Thank you for your response, Dudley, it is appreciated.
Dudley Henriques wrote:
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.
Quote:
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,
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