AAIB investigation leads to manslaughter charges. UPDATE: Prosecution Withdrawn
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I decided the other day to have a look at a report of the Marine Accident Investigation Branch into a fishing boat accident. The first thing that struck me was a statement on the first page:
"Extract from
The United Kingdom Merchant Shipping (Accident Reporting and Investigation)
Regulations 2005 – Regulation 5:“The sole objective of the investigation of an accident under the Merchant Shipping (Accident Reporting and Investigation) Regulations 2005 shall be the prevention of future accidents through the ascertainment of its causes and circumstances. It shall not be the purpose of an investigation to determine liability nor, except so far as is necessary to achieve its objective, to apportion blame.”
NOTE
This report is not written with litigation in mind and, pursuant to Regulation 13(9) of the Merchant Shipping (Accident Reporting and Investigation) Regulations 2005, shall be inadmissible in any judicial proceedings whose purpose, or one of whose purpose is to attribute or apportion liability or blame."
I have never seen such a statement in an AAIB report - seems strange the two sets of legislation are different.
"Extract from
The United Kingdom Merchant Shipping (Accident Reporting and Investigation)
Regulations 2005 – Regulation 5:“The sole objective of the investigation of an accident under the Merchant Shipping (Accident Reporting and Investigation) Regulations 2005 shall be the prevention of future accidents through the ascertainment of its causes and circumstances. It shall not be the purpose of an investigation to determine liability nor, except so far as is necessary to achieve its objective, to apportion blame.”
NOTE
This report is not written with litigation in mind and, pursuant to Regulation 13(9) of the Merchant Shipping (Accident Reporting and Investigation) Regulations 2005, shall be inadmissible in any judicial proceedings whose purpose, or one of whose purpose is to attribute or apportion liability or blame."
I have never seen such a statement in an AAIB report - seems strange the two sets of legislation are different.
The Chief Inspectors statement on the front page of the AAIB website is:
"The fundamental purpose of the AAIB is:
"To improve Aviation safety by determining the causes of air accidents and serious incidents and making safety recommendations intended to prevent recurrence. ...It is not to apportion blame or liability"
VP
"The fundamental purpose of the AAIB is:
"To improve Aviation safety by determining the causes of air accidents and serious incidents and making safety recommendations intended to prevent recurrence. ...It is not to apportion blame or liability"
VP
I guess the first question will be the admissibility of the report.
Having said that, I do not understand what could have possessed anyone to not comply, or attempt to comply, exactly with a service bulletin.
Having said that, I do not understand what could have possessed anyone to not comply, or attempt to comply, exactly with a service bulletin.
The reasons for the pilot (for it was his responsibility under the regulations) not complying with the bulletin are unknown, but there has been much speculation.
Certainly the service bulletin as originally issued at this time was not very clear and very little emphasis was placed on the safety implications.
I have wondered quite how reasonable it was for a company to supply the owners of a £24000 aircraft with a 4.8mm drill bit, four 3/16 Avdel MonoBolts and a photocopied two page set of instructions with an undimensioned sketch and expect them to take a Black and Decker to primary structure themselves.
VP
Certainly the service bulletin as originally issued at this time was not very clear and very little emphasis was placed on the safety implications.
I have wondered quite how reasonable it was for a company to supply the owners of a £24000 aircraft with a 4.8mm drill bit, four 3/16 Avdel MonoBolts and a photocopied two page set of instructions with an undimensioned sketch and expect them to take a Black and Decker to primary structure themselves.
VP
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Originally Posted by VP959
I have wondered quite how reasonable it was for a company to supply the owners of a £24000 aircraft with a 4.8mm drill bit, four 3/16 Avdel MonoBolts and a photocopied two page set of instructions with an undimensioned sketch and expect them to take a Black and Decker to primary structure themselves.
VP
VP
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Originally Posted by soddim
It's a good point made by VP959. A 24k car would have been subject to service recall, so why not a microlight?
