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AAIB Report - Microlight Accident

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AAIB Report - Microlight Accident

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Old 18th Nov 2005, 19:13
  #21 (permalink)  
 
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Good luck is indeed needed EGBT, but not for me.

The person needing all of the luck, good wishes and support from the aviating community as a whole is the one that feels he is being made a scapegoat for a tragic accident.

Having been appraised of all of the facts, listened intently to much of the gossip and spent a great deal of time conducting my own enquiries, I am convinced that the AAIB report is significantly flawed.

Critical factors, such as the fact that the aircraft was being flown at an IAS 25% above Va in an area well known locally for severe low level turbulence with the wind in the N to E sector, were glossed over.

The design reserve factors in the structure, which are lower by far than currently accepted by the CAA are another area that does not get proper attention in the report.

All told this report falls below an acceptable standard with regard to impartial investigation of the facts and I know that I am not alone in having come to this conclusion.

I am deeply saddened that such a well-respected body as the AAIB could publish such a report, particularly as the result has been to drive a 61 year old man, who acted with the very best of intentions to help a friend, into probable bankruptcy and possible loss of freedom for the rest of his life.

We are not talking about a professional, paid, engineer here, but an unpaid volunteer who gave freely of his time for very many years to help others achieve and maintain the joy of flight. In my view, as aviators we all need to act in concert to defend our fellows, whatever form of flying machine we choose to leave the surly bonds of earth.

VP
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Old 18th Nov 2005, 22:22
  #22 (permalink)  
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I have read the report and find that it is balanced and fair.

To my reading, it explores all relevant issues in the case investigated and based on the available evidence makes a finding of the most probable cause and the issues both relevant to that probable cause and other possible causes.

Simple things like not having the required placard with the required information for the passenger may seem petty or irrelevant to some but that attitude that certain legal requirements are petty or irrelevant or can be ignored is exactly what the AAIB see as the start of a slippery slope that needs to be stopped.

One can go to certain airfields in the UK and out of a sample of microlights will find a proportion have undocumented and uncertified modifications. Many would be minor and not of any serious consequence. However, the fact that they exist shows what the AAIB quite rightly in my opinion describes as a minority of operators who choose to ignore or are unaware of legal requirements.

A microlight operator I know of when faced with an airworthiness problem decided that under no circumstances would the BMAA be informed because "if the CTO finds out he will ground all the aircraft and how will we make money then".

That is a quote from a very experienced microlight pilot about a common microlight type. Having experienced that attitude to flight safety, not only would I agree with the AAIB comments but would say that they are only skimming the top.

Regards,

DFC
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Old 19th Nov 2005, 05:31
  #23 (permalink)  
 
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There is no one in microlighting who was not shocked by this terrible event and who has not reviewed their own conduct as a result of the lessons learned.

CAP 735 calculated that microlights had a fatal accident rate of 18 per 1,000,000 hours flown, compared with 23 for gliders, 18.1 for helicopters and 13.9 for light aeroplanes. Furthermore, as is the case in all forms of aviation, the overwhelming majority of fatal accidents in the period in question resulted from pilot error, not airworthiness.

Anyone who has read the AAIB report from cover to cover several times as I have over the past 6 months cannot but wonder if the AAIB itself has lost the plot here.

There may be weakenesses in the BMAA Inspector system as there are in every system without exception.

Keith




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Your final comment was totally unacceptable while there is a an alleged manslaughter case pending.
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Old 19th Nov 2005, 07:08
  #24 (permalink)  
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It came out on Tuesday, but since Keith is chairman of the BMAA, presumably he was party to discussion of pre-publication drafts of the report.

G
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Old 19th Nov 2005, 08:11
  #25 (permalink)  
 
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DFC

If you only consider the facts given prominance by the AAIB in the report, then you would come to that conclusion.

There are other factors that have been dismissed or overlooked that, when integrated with the AAIB's own scientific data, support an entirely different outcome.

Your views on microlighters are unfounded and, I suspect, urban myth. Just as some GA pilots have done, I am sure, if you look hard enough, you will find a microlighter that has fitted a GPS without sending in a mod form. You cannot totally dismiss a system because a few rogues who decide to ignore it.

