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AAIB Report - Microlight Accident

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Old 15th Nov 2005, 21:56
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AAIB Report - Microlight Accident

Noticed a special bulletin released today by the AAIB about a microlight accident last year which resulted in the tragic and sad death of the pilot and a 'fare paying passenger.'
It makes pretty damning reading and begs the question that many of us have been asking for a long time - just how safe are these so called 'air experience' flights in microlights??
The report points out startling deficiencies in the maintenance schedule of the microlight, the competence of the Inspector and the cavalier attitudes prevelant amongst the microlight community.
Having just lost their CTO who was, by all accounts, well respected at Gatwick one wonders what the outcome of all this will be. It is such a damning report I was surprised not to see comment about it anywhere on the web.
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Old 15th Nov 2005, 22:12
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Yes I read that lastnight and it is pretty tragic. I've been looking into going for a microlight but this has really made me think. I suppose anywhere in aviation you can get incomplete history, unrecorded maintenance etc which was just part of the problem with this A/C but not correctly embodying a Service Bulletin is inexcusable and you'd think the inspectors should know about the construction of the A/C and differing rivets.
I would say the Air Exp flights are a safe in these as any other mode of flight although all these Air Exp flights are questionable really (commercial flight?)
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Old 16th Nov 2005, 08:24
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Theres over a hundred of these types flying on the uk register at the moment its the first to suffer an in flight incident such as this that Im aware of.If you read all the report,it mentions all the main reasons as to why this accident took place.None of which point out that the design is faulty.There are some reccomendations following this report but the "Quik" aircraft are still flying and havent been grounded so that must say something.

The BMAA have issued the following statememnt


"The BMAA, with its regulator the CAA, will study carefully the
recommendations made in the report and will respond accordingly where
action has not already been taken."



Regards

Barshifter
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Old 16th Nov 2005, 09:56
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If I may correct Barshifter on a couple of points... There are 72 Quiks on the register, not quite 100, but it is still the biggest selling flexwing for the past few years.

The aircraft were grounded, following the accident, when the modification was upgraded to "before further flight". A subsequent request for a second inspection also grounded some who could not get it done within the specified 5 hour limit and were faced with getting inspectors in or trailering to them.

The report is the worst I have seen from the AAIB, but follows an apparent trend for AAIB reports into microlight accidents. The report contains plenty of science and investigation, it also contains an alarming amount of supposition and links that are tenuous beyond belief, none of which should appear in a section entitled Factual Information. Clearly anyone who has ever criticised the CAA has a an anti-safety mindset and should not be allowed near aircraft

There are already criminal proceedings taking place and its very likely that civil proceedings will take place after these. There are some huge voids in the report but as I know people involved in the case, I'd rather not comment on any of the specifics.

The only winners in this one will be the lawyers.
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Old 16th Nov 2005, 11:41
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The report itself is a bit raw of course and I feel for the families and friends of the victims.

The incident was tragic, but NOT typical of the microlighting fraternity and it's aircraft.

There will always be scope for human error and failures in the process to minimise it but don't tar the whole community with one incident which is, as you say, still sub judice despite the issue of this "report" into the public domain.

Microlight flying is a safe, exhilarating way to get us normal bods into the air and as I fly group A and Microlights I can assure you that there have been similar tragedies and human error in GA, and on our roads every hour of every day !

The fairly spectacular and avoidable nature of this incident just emphasises the waste of human life and consequent grief of the families. Life is dangerous, and some of us humans choose to accept manageable risk as part of the fun of flying but as a society, I can't help feeling that the developing HSE culture would have us all wrapped in cotton wool and monitored for individual thought and action. ALL my colleagues in microlighting are very responsible individuals with familes to think of so short cuts are unthinkable to them

I personally think certain aspects of the report is crap and there appears to be an element of emotion and knee jerk reaction involved for reasons I can't quite understand. Purely my opinion of course having read and re-read it several times.

