AAIB investigation to Hawker Hunter T7 G-BXFI 22 August 2015
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I am not sure there is a public demand for criminal as opposed to civil proceedings gouli. time will tell. In the meantime I hope professional pilots will reflect on the precedence this might set for aviation and try to avert a witchunt that might effect many of us in the future
I agree with Hebog that any considerations will not be that simple. But I dont think we can judge HA's decisions against that of an established hunter pilot. The regulator and the rules are satisfied for this display to be conducted by a pilot with perhaps only 60 hours on type and a degree of self education. He will be judged by those standards, and others may need to answer as to whether the standards were adequate.
I agree with Hebog that any considerations will not be that simple. But I dont think we can judge HA's decisions against that of an established hunter pilot. The regulator and the rules are satisfied for this display to be conducted by a pilot with perhaps only 60 hours on type and a degree of self education. He will be judged by those standards, and others may need to answer as to whether the standards were adequate.
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GOULI
To completely mitigate the risk to people not involved or attending an air display, due possible aircraft malfunction or pilot error as you appear to want, is unrealistic.
You would need to sterilise(i.e temporarily remove all the inhabitants)in the area around and under the intended flightpath of display participants. In this case no off airfield spectators on all roads under the flightpath, all local highways closed to traffic, large police presence to enforce, and empty most of Shoreham town.
or of course ban all air displays.
Nothing in life is risk free. This was a tragic accident and knee jerk reactions are not the solution.
To completely mitigate the risk to people not involved or attending an air display, due possible aircraft malfunction or pilot error as you appear to want, is unrealistic.
You would need to sterilise(i.e temporarily remove all the inhabitants)in the area around and under the intended flightpath of display participants. In this case no off airfield spectators on all roads under the flightpath, all local highways closed to traffic, large police presence to enforce, and empty most of Shoreham town.
or of course ban all air displays.
Nothing in life is risk free. This was a tragic accident and knee jerk reactions are not the solution.
Personal opinions stated as facts.
Sadly, for an aviation forum where one might expect a degree of knowledge of the subject under discussion, there are the usual unfounded assumptions and accusations going on here.
The ones that stand out are:
Please provide evidence of your accusation.
No where in the evidence in this or previous reports is there evidence to support your libel. In fact, the body of the report contains a number of statements that the reason he continued the manoeuvre could not be determined although possible explanations were given including obscuration of the digit counters by the altimeter needle and glare, etc. You have no basis for your claim.
The engine was not producing full power, the report is clear that it could not be determined what the pilot had selected with the throttle and that previously this mark of Avon engine had produced less than maximum power for reasons that were never determined.
See my earlier comments. What mistake do you think he made?
What was the bad decision? With the amount of doubt cast on various unserviceabilities and obscuration of the Altitude counter, there is every possibility that it was a good decision based on bad information.
Nowhere in the report, nor in previous reports has this ever been stated. The report is careful to list a number of different mitigations, which you have clearly ignored or not read.
See my previous remark. You have no grounds to draw that conclusion.
No evidence for that assumption whatsoever.
Where does the report say that? The report clearly never states that. The report clearly states why that conclusion cannot be drawn.
Please show me where there is stated evidence in the report to support that conclusion.
In the same way that the Mull of Kintyre accident ended up with the same verdict made by someone equally blind to the burden of proof as you clearly are.
The ones that stand out are:
Originally Posted by HOMSAP (post #55)
This pilot had a track record of violating regulations in respect of Lancing College
Originally Posted by Leon Jabachabicz (post #59)
The pilot porked it
Originally Posted by Homsap (post #23)
Full power is not applied
Originally Posted by Sharksandwich (post #82)
The pilot made a mistake
Originally Posted by JEM60 (post #81)
If I made a split second bad decision
Originally Posted by HOMSAP (post #69)
The display pilot did screw up
Originally Posted by Sillert (post #79)
The accident happened because the pilot made a mistake
Originally Posted by Arfur Dent (post #41)
confused and thought he was in a JP
Originally Posted by ROBSAUSTINHEALY (post #43)
So the primary cause of this dreadful, and avoidable, accident was pilot error
Originally Posted by SASKATOON9999 (post #51)
It appears severe negligence has been proven
Originally Posted by Sidestickbob
This is a simple case of gross negligence
Last edited by Courtney Mil; 4th Mar 2017 at 13:26.
Despite some of you arguing that an accident is an accident...entry height was lower then his authorization allowed, entry speed was lower then usual for this maneuver and apex height was lower then usual.