Your suggestion that a school have not reported a fault for fear of having a fleet grounded is, I believe, pure fantasy. If I am wrong, then it is your duty to report the matter to the CAA and I would urge you to do so today. Once you have done so, perhaps you can tell us the details.
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Old 19th Nov 2005, 08:22
  #26 (permalink)  
 
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What appalls me most is not the tosh talked by people like DFC but that the AAIB inspector took the time to read this junk from the lists and then used it to reach his conclusions.

Forget the rhetoric and read the accident statistics. Things that are wrong must be put right but microlighting is at least as safe as any other form of recreational aviation.

Keith
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Old 19th Nov 2005, 09:42
  #27 (permalink)  
 
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Although the accident data quoted by Keith Negal is undoubtedly correct, the law will not normally overly concern itself with broad statistics when dealing with a specific case.

We all know that a volunteer system is unlikely to be perfect, as Keith has pointed out. Nevertheless the future of amateur flying under the auspices of the BMAA, PFA or BGA may well hang in the balance as a consequence of any highlighted imperfections.

I would speculate that a random sample audit of a few inspectors, using some carefully chosen questions to test their knowledge of some the deeper ramifications of the airworthiness of structures might show "failings in an organisation".

When a man's freedom is at stake then it is quite reasonable to expect people to go to extraordinary lengths to prove their innocence.

Many of us may have to live with the repercussions of this for a long time to come.

VP
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Old 19th Nov 2005, 18:47
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Will somebody puleeze publish the link to the report? (I'm crap at finding my way round their site nowadays).

Steve R
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Old 19th Nov 2005, 18:48
  #29 (permalink)  
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http://www.aaib.gov.uk/publications/...005_g_styx.cfm

It may take you several cups of coffee to get through!

G
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Old 20th Nov 2005, 13:55
  #30 (permalink)  
 
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I'm a bit confused with the various opinions above. Having read the discussion, I went and read the report from end to end and I have to say that it seems the AAIB did a reasonable job:

They investigated the facts and arrived at a probable cause for the accident. They then looked a little wider to investigate the circumstances that led to the defects in the accident aircraft. Surely, that is their job?

I didn't interpret the contents of the report as a damning indictment of the BMAA's processes (even the recommendations are that some of the procedures be reviewed, not that they be scrapped).

However, since the investigation points quite convincingly to a structural failure, of which one major causal factor was the failure to carry out an AD correctly (and not to subsequently spot the error), it does seem reasonble to attempt to recommend actions that may prevent the same thing happening in future.

As a PPL(A), it does concern me that whilst a trial lesson in a light aircraft would require a public transport CofA, the same thing in a microlight could be done in an aircraft that had at best a sketchy maintenance history. It's also worrying that there is no clear procedure for an inspector to be assessed as competant to do their work.

Back to the report, even the paragraphs hinting at a minority that resent interference by the CAA are written carefully, using the word 'inadvertently' and pointing out that the minority referred to might actually be competant to question certain regulations but that this might have caused others to be caught up in an air of anti-regulation without that competence and understanding.

However, given all that, if this report is actually being used by some to blame the inspector for this accident then that is also wrong since it's absolutely clear from the report that there was a long chain of events here (as in almost all air accidents).

I would also concede that only some of the report's recommendations are actually relevant to the actual accident (but arguably all do have safety implications).

Mark
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Old 20th Nov 2005, 14:15
  #31 (permalink)  
 
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"However, given all that, if this report is actually being used by some to blame the inspector for this accident then that is also wrong since it's absolutely clear from the report that there was a long chain of events here (as in almost all air accidents)."

The only blame so far arising from the long chain of events leading to this tragic accident has fallen upon the inspector. He has been charged with manslaughter and is currently on bail.

As far as I am aware no other action is being taken, except for the inevitable tightening of procedures, as recommended.

I feel inherently uncomfortable that a man who chooses to voluntary help a friend do some work on his aircraft, for no charge, ends up with his life in tatters. All is not quite so clear-cut as the report makes out, which further complicates the issue of blame.

Even if found innocent he will still have to bear the burden of the loss of life of a friend and that of an innocent passenger. He also has to bear the very considerable financial costs from legal representation, whatever the outcome. I understand that the BMAA do not provide financial assistance for their volunteers. Perhaps the PFA and BGA are the same; all are reliant upon volunteers, I understand.

Whether this is right and proper is a matter for others to consider and decide, but I cannot help but feel that it undermines the future viability of any BMAA, PFA or BGA voluntary posts that carry any airworthiness responsibility.

