|Sweeping new safety changes being put in place for all future UK air shows.|
SUNDAY MARCH 5th
UPDATE REPORT PUBLISHED:
FRIDAY MARCH 3rd 2017
'Pilot errors' and 'ineffective measures to protect the public' led to the deaths of 11 men when a 1955 Cold War vintage jet aircraft crashed onto a dual carriageway alongside, and during the Shoreham Air Show, assert AAIB Investigators in their Final Report.
The Final AAIB report on the Shoreham Air Crash has been published,the highly detailed report in summary says that on 22 August 2015, a Hawker Hunter G-BXFI crashed onto the A27, Shoreham dual-carriageway Bypass, while performing at the Shoreham Airshow. Fatally injuring eleven road users and bystanders. A further 13 people, including the pilot, sustained other injuries.
The AAIB investigation considered over an 18 month period the circumstances in which the aircraft came to be in a position from which it was not possible to complete its intended manoeuvre, and the reasons for the severity of the outcome.
The report recognises that as well as being enjoyed by large numbers of spectators and participants, flying displays are also considered to provide important economic and educational benefits, but equally points out that a safe flying display relies on the training and experience of the display pilots, airworthiness of the aircraft, and importantly planning and risk management of the event, suggesting regulations, guidance and oversight provide the framework for these activities.
The aircraft was carrying out a loop manoeuvre involving both pitching and rolling components, which started from a height lower than the pilot’s authorised minimum for aerobatics, and at an airspeed below his stated minimum, and also proceeded with less than maximum thrust. It simply was not powerful enough for the intended display.
This resulted in the aircraft achieving a height at the top of the manoeuvre less than the minimum required to complete it safely, at a speed that was slower than normal.
The AAIB investigators suggest it was possible to abort the manoeuvre safely at this point, but it appeared the pilot did not realise the aircraft was too low to complete the downward part of the manoeuvre.
An analysis of human performance commissioned for the AAIB identified several credible explanations for this, including:
not reading the altimeter due to workload,
distraction or visual limitations such as contrast or glare;
misreading the altimeter due to its presentation of height information;
or possibly incorrectly recalling the minimum height required at the apex ( the peak or top of the 'loop')
The AAIB investigation found the guidance concerning the minimum height at which aerobatic manoeuvres may be commenced is not applied consistently and may be unclear.
There was evidence that other pilots do not always check or perceive correctly that the required height has been achieved at the apex of manoeuvres.
Training and assessment procedures in place at the time of the accident did not prepare the pilot fully for the conduct of relevant escape manoeuvres in the Hunter say the AAIB report.
The manoeuvre continued and the aircraft struck the ground on the northern side of the westbound carriageway of the A27 close to the central reservation. A ground tracking point at a slight angle to the direction of the road.
When the aircraft impacted, it broke into four main sections.
Fuel and fuel vapour released from the fuel tanks then ignited. In its path were vehicles that were stationary at, or in the vicinity of, the traffic lights at the junction with the Old Shoreham Road, and pedestrians standing by the junction.
The pilot says the AAIB did not attempt to jettison the aircraft’s canopy or activate his ejection seat.
However, disruption of the aircraft due to the impact, activated the canopy jettison process and caused the ejection seat firing mechanism to initiate. The seat firing sequence was not completed, due to damage sustained by its firing mechanism during the impact. The seat was released from the aircraft and the pilot was released from the seat as a result of partial operation of the sequencing mechanism.
Some of the pyrotechnic cartridges remained live and were a hazard to first responders until they were made safe.
The investigation found that the aircraft appeared to be operating normally and responding to pilot control inputs until it impacted the ground.
However defects in the altimeter system would have resulted in the height indicated to the pilot being lower than the actual aircraft height at the apex of the manoeuvre.
Information included in a previous AAIB report indicated that there had been several cases involving the type of engine fitted to this aircraft where an un-commanded ( ie unexpected/ unexplained ) reduction in engine speed had occurred and subsequent engineering investigation did not establish a clear cause.
This investigation was unable to determine whether a reduction in engine speed recorded during the accident manoeuvre was commanded by the pilot.
The aircraft’s engine was subject to a Mandatory Permit Directive (MPD) which imposed a calendar life on the engine type, and provided an option to extend that life using an Alternative Means of Compliance (AMOC).
Proposals for an engine life extension using an AMOC inspection programme had to be approved by the regulator.
Related tasks were being conducted by the maintenance organisation, but the regulator had not approved the operator or its maintenance organisation to use an AMOC to this MPD.
The investigation found that defects and 'stretching' of the aircraft’s operational limits had not been reported to the maintenance organisation, and mandatory requirements of its Airworthiness Approval Note had not been met.
During prolonged periods of inactivity (ie mothballing) the aircraft’s engine had not been preserved in accordance with the approved maintenance schedule.
The investigation identified a degraded diaphragm in the engine fuel control system, which could no longer be considered airworthy. However, the engine manufacturer concluded it would not have affected the normal operation of the engine.
The aircraft had been issued with a Permit to Fly and its Certificate of Validity was in date, but the issues identified in this investigation indicated that the aircraft was no longer in compliance with the requirements of its Permit to Fly.
The investigation found that the parties involved in the planning, conduct and regulatory oversight of the flying display did not have formal safety management systems in place to identify and manage the hazards and risks.
There was a lack of clarity about who owned which risk and who was responsible for the safety of the flying display, the aircraft, and the public outside the display site who were not under the control of the show organisers.
The regulator believed the organisers of flying displays owned the risk. Conversely, the organiser believed that the regulator would not have issued a Permission for the display if it had not been satisfied with the safety of the event.
