Shoreham Crash Blamed on Pilot

[bentwaters81tfw]

 

https://www.gov.uk/aaib-reports/aircraft-accident-report-aar-1-2017-g-bxfi-22-august-2015

Edited March 3, 2017 by bentwaters81tfw
AAIB report now available

[Vickers McFunbus]

AAIB reports don't apportion blame.

 

As an aside, it's not like he's the only one who has a lot to think about operating that report. Big issues to think about for any person, company or group operating aircraft in flying displays for one.

[bzn20]

There isn't much in here that wasn't mentioned in the  thread we had just after the "accident". Pilot error, wrong heights, course, slack under funded maint procedures not followed IAW set down procedure including anti det servicing, organisers blew it . Another disaster waiting to happen. Then people wonder why air displays are under threat because insurers don't forget and charge accordingly for cover.

We have a system in this country that (normally) sticks to the rules, nobody seemed to be doing it correctly. The legal people will have field day.

[Jimbobtheflimbob]

additionally the report says that the aircraft was around 40kts too slow and was not at minimum power, which was not evident at the time.

[Panzer Vor!!!]

Its said the height and speed are correct for a Jet Provost doing the loop but not a Hunter , investigators wonder if he confused which aircraft he was flying , only 48 hours on  a Hunter but more used to the Provost   

 

http://www.telegraph.co.uk/news/2017/03/03/shoreham-air-show-disaster-final-report/

[Stonar]

2 hours ago, Vickers McFunbus said:

AAIB reports don't apportion blame.

 

 

 

They don't, but they do attempt to establish the causes of any accident. I have just spent several hours reading the entire report and those causes are many and complex.

The sort of selective reporting, in which one or a few causal factors of the many is seized upon, perfectly demonstrated by the report in the Telegraph, is really not helpful. You will see a lot more of the same on various forums etc. over the next few days.

Unfortunately most journalists, like forum contributors, are as lazy as most of us, and will only read the summary before extrapolating from it to make a good headline or snappy post. Why struggle through 450 odd pages?

Cheers

Steve

Edited March 3, 2017 by Stonar

[F4u]

Nothing we already 

2 hours ago, bzn20 said:

There isn't much in here that wasn't mentioned in the  thread we had just after the "accident". Pilot error, wrong heights, course, slack under funded maint procedures not followed IAW set down procedure including anti det servicing, organisers blew it . Another disaster waiting to happen. Then people wonder why air displays are under threat because insurers don't forget and charge accordingly for cover.

We have a system in this country that (normally) sticks to the rules, nobody seemed to be doing it correctly. The legal people will have field day.

 

Totally agree , nothing we already new ! Like the way the news says looping the loop ! I hate that term,  it's a looping manoeuvre !!!

Now the legal case will begin and no doubt it will take a while .

Insurance will be affected and already is hitting some guy's already.

 

Guy

[Jabba]

35 minutes ago, F4u said:

 

Totally agree , nothing we already new ! Like the way the news says looping the loop ! I hate that term,  it's a looping manoeuvre !!!

 

Guy

 

Usually the BBC call it a stunt, which again is incorrect.

[Paul J]

One thing for sure; no more displays at Shoreham.

[F4u]

18 minutes ago, Jabba said:

 

Usually the BBC call it a stunt, which again is incorrect.

 

Something they do in movies isn't it ? 

 

Guy

[stevehnz]

3 hours ago, Stonar said:

 

They don't, but they do attempt to establish the causes of any accident. I have just spent several hours reading the entire report and those causes are many and complex.

The sort of selective reporting, in which one or a few causal factors of the many is seized upon, perfectly demonstrated by the report in the Telegraph, is really not helpful. You will see a lot more of the same on various forums etc. over the next few days.

Unfortunately most journalists, like forum contributors, are as lazy as most of us, and will only read the summary before extrapolating from it to make a good headline or snappy post. Why struggle through 450 odd pages?

Cheers

Steve

I'll not argue with your points Steve as I haven't read the whole report & don't intend too. I do think you're being a little tough on the Telegraph in that they appear to have distilled the essentials that most lay people will want to know & as I see it, for what ever reason, if Andy Hill hadn't been too low or too slow, had aborted the manouvre at the top of his loop ( half roll & exit stage left?) etc, then there would be no need for this report. Imho, all the other findings re Maintence, Airshow location etc are somewhat incidental to that particular bit of nitty gritty.

Steve.

