It seems like a lot of people 'screwed up' or at least failed to perform their roles to an adequate standard: regulatory, supervisory, management and administration. If any of these roles had been performed diligently, an accident would not have been a tragedy.

All I was interested in was a bit more detail on whether a stop call could have been made and why it wasn't.

There might be a lesson to be learned about the display monitoring process because it would seem there are cases where an effective stop call can't be a group decision.

My understanding is he DID admit a mistake, his point being he didn't know why as he could not recall. It was the others who have not yet admitted their mistakes.

Exactly ^^^^

A pilot in a single engine plane is one human being. As such there is always the possibility of a mistake or incapacity and if that happens sometimes the consequences can be catastrophic. In other circumstances the same mistake or incapacity may lead to either no damage at all or be confined to the plane itself and / or its pilot.

There are many circumstances around this tragedy that could have been avoided with better planning and also other failings that could potentially have led to a different accident.

For example, as a reaction to this incident, the centre of the airshow display point at Duxford has been moved further from the M11 and the public road that passes the end of the runway at Old Warden is now closed during flying displays. Had similar measures been in place at Shoreham there would have be fewer (if any) casualties.

Hasn't this always been the case with flight safety? The "I learned about flying from that" series in Air Clues was partly intended to gently highlight that chains of events lead to accidents, all it takes to prevent an accident is one link in the chain to be broken.

Accident reports are full of findings where a sequence of failings led to the accident, often just preventing one of those would have prevented it, or at least lessened its severity.

Who can honestly hold up there hand and say they have never made an error?

I clearly remember two, either of which could have killed me or caused the loss of the aircraft, but by good fortune everyone else had been diligent and so none of the "holes in the Swiss cheese" lined up on those sorties. No one has yet invented the infallible human being, or the perfectly trained one, come to that.

Closing the A27 (as opposed to the unclassified road that runs past Old Warden) would have been hugely disruptive.

Maybe so. It is not exactly popular with some of the the locals at Old Warden. Particularly as it is seven or eight times a year!

However, if an objective risk assessment says the road needs to be closed for an airshow to take place there are only two options. Close it (if that is possible) or don't hold the airshow at that venue.

Obviously there might be a compromise in some circumstances by excluding certain types of aircraft, restricting their display routine and / or moving the centre point as at Duxford. Duxford has also been to great lengths and expense to stop "freeloaders" assembling and watching from the so called "naughty fields" on the south side of the runway.

Over the years at Duxford there have been several fatal accidents at airshows. They have involved crashes close to the M11, on both sides of the road. Any of these could have been a Shoreham situation. The M11 has also been closed as a result of a model jet aircraft crashing close to the road and setting fire to the cornfield!

Obviously you cannot eliminate all risks. A lot has been done following terrible accidents at Farnborough (and other venues) in the past to protect spectators within the venue. That is all good but to my mind the highest priority must be to protect those who are not involved. If you go to spectate motor racing you are extensively warned that it is dangerous and that you are accepting an element of risk. Fair enough but with airshows and I suppose air races etc the danger extends well outside the venue.

Correct. However, the traffic lights at the junction were supposed to be at continuous green, with the side road closed off, to keep the traffic flowing, not backed up in a queue with a needless red light right under the 230m display line. Although the risk assessment was weak, this was a stated area of concern but, for some reason between the organisers and the council, this action to switch the lights to continuous green during the flying display did not occur as it had in previous years.

This and many other deficiencies mentioned in the AAIB report, and in some of the expert statements made at the Old Bailey (I did attend for a few days), underscore a poorly regulated, organised, supervised, managed and administrated event. Sadly, these were not reported in the press with the focus on the pilot's f-up which, in the end, sadly killed 11 people.

https://www.bbc.co.uk/news/uk-england-sussex-64040265

Shoreham air crash victims unlawfully killed, coroner concludes

Eleven men who died when a jet crashed on a dual carriageway during an air show were unlawfully killed, a coroner has concluded.

The men died when a Hawker Hunter plane crashed on the A27 in West Sussex as it carried out a stunt at the Shoreham Airshow on 22 August 2015.

The pilot, Andrew Hill, was cleared of manslaughter by gross negligence. Coroner Penelope Schofield said the plane crashing was "a result of the manner in which it was flown".
A series of errors was serious enough to reach a conclusion, on the balance of probabilities, that the men had been killed as a result of gross negligence manslaughter, she told the inquest in Horsham. The victims played "no part" in causing their own deaths, the West Sussex coroner added.