Last edited by Stafford; 16th Nov 2005 at 12:51.
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Old 16th Nov 2005, 11:44
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The only winners in this one will be the lawyers.
'Twas ever thus!

I read the report this morning - we mustn't forget that we're talking about people's deaths here, so a little respect is in order. There was also speculation about the underlying influences in a recent non-microlight fatality - see other thread

Perhaps the AAIB is just reporting what they see to be relevant facts to the case, as they did in the other case. And don't forget Barshaker, that the AAIB are part of DoT and not part of CAA.

Returning to 912ul's points, I don't think it begs his question at all. Perhaps he'd like to search out and report to us the statistics on serious accidents on microlight trial lessons (or helicopter or Tiger Moth or Jet Provost trial lessons for that matter).

912ul is clearly trying to provoke argument by his misrepresentation of the AAIB's view about the culture within microlighting; "cavalier" and "prevalent" are not mentioned - for those who have not read the report, I quote "that a minority of their members are inadvertently undermining the positive safety culture being promoted by the BMAA". This is a very different issue and is perhaps worthy of a thread of its own. I partly agree with Barshaker, however, that a couple of sentences in the "Factual" section might have been better placed under "Analysis" - but that's hardly a big enough error to damn the whole report.

Finally, 912ul's dig at the loss to the BMAA of its shortly-to-be-ex-CTO is misplaced. I believe the new incumbent of the post is as well (if not better) qualified for the job than his predecessor was on joining the BMAA.

Madam Breakneck
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Old 16th Nov 2005, 12:26
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Hang on a minute.................................
It costs very many thousands of pounds a year to keep a public cat aircraft in the year and the pilots who are allowed to fly 'fare paying passengers' in them are subject to extremely stringent training and the result is that passengers are transported in a safe, well maintained aircraft piloted by a professionally trained and responsible person.
The passenger who so tragically died in this instance had every right to expect that the aircraft he had paid to fly in was well maintained, safe to fly and was being piloted by a responsible and safe person.
The accusations being levelled by the BMAA are systematic failures of the Inspector system and failings in the responsibilities of pilots who have been granted huge concessions to maintain their own aircraft. The AAIB are only saying what many have said for years - there are those in the BMAA who give the rest a bad name. If proof were needed, just take a look at the BMAA chat group on Yahoo today. Is there one ounce of sadness, remorse or regret for the passenger who so needlessly died?? NO !!
It is all about attacking the AAIB for daring to aportion blame and a loss of freedom of speech because a few sensible people are trying to gag the loonies and prevent even more damage - that is the kind of attitude that the AAIB refers to.
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Old 16th Nov 2005, 12:48
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912

What do you expect from the microlighting community ? Flowers and wreaths a la Princess daft Diana ?

Thats not the style of anyone I know in microlighting and their sincere sympathy with the families of ALL involved in this tragedy goes without saying - we all share the same inherent, but very small risk of accident and fully appreciate the sentiments and grief of the victims loved ones.

There is, on the other hand, a necessary balance in ensuring that such human failings when they do occur (very infrequently) do not impinge even more on the rest of us by dint of a Nanny state mentality and knee jerk reaction all too familiar under the present style of Government we have today

The report does have some very fanciful comments which I believe belong in the "IMHO" category and not in such an important document.
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Old 16th Nov 2005, 13:27
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If proof were needed, just take a look at the BMAA chat group on Yahoo today. Is there one ounce of sadness, remorse or regret for the passenger who so needlessly died?? NO !!
With respect, you don't appear to research your comments very well. If you go back to the postings on that group at the time of the accident itself, there was plenty of sympathy expressed for the families of both on board.

My sympathy goes out now to those whose lives are ruined by this accident, in whatever way, and I'm sure that many others on this and other forums will agree - that doesn't mean that we have to grieve loudly and in public; it's not the British way is it?

