence), and have some recency of experience, and at least minimum proficiency, you are more likely to cock it up.
I've seen lack of confidence lead people to turn in their wings and deselect from flying status. So yeah, confidence is necessary.
Aerobatics, particularly at low level/display, is similarly a non trivial task to get right.
I won't comment further on aerobatics as Lomcevak has the floor and is a far better source.

Ridger 31st Mar 2019 10:06


Originally Posted by Lonewolf_50 (Post 10434702)
Was Fitts and Posners' work to do with aviation, or something else? We have a variety of skill sets that call for mastery or proficiency, particularly perishable skills, that also have currency requirements.
As an example, landing an aircraft on a naval ship at night.
Unless you know how to do it, have done it before (both are elements of confidence), and have some recency of experience, and at least minimum proficiency, you are more likely to cock it up.
I've seen lack of confidence lead people to turn in their wings and deselect from flying status. So yeah, confidence is necessary.
Aerobatics, particularly at low level/display, is similarly a non trivial task to get right.
I won't comment further on aerobatics as Lomcevak has the floor and is a far better source.

Well, this is exactly why I asked the question really - I'm interested in seeing any aviation research which has tested the role of confidence in skill based tasks


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