All links in the chain of events....controlled by the pilot.
Whether the fuel diaphragm had anything to do with the engine not being at full power but we'll never know.
However airspeed an altitude should have been noticed.
All links in the chain of events....controlled by the pilot.
Whether the fuel diaphragm had anything to do with the engine not being at full power but we'll never know.
However airspeed an altitude should have been noticed.
B2N2,
Page 29 of the report - picture. At X750 feet on the altimeter, the broader part of the needle obscures the thousands of feet and the tens of thousands of feet on the counter.
From page 128 of the report:
Page 29 of the report - picture. At X750 feet on the altimeter, the broader part of the needle obscures the thousands of feet and the tens of thousands of feet on the counter.
From page 128 of the report:
‘Analysis has been undertaken to identify the scope of human actions and/or decisions to have contributed to the loop being continued when below the pilot’s stated minimum height at the apex. It is not possible to determine which, if any, of these actions took place based on the evidence available for the HF analysis, but the following accounts are considered credible and feasible:
a. The altimeter may not have been seen or read at the apex of the loop as a result of scan pattern, high workload, allocation of attention, distraction (for instance, from detecting a reduction in thrust during the climb or the airspeed being lower than expected), and/or visual limitations (such as contrast and glare).
b. An inaccurate perception of aircraft height may have been obtained, specifically, that the aircraft was higher than it was as a result of the altimeter displaying the incorrect altitude, a misleading or ambiguous display of the altimeter digit drum [height counter], the altimeter digit drum [height counter] being partially obscured, and/or the altimeter being misread.
c. The minimum height required at apex may have been recalled incorrectly.
d. An escape manoeuvre may have not been selected as a result of the limited time available to select and implement the action, and the guidance and training that the pilot received with regard to performing an escape manoeuvre at the apex of a loop in the Hunter.’
a. The altimeter may not have been seen or read at the apex of the loop as a result of scan pattern, high workload, allocation of attention, distraction (for instance, from detecting a reduction in thrust during the climb or the airspeed being lower than expected), and/or visual limitations (such as contrast and glare).
b. An inaccurate perception of aircraft height may have been obtained, specifically, that the aircraft was higher than it was as a result of the altimeter displaying the incorrect altitude, a misleading or ambiguous display of the altimeter digit drum [height counter], the altimeter digit drum [height counter] being partially obscured, and/or the altimeter being misread.
c. The minimum height required at apex may have been recalled incorrectly.
d. An escape manoeuvre may have not been selected as a result of the limited time available to select and implement the action, and the guidance and training that the pilot received with regard to performing an escape manoeuvre at the apex of a loop in the Hunter.’
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You can't do that {prosecute the pilot} if he didn't wilfully do anything that he knew broke the rules,
So the pilot enters the manouvre at 185ft, his minimun height should have been 500ft, Entry speed 305 kts, should have been 350 kts,
In interview the pilot does not know the speed for the escape manouvre. Not really convinved that he had confused the speeds and safety gates between the JP3/5 and the Hunter, surely he knew what aircraft type he was flying.
This has no personal attention, just general human behaviour considerations.
In commercial flight training we are taught to identify the root cause of an error. It can be a long way before the error becomes apparent. What we emphasise is errors will happen; it is what you do next that is important. "When in a hole, stop digging" is one mantra. Equally, "realise you are in a hole and climb out." However, how did you dig the hole in first place = root cause. Low energy at entry seems to be a root cause, but... it was exacerbated by not following PPPPPP. Not having made Proper Preparation of knowing the escape manoeuvre before entering a possible deadly manoeuvre could also be a root cause, and it occurs earlier in the chain. A Swiss Cheese indeed.
As to point one I assume the entry height and entry speed were wilfully actioned. Why they were wrong is for debate: confusion of type (back to PPPPPP) or lack of attention?
I fly light a/c aerobatics and not being very current nor hot at them I make sure there are lots of margins buffering my performance, and I've read the manufacturer's notes about the what & how. Equally, before attempting any of these I have a QFI polish my stall & spin recovery technique. PPPPPP.
It would be blatantly unfair of CAA to start knee jerk reactions towards other displays. One muppet crashes a Ferrari because they drive it beyond their capabilities doesn't cause a blanket ban on all Ferraris being driven as they were designed. If a crash-causing fault is found, that is something else.
If it is true that the CAA authorisation & oversight might be involved, then I would suggest they look inwards first and sort that out before looking outwards. However, they might want to audit their display authorisation department to see if there is another Shoreham waiting to happen.
