Warbird Aerobatics

[Dave Hadfield]

Found the facts.....


"The investigation established that the accident resulted from a loss of control of the aircraft associated with a temporary loss of power from the left engine."

http://www.aaib.gov.uk/cms_resources.cf ... 501355.pdf

Getting back to the main point, warbird aeros in twins involves extra risk. If one quits and you're below Vmc, you've got to pull the other one back, and if at that point you're pointing steeply up, perhaps inverted, at fairly low altitude, options become limited. Or non-existant.

Dave

[JohnH]

The same site with the info and analysis on the crash also has video of the start of the A-26 Biggin Hill incident.


http://vectaris.net/id510.html

[marine air]

IT wasn't incredible flying at Biggin Hill , just recklessness. The crazy picture of the B-17 shows he had a track record of needless recklessness that had been going on for some time, IMHO.
He should have been grounded years before and he would not have killed a bunch of people on board.

[Chris]

I like to see them flying right side up doing circuits. That's plenty to impress me

[Oscar Duck]

remember this chaps;

even a roll can end in disaster.

http://www.youtube.com/watch?v=U4HF0I8caR0

[JDK]

James, I don't see anything in his comments that are innacurate. He even caveated that the only thing he remembers was what they got word on at the time of the incident.

I fail to see how this diminishes his authority or he pontificated.

I would humbly submit that it is you who are diminishing his authority by making such statements without reading, in full, what is posted on the screen in front of you.

A quick clarification. First I have the utmost respect for Dudley's input (and CAPflyer too) as a rule. My concern, and reading of the posts stands, however.

Dudley's posts are in general not clear which accident he is referring to between the Mosquito and A-26 examples previously quotes. The remarks (I understand) where he does talk of the Mosquito accident (and I quoted) are partial and therefore potentially misleading in they refer to a preliminary and partial understanding at the time of the accident. I would submit that there is no excuse given the report has been avaliable for a decade now, to be presenting part of the story, glossing the main causal factor. (The discussion as to the other factors, I would agree merit discussion but cannot occur without the carburettor issue being considered.)

Thanks to Dave Hadfield for finding the report. I had a museum to go volunteer at.

FWIW, it's not for me to "diminish Dudley's authority". That will stand or fall on his own actions, and I suspect he'd agree that the posts lack the clarity he normally offers. As to if I pontificate, that's also not for me to judge, but I have no problem with being factually corrected or disagreed with - or ignored. In this case I'd rather be wrong.

I've written more, but at the moment I don't see that this is the forum for it. Having had the sad and unpleasant task of publishing the Mosquito accident in Warbirds Worldwide, to enable a the lesson that cost two lives to be learned, as well as the web access above, it's a pity that that lesson's evidently not important enough to get the facts right.

I'd be interested in Dudley's review on this discussion and issues, even if it is for me to be best ignored.

Regards,

[Dudley Henriques]

James, I don't see anything in his comments that are innacurate. He even caveated that the only thing he remembers was what they got word on at the time of the incident.

I fail to see how this diminishes his authority or he pontificated.

I would humbly submit that it is you who are diminishing his authority by making such statements without reading, in full, what is posted on the screen in front of you.

A quick clarification. First I have the utmost respect for Dudley's input (and CAPflyer too) as a rule. My concern, and reading of the posts stands, however.

Dudley's posts are in general not clear which accident he is referring to between the Mosquito and A-26 examples previously quotes. The remarks (I understand) where he does talk of the Mosquito accident (and I quoted) are partial and therefore potentially misleading in they refer to a preliminary and partial understanding at the time of the accident. I would submit that there is no excuse given the report has been avaliable for a decade now, to be presenting part of the story, glossing the main causal factor. (The discussion as to the other factors, I would agree merit discussion but cannot occur without the carburettor issue being considered.)

Thanks to Dave Hadfield for finding the report. I had a museum to go volunteer at.

FWIW, it's not for me to "diminish Dudley's authority". That will stand or fall on his own actions, and I suspect he'd agree that the posts lack the clarity he normally offers. As to if I pontificate, that's also not for me to judge, but I have no problem with being factually corrected or disagreed with - or ignored. In this case I'd rather be wrong.

I've written more, but at the moment I don't see that this is the forum for it. Having had the sad and unpleasant task of publishing the Mosquito accident in Warbirds Worldwide, to enable a the lesson that cost two lives to be learned, as well as the web access above, it's a pity that that lesson's evidently not important enough to get the facts right.