Madam Breakneck
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Old 16th Nov 2005, 13:28
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912

Your post ignores the human failings that can occur in any otherwise good, workable system.

If a LAE forgot part of the service, would you scrap the Public Cat as it was flawed? There are statistics that show PubCat aircraft are more likely to have an engine failure soon after a service. An alarming number of GA engine failures are fatal. Should we scrap the LAE system?

Microlights are simple aircraft, with restrictions on their use which creates a safe, affordable category of aircraft/flying. The training of pilots is geared towards microlights in that PFLs are drummed in and basic maintenace is part of the sylabus.

One person who ignores a service schedule does not make a fleet of dangerous aircraft.

Microlight pilots are able to carry out their own basic maintenance, but many do not, prefering an experienced mechanic to do it for them. Alteration of the primary structure or the power plant requires an inspector's signature. Changing the oil and plugs does not.

To perform trial flights, the pilot must hold at least an AFI rating.

As for posts on the microlighters' group, the grieving was done 15 months ago and the pilot was well known in the part of the country where I live. Any loss of life in aviation is always sad and your comment implies that the microlight fraternity don't give a toss about the pilot or his passenger. Nothing could be further from the truth.

There are many questions missing from the AAIB report and there are many opinions in the report which neither help air safety nor have they any basis in fact. It is understandable for people affected to react in a protectionist way.
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Old 16th Nov 2005, 14:32
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It costs very many thousands of pounds a year to keep a public cat aircraft in the year and the pilots who are allowed to fly 'fare paying passengers' in them are subject to extremely stringent training and the result is that passengers are transported in a safe, well maintained aircraft piloted by a professionally trained and responsible person.
The passenger who so tragically died in this instance had every right to expect that the aircraft he had paid to fly in was well maintained, safe to fly and was being piloted by a responsible and safe person.
I would agree if you were comparing apples with apples but you are not.

There is a general principle that passengers in public transport operations are protected. For this reason we have regulations covering Public Service Vehicles, Passenger Ferries and Aircraft which are designed to ensure that a member of the public getting on a bus ferry or transport aircraft is protected.

However this isn't what happens in training, whether its on an aeroplane, motorbike, car or boat. If you are having a lesson it's not the same as being a fare-paying passenger where you are paying to be transported form A to B. You are undertaking an activity that is more hazardous than being a passenger of a public transport undertaking and that is a risk you accept. If you learn to sail, the boat doesn't need a Passenger Carrying Certificate. If you learn to drive the vehicle doen't need a public Service Vehicle Licence and if you learn to fly the pilot does not require an ATPL or a CPL and the aircraft does not require a Transport Cat C of A.

There are requirements that come in to play where payment is made either for the hire of the aircraft or to the instructor and these vary according to circumstances but these relate to the fact that payment is made, not to the fact that it is a trial lesson.

The suggestion in the AAIB report is that a modification was carried out incorrectly. In any safety regime it is always possible that someone will get something wrong with tragic results and there are many examples of this happening in public transport aircraft as well as permit types. Taking a "holier than thou" attitude to one airworthiness regime in preference to another is not the answer.


Final paragraph edited.
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Old 16th Nov 2005, 16:56
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Having read the report I wonder if the BMAA can survive if it does not make very major changes to it’s procedures and even bigger changes to it’s culture to ensure that they are followed.

IMHO everyone has a right to expect, when taking a flight in or buying an aircraft, that the aircraft conforms to the standards which the governing body says it does. I take Mike’s point about acceptance of risk but in this case the risk was being misrepresented –
  • The aircraft had not in the past been maintained to the schedules - a 200 Hr service at > 300 Hrs! (OK perhaps not directly relevant to this accident but an accident waiting to happen)
  • The mod was signed off by an inspector but was incorrectly done and not understood or checked properly.
  • There was essentially no paperwork and the wing had (probably) not been inspected per the schedule.
  • The inspector had signed that the paper work had been checked and was correct!
  • The BMAA’s inspection system shown to be in some disarray – putting it kindly!
The BMAA system, in the widest sense of the word, did not pick any of this up and revalidated the aircraft’s permit. Thereby failing it’s customers, in its duty of care and the duty it assumed by asking for and accepting a regulatory role on behalf if the CAA.