A microlight is sports equipment. No, I don't mean that in the slightest in a derogatory sense. But the microlight is better compared with a racing car, not a family runabout...
R1
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they said:
AAIB: "A modification kit, that included the Service Bulletin, Avdel rivets and drill bit, was sent to the owner, who asked a BMAA inspector to assist him with the embodiment. The inspector sought advice from another individual who assured him that it was a simple job....
...the inspector has stated that he did not see a copy of the Service Bulletin before starting the job. After some discussion it was decided to fit the new rivets below the existing ones, because they felt it would be less likely to cause or create a crack in the aerofoil extrusion....
...The inspector could not explain why the wrong rivets had been fitted and did not appear to be aware of the differing mechanical properties of different types of rivets, how to determine if they had been correctly formed, or the importance of fitting them in the correct positions...
...Whilst the inspector read the Service Bulletin prior to signing the aircraft logbook, he still believed that his decision to fit the additional rivets below the existing rivets was correct."
In November 05 egbt wrote: [in full]
"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."
...the inspector has stated that he did not see a copy of the Service Bulletin before starting the job. After some discussion it was decided to fit the new rivets below the existing ones, because they felt it would be less likely to cause or create a crack in the aerofoil extrusion....
...The inspector could not explain why the wrong rivets had been fitted and did not appear to be aware of the differing mechanical properties of different types of rivets, how to determine if they had been correctly formed, or the importance of fitting them in the correct positions...
...Whilst the inspector read the Service Bulletin prior to signing the aircraft logbook, he still believed that his decision to fit the additional rivets below the existing rivets was correct."
In November 05 egbt wrote: [in full]
"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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The inspector was a capable person in a position of responsibility who just didn't have the knowledge and expertise for the job in hand. As an ignorant guest landlubber I can't see how someone with no formal engineering qualifications and apparently limited technical expertise can have been entrusted by the BMAA to inspect and sign off aircraft. However, in carrying out the work and signing for it he clearly accepted responsibility when he should have deferred it.
The mod was embodied after the Permit renewal.
BMAA inspectors are not authorised to carry out work or repairs, or to help with them. If they do, then they are doing so as ordinary individuals, not BMAA inspectors.
It is the pilot/owners responsibility to ensure maintenance is carried out properly.
There is no requirement for the inspector to be shown proof of normal engine maintenance per se, he just has to be satisfied that the owner/pilot has done it. An inspector would have no way of knowing if an owners log book entry was correct or not., and has to largely take it on trust.
I agree that this investigation found many problem areas, but we are talking about a self-help organisation largely run by volunteers in their spare time. If one were to forensically examine any sporting association, say an amateur motor racing club, then I suspect similar problems might be highlighted.
The vast majority of BMAA inspectors have no formal aircraft engineering background and most will have been completely unused to dealing with structural repairs. Most inspection is making sure nuts and bolts are OK, tubes and wires aren't worn or damaged and that fabric is still in good condition.
VP
BMAA inspectors are not authorised to carry out work or repairs, or to help with them. If they do, then they are doing so as ordinary individuals, not BMAA inspectors.
It is the pilot/owners responsibility to ensure maintenance is carried out properly.
There is no requirement for the inspector to be shown proof of normal engine maintenance per se, he just has to be satisfied that the owner/pilot has done it. An inspector would have no way of knowing if an owners log book entry was correct or not., and has to largely take it on trust.
I agree that this investigation found many problem areas, but we are talking about a self-help organisation largely run by volunteers in their spare time. If one were to forensically examine any sporting association, say an amateur motor racing club, then I suspect similar problems might be highlighted.
The vast majority of BMAA inspectors have no formal aircraft engineering background and most will have been completely unused to dealing with structural repairs. Most inspection is making sure nuts and bolts are OK, tubes and wires aren't worn or damaged and that fabric is still in good condition.
VP
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Is it just me having problems finding any posts dated later than 2.2.06 in this thread? There was one posted supposedly at 16:59hrs yesterday and one today at 14:22hrs but, as they were both made by the same person would I be correct in thinking they may have been removed because they were in some way unsuitable? 
