No person or organisation associated with the 2015 Shoreham flying display accident escaped criticism – implied or actual – in the Air Accident Investigation Branch’s final report.
When the aircraft that later crashed, the Hawker Hunter T7, took off from its North Weald, Essex base heading for Shoreham to fly the display, it had several time-expired or unserviceable components in it. In retrospect the AAIB report says it was not in compliance with its permit to fly, yet none of these faulty components caused the accident.
The Flying Display Director hired to manage show safety was fully qualified in terms of knowledge, experience and expertise to oversee all aspects of the flying display, but the report implies there were some things – like the exact display routine the Hunter was to fly – he should have risk-assessed manoeuvre by manoeuvre. Yet even if he had, the crash might still have happened.
The Hunter’s pilot was fully qualified in terms of experience, training, flying recency and medical fitness to carry out the display he had planned, but on the day he got one of the aerobatic manoeuvres badly wrong, making mistakes that are difficult to understand in somebody so experienced.
The mistakes meant that he himself was seriously injured when thrown clear of the aircraft on impact with the A27 highway next to the airfield, but 11 people on the road were killed.
By flying a similar Hunter through the same manoeuvres, the AAIB has determined that the pilot could not have pulled the aircraft out of his “bent loop” without hitting the ground once he had passed the apex too low and failed, at that point, to carry out an “escape manoeuvre” by rolling the aircraft upright.
If he had used his ejection seat during the high speed descent from the loop it would not have saved him, and the pilotless aircraft would have continued to impact with the ground, possibly in much the same place. The only way the pilot could have prevented killing the people on the A27, says the report, was to crash the aircraft into nearby fields, but during the last second or so he probably still hoped he could avoid harm to road-users by pulling up in time.
Why was he too low at the loop’s apex?
He should have entered the loop from a 500ft base, but he started at about 185ft. The height of the top of a loop compared with the entry height is a product of speed and engine power at entry. The aircraft should have entered at a minimum 350kt with full power selected, but the Hunter entered at 310kt with less than full power until well into the pull-up. The pilot should have aimed for a 4,000ft apex with 150kt indicated airspeed over the top, but in fact it got to less than 3,000ft with 105kt.
Unless the pilot recognised the lack of energy at that point and carried out the rolling escape manoeuvre, he and the aircraft were doomed.
Why a pilot with so much experience of teaching, let alone flying, aerobatic manoeuvres failed to heed these indicators that the loop was going wrong may never be known, because trauma has obliterated the details of the fatal flight from the pilot’s memory, according to the report.
Air shows involve risk. A study by the AAIB has recently quantified that risk, and my blog a year ago describes the findings in detail.
The final Shoreham report confirms the impressions given by the earlier AAIB bulletins on the subject. Because no-one in an on-site air display audience in UK has been killed since the early 1950s, such success appears to have led to complacency.
Not rampant complacency, but a relaxed belief that all the people involved are experts who know what they are doing, so they don’t need to be given the third degree before a show.
The sign that not all was well was the number of serious air display accidents, mostly fatal, that occurred just outside the area controlled by the display organisers – just like the Shoreham Hunter crash.
The AAIB found that 65% of all air show accidents came into that category, but almost always the only person harmed was the pilot. So nobody, including the CAA, raised the alarm, until now.
Meanwhile aerodromes used for decades as air show venues have suffered encroachment at their boundaries by expanding residential and industrial development. This affects the profiles aircraft are allowed to fly during a display, and flight display directors are bound to take this into account.
No longer are display lines, and entry and exit profiles dependent purely on where the display audience “crowd line” is, they have to take into account what each aircraft would have to do in the event of a technical or operational mishap during the display to avoid crashing into a nearby populated zone.
These are considerations that will affect air shows in the future. If a flying display stops being exciting, it might as well give up. Or go somewhere else more rural.
Coastal air displays will survive, because the escape route for aircraft in trouble is obvious.
The best example of the conundrum air show organisers face is what has happened to the traditional Red Arrows display at the biennial Farnborough International Air Show. When the Reds reviewed their Farnborough routine in detail following the tightened guidelines published in the early Shoreham bulletins, they found they had to curtail their display considerably.
In a statement following the release of the Shoreham final report, the CAA says: “We are fully committed to ensuring that all air shows take place safely, for the six million people who attend them each year in the UK and for the communities in which they take place.”
Let’s hope the CAA means what it says.
Learmount.com 
Well said, True North Learjet: Alas, absenting the “Third Degree”; invites POTUS: El Donaldo Juan Trumpez-like Trumpian, “Fake News-VD(Viral Deception)” via the “Fourth Estate”to vill the vacuum via Venturi effect . Prego-QED!
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That’s why from the very day after the disaster the BADA have continued to put out the spin that one should not overregulate because it would damage important commercial interests, and the disaster was caused because the road was simply in the wrong place. BADAs efforts are always dominated by the needs to protect the Farnborough display. Look at their record since the disaster.
