AAIB investigation to Hawker Hunter T7 G-BXFI 22 August 2015

[9 lives]

I am aware that air accident investigators will include consideration of the pilot's demonstration of skill, precision and discipline relative to the flying task involved. Those three personal characteristics may be an indicator of the person's attitude, or may just be a demonstration of the limits of their capability. I've known pilots who flew with great precision, though were "mechanical" and did not handle the aircraft well (display with ease). I've known excellent "hands and feet" pilots, who displayed wonderfully, but were not inclined toward precision. Airshow display pilots require an extra measure of both characteristics.

My opinion of the Shoreham accident, based upon the video I saw, and the authoritative information I have seen suggests a pilot who did not apply the required precision and discipline, and when the aircraft was not where it needed to be, he did not attempt to escape, but rather continued. My opinion of the video of the Jet Provost airshow display linked earlier is that the pilot was not positioning the aircraft precisely relative to the show line. If that video was recorded by a person who was located behind the crowd line, the flying was worrisome in terms of compliance.

In my time, I've had to say to a few pilots: "You're a nice fellow, but the skill/precision/discipline you've demonstrated was not adequate for the flying task here.". I believe, from a number of discussions I've had with accident investigators about accidents I've known, that they will at least consider these foregoing pilot personality factors too as possible factors in an accident.

Like the condition of the aircraft, the pilot's medical condition, and the weather, information understood about the skill, precision and discipline of the pilot's flying in that realm, may also be a factor in an accident.

[wiggy]

If we are going to persue the "rogue pilot" theory and and start looking at "personal characteristics" it's perhaps worth bearing in mind in that every sector AH flew as part of his day job would have been run through the company monitoring monitoring system, which is actively scans for breaches of SOPs, "gate" busting etc.......

[9 lives]

flew as part of his day job would have been run through the company monitoring system, which is actively scans for breaches of SOPs, "gate" busting etc.......

This was a factor in a fatal accident of a pilot I had trained for a contract. He flew very well when monitored (operator on board at all times). The very first flight he flew solo, to bring the plane back to me at the end of that project, he decided to flew as he wanted, and literally killed himself with carelessness within ten minutes of taking off. No one minded his choosing to deviate from the norm a little while solo, but everyone was totally unhappy about the fatal outcome.

I have noticed that pilots who fly "supervised" may explore extra freedom when flying in a different (or differently/not supervised) operation.

[wiggy]

Fair point, I've seen similar in a military context.

[Direct Bondi]

The CAA did not ensure it closed a very large hole in the Swiss cheese.

After witnessing the display at Southport the CAA had evidence to suspend or revoke the pilots display authorization. At minimum, had the CAA issued a formal notice of regulatory non-compliance, the pilot may have applied an increased margin of safety (height and distance) to ensure regulatory compliance at subsequent displays.

Some may argue the CAA did not fulfill its duty of care and duty of competence.

The AAIB report neither includes the prior history of illegal maneuvers nor identifies the CAA missed opportunity for more affirmative action to prevent any reoccurrence. Some chump said this was omitted from the report as not relevant. I say it is omitted as convenient.

The Coroner will be made aware of facts regarding CAA misguided priorities and resources involving medical department witch-hunts (proven to be groundless) in the weeks before this accident. Had the CAA applied the same resources and intensity to investigating the non-compliant Southport display, the Shoreham tragedy may have been prevented.

CAA observed Southport display:

https://www.youtube.com/watch?v=ZHngQ8TmqU4

The Telegraph article:

http://www.telegraph.co.uk/news/avia...r-earlier.html

[Hebog]

Lots of people/organisations failed in their duty of care.


Maintenance companies - for lying that the aircraft was airworthy and meet CAA requirements for the renewal of its permit.


CAA - for allowing the maintenance companies to self-certify that they have cried out work and that the aircraft meets CAA requirements. Accepting flight tests that were not carried out. Allowing airshows to be conducted without sufficient regulation and inspection.


Airshow Organisers - for not having full risk assessments and policies in place regarding planned displays.


Pilot - for not providing the airshow a flight plan (even though they had not requested one). Not performing a flight briefing with the FDD or the other pilot/ or another competent display pilot.


I too agree there appears to be some things missed or not covered/mentioned in the AAIB report, but it is objective as to whether these are deemed relevant as it may be to some parties but not to others. The coroners investigation will again not be apportion blame but to establish who, when and why the person/s died. It will be upto the police/CPS to deem if any crime has been committed and if it is in the public interest to prosecute.

