Air show risks highlighted by Shoreham crash probe

People flock to air displays to see thrilling flying. The fact that it looks dangerous is part of the attraction.

It turns out – in case anyone ever doubted it – that display flying is very dangerous. But mainly to the pilot rather than the audience. The UK Air Accident Investigation Branch has just put some figures to the display flying accident rate, which had not been done before.

The AAIB reveals that the fatal risk to display pilots at UK air shows is nearly twice that to pilots at US air displays.

This deep examination of the whole business of air display safety is the official reaction to the crash in August 2015 of a Hawker Hunter T7 jet onto a busy road next to Shoreham airfield during an air display routine. The pilot survived, but 11 people on the A27 road died – the first time since 1952 that UK air show onlookers have been killed.

The final report is not yet complete, but the AAIB has issued two interim reports and a load of recommendations.

The AAIB has now estimated that the fatal display accident rate in the UK is one accident causing death or serious injury per 219 display hours. The agency explains: “Over the ten years to the end of 2015 there were nine display accidents in which the aircraft was destroyed and either a fatal or serious injury resulted.  This equates to one such accident per 219 display hours or 456 such accidents per 100,000 flying hours of which – historically –  55% have involved fatalities.” Those figures were reached by assuming the duration of the average individual display routine is eight minutes.

By comparison, the fatal accident rate for UK general aviation activity as a whole is 1.5 fatal accidents per 100,000h. That makes display flying roughly 300 times as dangerous as the GA flying average.

Another AAIB revelation makes clear why they have decided it’s time to tighten up display flying management. The report says: “Among UK display accidents, 65% involved the aircraft crashing outside the area controlled by the organisers of the display.  This equates, at 2015 levels of activity, to one display aircraft crash in an area accessible to the public every 1.7 years.”

It seems everyone knew air display flying was dangerous, but not precisely how dangerous. I suspect the attitudes that allowed this regime to continue unquestioned until now are inherited, dating back to the early days of flying when thrills and spills were considered all a part of the fun, and providing spectators didn’t get hurt, that was fine.

The Shoreham inquiry has also thrown up the fact that the existing rules governing the conduct and management of air shows were sound, but they were often not tightly policed. It turns out that the Shoreham flight display director (FDD), a display pilot and former CAA safety expert, was not required specifically to know in advance the sequence of aerobatic manoeuvres the Hunter was to carry out – and he did not know them.

Yet there was also a requirement that the FDD conduct a risk management assessment of the display, and that could not be done without knowing the planned sequence.

If the FDD had checked the Hunter’s planned sequence and speeds in advance, he would have discovered that – at many points in the routine – the aircraft would inevitably exit from the permitted display areas defined by the location of built-up areas close to the airfield. Indeed the same aircraft, displaying the previous year, had done just that, but no-one got hurt so it was ignored.

This is just one example of the fact that the main requirement for improving display safety is to apply existing rules more strictly, rather than rewrite them completely.

The rules about how display flying and air shows should be conducted are set out in the CAA’s publication CAP 403. Perhaps the key statement in it is this: “The impromptu, ad hoc, unrehearsed or unplanned should never be attempted.” That means every part of every routine must be known by all parties, rehearsed before the show, and strictly adhered to.

If that rule alone – which had always been there – were to have been applied strictly at Shoreham in August last year, the crash would not have happened. Indeed the Hunter routine that led to disaster would either have been banned or modified considerably to make it comply with existing rules.

 

 

92 thoughts on “Air show risks highlighted by Shoreham crash probe

  1. Excellent – your reports always most welcome and respected, David.

    Do keep em coming …!

    Best … Reg Pycroft

    Sent from Reg Pycroft’s iPad – on the road.

    >

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  2. Thank you David for your interesting and thought provoking piece on the Shoreham tragedy.

    I have heard some real crass comments being made about this Hunter crash recently. How could people be allowed to stand under the display line? The organizers didn’t do a proper risk analysis…… The organizers did not know what the pilot was doing.

    The essence of CAA airshow approval is limited to setting up a display line and a display box for pilots to display in, and hold areas. Knowledge of what the pilot will do in his or her display is generally up to the pilot and the owner of the aircraft. As an organizer, you don’t tell the pilot how to fly his/her machine. You just give him/her a display box to do their thing. The pilot flies and displays his plane as he or she sees fit for purpose. How many airshows have the luxury of a rehearsal? Furthermore, how will a risk analysis help in the slightest here? Ensure that display pilots are approved by the CAA perhaps? Previous Shoreham shows have had accidents, but with no “collateral” damage thankfully. These incidents didn’t warrant an inquiry, and were classified as “these things happen”. One has to really ask, do all main roads near an airshow have to be closed during displays? Look at Farnborough. My exposure to risk analysis is we list all the improbable things that could happen and assign a low probability to them. This Hunter crash, very unfortunate as it was, was an extremely rare event, and any knee jerk reaction is completely idiotic and politically motivated.

    In this case apparently, a perfectly serviceable aircraft crashed due to unknown circumstances. Clearly, the lucky/unlucky pilot could be blamed, but maybe he blacked out for a moment…. Accidents happen. Airshows are never 100% safe, and this crash just emphasis this point. We just need to move on from this horrible crash, and not bring in measures to restrict the enjoyment of airshows, and the number of airshows in the future.

    Hope my comments put some perspective on this terrible tragedy at Shoreham. Some people just like to read more into this crash, and perpetuate the “Nanny State” mentality. I for one, hope they fail…..