So the pilot enters the manouvre at 185ft, his minimun height should have been 500ft, Entry speed 305 kts, should have been 350 kts,
In interview the pilot does not know the speed for the escape manouvre. Not really convinved that he had confused the speeds and safety gates between the JP3/5 and the Hunter, surely he knew what aircraft type he was flying.
This has no personal attention, just general human behaviour considerations.
In commercial flight training we are taught to identify the root cause of an error. It can be a long way before the error becomes apparent. What we emphasise is errors will happen; it is what you do next that is important. "When in a hole, stop digging" is one mantra. Equally, "realise you are in a hole and climb out." However, how did you dig the hole in first place = root cause. Low energy at entry seems to be a root cause, but... it was exacerbated by not following PPPPPP. Not having made Proper Preparation of knowing the escape manoeuvre before entering a possible deadly manoeuvre could also be a root cause, and it occurs earlier in the chain. A Swiss Cheese indeed.
As to point one I assume the entry height and entry speed were wilfully actioned. Why they were wrong is for debate: confusion of type (back to PPPPPP) or lack of attention?
I fly light a/c aerobatics and not being very current nor hot at them I make sure there are lots of margins buffering my performance, and I've read the manufacturer's notes about the what & how. Equally, before attempting any of these I have a QFI polish my stall & spin recovery technique. PPPPPP.
It would be blatantly unfair of CAA to start knee jerk reactions towards other displays. One muppet crashes a Ferrari because they drive it beyond their capabilities doesn't cause a blanket ban on all Ferraris being driven as they were designed. If a crash-causing fault is found, that is something else.
If it is true that the CAA authorisation & oversight might be involved, then I would suggest they look inwards first and sort that out before looking outwards. However, they might want to audit their display authorisation department to see if there is another Shoreham waiting to happen.
Page 29 of the report - picture. At X750 feet on the altimeter, the broader part of the needle obscures the thousands of feet and the tens of thousands of feet on the counter.
Now say a court of law wants to find a C130 captain not guilty of taking off someone's head due to a faulty rad-alt, then so be it, but to claim that is the actual reason is a very poor excuse. You could apply similar to the 'possibly mis-read' altimeter.
Courtney
Report P 2-4-2-5 Monitoring by the Pilot
"The pilot could not explain why he continued…."
"Height and speed achieved was similar to that achieved at the apex of 4 looping manoeuvres the pilot conducted during 2 displays in a JET PROVOST the previous weekend."
What do you think that implies??
Report P 2-4-2-5 Monitoring by the Pilot
"The pilot could not explain why he continued…."
"Height and speed achieved was similar to that achieved at the apex of 4 looping manoeuvres the pilot conducted during 2 displays in a JET PROVOST the previous weekend."
What do you think that implies??
Arfur Dent,
He could not explain lots of things because he received injuries in the crash, was placed in an induced comma and has suffered PTSD and memory loss. It implies nothing, but you are inferring more than you have evidence so to do.
He could not explain lots of things because he received injuries in the crash, was placed in an induced comma and has suffered PTSD and memory loss. It implies nothing, but you are inferring more than you have evidence so to do.
D Type. Again read the full report. He stated he did not recall the minimum speed for rolling out at the apex. Large aileron inputs at low speed do not always deliver the expected results in high performance aircraft. Case in point, rolling at high aoa in the F4 resulted in roll reversal and departure.
I am more than a little puzzled by the approach of some here.
The basics of the accident are fairly clear from the AAIB's report. The final manoeuvre was entered from too low a height, at too low a speed and the engine was not delivering full power during the climb into the manoeuvre, for reasons unknown.
The pilot's background and overall experience suggests that he should have been well capable of recognising this was not going according to plan, both in position and available energy. Most of us would presume that would involve changing the plan, not continuing. It is why we try to have alternatives available in flying, to cater for the unusual/unexpected.
That the pilot did not abandon the manoeuvre seems to be either an indication of gross misjudgment of the physical situation or an indication of over confidence or 'press-on-itis' - under the pressure of being on display. Not the first of us to fall foul of these, and sadly highly unlikely to be the last. Those two have killed many pilots over the years and given many more of us bad frights. Unfortunately it appears the pilot cannot throw any more light on any of this.
The underlying root causes which led to those errors require more consideration and go much wider than just a series of cumulative errors by the pilot on the day, but the first level 'causes are clear.