VP

Last edited by VP959; 20th Nov 2005 at 14:26.
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Old 21st Nov 2005, 14:01
  #32 (permalink)  
 
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Sorry VP959, but good intentions is not a valid legal defence. People have died , and IF it is his negligence to blame, then he deserves to pay the price.
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Old 21st Nov 2005, 18:37
  #33 (permalink)  
 
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In virtually every aircraft accident report I've read, there have been a chain of actions taken by different people that led to the eventual tragedy. This one is much the same.

Why should one link in that chain carry the entire burden of blame?

In my experience, there is rarely one very clear, absolutely definitive, cause for an accident.

I faced a BoI many years ago, after having missed something through lack of foresight that nearly caused the loss of a Canberra. The words of the BoI chairman still ring in my ears "You are only getting away with a formal reprimand because you were foolhardy enough to fly in the aircraft after signing that the TI was safe". The chain of events leading to this incident was so far-fetched as to still cause disbelief amongst those who hadn't witnessed it.

Needless to say, this has caused me to exercise a great deal more care from that day on, but I regret to say that I have still missed the odd potentially dangerous item from time to time. We should, perhaps, accept that human fallibility is a generic attribute that we have to accept to a limited degree.

VP
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Old 22nd Nov 2005, 10:57
  #34 (permalink)  
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Keith,

While I may be talking "tosh" and am only an outside observer wrt microlights, perhaps you should pay a visit to Wantage and ask the manufacturer who is having to make structural repairs at their factory to a certain microlight type how is it that aircraft with structural defects are being flown in for repair?

Or better still ask those operators who fly the aircraft in, how they deemed the aircraft to be fit for flight with a structural member disconnected through cracking?

The reason why I am familiar with that case is because I was at an airfield the day they found the crack. I was more shocked to discover that rather than trailer the aircraft to the factory, it was flown there.

It is cases like that that make observers like myself think that the AAIB were only skimming the surface.

The fact that there was a senior member of the BMAA presenting themselves for an instructor renewal flight test and proposing to the FI examminer to fly at a weight above the maximum allowed and then creating a fuss because the FIE refused along with the latest information that "it is up to individual instructors if they want to fly within the maximum weight limitations or not"........all leads me to expect that there are many large instructors out there that take large trial flight people up in aircraft that are above the allowed weights (either seat or MTOW limitations). Thus they are uninsured, illegal and open to claims if something goes wrong even if it is unrelated. The BMAAs "it is up to the individual" is simply not suficiently strong guidance.

---------

The difference to me between the BMAA and the PFA system is that the BMAA is the one where members of the public pay for the ability to fly in a permit to fly aircraft (trial flights). Thus I believe that it should have the more rigerous oversight system in those areas.

If people want to build their own aircraft, maintain it to a poor standard and kill themselves then that is up to them. That is why I see no serious problem with single seat unregulated microlights restricted to class G airspace. However, expecting the paying public to fly in aircraft that for whatever reason may not be what is advertised is a different matter.

-------
Bar Shaker,

I am not a Policeman and thus have no responsibility to report matters to the CAA that have no safety effect on me. However, the microlight industry is not that big and the example I used above is easily checked by Keith if he chooses to do so.

Could the fact that microlighting has been taken from a totally unregulated industry to the current situation of limited regulation present a situation where there are people within the industry who remember the "freedom" of unregulation and try to retain such "freedoms" as much as possible even if it means bending a few rules or doing what outsiders might considder dangerous when compared to the more regulated parallel areas of aviation?

Personally, having spent some time looking at the idea I can't see how one can make money by operating a school in the microlight industry unless corners are cut.

Regards,

DFC
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Old 22nd Nov 2005, 11:39
  #35 (permalink)  
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I can at-least answer that last question. I don't believe that anybody does make money by operating a microlight school in the UK - they make money by operating a microlight business. When you combine a school, maintenance facility, hangerage provider, and often aircraft dealer as well - it's possible to make a living. But, it's common that the school is at the centre of that.


Incidentally there is a deep iniquity regarding seat weights that microlighters rightly feel aggrieved about. Most light aircraft are designed and stressed (including normal and crash loads) to 77kg per seat [the same applies to airliners]. All microlights are designed and stressed to at-least 86kg, and the majority to rather more (the latest are getting up to 120kg per seat). Yet, whilst in a light aircraft or an airliner it's perfectly legal for a 140kg adult to occupy a seat that was never designed for that sort of load, in a microlight an 87kg adult in an 86kg seat is deemed to be unacceptable.