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    • “The organizers didn’t do a proper risk analysis…… The organizers did not know what the pilot was doing”.

      Indeed crass of DL and the AAIB to mention it and daft of people to be in a town when a display was planned to go over it for the second year in a row. Fully agree with you.

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      • I’m behind you 110%. The boss of all Air Shows said on his video that the rules were robust. Yet the AAIB made sure there were loads and loads of unnecessary new ones!!!!!

        Something completely cretinous and not fit for purpose going on here.

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  3. I saw on the Love Shoreham site that John Turner, Chairmen of BADA, had this correctly assessed — the problem was ‘the road was in the wrong place’. Should be left to the experts.

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  4. Your knowledge of air transport and military aviation is well known however I am not aware of your expertise in the airshow world other, perhaps, for the hospitality chalets at Paris or Farnborough. You are often put up by the television media as being an “aviation expert” but stick to the limits of your knowledge.

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    • Nasty!

      Well blow me. Rod Dean, the FDD responsible for the display and who was lambasted by the AAIB for his lack of ability in providing an adequate or unique risk analysis for Shoreham or providing for the safety of the public, is as a result seen as an appropriate speaker and mentor at the BADA business day, today. God help us!

      http://www.bada-uk.com/2017/10/latest-business-day-agenda/

      What will the press make of this ?

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      • The DADA Business Day today at Duxford was excellent with some fine speakers and much discussion. Rod Dean gave a thought provoking talk on both past efforts by the UK air display industry as its prime representative body to be effective and put forward some interesting thoughts for the future. Rod had a long and distinguished career as a display pilot both while in the RAF and as a civilian. He was Head of the General Aviation Department at the CAA for several years and has been the Flying Display Director at many large airshows. Despite the comments made by Nimrod and some criticisms by the AAIB following the Shoreham tragedy I can think of no one who would make a better FDD. Hindsight is a wonderful thing, especially when exercised by armchair critics. We all await the outcome of the inquest into the tragedy, the first occasion where a spectator or third party has been killed at an airshow since 1952 and John Derry’s accident at Farnborough, some 63 years earlier. It was indeed a tragedy and all must learn from it but media pressure focused on it while ignoring the number of deaths on UK roads which happen every month.

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      • Andy was a better choice.

        For the record:George Bacon of the British Air Display Association said Mr Hill was “an unbelievably experienced chap” who was “very thorough and professional” in his preparation.

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    • LupeLoo. I don’t think the grand “DADA”s will ever change their view that the reason for the disaster was simply that the road was in the wrong place, despite all the evidence in the world from the AAIB. No lessons learned which is why there will now be a government review and further regulation!

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      • . A breach of a duty of care that causes, or “significantly contributes to”, a death is gross negligence manslaughter. The AAIB chose their words carefully regarding the organisers contribution to the deaths.

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      • LupeLoo

        Learmount was also very specific as well which implies he had a firm grasp of the legal ramifications regarding the failures and consequences for those responsible when he penned this article. Probably the most informed writer in his field.

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      • If it is legitimate there is the prosecution of the pilot under Article 137 of the Air Navigation Order 2009 then given the conclusion presented in this article the organisers should be prosecuted under Article 138.

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  5. “The impromptu, ad hoc, unrehearsed or unplanned should never be attempted.”

    — So CAA regulations breached. Negligence causing loss of life. Corporate manslaughter committed by the Directors of Shoreham Airsbkw Ltd. Is that what you are saying?

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    • The CAA have been peddling ‘just Culture’ for the last few years. Seems if was just some jobsmith filling his day!

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      • Just Culture requires that breaches of safety rules are punished. As the author states, if the organisers had kept to the CAA rules, nobody would have died.

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  6. Stevie, I’m not saying that, I’m quoting CAP 403 which says “The impromptu, ad hoc, unrehearsed or unplanned should never be attempted.”. If it turns out that the display was impromptu, ad hoc, unrehearsed or unplanned, then it will have been contrary to the CAP 403. If that was so, then it would be up to a court to pass the judgement you have suggested. It might or might not see fit to do that. I am not a lawyer.

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    • Is it correct to say the Hawker should not been doing stunts at the Shoreham Air show without a plan?

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      • Remember the final AAIB report on the Shoreham crash has not yet been published. We only have limited information from the two interim statements.

        At this stage we cannot say for certain that the Hawker pilot had a planned routine, but according to normal practice he almost certainly did have one. But because we don’t know what his plan was we don’t know whether he stuck to it or deviated from it. The AAIB, however, have interviewed the pilot so they may know.

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  7. Well if he did not deviate from his chosen plan it was as has already been stated a lunatic plan or he was showing off. What is interesting is that the FDD at Shoreham was a CAA insider and it seems the CAA did little to check his submissions or his displays despite infringements the previous year. Perhaps the AAIB needs make a statement to the effect that nothing was skimped because he was a ‘mate’. The CAA has to protect its reputation and I do think they need to confirm this to avoid any such suspicion.

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  8. — sorry I don’t want to dominate your space, so last post. Just need to remake the point that despite only having interim reports the AAIB does state ‘either these regulatory infringements were not detected or not understood by the display organisers’. The AAIB has concluded that the display organisers have a case to answer already. Action can be taken against the display organisers now and the sooner the victims see justice the sooner people can get some peace. They don’t deserve the extra grief they are getting from the stonewalling and constant denials from the display organisers who still post they infringed no rules … pure BS.