A number of the victims' family members were present and in tears as the conclusion was delivered. Ms Schofield said: "Eleven innocent lives were cruelly lost, lives that were cut too short.
This huge loss will be borne by their families for the rest of their lives."

Mr Hill has always maintained he has no recollection of the crash. His defence at his trial in 2015 argued he had been suffering from "cognitive impairment". An Air Accidents Investigation Branch (AAIB) inquiry concluded that the crash could have been avoided and was caused by pilot error when Mr Hill flew too low and too slowly while carrying out a manoeuvre. All 21 safety recommendations made by the AAIB were accepted by the Civil Aviation Authority (CAA).

They included a review into whether changes should be made to the minimum distance required between the public and display aircraft, and a review of guidance for air show organisers, including how they carry out risk assessments.

What effect does this have on the outcome? What's the point in this ruling?

From the Sky News report at https://news.sky.com/story/eleven-me...ules-12772021:
If it helps the families of the victims in some way, that seems like sufficient justification.

Does the change in the double jeopardy law have any impact?

Might it now be possible for Andrew Hill to face a re-trial, on the basis of the findings by the coroner?

I'm not sure that anything would be gained from doing so, in terms of true justice. Nothing changes the fact that these innocent people were killed, nor that human error was the cause of their death. Very sad as events like these are, I'm never really sure that prolonged legal action ever really makes anyone feel any better about the tragic outcome, other than the results from an inquest. I suspect that the same will be true for other tragic events involving the loss of life. Grenfell Tower springs to mind, and with no wish to go off-topic I strongly suspect that none of those guilty of errors and deliberate corner cutting will face criminal charges.

The following should help clarify the situation:

​​​​​​​YS

Many thanks, I had missed that.

The standard of proof for all Coroner's Court decisions, including unlawful killing, has been 'the balance of probabilities' since a Supreme Court judgement in November 2020. Conversely Mr Hill's acquittal reflects the higher test of 'beyond reasonable doubt' applicable to criminal proceedings. What this verdict does is confirm that it was more likely than not Mr Hill's fault that the bystanders were killed, and that he very likely owes his freedom to his lawyers and the 'cognitive impairment' argument authored by his non-AvMed qualified paediatrician friend, which the jury evidently considered as having introduced reasonable doubt at his criminal trial.

I believe that the vast majority of people who have flown ac similar to the Hunter or flown a relatively dynamic routine at an Airshow will opine that AH’s ‘mishandling’ was indeed the root cause of this tragedy; the Coroner has obviously agreed, so this does bring some closure to the friends and relatives of the people that died as a direct result of AH’s avoidable error(s).

It isn't "non-standard", think of it as a flexible process. Coroners cover everything from an elderly person dying after a fall, the Shoreham case discussed here, through to the really big ones - Hillsborough, Lockerbie etc. All done within the same standards and procedures, and it works very well.

The Coroner is obliged to rule on what, in her opinion was the underlying cause or causes. That she has now done.
This gives some clarity to the victims' relatives and friends, unlike the rather poorly handled criminal trial. This verdict seems to accord with the views of quite a number of people with appropriate & relevant aviation experience, sadly.

It is, I think, quite feasible that civil prosecution(s) of Mr Hill could follow, perhaps either to try to get fuller acknowledgement from him or for damages. Not necessarily very useful, but possible.

The criminal trial may not have been the verdict that many biased by news snippets and rumour wanted to hear but 'poorly handled' it was not. I get it, we want someone to pin all the blame for a tragedy, that is human nature, and the pilot who ultimately caused the crash is the obvious person. This coroner's verdict saves the complexity of investigating those that set up an unsafe environment for which only a public enquiry could have the time and resources to explore.

However, If you mean 'poorly handled' is listening to a broad range of experts and witnesses under cross-examination by the UK's best QCs in front of an impartial judge and jury then I would suggest you views of the criminal trial is bizarrely warped. Did this coroner seek a broad range of SMEs with different analyses and opinions and did she, or the lawyers represented, cross examine them? Did she only seek those experts who had a purpose to hide their own (or their organisation's) deficiencies which set up the inevitable tragedy? I don't know as I've only read news snippets.

Come on KK; the Hunter crashed because the loop was mishandled!

Dreadfully unfortunate where it crashed, and I understand the desire by some to blame the Display organiser, but if the manoeuvre had been properly flown then the accident wouldn't have happened!