Shoreham

[gookah]

what are our aviation guys on here, thinking about the accident and pilot's trial?

I was all for the pilot being locked up for not doing the manoeuvre with enough height and a cavalier attitude, as allegedly was in his nature,
but then some experts are saying that he did not seem to be trying enough corrective actions to avoid the crash. No engine increase at the bottom, no urgent movements in the cockpit shown on the go pro he had behind him,
not even the use of the ejector seat,

Had he been impaired somehow or maybe ill, that prevented him taking enough and appropriate avoiding action?
was the loop high enough to begin with, but he wasn't fully in control and let it slip too much.

I am now thinking along the latter, what do others think?
For the sake of another 1000ft why would you even risk it? it would only have probably needed another 50ft to have it become a near miss instead.

 

[andyglym]

Possibly impaired, unlikely that a pilot of this experience would be so cavalier (but not unknown). I don't think we'll ever know the exact reason, however, one thing that is almost certain is that it's very very unlikely that a pilot would bang out whilst others were at risk. They tend to 'go down with the ship' as it were whilst trying to rectify the situation until the point of impact.

 

[Dalek]

My flying experience is just in small Cessnas and the like and I have no experience of fast jets and certainly very limited aerobatics hours but I was surprised to hear experts talk of his ‘cavalier attitude’. I know quite a few pilots, and whilst I would be the first to admit some of them are a bit gung ho, that has only applied to the normal everyday pilots. Those that are aerobatics or flying display pilots are always, in my experience, highly disciplined and would never take unnecessary risks.
That said, we are all human and can make mistakes. I think that this is just a horrible accident and my heart goes out to all those involved.

 

[mwpe]

I agree with previous comments and I think it was a simple misjudgement. It appears that although the pilot had some 40 hours on the Hunter his normal display aircraft was the lighter nimbler Jet provost. The hunter is a heavy aeroplane and needs more room to loop. I have flown as a passenger it the two seat hunter and it does pull a lot of G.

 

[t-tony]

horrible accident

I think you're dead right here Paul, it was an accident and sadly they happen. But, in this world someone has to be held accountable.

Tony.

 

[Redline]

It was reported before that he had acted a at east one other display against the display flight director’s instructions. Guess that will come out later in the trial.

No pilot deliberately flies into the ground. But, as the old saying goes, there are old pilots and there are bold pilots, but, there are no old bold pilots.

Think here it’s the same as many drivers who run out of skill, luck and tarmac after misjudging their actions. The problem is, as the years have shown, there is no room for misjudgment in this game. The pilot was phenomenally lucky to be thrown from the crash while those on the ground suffered the consequences.

There’s nothing like watching air displays from close to the flight line. Unfortunately pure accidents and avoidable ones happen. Sadly displays will become rarer to see because of this one.

Btw - I didn’t think privately owned aircraft like this were allowed active ejector seats. The explosives involved make them too dangerous to be used.

 

[smiffy]

There is a thing in aerobatics called "gates". These are specific points in a manoeuvre where certain criteria are required in order to achieve a safe manoeuvre.

For example, for a loop performed from the end of a flypast. Note the following are just example figures

Gate 1. Loop entry, height 500ft, speed 200knts
Gate 2. Vertical climb speed 190knts,
Gate 3. Top of loop, height 3000ft, speed 180knts
Gate 4. Vertical decent, speed 230knts, pulling 3G
Gate 5. Exit, level, height 600ft, 260knts

So Gate 1 you set during your flypast
Gate 2 you check and adjust power setting if required
Gate 3, the important one, if either of these have not been achieved, you roll out of the manoeuvre and start again.
Between Gate 3 and Gate 4 you go from 0% to 100% committed.
So Gate 3 is your critical decision point.

If you don't achieve your Gates, you can't complete the manoeuvre safely.

Now, I am loathed to analyse this specific case or the AAIB report on a publicly viewable page as it could be picked up by the red top media and affect the trial, but applying the above logic to the AAIB report should help you draw your own conclusion.

 

[Jonnysnapzzz]

I know bugger all about flying other that my trips to the sun. But i do know people. I think that given a crowd to play up to most people will want to put on a good show and in flying displays this often means low and daring.
I think its easy for many people to develop a cavalier attitude when the conditions are right. Have years of experience without incident can also breed a feeling of invincibility.
I am sure pilots are very skilled and highly professional but they are also human.