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  9. I’ve seen an interesting development regarding the statement contained in the AAIB third interim report:

    ‘The flying display community in the UK are a small group of individuals who are often well known to each other and there will always be conflicts of interest.’

    The question being raised for the eventual inquest is did the BADA play a simular role at Shoreham to the Masons at Hillsborough?

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    • Retired RAF Squadron Leader: Chris Heames who was listed to fly the wrecked Hawker Hunter jet:

      “It very clear where you have to fly and it’s very carefully planned, he said. I flew the same plane at the same event last year and the year before. I have no concerns over safety’.

      “It is a wonderful piece of British engineering and impeccably maintained”.

      George Bacon: British Air Display Association, described Andy Hill as ‘unbelievably experienced’ and said: “his preparation for air displays was second to none”.

      It’s little wonder there are so many crashes when the assessments of their own capabilities by those running displays is so very very different from the reality as revealed by the AAIB. “Self-certifying”, ‘mutual appreciation society”, “Cosy club”, lots of quotes out there.

      Obviously when the CAA bestows its accreditations, sound judgement has no part of their fitness assessment process. Time someone from the CAA was in the dock for gross negligence.

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  10. I’ve seen an interesting development regarding the statement contained in the AAIB third interim report:

    ‘The flying display community in the UK are a small group of individuals who are often well known to each other and there will always be conflicts of I retest.’

    The question being raised for the eventual inquest is did the BADA play a simular role at Shoreham to the Masons at Hillsborough?

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  11. … seems like some undue influence here when the AAIB gives the risk analysis to the HSE for advice but refuse to let the police have a copy. Someone is pulling strings to block the prosecution of the air show directors. Looks like Hillsborough more and more.

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  12. It will surely be questioned that the AAIB have delayed their final report until they know that the evidence and therefore their report is open to scrutiny!!! This is the first time to my knowledge and one wonders about the validity of all previous reports. It’s telling that the police don’t trust the AAIB reports but want the true evidence !!! It shows the police smell a rat.

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  13. British Transport Police take 24 hours to arrest killer Tram Driver with no previous in Croydon. AAIB still sitting on their backsides and it looks like being 24 months before they get this lunatic pilot with previous charged. AAIB are clearly incompetent or delaying to protect their mates. An investigation of the AAIB is needed!!!

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  14. Stevie – the Crown Prosecution Service is gathering evidence on this case, has interviewed the pilot, and will, in due course, make a decision whether to prosecute according to whether they judge there is sufficient evidence to initiate a successful criminal prosecution. That is also what is happening in the case of the tram driver. The AAIB does not have the power to prosecute anyone. It is not the AAIB’s task to do that. But the AAIB or the Civil Aviation Authority will draw the attention of the police and the CPS to a case if it believes there may be a criminal case to answer. But it is the job of the police and CPS to gather evidence to that effect. The facts the AAIB gathers are not gathered for the purpose of establishing blame, just what occurred and why/how, and are therefore not admissible in a court of law. The facts have to be stood up independently by the police/CPS according to court standard of proof.

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  15. Good measured piece by you on Sky covering all aspects. One has to look under every stone to prevent this ever happening again. Good to see that will finally happen.

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  16. Well the AAIB have done a good job in the report. However many of their recommendations so far enacted by the CAA have been implemented without any significant consultation with those in the UK airshow industry that would be and are adversely affected. The implementation has been without regard to proportion, evidence, statistical analysis or sheer common sense. Some have been ‘gold plated’ to a huge degree in defiance of the initiative of Grant Shapps MP to rid the CAA of this tendency that has been prevalent for decades. The UK airshow industry is at risk and the tradition of airshows going back to the earliest days of powered flight in the UK is under considerable threat. All because of human factors which are inseparable from any human activity, no matter what.

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  17. Barry, I couldn’t agree more. The CAA has to ensure it doesn’t once again earn its reputation as the Campaign Against Aviation. Tightening up sensible practices is fine, but introducing the kind of bureaucracy the purpose of which is to cover the agency against legal action will kill the display industry and, in the process, do irreparable harm to the UK’s aviation and air transport industry.

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  18. DL

    I didn’t imagine that there was anyone in any capacity in any business who did not know that you had a legal and moral duty of care to all those you come in contact with. You are required to do what is reasonably expected of you. For some it is more a matter of honour that you go beyond reasonable and you do your best. Unfortunately those that run air displays believe they can pass their duty of care onto somebody else, and we saw the consequence. You seem to recognise this whilst none of your contemporaries do. Thank you for that. If the dinosaurs running our air displays do not recognise this there will be none. Your remark about Farnborough, its illegality and the absence of the Red Arrows on Sky News, pretty much indicates how much damage is being done.

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  19. Flying Medic,
    You spoke of the the duty of care and I quote – “Unfortunately those that run air displays believe they can pass their duty of care onto somebody else, and we saw the consequence. You seem to recognise this whilst none of your contemporaries do. Thank you for that. If the dinosaurs running our air displays do not recognise this there will be none”.
    You may honestly believe those that those who organise UK airshows are dinosaurs. I can assure you they are not. It is the CAA and thee MAA who grant the legal permission to hold any airshows in the UK. They are the ones who must take final responsibility for permitting the shows to take place. I write as an aviation professional for over 60 years and as a lifelong aviation enthusiast from childhood. I was active as an airshow pilot for over 55 years with some 2,300 airshow performances in the UK, Europe and the USA. From your pseudonym you are also an aviation professional as an AME. My battles with your fraternity might interest you and if you contact me I would like you to read them..