Throwing in things like altimeter discrepancies seems to me simply an attempt at a smoke screen - interesting and well worth debate for future but surely quite irrelevant here, given the direction in which that error would have shown itself. As for the technical failures of maintenance and associated paperwork, while they are appalling and indicative of corner cutting, possibly for cost reasons, they are not germane to the accident per se.
I don't want to see this pilot pilloried for a disastrous series of errors, any one of which any of us might make (though I'd hope most would manage to spot the trend before the lost cause point!) but I don't believe it does the cause of flying and flying safety any good to be seen touting pointless excuses as a 'get-out'. That has happened too often before and as a result lessons are not properly learned.
The basics of the accident are fairly clear from the AAIB's report. The final manoeuvre was entered from too low a height, at too low a speed and the engine was not delivering full power during the climb into the manoeuvre, for reasons unknown.
The pilot's background and overall experience suggests that he should have been well capable of recognising this was not going according to plan, both in position and available energy. Most of us would presume that would involve changing the plan, not continuing. It is why we try to have alternatives available in flying, to cater for the unusual/unexpected.
That the pilot did not abandon the manoeuvre seems to be either an indication of gross misjudgment of the physical situation or an indication of over confidence or 'press-on-itis' - under the pressure of being on display. Not the first of us to fall foul of these, and sadly highly unlikely to be the last. Those two have killed many pilots over the years and given many more of us bad frights. Unfortunately it appears the pilot cannot throw any more light on any of this.
The underlying root causes which led to those errors require more consideration and go much wider than just a series of cumulative errors by the pilot on the day, but the first level 'causes are clear.
Throwing in things like altimeter discrepancies seems to me simply an attempt at a smoke screen - interesting and well worth debate for future but surely quite irrelevant here, given the direction in which that error would have shown itself. As for the technical failures of maintenance and associated paperwork, while they are appalling and indicative of corner cutting, possibly for cost reasons, they are not germane to the accident per se.
I don't want to see this pilot pilloried for a disastrous series of errors, any one of which any of us might make (though I'd hope most would manage to spot the trend before the lost cause point!) but I don't believe it does the cause of flying and flying safety any good to be seen touting pointless excuses as a 'get-out'. That has happened too often before and as a result lessons are not properly learned.
Maybe could have / should have done better. However, I believe the manoeuvre would have been completed successfully if the engine had reached and maintained full power.
For me, this is the primary cause.
At 100kts, upside down, the aircraft have to go into a vertical dive to gain flying speed, or enter a spin with injudicious control input.
For me, this is the primary cause.
At 100kts, upside down, the aircraft have to go into a vertical dive to gain flying speed, or enter a spin with injudicious control input.
Biscuit, basically sound points, but look at the words you use.
Reasons unknown
Suggests
Presume
It appears
Seems to me
I prefer the well considered, thorough and neutral language of the experts that crafted the report. I do not consider the summary to be reflective of a number of issues that cast enough doubt on certain events on the day. Apart from that, they have raised plenty of recommendations that should contribute to safety in the display circuit.
None of it provides hard evidence of negligence, error or deliberate act on behalf of the polit.
Reasons unknown
Suggests
Presume
It appears
Seems to me
I prefer the well considered, thorough and neutral language of the experts that crafted the report. I do not consider the summary to be reflective of a number of issues that cast enough doubt on certain events on the day. Apart from that, they have raised plenty of recommendations that should contribute to safety in the display circuit.
None of it provides hard evidence of negligence, error or deliberate act on behalf of the polit.
Below the Glidepath - not correcting
I don't want to see this pilot pilloried for a disastrous series of errors, any one of which any of us might make (though I'd hope most would manage to spot the trend before the lost cause point!) but I don't believe it does the cause of flying and flying safety any good to be seen touting pointless excuses as a 'get-out'. That has happened too often before and as a result lessons are not properly learned.
Maybe could have / should have done better. However, I believe the manoeuvre would have been completed successfully if the engine had reached and maintained full power.
For me, this is the primary cause.
At 100kts, upside down, the aircraft have to go into a vertical dive to gain flying speed, or enter a spin with injudicious control input.
For me, this is the primary cause.
At 100kts, upside down, the aircraft have to go into a vertical dive to gain flying speed, or enter a spin with injudicious control input.
As highlighted in previous posts, the actual apex of the loop is not the best place to try to spot roll out if it. No, neither do you wait for the vertical when it's too late. Ease off on the pull, let the nose continue to drop below the horizon, IAS rapidly increasing, aileron roll 180 then ease out. You could probably achieve the entire recovery within 1000ft or less.