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There was also a comment I’ve seen regarding the length of time it is taking to bring this matter before the courts and therefore any attempt to provide justice for the victims. Part of the delay in taking action in this matter is because there has been a lack of cooperation from those that run the air display industry. The CAA have been so exasperated by this they have publicly denounced this behaviour in the national press. The question is why the attempt to kick this into the long grass? Given those involved in the stonewalling, the answer would seem to be Farnborough as those who have come under fire from the CAA, and appear in the guise of representing the air display industry as a body, are actually employed by Farnborough. It is obvious that if Shoreham is an unsuitable venue for an air display, the more so is Farnborough. However the way this campaign was undertaken was so blatant and obvious it just got everyone’s backs up – principally the media starting with the BBC and the disaster of an interview by BADA on Radio 4, and of course the CAA who were furious. Its rebounded on Farnborough with the Red Arrows refusing to perform there, a now suspicious and hostile media, CAA and general public, and even the AAIB calling for an unprecedented Department of Transport Enquiry. Someone stirred up a hornets nest there and then shoved their dick into it for good measure.
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In 2014 BADA published on its website information that its members are required to take account of the H & S Purple guide in display planning. The FDD for Shoreham was and is one of the most senior figures in BADA. Seems very odd that knowing that they needed to apply the rules of the Purple Guide, the directors of Shoreham Air Display limited, listed as an event management company, didn’t. That’s the main question of competence and liability they have to answer in court.
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I had a recollection of being told the FDD for Shoreham was also FDD at Farnborough? If so one wonders at their standards given the AAIBs assessment of his competence.
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The final AAIB report was a bit of a waste of time, on day one it was clear to those with minimal expertise that the pilot was too low, was over a built up area, and it was a ‘lunatic’ stunt that should never have been planned and certainly curtailed as happened at events when Andy Hill previously messed up.
The interim reports are more significant when one looks at the reasons for the deaths. David Learmount made a very reasoned summation in this regard.
David Learmount is an aviation expert of high standing and has written extensively on this and one would expect to see his expert testimony used in court. He has written on breaches of the rules by the the FDD on completing risk assessments but the quote below alone is enough to conclude CAA rules were categorically broken by the show organisers. As is said by David Learmount, if they had followed the rules, there would have been no air disaster, no deaths.
So the quote that says it all:
“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.”
Of course BADA has put out a statement saying David Learmount has it all wrong, no rules were broken. Well there are lies, damn lies and blatant politicking. OK ask yourselves, has BADA ever been interested in anything else than blatant politicking? It had the chance to really do something, to support the smaller shows run by enthusiasts who needed support and expertise. That clearly never happened, the CAA census showed that. Did BADA put all its best efforts into promoting it’s own profile? It seemed at times you could just smell the lust for a gong, and did other matters like standards go out the window as a consequence? Well for whatever reason people, and an industry has died. Well done BADA. Its pretty clear that questions like these will be asked when it goes before the coroner and whether the mentally BADA perpetuated may well be seen as a significant t problem. Let’s wait and see!
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Rocketman.
I think the CAA will make Farnborough rue the day their creatures tried to railroad them through spin doctoring and playing the ‘blatant politicking’ card
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– yep the CAA clipped the wings of those responsible, good judgement.
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They have had their wings clipped by the CAA. More to come from the local authority (-:.
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Shoreham bosses never learn. Regulation needed!
http://www.worthingherald.co.uk/news/shoreham-air-show-crash-caused-by-unplanned-manoeuvre-1-1140444
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Things do not get any better. There are reports in some papers that the pilot of the Hunter had only 20 hours on type, and many professional pilots I know think that a pilot whose day job is as a transport pilot is unlikely to be able to spend enough time practising aerobatic manoeuvres in an unfamiliar fast jet.
It is always the case that pilots take full responsibility for what happens to their aircraft, but one wonders whether exactly the same attention should be given to the people who authorise them to fly.
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Pilot was in the clear. It’s the organisers who now have to take the responsibility for 11 deaths etc.
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To all potential commenters:
The court case examining the Hunter pilot’s role in the accident began a few days ago, and to avoid accusations of contempt of court by this public site I will – respectfully – not be approving any comments on the Shoreham accident or the associated court case on this blog post or the other related ones on the Learmount.com site until the court case is completely finished and has delivered a verdict. Blocking comment will not indicate my disagreement or disapproval, just respect for the judicial process.
Thanks for your patience.
David Learmount
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[…] aviation in general, have had cause to do some deep soul-searching. As a result of being put under the Air Accident Investigation Branch’s microscope, air displays will be different now, mostly by virtue of sticking to the rules that already existed […]
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Thank you for all you have said David. I feel gutted for all of the victims, including all of those who have been injured whether physically or mentally or emotionally themselves, and their families and friends. I know some who have been suicidal with PTSD, and a child who has had to leave school at 13 years of age.
We were taught the 7Ps:
Proper Planning, Preparation and Practice Prevent Poor Performance.
I would have wanted to practice the display in the Hunter two or three times in the week before the show.
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