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    • The CAA has SOME responsibilities for aviation specific safety matters and provides some guidelines and certifications. The H&SE supported by relevant legislation has FULL responsibility for the safety of people in general. It is especially pertinent to the Shoreham tragedy as those killed and burned were members of the public in a public place. This legislation covers an event such as Shoreham, requires a competent risk analysis and states the organisers of an event must take ownership of the risk. I believe only a relic from a bygone age would not have known this. I’m sure the coroner will put this more eloquently.

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      • Your knowledge of the stranglehold H&SE has on much in the UK today is quite obviously superior to my own. As they say in my home county ” I am nobbut a pilut….!!!” and next year I learn to spell it. We live in times where “if there is blame there is a claim” and the leech like lawyers will relish their inflated fees coming from this tragedy. Any airshow can only happen with a legal permission from the authority, CAA or MAA, signed by a senior staff member of that organisation who is formally authorised to do so. It should not be granted if there is any doubt whatsoever that all safety considerations have been dealt with appropriately. Not happy then no signature, no permission, no show and once again the CAA lives up to the adage “Cease all Aviation” or. in this case “Cancel all Airshows”. If indeed I personally am a relic from a bygone age then in some respects I am proud to be so but do not tar every airshow organiser or FDD with the same brush, that it an insult. As you have said it is the coroner, after due consideration of all the facts, who will decide and bring this tragedy to a conclusion. Then leaving the way open for any claims or legal action to begin.

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      • The coroner has formally recognised interested persons for the Shoreham Air Disaster inquest and it includes:

        Rod Dean Flying Display Director
        RAFA Shoreham

        Section (f) of the related documentation states an interested person in this context is “a person who may by any act or omission have caused or contributed to the death of the deceased, or whose employee or agent may have done so”.

        Interesting.

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  20. When someone posts an essay, one generally comments on aspects of it, as I have. I extended it a little to cover DL’s comment on the damage this ineptitude caused to the industry referring to DL’s comments on Sky regarding Farnborough. I think that is how far one legitimately goes with a comment, I think you are going of track. Its an essay about current RISK, its in the title.

    Yes the CAA provides some certificates on the basis the rules are followed. There are rules the CAA imposes, and implied laws of the land, many of which are H&S in this case covered in the Purple Guide which I assume all involved in air shows know pretty damn well. Taking a simpler example, you can be licensed to own a gun, car, boat, dog. But it is obvious you follow the implied rules and for example as a duty of care will not allow your dog to crap in a kiddies play area, if it does its your fault as the owner, not the council who issued the dog licence or put the play area close to where you personally like to play or the kids for using it.

    The CAA issue a licence on the grounds the rules and laws would be followed.

    They were not. DL states:

    ‘ If that rule alone – which had always been there – were to have been applied strictly at Shoreham in August last year, the crash would not have happened. ”

    Argue with the AAIB who state the FDD was not up-to-speed on many areas of the rules regarding risk mitigation. They are clearly outlined in the Purple Guide and the coroner will focus on that as it outlines ownership of risk and responsibilities for risk.

    Argue with DL, its his piece not mine. He says the Organisers did not follow the rules and if they had there would have been no tragedy.

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    • English Law incorporates the notion that every citizen has the “right to life”. Do you disagree???

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  21. It’s simply not possible to rule out the individual practitioner’s responsibilities either. In this case the FDD had not ascertained exactly what the Hunter routine would be, so he could not have carried out a risk assessment on it. But just imagine he had done that, and told the pilot to modify the routine, the risk of a misjudgement from the pilot in carrying it out is always present. I suspect the CAA knows it can’t eliminate risk, especially through writing rules, but I hope it doesn’t kill air shows because of the way it wields its influence.

    The AAIB has done a good job, and what it has revealed is that air show organisers – with the possible exception of Farnborough because of its incredibly high profile – had not kept their eye on the ball, and what is really needed is for them to sharpen up.

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    • As you reported on TV, Farnborough were no better than the organisers at Shoreham who year on year put pressure the Red Arrows to put on a show to be sensibly refused by the Red Arrows. Show organisers have shown themselves to be irresponsible. The ministry of transport needs to step in and sort this mess out.

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      • I think you will find everyone in this industry bows down to Farnborough and their favours. Thankfully the Reds are independent.

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      • Lupe

        So our membership is being used to subsidise some trade show for the benefit of some fat cat?

        Patronage at its finest.

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      • “thanks to Farnborough’s already stringent regulations, changes to the display will be minor, and visitors will continue to enjoy a spectacular air show, as in previous years.

        That’s the view of John Turner, Farnborough’s flying display director”

        Well The Red Arrows, “the main attraction”, could not display for safety reasons, which only an idiot would describe as a “minor” change. No refund no apology. There are plenty of better shows which have The Red Arrows displaying and more to the point the general public are actually welcome and respected!!!

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      • We have the advantage of hindsight. But given the Red Arrows – on safety grounds – refused to perform at Farnborough, despite considerable pressure and false assurances that the venue was safe, it would seem the CAA were entirely justified in their actions; and are entirely vindicated and deserve an unreserved apology for the ill-judged hand-bagging they received from the air display community. The attack in the press is a lasting embarrassment.

