In the usual analysis of accidents, there is always a 'root cause' which cascades other factors that build the consequences of the accident. Regulation did not cause this accident, it might have prevented it, but a mishandled loop was the direct cause of the aircraft hitting the ground. Everyone has expressed their views on why the mishandling occurred, and a court has accepted one explanation, but the exact reason will never be proven.

Having followed this thread from the outset, and made a few contributions along the way, it does strike me that we are now reaching a point where there is significant degree of consensus around the key points:
- The regulators failed dramatically. This aircraft should not have been flying, this pilot should not have been flying it, and they should not have been attempting to fly this display. Prioritise these any way you like, but had the existing regulations been effectively applied to any one of them, we would not have had this incident.
- The investigation has not provided a convincing or ( in my view at least) credible outcome. For example, The apparent power deficit during the fateful climb and the evidence regarding the fuel pump diaphragm were staring them in the face, yet they chose to ascribe a conclusion to Rolls Royces analysis which Rolls Royce themselves had avoided.
Also, how come the traffic lights weren’t set to Green as had been mandated? If the traffic hadn’t been queuing, it seems highly likely that fewer lives would have been lost. Why is this not properly developed as a theme?
- The Coroners conclusion regarding the victims being “unlawfully killed” verges on the Kafka-esque. A moments consideration of the facts by primary school pupils would lead to that conclusion. Leaving aside there isn’t a verdict of being “lawfully killed” , the tragic victims obviously did nothing to warrant what transpired. Ignoring some of the directly pertinent evidence to arrive at such an arcane verdict does little to enhance the credibility of the process, and I fear will provide little enduring comfort for the relatives of the deceased.

The existing system could and should have prevented this incident, and made its consequences less severe. None of those who presided over or were directly responsible for the failure to implement it have been held to account. I’m sure the various changes which have been introduced can make things safer still, but ONLY IF THEY ARE ACTUALLY APPLIED. Where does the confidence that they will be come from?

Job 1 for people who plan airshows, run airshows, and fly in airshows is to not to kill anyone on the ground. Epic failure at all levels led to horrific and preventable fatalities.

Falcon 900 has articulated the challenge for future airshows. Talking about loop geometry may explain how this accident happened but won’t prevent the next accident.

Point of information : in the correct circumstances that verdict can be given. I know because it was decided by the coroner's jury of which I was foreman.

Encapsulates the matter very well, especially the last sentence - thanks BPF. That is not only a matter for those supposed to be overseeing, but also for the pilot. More ego than competence, demonstrably. Many of us have been there or close to that, at some point, fortunately generally without tragic consequences.
Sadly, probably a lesson all directly concerned have now learned, or at least realised as relevant.

Really? I know AH. Egotistical he is not.

I would say its more likely that it might not have reduced the number of casualties, as they were all from the cars stationary at the red lights on the westbound carriageway, and thus the traffic on the eastbound carrieageway were also being held on the red, further to the west of the impact point, and thus the eastbound carriageway was free of traffic when the impact occured.
Had the lights been set to full time green, it would have thus been for both carriageways and thus there would have been flowing traffic on both carriageways, which might have meant less, or possibly even more with traffic flow in both directions. As such its an unknown variable, so can't be taken as a factor.

Well yes, but also that the lights could not all be set to green for the very reason lights were needed there in the first place.

Well, not really, the two side roads either side of that junction were closed to traffic because of the airshow, so there was therefore no need for them, so that's why the lights were supposed to be set to full time green for the duration, so as to not have static traffic being held on the westbound carriageway, and thus under the display area, which is why people are saying because of this there could have been less casualties. However as pointed out the eastbound traffic was being held at the lights as well so was therefore traffic free at time of impact, and therefore it can't be certain that there would thus have been less casualties. Its a possibility not a certainty.

Indeed, but yet further evidence of the fact that what the various existing rules and regulations had prescribed was not being carried out. Prescribing yet more rules and regulations is especially pointless where the existing ones can be ignored with impunity it seems.
what about those responsible for allowing that aircraft to fly? What about those responsible for allowing it to embark on that display? And yes, what about the person who failed to implement the mandated condition for the traffic lights? Why are they all being given a free pass?

"Why are they all being given a free pass?"

Because it would open up th can of worms referred to be several posters on here . Who ever was fingered would immediately drag in all the old cases where things were swept under the carpet as evidence of the culture and processes ACTUALLY in place rather than the ones laid down in the law and regs

Because, as has been pointed out by several posters, there is no way to determine whether the lights were a contributory factor towards the number and/or type of fatalities/injuries.

Excellent post, f900. Shoreham has been treated, like other airworthiness associated fatal air accidents in this forum, as separate and unique. What tuc terms 'stovepiping'. In reality of course it's just the same old same old. A Regulator fails in its primary purpose of ensuring that the aircraft within its purview are airworthy. An Air Accident Investigator fails to hold that Regulator to account when evidence confirms that the aircraft involved in the accident was not airworthy. In this case it seems it even fabricated evidence to show that an unairworthy component fitted to the unairworthy aircraft played no part in the accident. Who guards the guardians? Oh, and just to keep the lid on things it gets a High Court ruling that prevents the Coroner from raising issues stemming from the AAIB Report. The rot is spreading....

And your evidence that it did play a part is ... ?

DR, I don't think that Chug is saying that the fuel pump did play any part in the accident. It seems that he is suggesting that evidence was fabricated to minimise the chances of the accident being laid at that door. Guarding the guardians.

Ah, OK. But either way it's hardly a smoking gun pointing to evidence having been fabricated.

Anecdotal evidence on this forum suggests that there might have been a reduction in engine power during the loop ascent. That may or may not have happened. If it did happen it might have been pilot input, conscious or otherwise, or it might have been a technical malfunction. The fuel pump was found to be compromised by RR but the AAIB said that RR didn't consider that to be relevant to its performance. RR said no such thing. It seems to me that the AAIB is now part of the problem and its investigation needs to be investigated. The High Court ruling ensured that the Coroner wasn't able to do that. Thus no smoking gun.

None whatsoever, just as we don't know if the positively dangerous Chinook Mk2 FADEC played a part in the deaths of 29 people on the Mull of Kintyre in 1994. What we do know is that both aircraft were unairworthy, a fact that both investigations preferred to pass over.

I am just beginning to look back with some nostalgia on the days when “Pilot error” was all that needed to be said about an accident.

The point is not whether you or I with the benefit of 20/20 hindsight consider the lights made a difference. The point is that someone before the incident conducted a risk evaluation which determined that it was important that they were set to Green, and the display was authorised on the basis that they would be. You might be right that there was no incremental loss of life as a result of there being a queue of traffic for the aircraft to plough into ( good luck arguing that one) but it remains the case that a condition precedent was not fulfilled, and nobody has been taken to task.