I went to an unexpected death inquest four years ago and was slightly surprised that the only people present were the coroner, a friend who provided a statement of the deceased's life and me as another friend. Three people... Statements from police and doctor were read out by the Coroner, but I had expected there to be a few more officials! Glad Pete and I went, otherwise the Coroner would have been on her own!

Having been a juror at a coroner's inquest I may be able to shed a little light. The jury can ask questions that the coroner may not have the remit to pose. In my case the pertinent questions were about the administrative arrangements for the gold and silver commanders of a police force. Having been aired they became part of the coroner's narrative which exposed systemic weaknesses. Similarly health trust problems can be exposed by a jury. The narrative goes beyond the 'who, where and how' which is the coroner's verdict.

The Coroners' Service says 'A Coroner will hold an Inquest with a Jury in certain circumstances such as when someone dies in prison or police custody or other state detention such as an immigration detention centre'. This differs significantly from other individual local Coroners' websites which add (e.g.) 'or in circumstances which may affect public health or safety'.

The former definition might explain the current case, but the latter would make it seem a candidate for a jury. Very confusing, but at the end of the day the bereaved rely on the integrity of individual Coroners. Sadly lacking in many of the cases discussed here (recent Hawks, Sea King ASaC), highly commendable in others (Hercules, Nimrod).

At the most recent one I attended, the Coroner had a WTF moment when the GP's report was read out, saying 'this 87-year old a woman...', and it was pointed out to her that the birth and marriage certificates said she was 57. She carried on, but in her decision said the GP's surgery was 'grossly incompetent' and had failed in its duty of care, prescribing the wrong medication. The GP involved quietly retired a few months later. If you want justice, might I suggest popping your clogs in Avon & Somerset.

Seems a curiously non-standard process to me. I'd always assumed that the way that Coroner's worked was the same everywhere, I had no idea there was so much apparent variation. Then again I've only ever been to one inquest, and only then because I had a personal interest in the accident, having seen it happen and been one of the first on scene. I, wrongly it seems, assumed they all worked in the same way, to the same standards and procedures.

Give thanks that they don't AJ! As tuc says, some are exemplary in their duties, witness the Oxford Coroner informing the MOD that there is something wrong with their bloody aeroplanes! If they all sang from the same hymn sheet they would merely follow the lead of countless ministers, MPs, members of the HoL, Chief Constables, QCs, etc, etc, in not rocking the boat and sticking to the script. It is a +700-year-old institution that allows Coroners, if they so wish, to put their duty above all other considerations. BZ's to those who choose to do so!

The coroner can direct the jury that certain verdicts are not appropriate in law, for the case before them, so cannot be used. Sometimes that can mean that only one verdict can reasonably be reached in which case it is not far short of a direction. However, if more than one verdict could reasonably be reached for a particular case, then jury should certainly not be steered as to which of those to return.

It is different from a criminal case where the judge can decide that the evidence on a particular charge is so weak that no reasonable jury could consider convicting. In that case he or she can direct the jury to acquit. What the judge can never do is direct the jury to convict!

Wouldn't it be better if there was some attempt to get all coroners to strive to do things in the way that the best of them do, though? I can't help but feel a certain discomfort in knowing that there is such an apparent degree of variability in carrying out such a key role. I have to say that finding that out here has somewhat dented my faith in what I had assumed was a robust process.

Well you could apply that argument to any death, other than the driver, in a road traffic accident.

In the particular case we are discussing how wide would you spread the net? Just a few examples...

Was it an appropriate place to hold an airshow?
Was it only acceptable if the road have been closed?
Although apparently not the cause of this crash, was the aircraft maintained to an adequate standard to be considered safe to display?
Although licenced to conduct the flight were the requirements stringent enough?
Should there be a lower age limit, higher currency requirements, tighter medical requirements?
Should a civilian aircraft be allowed to fly with a live ejection seat (let alone one with expired cartridges)?
And so on.....

How much, if any, of this should be down to a coroner? Should there be a public inquiry? If so, who sets the terms of reference?