        What is clear from DL’s piece on Sky TV is that this gaff has brought Farnborough into the spotlight. With the coroner positioning “The licensing, control and safety of all air shows” at the top of her list of things to investigate, Farnborough will surely be under the microscope. More embarrassment for the industry. To bait the regulator in this way was a massive mistake one can only put down to an organization with a collectively massive ego.

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      • Max

        As the AAIB has reported, the organisational structure of air shows was controlled by a tiny number of people, well known to each other, and there were naturally conflicts of interest. Or as the litigators are spinning it – “cosy pilots club”.

        It has been easy for them make a case for a conflict of interest between safety and commercial considerations, given the initial statements made by the air display community immediately after the Shoreham disaster.

        In actuality there are two clubs controlled by basically the same people and acting as one to slag off the CAA. It seems likey the CAA saw into that and the will question the motivation.

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      • Nimrod

        Its not unusual for so called independent industry spokesmen to have been found to have cosyied up to commercial interests. Examples have been found in the Food and Drinks and industries to the deprement of public safety. As has been said, there is an “eyewatering amount of money floating around aerospace” .

        It is for the regulator and if they won’t for the coroner to get to the bottom of the “conflict of interest” reported by the AAIB. So far the CAA seems to has been reluctant to investigate and take sanctions. This will not be allowed to be brushed under the carpet as fortunately we have the coroner as a backstop and lawyers who have specifically drawn attention to the “cosy club”.

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      • The blatant down-playing, and attempts to have this disaster simply passed over as “tough, it happens, there are more important commercial considerations to be taken into account”, by the spin-doctors of the display community has deeply increased the hurt and pain felt by the breieved during this extended process!_Their impact statements in court will reflect this, and hopefully be taken into account with sentencing.

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    • Exactly.
      Exactly, as you say David “It’s simply not possible to rule out the individual practitioner’s responsibilities”. What BADA wants to do is duck those responsibilities. Cowardly.

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      • The decision is it’s commercially expedient for Andy Hill to take all the rap for this and he has consequently been thrown to the wolves. He has had no support. There may be “honour amongst thieves” but support from pilots and noticeably from The Honourable Company of Air Pilots, for this pilot has been zero. In fact it’s been negative.

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    • Just Culture – the term recognised by the CAA and the flying community to deal with blame makes no attempt to rule out the individuals responsibility. Quite the opposite. It says anyone who brakes safety rules will be punished. And as has been said the rules were rigorous. And as has been said the rules were broken. And as has been said if the rules had not been broken there would not be people dead, people injured and massive destruction. I’m quoting the lawyers acting for the victims, BADA, the CAA and this article directly.

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      • Just Culture doesn’t automatically punish anyone who breaks the rules, although the authorities are entitled to do so. The key word is “intentionally”, or “knowingly”, or even “negligently”. To have a Just Culture that works it is essential that the spirit of the culture is respected. That’s why it’s called a culture.

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      • There is the presumption that the required standard under H&S law has not been met when there is an accident. So equally a presumption of negligence in such cases is difficult to defend, especially when the culpability as you outline it is so obvious. When the harm so severe it is usual to hold ones hands up at the earliest opportunity in mitigation.

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  22. I stand by what I posted here last March on this tragic incident. Airshows can never be 100% safe. No amount of risk analysis, H&S rules, CAA approvals, etc. will prevent a mechanical or pilot failure resulting in a crash. In my humble opinion as an aviation professional and enthusiast, we have to answer the question do we want to have airshows that people can enjoy with minimal risk to their personal safety. For example, separating the crowd further from the display line is not increasing safety. This will only encourage more enthusiasts to go outside the airfield to be close to the display line….

    I am surprised some comments here indicate that all airshow organizers are dinosaurs. We should be thankful that a brave band of people take on this task for the enjoyment of millions, and do what they can for safety. Responsibility for risk is lawyer talk for who will we sue if there is an accident. In the case of the Shoreham tragedy, the finger is firmly pointing towards the pilot. He was perhaps having a bad day, and no amount of bureaucracy will change this re-occurring in the future.

    We have to put this accident in perspective. Millions of airshows have been held over the last 100+ years, and the number of crashes has become really low in modern times. The risk to spectators is already as low as it can be (probably up there with airline safety), and much less than when they get in their car to drive home….. Do we see such a knee jerk reaction to thousands of road deaths each year? Of course, we don’t! We accept this risk, every day. So my message here is to do the same, when attending an airshow. Any further attempts to reduce airshow risk (low as it is already), is going to stifle events due to the proximity of roads and population centres, and high setup fees. As David Learmount has so rightly said, we must not let the CAA stand for Campaign Against Aviation, or the UK will be doomed to be an embarrassing ‘Nanny State’, with fewer airshows and only straight and level displays…..

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    • Put simply. You have a duty under the law not to take unnecessary risk with other peoples lives. You all seem happy to take risk so if you kill someone do you have any defence in law it was a justified risk? Well clearly you have to show you calculated the risk if nothing else. That’s where you need a faultless risk assessment. If you don’t, then if you kill people, its gross negligence. Its good to have a faultless risk assessment. Its bad to have the AAIB saying it was not fit for purpose.

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    • The investigation has shown the deaths were entirely preventable. Anyone who has argued otherwise has clearly demonstrated an unsatisfactory attitude to ever be allowed by the CAA to participate in an air show. That the CAA were culpable in allowing such people to participate in the first place will cost them very very dearly when it finally comes to litigation. Litigators are paid handsomely to have long memories and will ask some very unsavoury questions in some very public trials.