I'd be interested in Dudley's review on this discussion and issues, even if it is for me to be best ignored.

Regards,

First of all, I understand your justifiable feelings about having to document the death of two fine individuals. After attending the funerals and/or having to deal directly with the display associated deaths of many of my personal friends and associates throughout my career in aviation, I can assure you I have felt this way myself dozens of times. It's for this reason I remain active in accident investigation and flight safety.
This having been said, I'll address the Mosquito accident for you as requested.

As it happens, I read the AAIB report and have a copy in our files where it has been for many years. The Mosquito accident was profiled in detail in Des Barker's definitive book on display flying safety "Zero Error Margin"; a work within our community that I was privileged to have been asked to contribute.

Let me put this in perspective for you.
There are several levels from which an AAIB report, an MIR, or a NTSB report can be viewed. For the reporter, or the "interested fan", a report that attributes the failure of a left engine as the cause of an accident might be sufficient to call that evidence conclusive. In the business of accident PREVENTION however, these reports unfortunately are where you BEGIN as you contemplate the recommendations necessary to prevent another occurrence.
At this level, unless a DIRECT CAUSE of an engine failue is known, ALL such reports are considered inconclusive.


In the case of the Mossie, it was known the issue concerned the left engine. This was a given. But reading down the summary, the investigators make it perfectly clear that several contributing factors couldn't be eliminated from the failure equation.
Unless those factors could be eliminated, the EXACT cause of the left engine failure has to be considered as being inconclusive for the purpose of preventing another occurrence. It's for this reason that the recommendations that go forth from many of these reports cover several areas of concern and are general in nature. It is hoped by doing this that the actual cause of the failure will be caught and corrected. This approach defines the very meaning of "Probable Cause".
The carb was highly suspect in the Mossie crash, but not enough evidence was available to pin the exact cause on this single factor.

So for many of us in the safety community, unless the direct cause of a failure is known, the report is considered as stating a general cause and thus inconclusive. Thus, instead of a single preventave step being taken to prevent another like ocurrance, a more general approach is taken post accident in an attempt to deal with the "suspected" causes and thus possibly preventing another accident.

I am not interested in who has and who doesn't have "authority" here as these issues are trivial and not worthy of the bandwidth required to deal with them.

Thank you
Dudley Henriques


Dudley Henriques

[JDK]

Thank you for your response, Dudley, it is appreciated.

Let me put this in perspective for you.

I have it in good 'perspective' already. Part of that was your omitting the direct cause of the accident that therefore misleads to the process. Having clarified that omission, by a rightly respected and therefore 'authoritative' person here, we can move on.

There are several levels from which an AAIB report, an MIR, or a NTSB report can be viewed. For the reporter, or the "interested fan", a report that attributes the failure of a left engine as the cause of an accident might be sufficient to call that evidence conclusive.

Not this reporter, and that was never the limit of my interest or understanding.

Let's recap, with the right facts in the right order.

Simply put, a the carburettor fault (outside the pilot's reasonable expectation) caused a problem with one engine. Due to the flight regime and altitude the aircraft was in, there was not sufficient altitude to recover. It was noted that the pilot had almost recovered at impact.

Three major factors contributed to the crash - a technical fault; lack of altitude; and the aircraft's manoeuvring, a partial cause also of the carburettor issue. Had any one of those factors been removed the accident would not have occurred. More, had the first factor not occurred, we know the accident wouldn't have happened, because it had not previously.

I would hope we all here can appreciate that firstly that display had been flown like that numerous occasions by that pilot and engineer; that the display had been authorised by the aircraft's operators and owners - BAe, no small careless business; that the display had been checked and authorised by the CAA examiner in place at the commencement of that show season, and probably reviewed since. None of them decided that the display offered too little margin for the problem that eventuated.

That can therefore be argued to be a systems failure, or a charge that there were issues with the regulatory framework - touching on your earlier point.

It can be argued, and I'd suggest this is a crucial point for any pilot to take away - that the displays performance and risk had 'crept' into a more 'aggressive' display with less margin of safety, and that creep was causal in the carburettor issue occurring. (Note I don't know and I'm not speculating. As per Dudley's earlier remarks, we move here to lessons for accident prevention.) The lesson here is that just because it was OK yesterday doesn't mean you can dispense with any of the safety margin tomorrow - or that the display will be OK tomorrow. Complacency, or over-familiarity, in display aviation is a killer.