 

[abh29]

I think you're dead right here Paul, it was an accident and sadly they happen. But, in this world someone has to be held accountable.

Tony.

Unfortunately in my opinion the wrong person is being "held accountable" in this case.

If the organiser had completed [and complied with] a fully detailed risk assessment he would have considered the consequence of an "incident " occurring [if any remote chance of an incident the effect has to be considered next] , so he should then have considered the effect resultant from that incident.
An incident involving an aircraft losing control and crashing would need to be considered, the consequential risk being serious harm to people on the ground. His Risk Assessment would have then covered the means of reducing that risk in the event of the incident occurring, not just to visitors in the airfield but any people [or property] in the are that could be effected.
It seems clear that the easiest [and action most likely to succeed] way would have been for aircraft to perform over the adjacent open sea.
It is clear this option was not taken , but instead the aircraft were to perform over an adjacent busy highway , being used by people who were not in any manner involved in the display. Using this area reduced the risk to visitors to the event inside the airfield, but increased the risk to anyone using the highway.
It seems that the pilot was operating on the location route supplied by the event organiser to fly over the highway, when the unfortunate "incident" occurred.
The fatalities have occurred because the display was over a public highway, if it had been over the open sea no fatalities would have occurred. The injury's being limited to those incurred by the pilot.
We have a fantastic air display in North Wales each year ,but it is held over the open sea not over the adjacent populated area.
As said by @Redline "Sadly displays will become rarer to see because of this one."

 

[gookah]

My view is different on that.
We have an acrobatic air display every year in Telford, crossing busy roads and houses too
Cannot get further inland, so they would be stopped using the above risk assessment reasons.
Look at Kegworth disaster they land crossing the M1, still carrying on.
Should they put those organisers in court too then? (and in Kegworth maybe they were)

You can minimise or even eliminate risk, and in coastal cases, over the sea (in hindsight) would have been ideal, but risk assessments, also take likelihood and history into account not just consequences.

I suspect the likelihood and history has shown these acrobatics are normally extremely safe even inland.
Now if the organisers had prior information that the bottom of the loop was to be within 20ft of the road and not 600ft or 1000ft, they would have decided that it was not allowed I'm sure.
That is for the pilot to be questioned about, more so than the organisers, but they will probably end up in court as well.

the questions for them would be, did they know he had been stopped at previous airshows for alleged unsafe practices, if not why not, and if they did know, what persuaded them to let him perform?

 

[smiffy]

In order for the organiser to carry out the level of risk assessment suggested, they would need to be fully conversant with displaying every aircraft type in the display. As every type performs differently, you just won't find that person.

In the same way, a building site supervisor would rely on the competency and qualifications of say a crane driver, a job the supervisor can not do, the display director has to rely on the competency of each pilot. Even then, if the pilot deviates from his planned flight path and gate targets, the display director has no real time control other than to call "stop, stop, stop" over the radio.

 

[abh29]

In order for the organiser to carry out the level of risk assessment suggested, they would need to be fully conversant with displaying every aircraft type in the display. As every type performs differently, you just won't find that person.

In the same way, a building site supervisor would rely on the competency and qualifications of say a crane driver, a job the supervisor can not do, the display director has to rely on the competency of each pilot. Even then, if the pilot deviates from his planned flight path and gate targets, the display director has no real time control other than to call "stop, stop, stop" over the radio.

Sorry but the Building Site Supervisor can not just rely on the competence and certification of the operator for lifting on a site.
For any lifting to be carried out a Risk Assessment has to be completed. If the crane [fork lift, telehandler or whatever] is going to be used continuously on that site ,this will in all likelihood be subject to a single initial generic plan, but if the crane is being bought in for specific lifting operation a Lift Plan will be developed for that lift.
In the generic plan , not only will the suitability of the crane have to considered but the following points , not all of which become relevant.
correct choice of the crane, checking its certificates are all in order
suitability of slings .chains ect.
working under suspended loads
environment
location of crane
overturning
proximity hazards
derating
lifting people
overload
pre use checking
ground conditions below the crane
the certification required to be checked for all involved.

As well as the crane operator being correctly certified , the banksman/slinger ect must also be certified.