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      • An article 2 inquest means that the focus is on organisations, not individuals. Those organisations will very likely face very significant fines and damages. The CAA has vigorously opposed an article 2 inquest as clearly it gives scope for them, amongst others, to be investigated on a microscopic level. The CAA needs to show it has cleaned up it’s act or if will make a bad time in court, rather worse.

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      • The CAP regulations explicitly state that the FDD is responsible to the CAA for safety. The FDD is named and signs off on that responsibility. The buck stops with the FDD if The CAA is the ultimate regulator.

        However there CAP regulations explicitly state that other related regulations always override the CAP regulations. So the coroner’s aim to hold an Article 2 inquest under the European Court of Human Rights means the buck stops where it stops. So the CAA may not be able to pass the buck. This is why I believe the FDD is supporting the coroner in this and the CAA opposing it. You can knock the nanny state but in this respect she is fair and thorough.

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  23. DL yes the risk is always present. But if everyone does their bit competently it is minimised. One can say I did my best, I stayed awake at all the briefings, read all the circulars, attended the peer reviews, took responsibility for the risk under my second by second control.

    I don’t see anyone but you standing up and saying we can do a better job and convince the authorities to cut us some slack. All I see are t a lot of people making excuses and flaming others who just do the job properly. Some have not done such a lamentable job or been so outrageously rude to the authorities or been so obstructive to cause the CAA to react as they have. Clearly not everyone is a dinosaur.

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  24. Quoting the experts at the AAIB exactly:

    … A safe flying display relies on the training and experience of the participating pilots, airworthiness of the aircraft, and the planning and risk management of the event.

    As the AAIB quotes below state exactly. Every aspect for a safe display was dealt with complete disregard for any duty of care to the public.

    On training and experience of the participating pilots the AAIB states:

    “An escape manoeuvre was not carried out, despite the aircraft not achieving the required minimum apex height.

    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.

    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”.

    On the planning and risk management of the event the AAIB states:

    ‘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”.

    On the airworthiness of the aircraft the AAIB states:

    “the issues identified in this investigation indicated that the aircraft was no longer in compliance with the requirements of its Permit to Fly”

    There are a accidents, but quoting the AAIB here there were breaches of regulations in not one but EVERY single aspect related to safety at RAFA Shoreham. Simply stated this was not an accident it was gross incompetence. Argue with the AAIB if you will. Action please coroner!

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    • One of the areas dealt with, the pilot is facing a trial with a possible life sentence. The plane owner, FDD and show organisers still have to face the courts.

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    • She got the message:

      The coroner , Ms Scofield said her inquiry would “investigate the circumstances that led to the death of 11 individuals following the crashing of a Hawker Hunter T7 Registration G-BXFI onto the A27 Shoreham bypass whilst performing an air display at the Shoreham Airshow on August 22, 2015.”

      She said that the inquest would include but not be limited to

      l The licensing, control and safety of all air shows

      l The organisation, planning and running of the 2015 Shoreham Airshow

      l The safety measures and risk assessment put in place to protect those attending show and those watching from the A27 bypass.

      l The management and control of the flying display.

      l The training and experience of pilot Andy Hill and

      l Hill’s actions on the day

      Ms Scofield added that she also intended to hold an Article 2 inquest under the European Court of Human Rights.

      Article 2 inquests look into the duty of the state to prevent loss of live.

      Ms Schofield said she had concluded from the Air Accident Investigation report published last year that there was “sufficient evidence to suggest that there may have been system failures”

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      • Top of the agenda:

        “The licensing, control and safety of all air shows”.

        Well done the BADA. You were the real “blatent politickers”. No representative body could have handled this worse. You alienated everyone and have caused a backlash. Beggars belief!

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  25. LupeLoo. I don’t think the grand “DADA”s will ever change their view that the reason for the disaster was simply that the road was in the wrong place, despite all the evidence in the world from the AAIB. No lessons learned which is why there will now be a government review and further regulation!

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  26. Andrew Blackie, senior investigator for operations AAIB, said the risk assessments had not been “fit for purpose”.

    QED

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    • I do believe that based on my experience most reasonable people reading David’s Learmount’s well argued and logically developed arguments have seen that it outlines a clear example of negligence and noncompliance by the organisers and FDD who is specifically criticised in this article. It’s an article I see most often when people open their files on this subject.

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  27. Purple guide:

    Beggars belief that BADA would elevate an individual whose work was “not fit for purpose” to that of a mentor. Sacking would seem more appropriate.

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    • I regret that a typo changed the initials of the British Air Display Association (BADA) to DADA in a previous post of mine. Sorry. to all of you who were mystified.
      As I have said previously Rod Dean is quite the best Flying Display Director I have ever encountered and his presentation at the BADA Business Day at Duxford was superb. Rod is a friend of long standing and a former colleague in the CAA. His experience in the airshow world both as a pilot and as a regulator could rarely be equalled. At present the UK airshow industry is burdened by increased regulation and charges from the CAA. Much of which was introduced without any meaningful consultation, contrary to the UK Governments ‘Better Regulation’ policy and undertaking.
      The inquest into the tragic Shoreham disaster is some way ahead and that will be the opportunity for all the relevant facts to emerge. The pain still felt by those bereaved and the friends of the deceased must still be intense and they have my deepest sympathy. This as a retired airshow pilot of some 55 years experience and with the passion I have for this ever popular outdoor entertainment, second only to football in the numbers who attend.