[Dave Swindell]

19 minutes ago, stevehnz said:

Imho, all the other findings re Maintence, Airshow location etc are somewhat incidental to that particular bit of nitty gritty.

I don't think so, Steve. Any one of the other findings should have prevented him from even taking off, eliminating the risk of the accident altogether, so hardly incidental. There were lots of failures that day, and the pilot being low and slow was significant only in it being the last.

[bentwaters81tfw]

23 minutes ago, Dave Swindell said:

I don't think so, Steve. Any one of the other findings should have prevented him from even taking off, eliminating the risk of the accident altogether, so hardly incidental. There were lots of failures that day, and the pilot being low and slow was significant only in it being the last.

To be fair, the diaphragm was discovered  post crash, and covered 4 different types of RR engines. RR themselves found the perished part had no effect on engine performance. The right altimeter was defective, but he would have been flying on the left instrument, which was working correctly.

 

He would have known he had lost energy through the flight controls, and should have taken steps at that point. Furthermore, the DAA should have called it off when he entered the manoeuvre at under 200 feet when the criteria was 500 feet. Not as though he hadn't done this sort of thing before.

 

[sinnerboy]

2 hours ago, Paul J said:

One thing for sure; no more displays at Shoreham.

that's for sure, shame used to enjoy it

[Dave Swindell]

14 minutes ago, bentwaters81tfw said:

To be fair, the diaphragm was discovered  post crash

To be fair, I didn't mention the diaphragm, and wasn't referring to it per se. I wasn't referring to any particular technical problem preventing the aircraft from taking off.

I was referring to all the findings relating to procedural, operational and assessment failings which would have meant he shouldn't have been permitted to take off to perform that particular display in an aircraft not maintained to meet the requirements to permit it to fly.

 

[stevehnz]

3 hours ago, Dave Swindell said:

I don't think so, Steve. Any one of the other findings should have prevented him from even taking off, eliminating the risk of the accident altogether, so hardly incidental. There were lots of failures that day, and the pilot being low and slow was significant only in it being the last.

Yes, true,  BUT, once he was in the air, unless there is something in the report that points to aircraft serviceability being a causitive issue, then it all comes back to the pilot & his decision making & experience or lack thereof. As far as the general public are concerned, that is about all that will matter to them. To the airshow industry the greater depth of the report & the contributing factors listed therein will be of much greater long term relevance. To the man/woman on the street, the issue is whose fault is it? To me, simple answer for possibly not so simple reasons, is it was the pilots fault.

Steve.

Edited March 4, 2017 by stevehnz
missed word

[bentwaters81tfw]

Yes there were several areas that were not according to the book as inspections and responsibilities were fudged. The paperwork was not in order, although the airframe and engine were in airworthy condition. I also suspect, although it was not mentioned, he was due to display elsewhere that day, and had a full load of fuel, including tanks. Rather more weight to compensate for, but still a badly handled airframe on the day.

[bzn20]

Had anyone that mattered found out about the anti det maintenance (because of the inactivity of the engine being run) not being carried out. It would never had been allowed to fly, Red Lined Entry. Other defects could be OK'd as "Fit to Fly" and some restrictions may be applied but it must be checked not just assumed or ignored. That's how the system works. No good saying it does really mean anything , it shows a lack of understanding of what their job is and responsibilities they have. I wouldn't trust them with a bicycle. Spent too many years working in and with these regulations that are set in stone. It's also a kind of Law, ignore them and people can be locked up for it.

[Vickers McFunbus]

6 hours ago, Stonar said:

 

They don't, but they do attempt to establish the causes of any accident. I have just spent several hours reading the entire report and those causes are many and complex.

The sort of selective reporting, in which one or a few causal factors of the many is seized upon, perfectly demonstrated by the report in the Telegraph, is really not helpful. You will see a lot more of the same on various forums etc. over the next few days.

Unfortunately most journalists, like forum contributors, are as lazy as most of us, and will only read the summary before extrapolating from it to make a good headline or snappy post. Why struggle through 450 odd pages?

Cheers

Steve

 

I quite agree - I was just making a point of order (which was contained in the summary on page 1/472!)

[Stonar]

13 hours ago, stevehnz said:

I'll not argue with your points Steve as I haven't read the whole report & don't intend too. I do think you're being a little tough on the Telegraph in that they appear to have distilled the essentials that most lay people will want to know & as I see it, for what ever reason,

Steve.

 

Unfortunately for the Telegraph's headline, the fact that the pilot 'may' have thought he was flying another aircraft is not one of the many far more important factors that led to the calamitous outcome of the display. It was in fact neither a causal, nor contributory factor in the accident, according to the report.