In the event of the lifting operation being more than can be covered in a generic RA-- a detailed Lift Plan must be developed ,this will drawn up by [all in accordance with LOLER Approved Code of Practice] a person certified to do so and the lift then comes under the control of the Lift Supervisor on site.
The person drawing up RA will have to take advise from third parties if his own knowledge does not extend to that part of the risk, ie assessing the load capacity of the ground, accessing the equipment into the site.

As you point out at an air display you may not find a person with all the knowledge required, I would think you would take third party advice from as many who do know.

For the purpose of carrying these RA and detail Method Statements I was fully certified [as Appointed Person] to complete documentation myself and to check documentation carried out by my staff, and delegate the role of lift supervisor in my absence.

I retired 10 years ago after over 40 years in construction, an industry where for many years far to many people were killed.
but I do actually consider the industry had gone to far the other way, and ceased to actually take full account of the experience and skills of its workforce ,and just assume that because someone has the required bit of plastic they are the expert.

 

[abh29]

My view is different on that.
We have an acrobatic air display every year in Telford, crossing busy roads and houses too
Cannot get further inland, so they would be stopped using the above risk assessment reasons.
Look at Kegworth disaster they land crossing the M1, still carrying on.
Should they put those organisers in court too then? (and in Kegworth maybe they were)

You can minimise or even eliminate risk, and in coastal cases, over the sea (in hindsight) would have been ideal, but risk assessments, also take likelihood and history into account not just consequences.

I suspect the likelihood and history has shown these acrobatics are normally extremely safe even inland.
Now if the organisers had prior information that the bottom of the loop was to be within 20ft of the road and not 600ft or 1000ft, they would have decided that it was not allowed I'm sure.
That is for the pilot to be questioned about, more so than the organisers, but they will probably end up in court as well.

the questions for them would be, did they know he had been stopped at previous airshows for alleged unsafe practices, if not why not, and if they did know, what persuaded them to let him perform?

In doing a Risk Assessment the first section is the list of risks.

I am not experienced in flying aircraft but I would consider one of the first risks to consider would be

"incident occurring in the air"
you look at the consequences of these and I would consider the first being loss of life if plane crashes.
so what can be done , can we have the planes flying over an unpopulated area , sea will be ideal. Safety is not just to be considered after the event, the purpose of assessing risks before is to reduce the risk and consequence thereof.
If we have no choice but to fly over populated areas what actions can be taken to reduce consequential risks , perhaps fly a bit higher to give more safe space to retrieve the situation, Its not my field of expertise so I don't know the answer.
If the person drafting the document does not have all the knowledge required for each section [or aircraft]consult others who do.
It seems to me that the pilot in this case was very well qualified and experienced so would have passed the requirement on that score. Its said he made a mistake before , is this recorded for all others see , and should that be the case. If he has a good history except for an isolated incident, we all make the odd error.

Our local display is over water , and I can not see why this one was programmed over a highway.

I like your view we can eliminate risk, I doubt it , and life would be too overcontrolled.

I have sat in a meeting when we were sorting out overcoming a problem that had arisen , when the Principle Inspector from the HSE brought all our thoughts to a halt, by deciding before discussing how we went forward, WHY we had got in the situation we were in. We had not had an incident ,but very difficult meeting , we [contractor and designer] had not correctly assessed all the consequences of one of the risks.

 

[smiffy]

@abh29 and once the crane driver is in the cab and the load is suspended, what stops him making an error and hitting the scaffold with the suspended skip? You can only "risk assess out" 99% of human error.

Here is the link to the AAIB report https://www.gov.uk/aaib-reports/aircraft-accident-report-aar-1-2017-g-bxfi-22-august-2015

 

[abh29]

@abh29 and once the crane driver is in the cab and the load is suspended, what stops him making an error and hitting the scaffold with the suspended skip? You can only "risk assess out" 99% of human error.

Here is the link to the AAIB report https://www.gov.uk/aaib-reports/aircraft-accident-report-aar-1-2017-g-bxfi-22-august-2015

You never will remove all risks
Unfortunately most incidents with crane operation results from error made in the slinging not errors by the crane operator. On a lot of construction site the operator is fully certified but anyone seems to act as a slinger.

 

[abh29]

@abh29 and once the crane driver is in the cab and the load is suspended, what stops him making an error and hitting the scaffold with the suspended skip? You can only "risk assess out" 99% of human error.