And before the flaming starts I have no particular interest in PFA vs BMAA wars as I am not associated with either, although there is a strong probability I will be moving from a certified a/c to a permit one in the near future.
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Old 16th Nov 2005, 18:45
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bar shaker


Nope not 72 theres 126 to be precise according to G-INFO on the uk register.The 72 your are confused with I think are the the ones that have been affected by the mandatory mods as mentioned in the report.



Check here to find out.

Cheers

Barshifter

Last edited by Barshifter; 16th Nov 2005 at 19:46.
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Old 16th Nov 2005, 19:12
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Having read the report I wonder if the BMAA can survive if it does not make very major changes to it’s procedures and even bigger changes to it’s culture to ensure that they are followed.
Let us hope that the new Chief Inspector is able to pull this off. Without the BMAA we wouldn't have had any worthwhile microlights in the UK at all, and they are all that many of us can afford to fly.

It is worth considering just how rare in-flight break-up is these days, even with the weaknesses in the inspection regime which the report identified. After all, even Public Transport cat machines fall apart sometimes (engines falling off Boeings, tails off Airbus, cargo doors off McDonald Douglas, and a big fire aboard Concorde, for instance )
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Old 16th Nov 2005, 19:27
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egbt

The points you raise are, as I see them, valid with the exception of the last permit issued. The aircraft had undergone a 200hr service which baselined the maintenance requirements so, in this matter, the signature was correct.

The age old rule on buying any aircraft, permit, CoA, whatever, is if the aircraft paperwork does not seem right, then walk away.

The BMAA have already undergone a massive overhaul of the inspector network and have implemented most if not all of the recommendations long before the report was issued. They, I hear, are about to appoint a new Chief Inspector who brings with him a wealth of experience. We can only wait and see what a future appointment brings.

In their audits with the CAA (also criticised in the AAIB report) the BMAA were seen to be complying with their remit.

Human factors have let down a system. The system may have needed improvement, but it was assumed to be working well until this incident. The systems that were in place were built from experience and I am sure that the new ones will be built on experience too. The regulation empire that we all fly under is based on previous experience. We should not forget that we are one of the most heavily regulated countries in the world and, as far as microlights are concerned, we are by some margin the most heavily regulated. That regulation did not stop this accident and whilst the aircraft in question is sold throughout the world, the failures occured under our heavily regulated regime.

This brings its own questions. There are those that say if you impose regulations, people will generally comply with them, but they will go no further. The FAA impose considerably lighter regulation on GA and none on their microlight fleet. Their level of fatality is slightly less than ours (per hour flown). Is this because more responsibility is put on the aircraft owner/pilot to ensure that the aircraft is up to scratch.

Who has not collected an aircraft from an annual and flown it on the basis that it will, at that time, be at its most reliable?

Barshifter, yes you are correct. I was quoting the figures from the AAIB report.

This report raises many interesting questions. The correct answer is often not the most obvious answer. In saying that, the report is very focussed on the BMAA and, as such, has missed or overlooked many questions which I consider equally important.

As to the survival of the BMAA? This is the only case of structural failure that in an extended recent history. We learn from experience, some of it tragic. We would not be where we are now unless we learnt from tragedies and we will be in a better position when we have fully learnt from this tragedy.
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Old 16th Nov 2005, 20:26
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Bar Shaker,

I think you will find that the 200 hour service related to the engine only; there is no evidence that the wing had been stripped and inspected as required and the report suggests that if it had been the problem might have been discovered. Also (from memory of my earlier reading, it’s too late to re-read!) the a/c should have been air tested by the distributor/manufacturer each year but was not, I accept that this may not be a permit renewal requirement.