As you rightly go on to say, in accident prevention certain lessons can be taken away from the accident at this point. You need all the details however. I submit, your earlier comments were careless of the data you had, but did not present, and this does not convey the issues and the lessons we need to have drawn from the accident.

I'm well aware of the broad context of your following remarks, an excellent summary of the issues that we all face in ensuring the development of a safe aviation culture. I absolutely agree.

It is only a pity, hopefully a beneficial one, that we had to have this disagreement for your expertise to be laid out properly.

I also agree that arguing about authority is indeed trivial - however that also connects with the authority people have by the knowledge the bring to bear and the data and quality of analysis presented - whether pilot, investigator, journalist or humble (because the rest sure aren't scoring points with it) "fan".

Relating to an earlier point, the issue rests with the (display) pilot in charge. He or she needs to ensure they abide by the regulatory framework set (and contribute to its being a good framework). He or she needs to know the limits plus a margin of themselves, their aircraft, their environment and their organisation on the day. All obvious, and standard. All missed, often fatally by one or more display pilots every year. Clearly not clear enough to some.

Secondly, we all (that is those that think flying vintage aircraft for display is 'a good thing') need to contribute to a safer culture. It is not currently good enough. Display pilots need to listen to feedback and act on it where appropriate. They need to demonstrate they clearly understand the causes and prevention of the accidents they risk, as I complained was not clear and not clearly laid out earlier here. There is still too much show-off ego, and an unwillingness by some, at times, to dismiss non-pilot feedback. At this level of detail, the majority of us can understand the issues and act - however the willingness to listen and learn is needed. I refer anyone questioning it to the new post of mostly good quality by flyboyj: 'Tehachapi L-29 Crash - Setting the Record Straight!' and the abrupt dismissal of criticism made earlier. Perhaps justified in that case, but the issue of culture stands.

Which takes me to one of the hot issues in this regime. Display flying, despite the complaints earlier of regulatory interference, compared to many other regimes, is a remarkably self-policed and self-managed arena by display pilots, and mostly that works.

However, as touched on by Marine air 'He should have been grounded years before and he would not have killed a bunch of people on board.' 'He' is referring to the pilot of the A-26 Biggin Hill crash. I think it is likely that man would not be able to fly in the current display environment in the UK, USA or many other places. However I can think of several pilots, while not as dangerous as that man, are still unable to operate within their and other limits, but are allowed to fly to what they think is 'OK' - taking risks that have experienced pilots observing them suck their teeth.

I can think of at least three examples (in three different countries, all with 'u' in their abbreviation) featuring pilots that were they to crash tomorrow there would be a number of authoritative pilots stating they were not surprised by it. (This is based on firsthand off-the-record conversations with experienced display pilots watching, or after, specific displays by less-than-adequate pilots.)

Yet, beyond an 'old boys club' level of taking that person to one side and suggesting he brushes up his act, I see no evidence that those accidents-waiting-to-happen are being properly managed. Yes, display pilots are sometimes reprimanded for breeches. How efficacious is the system in removing the habitual transgressor? How many pilots are actually 'grounded' from display or high performance warbird flying? How many over-egoed (often rich owner-pilots) have been killed in the 'new toy' in the last decade?

The evidence is there, in accidents and histories of minor to major transgressions of good practice that come to light afterwards. You can tell me I'm wrong, but I know every display pilot here, if he or she is honest, can think of someone who fits that description.

Shocks to systematic problems like the CAF 'stand down' have a good effect, for a while. But there still remains the "it won't happen to me."

What is done, or to be done about it?



That's quite the essay. I've taken the trouble to arrange the argument, base it on principle and fact, drawing on my own accident, risk assessment and accident prevention training (not, I add, in aviation) and get it right as far as I can after a long day. My ego or any authority are utterly irrelevant. However the above is based on my twenty odd years of vintage aviation 'evaluation' including a lot of good sense, a fair amount of absolute bull, and many remarkable (careful) omissions by display pilots in firsthand conversation, in a good number of countries. As we all know there's a lot that doesn't get printed, but adds to the picture. I don't draw any national or regulatory differences here because that is, as I said, one of the base ego-errors I think committed by practitioners.

I'm not convinced, by the evidence of avoidable accidents, that we are achieving a high enough standard of display safety - and I don't mean 'the rules', just adhering to good, safe practice. The only people who can improve that standard is the display pilots. I look forward to the 'no accident' year. It is possible, it's not happened.

Regards,

[Dudley Henriques]

Thank you for your response, Dudley, it is appreciated.

Let me put this in perspective for you.