I do appreciate that the vast majority of people neither know, nor care, about the complexities of the issues, but for me the correct balance is not being found and this is due to the facile reporting by the press in general (not just the Telegraph!).

 

Just to clarify, the report does not state that the pilot may have thought he was flying a different aircraft type. It states.

 

"It is possible that the pilot misread or misinterpreted speed and height indications during the manoeuvre, or recalled those for a different aircraft type."

 

My emphasis. This is not at all the same as believing you are flying a different type.

 

I have read the entire report and no one involved in the organisation of the event, or the maintenance and flying of that particular aircraft comes out of it well.

 

I am not qualified to pass comments on our airshow community, like most here I just attend airshows to enjoy them, but there is some serious food for thought in that report.

 

Cheers

 

Steve

 

Edited March 4, 2017 by Stonar

[noelh]

Reverting to previous practice or action is known human factors issue and it has tripped up many pilots over the years and caused a few accidents. It doesn't even have to be a different type. It can be as simple as a switch in a cockpit being different. So it's not implausible that he flew the loop using Jet Provost speeds.

As ever though no accident has one single cause and that's why the report needs to be considered in full. A couple of friends of mine died when their Cessna spun in after running out of fuel. Open and shut case you might think: Pilot error. Well yes but the report highlighted a number of factors that led the pilot to believe he had sufficient fuel. 

It's rarely black and white when it comes to crashes.

Edited March 6, 2017 by noelh

[junglierating]

Swiss cheese people swiss cheese....lots of factors but he took the cab and a misjudgement caused the lump to fall out the sky not maintaince. There is always something found during any sort of investigation always but on thisooccasion it would appear to be human factors. It's a risk environment and sadly people died.I dont think anyone on here was on the board therefore we are just as informed as the telegraph.

But for the grace of god go I ....plus adhering to the regulations

And a good dose of experience. 

[Stonar]

On 06/03/2017 at 8:23 PM, noelh said:

 So it's not implausible that he flew the loop using Jet Provost speeds.

 

He entered the loop at over 300 knots IAS which, whilst slower than his own stated minimum for the Hunter, seems awfully fast for a Provost, but I'm not a pilot .

Can a Provost even go that fast at sea level? If not, then it is entirely implausible that he flew the manoeuvre using Provost speeds. The report suggests that he may have used Provost values (height and speed) at the 'safety gate' at the top of the loop, before making the catastrophic decision to continue the planned manoeuvre....but there is no hard evidence for this.

Cheers

Steve

[noelh]

I've no idea about Jet Provost speeds either so I checked the report again and have extracted these numbers from table listed on page 51 for a JP display the pilot flew previously. In brackets are the height and speeds the Hunter flew on the accident flight as shown in the diagram on page 47. The similarities are striking apart from the entry speed of the Hunter.

 

Loop entry:

Indicated altitude  (±50 ft) 200    (185 should be 500) 
Indicated airspeed  (±5 KIAS) 270 (310 should be 350)

Loop apex:

Indicated altitude (±100 ft) 2750 (2800 should be 4000)
Indicated airspeed (±10 KIAS) 125 (105 should be 150)

 

He had flown two JP displays the previous weekend.

 

I think the numbers speak for themselves.

 

 

[Stonar]

5 hours ago, noelh said:

I've no idea about Jet Provost speeds either

 

 

I have looked them up, and in level flight at what was effectively sea level the Provost can't make 300 + knots. If he entered the manoeuvre at a speed that only the Hunter could achieve (even if below his stated minimum for the manoeuvre) it makes no sense that he was flying to the requirements of the Provost.

Frankly I think that the suggestion in the report that, at the top of the loop, the pilot might have applied the criteria for the Provost at the 'safety gate' is no more than supposition, probably due to the coincidence of the numbers flown in the Hunter to those applicable to the Provost. There is precisely zero evidence for this in the report, and I have read the entire thing. The 'what caused the crash?' is that the pilot flew too low and too slow. The 'why did that happen?'is not something I am qualified to comment on, but the idea that the pilot somehow confused two different aircraft types seems a bit far fetched to me.

I'm not a pilot, have no axe to grind here and am doing no more than applying common sense. SWMBO and myself both drive different models of car by the same manufacturer, but I always know which one I'm driving

Whatever happened, it was a tragedy for 12 people (including the pilot) and their families.

Cheers

Steve

Edited March 11, 2017 by Stonar