Regarding the paperwork and buying an a/c I fully agree and would in any case have a survey of some sort done. However without suggesting that it would have happened in this particular case, if you have a blank Tech log and a certificate from the regulatory authority that the log book is signed up and correct what’s to stop an unscrupulous owner adding the missing entries?

I agree with your other comments (except that as an ex engineer I never trust anything straight from maintenance!) and with Madam B and also hope things get sorted - but lets not get too side tracked by the thankfully rare occurrence of in-flight break-ups. Failures in maintenance, servicing schedules and documentation requirements does no one any favours and certainly not the paying customer, the casual passenger or the owner.

As the man said, if you think maintenance / safety is expensive, try an accident. Unfortunately some people seem to have forgotten this old saw. I for one will certainly probe a little more before accepting a ride in other people’s a/c (including certified ones)

Edit: I was remiss in not throwing some mud in the CAAs direction.



Penultimate paragraph edited.
Heliport

Last edited by egbt; 16th Nov 2005 at 20:45.
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Old 18th Nov 2005, 09:14
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Caution is needed here, as I know for a fact that one of the AAIB investigation team spent more than one whole day surfing the internet chat rooms deliberately looking for "evidence" of a "poor safety culture" amongst microlighters to support his theories.

This is the "evidence" that went into the assertion in the report.

This is somewhat akin to reading a few internet motoring fora, which are often full of rhetoric about speed cameras, unsafe car performance modifications and over-zealous policing, and then concluding that all motorists have an inherently poor safety culture.

This report lacks balance and falls well below the impartial standard I have come to expect from such a formerly well respected body. Added to reports from visitors to Farnborough, who have told me of derogatory asides and comments made about microlight aircraft, I am of the view that the AAIB itself suffers from inherent and somewhat unwarranted bias against these aircraft.

I will refain from discussion on the actual accident details, as the matter is clearly sub judice now that a charge of manslaughter has been laid. I suggest we voluntarily restrict this debate to general points about the BMAA, the AAIB, the CAA etc, rather than fall into the trap of being overly specific.


Absolutely right - keep it general.
Others take heed.

Heliport
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Old 18th Nov 2005, 12:35
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This is the "evidence" that went into the assertion in the report.
VP, do you have evidence for that statement? I'm not disputing the assertion that the chat rooms etc may have been reviewed but if this just pointed the investigators in the right direction that IMHO would be reasonable. On the other hand, using such information unsubstantiated would indicate some very serious issues.

Fully agree regarding the specifics of this case.
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Old 18th Nov 2005, 13:16
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Yes I do.

I took a telephone call at home from Mr Brian McDermid from the AAIB and wrote detailed notes about our hour long conversation. He very clearly and specifically told me that he had spent a day reading through the messages on the microlight Yahoo forum and others, gathering evidence of what I believe he referred to at the time as a "endemic lack of a safety culture".

I was also told, again by Mr Brian McDermid, that an article published in my name would be quoted (out of context, as it happens) to substantiate this view. This was at the beginning of this year, when the draft report was being prepared.

I was so concerned by his stance that I telephoned the AAIB the next morning and expressed my concern to a more senior investigator. I was reassured then that this would be unlikely to go into the report and that it was "background". I complained about the attitude of the investigator, but was again placated by reassurances from a more senior investigator.

Those who know who I am, and know of the considerable airworthiness responsibilities I've held, will perhaps understand why this stance by the AAIB enraged me somewhat.

I guess this means that my long-preserved anonymity on here is now blown, but exposing these flaws in our regulators seems worth it.
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Old 18th Nov 2005, 13:27
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VP

An excellent post and position statement

As I said before I have no axe to grind regarding the BMAA however like you I am concerned about safety and appropriate regulation.

I don’t think it contradictory to wish you could luck whilst holding to the views expressed in my first two posts.
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