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      • Since you make your case for the best FDD, perhaps its fair if we can respond and broaden the discussion. Would not an evidence based analysis perhaps favor one like the FDD that made a stop call on Andy Hill at Southport, giving him the heads up when he was off track? Maybe if Hill had have had similar support at Shoreham things would have tuned out very different?

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    • What is trying to be explained by those who work in support and love the small air displays, to those that are intent on destroying them, perhaps because their day has gone is:

      That whether you agree with the AAIB or the multitude of respected sources that have said that Shoreham was an accident waiting to happen or not, that is the prevailing view and therefore the one that the regulator, the MPs …, the coroner, the CPS and the judges and any civil litigators are likely to follow. Because those that argue this have logic and evidence and expertise and a lack of bias on their side.

      That the AAIB stated that the air display community had become what has been termed an old boy network where personal interest conflicts with safety.

      That perpetuating this cosy club image irritates the very people who have the job to clear up this mess, when they witness those shown at fault blatantly deny all responsibility and in a perverse way are given the platform of air display mentor. This just shows the poorest of judgement by the BADA. Truly it beggars belief and can only lead to the regulators and the litigators having a cause to come down harder.

      I wonder if these people really are the friends they claim or is it just infignting? Because they have surely added to any penalty we might expect through what are a series of outrageous and damaging statements and actions.

      Time for some logic and reason!

      Liked by 1 person

  28. The ‘STOP’ call given to the pilot at Southport was given after the breach of the rules had taken place. I fear at Shoreham any ‘STOP’ call would have been too late as the inevitable crash would have happened. The impact occurred on the road but if it had been a mere 50 metres laterally in either direction it is unlikely that any third party death or injury would have occurred. Human factors and error can never be legislated out of existence but education in this area can do a great deal.

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  29. I understood the AAIB simulation analysis shows Andy Hill was off track long before he crashed? I’ve not seen tracks of the previous year but have seen it recorded that he was also off track, was that not something to be especially alert for this time? In addition it has been stated there was a short time to abort safely? What failsafe was built-in? Did anyone at least try to send a warning. That seems to be the acid test for the system.

    The key fact remains that at Southport with the intervention of the FDD the system failed safe, yet there was no such failsafe at Shoreham.

    The industry has made Andy Hill the ‘fall guy’. That seems unfair given the evidence. The whole system failed and two years running. It happened to fail when Andy Hill was in the cockpit. It happened to fail when people were on the bypass. If it had not have been Andy Hill it would have been someone else.

    Liked by 1 person

    • If anyone thinks an aircraft flight path runs on rails and thus being ‘on track’ they are very much mistaken. The pilot flies the aircraft in such a manner as to be where he wishes to be and in compliance with the laid down and briefed regulations set by the CAA and the FDD. As I have previously stated, at Shoreham any STOP call once the final manoeuver had started would have been too late to avert the tragedy. Only the pilot in his cockpit can see whether he has the correct speed and has achieved the height gates needed, the FDD has no such information..
      In any case this thread is achieving nothing. The inquest will be held and then the facts surrounding this tragedy will be out in the open. The coroner will then bring in his verdict and the legal profession will pursue their claims…… if justified. What the CPS will do in the meantime is anyone’s guess.

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    • The Hawker Hunter “overflew residential areas along the A259 south of Shoreham airport several times and in one manoeuvre overflew the central area of the town of Lancing at an angle of bank in excess of 90 degrees” without anyone instructing the pilot to stop ……..either these regulatory infringements were not detected by the display organisers or were not understood,” the interim report concluded.

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  30. Back to CAA regulations? We already covered them quite definitively:

    ‘ If that rule alone – which had always been there – were to have been applied strictly at Shoreham in August last year, the crash would not have happened. ”

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  31. The AAIB used the term off track when it highlighted one of the causes of the disaster. This analysis by aviation expert Learmount specifically referred to the FDD and the track taken over built up areas as quoted below. Seems pretty clear the FDD would have \ should have known early on the hunter was on the wrong track over a built-up area. Seems a critical assessment of the FDD in my reading.

    ‘If the FDD had checked the Hunter’s planned sequence and speeds in advance, he would have discovered that – at many points in the routine – the aircraft would inevitably exit from the permitted display areas defined by the location of built-up areas close to the airfield. Indeed the same aircraft, displaying the previous year, had done just that, but no-one got hurt so it was ignored.”

    Liked by 1 person

  32. Well we know the risk assessment was not fit for purpose, the AAIB said so. But I have a question on personal fitness. I was for my sins pushed up to some rotund old buffer, more neck than shoulders, indeed i vividly remember the neck flowed over his collar. He seemed unable to complete a sentence without weezing and he stammered badly. And yes this under normal circumstances would be horribly rude. But he was full of the fact he was an FDD and I was wondering how he might actually manage with his impediment to stammer out a stop call or anything?

    So the question. Do FDDs have any meaningful fitness or medical checks like ATCs, particularly when they are beyond retirement age?

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  33. PurpleHaze

    They are required to disclose any long-term physical or mental health issues. If such an issue came to light that had previously not been disclosed that would I believe be a false declaration and a criminal offence. It would certainly invalidate any insurance and FDD status. Be a lunatic stunt to pull.

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    • … Shoreham opened the pandora”s box where prosecutions are concerned. Some have attempted to save their arses by putting ALL the blame on the pilot. It will come back on them!