Where do you stop?

Good questions. Let us know if any Coroner gives you a lucid reply! The Coroners' Guidelines offer little help.

That is pretty much what happened. After several days of evidence, including two whole days from the AAIB alone, the Coroner ruled out all other options other than accidental death. He was right to do so, in my view, although the disparity between the AAIB evidence given in their report and the very different evidence presented in court caused me to feel slightly uncomfortable at the time. I assume this comes down to the Coroner only being concerned with whether that evidence materially changed the verdict, which I am sure it didn't.

Evidence seems to be touching upon some of the points I made in my previous post.....

https://www.bbc.co.uk/news/uk-england-sussex-63876398

There is a little bit more here:
https://www.theargus.co.uk/news/2317...old-stop-loop/

I'm particularly interested in this quote:

"Mr Dean said he did not see the crash or the build up as he was at a meeting."

I would have thought that one of the fundamental duties of a FDD (Flight Display Director) would be to monitor the display as it is happening; if the FDD needs to be elsewhere this responsibility should be delegated?

Without wading through 750 pages, was he using a 'g' suit?.
I ask because on my one Hunter flight my pilot pulled though a loop and I 'greyed' out at 5.5g; he had a 'g' suit, I didn't.
Before you ask we were at about 15,000ft.

Yes, he was.

Not sure, but he should have been aware of the benefit of the anti-G straining manoeuvre (a.k.a "grunt and squeeze") I would have thought. I'm far from being fit and current, but didn't I even notice 4.5g during a bit of fun and games with an aero friend a year or so ago during a birthday treat flight, and its a couple of decades since I'd flown in anything with any sort of performance. It was only afterwards when he commented that we'd pulled about 4.5g in the final loop of the series. I was a bit surprised, to be honest, as it didn't feel close to that. We're alll very different though. I well remember watching a bloke go completely nuts in the hypobaric chamber when his mask was taken off, Took four of us to hold him down whilst the instructor got him back on 100% O2. That was at only 25,000ft, I think. He looked fine when he first took his mask off, doing sums on a pad like a good un, then just completely freaked out.

dastocks, you suggest that ;Yes it is one of his fundamental duties. But another is conducting mandatory briefings of display participants. There is more than one briefing during the day. That was what Rod Dean was doing when the crash happened. His absence was also prolonged by having to consider the possibility of programme changes because of forecast crosswinds outside historic aircraft limits. Incidentally (pedant hat on) - it's Flying Display Director, not Flight Display Director! (pedant hat doffed)

But the Flying Control Committee (FCC) has the duty of monitoring the whole display, whether the FDD is present or not. None of the FCC was present at the inquest when Rod Dean was giving evidence, but he said that the FCC had noticed the low entry height and the strange performance of the first half of the loop: they had discussed a STOP call, but decided that it would be too much of a distraction to the pilot at what was clearly a very busy moment, he said.

I don't believe any of the FCC is due to give evidence. Indeed, the chairman has died since the show.

airsound

Thanks for the clarification. I don't think this was covered by the AAIB investigation and it didn't come out in any of the reporting from the criminal trial so it's been nagging for a long time.

It is difficult to see how a "discussion" which ultimately didn't lead to any action was relevant to either.

In any case how could they possibly have discussed it and made a stop call in time? One person making that call on their own judgement might just conceivably have been possible but I fail to see how a group of people could have discussed it quickly enough.

This was an extremely tragic event and understandably the aftermath is immense and far reaching and will linger on for many years.

But as far as the cause goes, it appeared to me, from the first video I saw, was that the aircraft was simply flown beyond its capabilities in that the speed chosen for a loop was more akin to that of a Jet Provost or a light single prop aircraft, rather than a swept wing fast jet (both of which were also flown by the pilot). If he had admitted that he made a mistake this would have caused far less anguish all round.

Spot on ST; a simple hand up “Sorry, I screwed up!” rather than all the baloney to ‘find’ an alternative theory! It’s made it all so much worse for the friends and relatives of the unfortunate victims.