I have it in good 'perspective' already. Part of that was your omitting the direct cause of the accident that therefore misleads to the process. Having clarified that omission, by a rightly respected and therefore 'authoritative' person here, we can move on.

There are several levels from which an AAIB report, an MIR, or a NTSB report can be viewed. For the reporter, or the "interested fan", a report that attributes the failure of a left engine as the cause of an accident might be sufficient to call that evidence conclusive.

Not this reporter, and that was never the limit of my interest or understanding.

Let's recap, with the right facts in the right order.

Simply put, a the carburettor fault (outside the pilot's reasonable expectation) caused a problem with one engine. Due to the flight regime and altitude the aircraft was in, there was not sufficient altitude to recover. It was noted that the pilot had almost recovered at impact.

Three major factors contributed to the crash - a technical fault; lack of altitude; and the aircraft's manoeuvring, a partial cause also of the carburettor issue. Had any one of those factors been removed the accident would not have occurred. More, had the first factor not occurred, we know the accident wouldn't have happened, because it had not previously.

I would hope we all here can appreciate that firstly that display had been flown like that numerous occasions by that pilot and engineer; that the display had been authorised by the aircraft's operators and owners - BAe, no small careless business; that the display had been checked and authorised by the CAA examiner in place at the commencement of that show season, and probably reviewed since. None of them decided that the display offered too little margin for the problem that eventuated.

That can therefore be argued to be a systems failure, or a charge that there were issues with the regulatory framework - touching on your earlier point.

It can be argued, and I'd suggest this is a crucial point for any pilot to take away - that the displays performance and risk had 'crept' into a more 'aggressive' display with less margin of safety, and that creep was causal in the carburettor issue occurring. (Note I don't know and I'm not speculating. As per Dudley's earlier remarks, we move here to lessons for accident prevention.) The lesson here is that just because it was OK yesterday doesn't mean you can dispense with any of the safety margin tomorrow - or that the display will be OK tomorrow. Complacency, or over-familiarity, in display aviation is a killer.

As you rightly go on to say, in accident prevention certain lessons can be taken away from the accident at this point. You need all the details however. I submit, your earlier comments were careless of the data you had, but did not present, and this does not convey the issues and the lessons we need to have drawn from the accident.

I'm well aware of the broad context of your following remarks, an excellent summary of the issues that we all face in ensuring the development of a safe aviation culture. I absolutely agree.

It is only a pity, hopefully a beneficial one, that we had to have this disagreement for your expertise to be laid out properly.

I also agree that arguing about authority is indeed trivial - however that also connects with the authority people have by the knowledge the bring to bear and the data and quality of analysis presented - whether pilot, investigator, journalist or humble (because the rest sure aren't scoring points with it) "fan".

Relating to an earlier point, the issue rests with the (display) pilot in charge. He or she needs to ensure they abide by the regulatory framework set (and contribute to its being a good framework). He or she needs to know the limits plus a margin of themselves, their aircraft, their environment and their organisation on the day. All obvious, and standard. All missed, often fatally by one or more display pilots every year. Clearly not clear enough to some.

Secondly, we all (that is those that think flying vintage aircraft for display is 'a good thing') need to contribute to a safer culture. It is not currently good enough. Display pilots need to listen to feedback and act on it where appropriate. They need to demonstrate they clearly understand the causes and prevention of the accidents they risk, as I complained was not clear and not clearly laid out earlier here. There is still too much show-off ego, and an unwillingness by some, at times, to dismiss non-pilot feedback. At this level of detail, the majority of us can understand the issues and act - however the willingness to listen and learn is needed. I refer anyone questioning it to the new post of mostly good quality by flyboyj: 'Tehachapi L-29 Crash - Setting the Record Straight!' and the abrupt dismissal of criticism made earlier. Perhaps justified in that case, but the issue of culture stands.

Which takes me to one of the hot issues in this regime. Display flying, despite the complaints earlier of regulatory interference, compared to many other regimes, is a remarkably self-policed and self-managed arena by display pilots, and mostly that works.

However, as touched on by Marine air 'He should have been grounded years before and he would not have killed a bunch of people on board.' 'He' is referring to the pilot of the A-26 Biggin Hill crash. I think it is likely that man would not be able to fly in the current display environment in the UK, USA or many other places. However I can think of several pilots, while not as dangerous as that man, are still unable to operate within their and other limits, but are allowed to fly to what they think is 'OK' - taking risks that have experienced pilots observing them suck their teeth.