The aircraft operator’s pilots believed the organiser had gained approval for overflight of congested areas, which was otherwise prohibited for that aircraft, and the display organiser believed that it was the responsibility of the operator or the pilot to fly the aircraft’s display in a manner appropriate to the constraints of the display site.
The AAIB suggests no organisation or individual considered all the hazards associated with the aircraft’s display, what could go wrong, who might be affected and what could be done to mitigate the risks to a level that was both tolerable and as low as reasonably practicable.
Controls intended to protect the public from the hazards of displaying aircraft were ineffective.
The investigation identified the following causal factors in the accident:
- The aircraft did not achieve sufficient height at the apex of the accident manoeuvre to complete it before impacting the ground because the combination of low entry speed and low engine thrust in the upward half of the manoeuvre was insufficient.
- An escape manoeuvre was not carried out, despite the aircraft not achieving the required minimum apex height.
- The pilot either did not perceive that an escape manoeuvre was necessary, or did not realise that one was possible at the speed achieved at the apex of the manoeuvre.
- The pilot had not received formal training to escape from the accident manoeuvre in a Hunter and had not had his competence to do so assessed.
- The pilot had not practised the technique for escaping from the accident manoeuvre in a Hunter, and did not know the minimum speed from which an escape manoeuvre could be carried out successfully.
- A change of ground track during the manoeuvre positioned the aircraft further east than planned producing an exit track along the A27 dual carriageway.
- The manoeuvre took place above an area occupied by the public over which the organisers of the flying display had no control.
- The severity of the outcome was due to the absence of provisions to mitigate the effects of an aircraft crashing in an area outside the control of the organisers of the flying display.
SB 3/2015, published on 4 September 2015, 13 days after the accident, reported initial information about the occurrence.
SB 4/2015, published on 21 December 2015, dealt with the safety of first responders to the accident scene, the maintenance of ejection seats in historic ex-military aircraft and issues regarding the maintenance of ex-military aircraft on the UK civil register. Seven Safety Recommendations were made.
SB 1/2016, published on 10 March 2016, considered the risk management of flying displays, minimum display heights and separation distances, regulatory oversight and piloting standards.
It contained a further 14 Safety Recommendations, and was published to inform the air display community ahead of the 2016 air display season.
A further 11 Safety Recommendations are made in this report.
THURSDAY MARCH 2ND:
A team of air accident investigators are to publish their final report into the tragic Shoreham Airshow disaster on Friday March 3.
As we have reported, the 18-month investigation by the Air Accidents Investigation Branch (AAIB) is specifically tasked with determining the cause of the crash and to make safety recommendations to the aviation industry also to prevent similar tragedies happening elsewhere.
|Hawker Hunter jet|
The purpose of the investigation is not to apportion legal liability or blame; but to assemble in minute detail, critical evidence to establish the possible cause of any accident; indeed the AAIB resisted a police legal challenge to turn over the unpublished evidence they had collected for the AAIB investigation.
Sussex Police applied for the disclosure of:
- Statements made by the pilot to the Air Accidents Investigation Branch in response to discussions or interviews;
- Film footage of the flight which was made by cameras which had been installed on the aeroplane in question on a voluntary basis; and
- Material which has been produced by various other people subsequently, such as experiments conducted and tests done on various aspects of the accident.
A spokesperson for the Air Accidents Investigation Branch said: “The AAIB is not able to release protected air accident investigation records of its own accord.
Only the High Court can allow for their release. We note today’s judgment and will now release the film footage to the Chief Constable of Sussex Police.”
Relatives of the deceased have been invited to attend a private face-to-face advance briefing on the AAIB’s final report on March 2, some 24 hours before it is publicly released and published.
Eleven men died when the vintage Hawker Hunter jet failed to pull out of a flying display loop manoeuvre during the Shoreham Airshow in West Sussex on August 22, 2015.
The 1955 plane was commanded by an experienced pilot Andrew Hill, who was thrown out of the jet before impact, sustained multiple injuries, but has survived. The Hawker Hunter jet lost height following a loop, ending in an explosion and fireball on the A27 dual carriageway, alongside the air show perimeter fence having first hit vehicles, drivers and pedestrians.
A total of eleven, all men, died in the disaster.
They were: wedding chauffeur Maurice Abrahams, 76, from Brighton; retired engineer James Mallinson, 72, from Newick, near Lewes; builder Mark Trussler, 54, from Worthing; cyclists Dylan Archer, 42, from Brighton, and Richard Smith, 26, from Hove; health professional Tony Brightwell, 53, from Hove; grandfather Mark Reeves, 53, from Seaford; Worthing United footballers Matthew Grimstone and Jacob Schilt, both 23; personal trainer Matt Jones, 24; and Daniele Polito, 23, from Worthing.
During the 1960s, long nose two-seater versions of the Hawker Hunter cold war jet remained in use primarily for pilot training and support roles with the RAF and the Royal Navy until the early 1990s.
During the height of the cold war in the 50's some early versions of the jet were housed in Swedish mountain roadside silos, the idea being the jets could quickly take off along the roadway and engage the enemy by stealth. They were extremely versatile. The Hawker Hunter jets were still in active service in some parts of the world in 2014.
JULIAN BRAY +44(0)1733 345581, Journalist & Broadcaster, Aviation Security & Airline Operations Analyst/expert, www.freelancedirectory.org?name=Julian.Bray.aviation.comment Travel / Maritime & Cruise Industry, NUJ, EQUITY, LIVE ISDN LINK, Broadcast ISDN COOBE ++44 (0)1733 345020 e&oe Old faithful NOKIA: 07944 217476 www.aviationcomment.com