[Super VC-10]

My gut feeling is that a prosecution is dependent upon what verdict the inquest returns. If a verdict of unlawful killing is returned, then you can almost guarantee a prosecution will follow. Misadventure or open verdict and it will be less likely. Accidental death and there won't be a prosecution.

[Chronus]

I think misadventure and open verdict can be ruled out. Unlawful killing or accidental death are the two to choose from. It is clear that the primary cause was pilot error. The question remaining is was it recklessness or negligence and if it was negligence was it criminal neglect. Was it dangerous flying.

[Tay Cough]

It is clear that the primary cause was pilot error...

To whom? Apart from you of course.

The question remaining is was it recklessness or negligence and if it was negligence was it criminal neglect.

Recklessness, negligence or some other circumstance beyond the control of the pilot.

[jindabyne]

And to all of the previously experienced Hunter pilots that I have spoken with.

[overstress]

Chronus, jindabyne, Step Turn, look again at Tay Cough's posting above:

some other circumstance beyond the control of the pilot.

Now look at section 1.18.3.4 of the full AAIB report. Why would the pilot have deliberately entered the manoeuvre slow, with less than full power, and reduced the power setting before making random changes to it?

If you are confident the pilot could not have been suffering some kind of transient health problem, then carry on blaming him.

Extract from 1.18.3.4

The rpm at pull up (derived from the spectrum analysis of
the action camera audio) was 7,530 audio, which reduced
to less than 6,800 audio, possibly as low as 6,500 audio
during the upward half of the manoeuvre and was increased
transiently to 7,210 audio. It was 7,010 audio at the apex.
This was contrary to the pilot’s declared nominal power
setting of increasing to full power at or shortly after the
pull-up. The throttle was not visible on the video and so it is
not possible to confirm whether the rpms were pilot selected
or due to an engine malfunction.

[Heathrow Harry]

Regretfully totally well and sane pilots regulary do soemthing stupid or ill advised - teh accident reports are littered with them

He made a mistake - which , in this case led to appalling consequences

I can't see how you can stick unlawfull killing on him but negligence certainly - not enough of a lawyer to understand the difference between criminal negligence and the common-or garden variety

[RAT 5]

Just a thought about the comments here, reference human performance being affected, detrimentally, and apparent thrust changes during the vertical: from all reports mentioned the start of the manoeuvre was too low, too slow & off line. Here was a 'root cause moment'. Is anyone saying that there were medical human factors that caused these 2 parameters to be less than approved & necessary?

[Hebog]

Originally Posted by Heathrow Harry

Regretfully totally well and sane pilots regulary do soemthing stupid or ill advised - teh accident reports are littered with them

Yes and the accident reports are also littered with maintenance errors by seemingly qualified persons too.


Unfortunately, it would appear that there were many stupid/ill advised actions in regards to this from seemingly well-qualified and experienced people - from the DA authorisation, the permit renewal, lack of risk assessments, possible engine issues previously etc

[Heathrow Harry]

PIC - Pilot in Command -says it all really

[LookingForAJob]

My gut feeling is that a prosecution is dependent upon what verdict the inquest returns. If a verdict of unlawful killing is returned, then you can almost guarantee a prosecution will follow.

Of whom? Just the pilot? What about the other people who failed to do their part to assure the safety of the flight/display?

[G0ULI]

The incident involved an aircraft that crashed outside the airfield boundary and outside the display area. The AAIB report has eliminated the possibility of any major fault in the aircraft as being responsible for the crash. Some pedants might argue otherwise, but essentially the aircraft was airworthy. That places the blame firmly upon the pilot. That will inevitably have to be the finding of the inquest and any further proceedings will carry on from there.

Various shortcomings have been discovered during the course of the AAIB investigation concerning safety procedures, but even if these had all been ccorrectly followed, it would not have altered the outcome of this specific incident. The organisers of a display have a responsibilty to try and ensure the safety of spectators at the display. They cannot be expected to take responsibility for unforseeable events that take place outside the display area.

[Chronus]

In considering the position of the organisers and the CAA, I would pose the following question. Would the outcome been different had another pilot of similar experience and qualifications been in command on that day.

[MacLaren1]

Oh, dear...

[Pozidrive]

Originally Posted by Chronus

In considering the position of the organisers and the CAA, I would pose the following question. Would the outcome been different had another pilot of similar experience and qualifications been in command on that day.

In command of the Hunter or in command of the airshow?