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DX Wombat
I have an interest in this thread, having advised/represented the engineer until I left the Bar, and have been watching it very closely since it appeared yesterday - after a break of 2 years.
No posts have been removed since then. 100% certain.
But there may be some important news posted very soon.
I have an interest in this thread, having advised/represented the engineer until I left the Bar, and have been watching it very closely since it appeared yesterday - after a break of 2 years.
No posts have been removed since then. 100% certain.
But there may be some important news posted very soon.
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Is it just me having problems finding any posts dated later than 2.2.06 in this thread? There was one posted supposedly at 16:59hrs yesterday and one today at 14:22hrs but, as they were both made by the same person would I be correct in thinking they may have been removed because they were in some way unsuitable?
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The Attorney General has issued a Nolle Prosequi in this case bringing proceedings to an end.
This is a rare procedure (I understand it may be the first Nolle issued this century) and followed successful legal argument at the Old Bailey in January, and then an application to the A-G by his lawyers to halt further proceedings.
Although the proceedings were discontinued before any trial, the allegations would have been hotly contested and there was a strong defence.
The volunteer BMA Inspector was awarded his defence costs.
This is a rare procedure (I understand it may be the first Nolle issued this century) and followed successful legal argument at the Old Bailey in January, and then an application to the A-G by his lawyers to halt further proceedings.
Although the proceedings were discontinued before any trial, the allegations would have been hotly contested and there was a strong defence.
The volunteer BMA Inspector was awarded his defence costs.
Last edited by Legalapproach; 18th Mar 2008 at 19:01.
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Congratulations are due to my friend and colleague Stephen Spence (barrister and PPL) who continued the defence when I left the Bar.
Had the trial proceeded, the defence would have challenged the prosecution case very strongly in several different areas and, although one can never forecast a verdict with 100% certainty, it was my firm view that the volunteer BMAA 'inspector' would be found Not Guilty.
I am no longer permitted to comment upon legal matters, but some might say this prosecution should never have been brought or, having been brought, should have been withdrawn a long time ago.
And some might say that, had the trial proceeded, the BMAA would not have come out of it smelling of roses.
As an aviator, I was disappointed (to say the least) to see the back-watching manner in which John Whelan, a volunteer 'inspector', was abandoned by the BMAA, although thankfully not by several members in a personal capacity - Jeremy Harris and others - who helped and supported him through this very long and extremely stressful process which has had dreadful consequences for his health.
I can only hope that, with the strain now over, Mr Whelan's health will gradually improve.
FL
Had the trial proceeded, the defence would have challenged the prosecution case very strongly in several different areas and, although one can never forecast a verdict with 100% certainty, it was my firm view that the volunteer BMAA 'inspector' would be found Not Guilty.
I am no longer permitted to comment upon legal matters, but some might say this prosecution should never have been brought or, having been brought, should have been withdrawn a long time ago.
And some might say that, had the trial proceeded, the BMAA would not have come out of it smelling of roses.
As an aviator, I was disappointed (to say the least) to see the back-watching manner in which John Whelan, a volunteer 'inspector', was abandoned by the BMAA, although thankfully not by several members in a personal capacity - Jeremy Harris and others - who helped and supported him through this very long and extremely stressful process which has had dreadful consequences for his health.
I can only hope that, with the strain now over, Mr Whelan's health will gradually improve.
FL
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playing the nutter card
i must be misunderstanding something ,...if someone in the position of an inspecter signs something off that he has not checked which kills two people he should be locked up ,its a disgrace.we pay a fortune to these people and mostly have nothing more than there word that work has been carried out. just because he gets a posh lawer who gets him off by playing the nutter card doesnt chance the fact he did it .you just prevent him from being made responsible for his actions...shame on you .reminds me of the usa ,if you pay enough cash you get away with anything...shame on you!!!!!!!!!