I can think of at least three examples (in three different countries, all with 'u' in their abbreviation) featuring pilots that were they to crash tomorrow there would be a number of authoritative pilots stating they were not surprised by it. (This is based on firsthand off-the-record conversations with experienced display pilots watching, or after, specific displays by less-than-adequate pilots.)

Yet, beyond an 'old boys club' level of taking that person to one side and suggesting he brushes up his act, I see no evidence that those accidents-waiting-to-happen are being properly managed. Yes, display pilots are sometimes reprimanded for breeches. How efficacious is the system in removing the habitual transgressor? How many pilots are actually 'grounded' from display or high performance warbird flying? How many over-egoed (often rich owner-pilots) have been killed in the 'new toy' in the last decade?

The evidence is there, in accidents and histories of minor to major transgressions of good practice that come to light afterwards. You can tell me I'm wrong, but I know every display pilot here, if he or she is honest, can think of someone who fits that description.

Shocks to systematic problems like the CAF 'stand down' have a good effect, for a while. But there still remains the "it won't happen to me."

What is done, or to be done about it?



That's quite the essay. I've taken the trouble to arrange the argument, base it on principle and fact, drawing on my own accident, risk assessment and accident prevention training (not, I add, in aviation) and get it right as far as I can after a long day. My ego or any authority are utterly irrelevant. However the above is based on my twenty odd years of vintage aviation 'evaluation' including a lot of good sense, a fair amount of absolute bull, and many remarkable (careful) omissions by display pilots in firsthand conversation, in a good number of countries. As we all know there's a lot that doesn't get printed, but adds to the picture. I don't draw any national or regulatory differences here because that is, as I said, one of the base ego-errors I think committed by practitioners.

I'm not convinced, by the evidence of avoidable accidents, that we are achieving a high enough standard of display safety - and I don't mean 'the rules', just adhering to good, safe practice. The only people who can improve that standard is the display pilots. I look forward to the 'no accident' year. It is possible, it's not happened.

Regards,

The very best to you.
Dudley Henriques

[JohnH]

Did something break on the lightning? I've heard it mentioned that something went wrong before. Watching that video again, the airplane seems like it's still rolling as it hits the ground. There are comments on You Tube that the aileron controls broke. The report I remember mentioned there perhaps was another factor that they couldn't identify.

[JDK]

Did something break on the lightning? I've heard it mentioned that something went wrong before. Watching that video again, the airplane seems like it's still rolling as it hits the ground. There are comments on You Tube that the aileron controls broke. The report I remember mentioned there perhaps was another factor that they couldn't identify.

The Duxford P-38 crash? IIRC, and again the report is available from the AAIB. From memory, there was no explanation as to why the rolls continued beyond the briefed number. There was speculation by the AAIB that there could have been a control foul, due to a multi-tool the pilot habitually carried for instance, but no evidence of it. No evidence of any failures or equipment issues as far as could be established post crash and from pre-crash evidence.

The pilot was the display chief pilot, an extremely experienced pilot familiar with the aircraft and venue, and gave the display brief, emphasising safety the day before (I sat in on that briefing). One would reasonably assume he was the least likely to depart from the plan.

Regards,

[ZRX61]

Did something break on the lightning? I've heard it mentioned that something went wrong before. Watching that video again, the airplane seems like it's still rolling as it hits the ground. There are comments on You Tube that the aileron controls broke. The report I remember mentioned there perhaps was another factor that they couldn't identify.

Shortly after it happened there was mention of a jammed aileron caused by a wayward nut or bolt. How the hell anyone could work that out is beyond me.

[warbird1]

Did something break on the lightning? I've heard it mentioned that something went wrong before. Watching that video again, the airplane seems like it's still rolling as it hits the ground. There are comments on You Tube that the aileron controls broke. The report I remember mentioned there perhaps was another factor that they couldn't identify.

Like any aviation accident or mishap, there were many factors involved. You can read the official accident investigation results here:

http://www.aaib.gov.uk/cms_resources.cf ... 501731.pdf

[JDK]

Thanks Warbird1. There was a question mark (no more) over a knee board (as well as the multi-tool I recalled), as mentioned at the report's end.

[JDK]

The very best to you.
Dudley Henriques

Dear Dudley,

No comments, corrections, additions or clarification?

No answers to any of the questions posed? No review of previous statements?

Even attempting the most neutral reaction, what conclusions can then be drawn?

I would hope airshow safety is something worth trying to get right. Is it not to be debated?

Regards,