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    • Is that the reality? Here is what it says in the Argus.

      The CAA allowed Rodney Dean, 72, of South Godstone, Surrey, to continue acting as the flying display director for the event but had not checked to make sure he was “fit and competent”.

      For certain the investigators see. keen on highlighting this laxness and more examples may be in the pipeline

      Like

  34. Tim Loughton will again speak on behalf of justice for the victims of the disaster in the House of Commons on Tuesday at 16:00.

    Like

  35. Well good news, looks like the plot to scapegoat the pilot failed. Now the path is open to go after the organisers who, as it says here, were responsible.

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  36. DL.

    The view of Just Culture was made in the context of your article, my apologies for not being clear. In your article you make the case that the organisers either knew or really should have known that built up areas were being over-flown as they also were the previous year. That’s your argument and we all agree with you. But even in the general sense you refer to, if a safety rule, let alone a critical safety rule is broken some reprimand, retraining, or simply sacking the person is the normal response. Be a poor unjust culture, to let the rules be broken over and over until innocent folk are killed, surely?

    I have to say you wrote an excellent article. I apologise for pushing the limits of this discussion at times. But it’s opened a wider discussion that has proved productive.

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    • Indeed the knowingly, and intentionally and outside the skillset defence will always fail. The fault must be dealt with at some level to avoid it being repeated. That is in essence the difference between the a “cosy club” culture that leads to disasters like Shoreham and the “just culture” that is designed to prevent them.

      For example if you say for example X was not trained to handle this situation then one simply moves up the chain to see who was responsible for training and oversight and that would be where the blame has to be dealt with. That is why the coroner will look at the system whole system for failures, not just the individuals. The system was flawed in every aspect as DL has stated elsewhere. Everything and everyone needs looking at. Not very cosy but necessary.

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  37. Sadly Domino, we had to be there.

    There were so many re-runs, clearly there were not enough booked acts for the circus, could not in all honesty call it an air display. And so many gaps? Was the ringmaster asleep, i know we were. Let most of the team go early, waste of time …

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  38. Will never go again on a public day , absolute joke to call it an airshow ,the flying display on Saturday was atrocious and badly organised in my opinion ,, lacklustre apart from the f16 which went up twice to fill in the obvious lack of content ,red Arrows restricted in what they can do in the airspace around farnborough and red bull air race that was underwhelming,statics were average with a handful of exceptions , people want to see the latest aircraft ,big aircraft and fast jets ,most of the interesting civil jets left before the public weekend began (antanov , dreamliner ,737 max , everything from the cargo village ,the list goes on ,£42 overpriced ticket I had , disgraceful ,last but not least the water situation was a joke especially in the temperatures for the Saturday,too few water stations and to queue for 20 /30 minutes in that heat was just madness ,poor planning ,poor layout of statics and the worst flying display I’ve seen at a premier airshow ,sorry I couldn’t be more positive but said how I seen it on the day

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  39. Maybe David Learmont might answer my earlier question, or better still write one of his most excellent essays. I see from Tempest’s original post that David is well placed to form a view of what is going on at Farnborough.

    This in my experience been a really excellent year for air displays and many people have put their heart and soul into it for very little reward. Yet Farnborough was dire and poor value for the public. So I repeat my earlier question. What’s gone wrong?

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  40. FlyingMedic, there are several factors behind the changes at Farnborough that have disappointed you. The first is that Farnborough is, above all, a trade show, and air displays are now considered less important as a sales and marketing tool than they used to be. Now they are often seen as an expensive luxury, and it’s enough to park your product in the static display area.

    As you know, the public are invited in at the weekend when almost all the trade visitors have gone and many of the stands and chalets are unmanned, but the idea used to be that the air show and the display was a good way of encouraging the great British public – especially the young – to back Britain’s aerospace industry, and to inspire young people to aim for careers in it. That intent is still very much alive, but the participants are trying to do it on the cheap.

    The second reason is the Shoreham disaster. One of the conclusions of the AAIB’s report is that airfields at which displays have taken place regularly for decades need to be re-surveyed because, in many cases, a great deal of residential and industrial development surrounding the aerodromes has taken place, which changes dramatically the manoeuvring aircraft are allowed do over the newly built-up areas, and the height at which the manoeuvring can take place. Development around Farnborough airfield’s boundary, and even within it, has been considerable.

    For example the Red Arrows carried out an audit of Farnborough immediately the AAIB made this point in the Shoreham report, and quickly made it clear that it could not continue the kind of displays it used to perform there without breaking the rules. By implication, the team had unknowingly been breaking the rules for years, but tradition is a powerful motivator to continue something that has always worked and continues to be very popular.

    Also Farnborough is now a very busy business aviation airport owned by TAG Aviation, a big player in European business aviation, and air movements by business aviation traffic using Farnborough for arrivals or departures take priority over all other traffic, including air display traffic. Since a lot of the people using these flights are VVIPs or HNWIs, unless they also happen to be aviation enthusiasts they are not the kind of people who like to be delayed.

    The message is that if you want a good air display, Farnborough is not the place to go for it because it’s not going to get better. The reverse, in fact.

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    • Perhaps in all fairness the general public should have been told.that, not that the display would be much the thrilling show as in previous years. Maybe those that actually bought tickets do indeed have the right to ask for.a.refund..Seems like tne cash cow is being well and truly milked. Sad to see it end though.

      Like

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