Here is the link to the AAIB report https://www.gov.uk/aaib-reports/aircraft-accident-report-aar-1-2017-g-bxfi-22-august-2015

Thanks for the links

In the report AAR1/2017 it states "parties involved in planning conduct and regulatory oversight of the display did not have formal safety management system in place to identify and manage the hazards and risks" it then goes on to explain that each party involved considered the
risk management was with another part of the organisations involved.
It later says "No organisation or individual considered all the hazards associated with display, what could go wrong, who might be effected ,what could mitigate the risks"
"The severity of the outcome was due to the absence of provisions to mitigate the effects of an aircraft crashing"
It appears on a quick read that the CAA did had a system of recommendations in place , but these were not being adhered to by the Display Organisation, and they did not pick up on that.

As a example the first category on Priority for Protection is "Uninvolved third parties" not accounting for this put the display directly over a highway. [I am assuming the pilot was told were to perform his display]

A quick read surprises me even more that the pilot is the only person in trouble over this incident. I note a fault in the aircraft resulted in a loss of Permit , but I don't know if he would be aware of that fact. While it seems that the pilot may have made errors [don't we all] to hold him solely responsible for the consequences seem unfair. When thinks went wrong the pilot would have very short time period to realise the trouble and correct it, whereas the organisers had amply time to get the papers work side sorted out. Surely those who put him in the situation were these consequences were inevitable in the event of a incident should also be held to account to at least the same degree.

The construction Industry has tried to avoid this situation by bringing all aspects of a project under the control of one named person [although sometimes in the early days a Corporate Body] in 1995 with the Planning Supervisor , then in 2007 to CDM Co -Ordinator and a couple of years ago to Principle Designer / Principle Contractor. The purpose of all these posts has been to enable the HSE to have a named responsible person in to hold responsible the event of an incident.

It does seem as if the CAA are bringing display organisers into line with other industry's, lets hope that display organisers actually work with them.

Yes I know Health and Safety is a pest --- usually due to being taken to absurd lengths. We got in trouble on one site from council H&S inspector for having a white cable on a kettle[came with it out of box] , 240v in construction industry should be blue, fortunately his boss saw sense.

 

[gookah]

I like your view we can eliminate risk, I doubt it , and life would be too overcontrolled.

Health and Safety first line of action is to eliminate risk, or, if it cannot be eliminated, go on to mitigate it afterwards,

You can easily eliminate risk from an airshow, by not holding an airshow in the first place.

How many accidents have there been in the Shoreham Airshow since?
None..... because the airshow has been stopped.
The risk has been eliminated.

 

[abh29]

But this is the risk, of not following the guidelines issued by the CAA (referred to in link provided by Smiffy )the organisers have deprived a lot of people of an enjoyable day out.
As for eliminating risk, I have never seen that achieved without cancellation ,which is not the purpose of Risk Assessment. It's to reduce the level of consequences in the event of an incident. The guidelines issued by the CAA refer to protection of third party persons , the organisers could have mitigated the risk easily by flying over the sea , not over a highway.
It would be interesting to know how they dealt with this risk to third party,s Ultimately the RA is part of a process to save life's
As I have pointed out I believe we are going too far down the safety road,and treating people as not having any common sense at all
Unfortunately the decision to put third party lives at risk by not moving the fly path a couple of miles over the sea just gives power to the extremists in the H & S.

 

[smiffy]

@abh29 I hold a pilots license, I've flown aerobatics. My mentor was a former fast jet pilot, by coincidence a Hunter display pilot and an air warfare instructor, also in Hunters. On that basis, I think I'll stick with my own ideas thanks.

I think your understanding and management of risk is different to that in aviation, I would suggest possibly booking a session with these guys might be a real eye opener for you and help you understand the processes and mindset involved.

https://www.ultimatehigh.co.uk

As I said at the start, I don't think discussing the specific incident is appropriate in a public forum considering the current court case.

 

[Gremlin]

Well I don’t wish to discuss the rights and wrongs of this. But this pilot did not get up that day and expect or want to kill those people and bring so much grief and sorrow to all those families nor do I suspect did he himself want to die, he probably now possibly wishes he had died himself rather than all those that did. He now has to not only injure and relive this in a court case,but he has to live with this for the rest of his life. Could you live with it I’m not sure I could. To live with it is sentence enough as far as I’m concerned.