Personally I'd much rather see all aircraft seats stressed to at-least 105kg (which would cover 99%ish of the adult male population, and a higher proportion of the overall human population), but it seems unfair that a considerably higher standard is applied here to microlights than to any other class of fixed wing aeroplane.

Of-course, anybody taking any aeroplane outside of overall weight and balance limits is a dangerous idiot and should be treated as such. I am only talking about seat limits here.

G
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Old 22nd Nov 2005, 14:51
  #36 (permalink)  
 
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Several minor aspects of the AAIB report are factually incorrect, or at least misleading.

Their reference to cockpit placard and their quote of ANO Article 9A(6) is incorrect. The correct wording is "...certificated to an International Requirement”.

You would have thought their research would get that simple fact right.

Further, their use of the term "pop rivet" is misused, because "Pop" is a registered tradename and unless the AAIB investigation has accurately determined the maker, then they should use a more generic term.

I know these are very nitpicking points, but the AAIB have a duty, due to the very seriousness of the investigation, to be wholly accurate. Indeed, their own wording reports on minor details found as a result of their investigation (and not necessarily having a direct bearing on the accident).
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Old 22nd Nov 2005, 15:39
  #37 (permalink)  
 
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I read the AAIB report prior to reading this thread. It is interesting that several people have the same impression as me, that this report was not the best ever researched and written by someone in the AAIB. I have generally been very impressed by the AAIB's work, I went on a 2 week accident investigation course a few years ago and was very impressed by the calibre of people from the AAIB.
I know nothing technically about flexwing aircraft so cannot comment about that part of the investigation, but I think there were far too many general comments not strictly anything to do with the accident and too much personal opinion. The investigator did the AAIB a great dis-service by trying to lump together trivial admin rule infractions with major airworthiness issues. To a mindless bureaucrat who knows no better, then not fitting an "admin" placard might be the same as not carrying out some essential maintenance. However I would have thought that an AAIB engineer would be able to differentiate between the two. Does he really want to bring down all improtant safety issues to the level of fitting a placard that is there to protect someone's arse in the CAA and has no bearing on how to operate the aircraft or its airworthiness.

I am not a BMAA member, I have occasionally flown in a microlight. Ive found it great fun and most microlight fields Ive visited have been well run and machines seemingly well maintained- often looking in a lot better condition than the average public transport C of A club Cessna or Piper!! From my experience I would say that there are the odd maverick in all forms of aviation, probably most are involved with public transport C Of A aircraft.
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Old 22nd Nov 2005, 16:21
  #38 (permalink)  
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Thanks Genghis.

I agree with your point. When I did my research it was purely with the idea of operating a training school. I can see that other areas could help support the flying end and generate more income.

I did not know that about the seats! Makes me wonder about the seat below me when I pull 6g! I remember the decathalon having past problems with the back collapsing during aeros. Seems I better read up on the seat limits!

Regards,

DFC
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Old 22nd Nov 2005, 16:30
  #39 (permalink)  
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It'll almost certainly be designed to fail at just above 170lb (190lb for aerobatic aeroplanes) x the g-limit x 1.5.

So, increase the pilot weight by 50% and you have no safety factor. Not an aspect of aircraft approvals that I've ever been all that comfortable about.

G
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Old 22nd Nov 2005, 18:51
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I've never been comfortable with this seat weight anomaly, and curiously neither have a large number of microlighters.

The Yahoo group that Mr McDermid from the AAIB spent so long perusing, is dotted with complaints from microlighters that their 86/90kg seat weight limits are too light and pleas for manufacturers to voluntarily increase their approved limits to a higher figure by extra testing or modification.

As G has pointed out, many microlight manufacturers have responded to this safety concern, raised by these fellows with an "endemic lack of a safety culture" and are now offering much higher seat limits.

One microlight, with which G will be familiar, has actually been tested to a seat and seat belt limit of over 130kg.

I wonder just how many light aircraft or public transport aircraft have seats and belts approved for over 20 stone people at +/-4.5g vertically, +/- 3g sideways and +9g forwards?

VP
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