Airshow disaster investigation shows risk assessment failings
Investigators into the Shoreham Arishow disaster found that the Flying Display Director (FDD) was unaware of the pilot's '˜sequence of manoeuvres'.
In an interim report released by the Air Accident Investigation Branch (AAIB) earlier this afternoon, the government agency made 14 recommendations for other airshow events to adhere to in the wake of the disaster last August.
One of its findings was the ‘number of deficiencies’ found in the Shoreham Airshow risk assessment.
It states: “It is not clear that those who assessed the risks and recorded the assessment had a full understanding of the purpose of the risk assessment.”
In reference to a pervious airshow event in Shoreham, is states: “Evidence from the 2014 Shoreham display indicated that it was not possible for G-BXFI [Hawker Hunter craft] to complete the intended sequence of manoeuvres while complying with the condition of its Permit to Fly; not to overfly congested areas.
“Knowledge of its intended routine would have enabled the FDD to determine if its attendance at the flying display was appropriate.”
The CAA informed the AAIB that when considering applications for air displays, and when attending air displays to conduct audits, it did not inspect or request copies of hazard logs or risk assessments.
There were also no site visits and the process did not benefit from local knowledge of the display sites and their surroundings.
It states: “The enhanced process did not require the assessor to allocate probability or consequence to the identified hazards, as would be expected in a risk assessment, made no reference to a hierarchy of protection or control, and did not consider which groups of people would be exposed to the identified hazards.”
In response, it recommended the CAA introduce a process to ensure that the organisers have conducted ‘suitable and sufficient risk assessments’ before receiving permission to hold a display.
Sequence of manoeuvres
The Shoreham FDD was an experienced display pilot but was not provided with a sequence of display manoeuvres that the pilot of the Hawker Hunter intended to perform.
Without prior knowledge of the manoeuvres or the area over which the pilot intended to perform it, the report states it was not possible for the FDD to identify the specific associated hazards and determine which groups of people would be exposed to those hazards.
Following an accident involving a Hawker Hurricane in Shoreham in 2007, the AAIB recommended that the CAA requires that the sequence of manoeuvres for a flying display is clearly specified in advance of the display.
The CAA accepted this recommendation and in a formal response to AAIB said, “The Flying Display Director during the planning phase of the event will be required to consider and manage pilot display programmes.”
Flying over public places
The AAIB said a condition from 2014/15 stipulated that no aircraft should take part in a display over any building or vessel which the commander has reason to believe is occupied by people.
It also states that an aircraft should not be flown over any assembly of people or any congested area of a city, town or settlement.
Video footage of the 2014 Shoreham Airshow indicated that the majority of the aerobatic manoeuvres were ‘conducted away from the airfield, over areas accessible to the public and outside the control of the display organisers’.
The CAA permits an aircraft taking part in a flying display should ‘fly below 150 metres (500 feet) above the ground or water or closer than 150 metres (500 feet) to any person, vessel, vehicle or structure if it is within a horizontal distance of 1,000 metres of the gathering of persons assembled to witness the event’.
In repsonse the AAIB said the CAA should clarify and publicise whether permission from the authority is required before exemption from the 500 feet low-flying rule.
In 2014 a display by the pilot of the Hawker Hunterperformed at a different venue and was stopped by the FDD following concerns about the execution of a manoeuvre.
The AAIB said that following an informal discussion with the pilot later that day the CAA took no further action and did not formally record the occurrence. It was not otherwise investigated and was not reported to the AAIB.
In response, it recommended that the CAA introduce a process to ‘immediately suspend the Display Authorisation of a pilot whose competence is in doubt, pending investigation of the occurrence and if appropriate re-evaluation by a Display Authorisation Evaluator who was not involved in its issue or renewal’.
Shoreham Airshow responds to report
Following the report’s release at 2pm today (to read the original story click here), Shoreham Airport organisers released a response.
A spokesman for the event said: “The release of any update on the tragic events of the 2015 Shoreham Airshow is likely to be a challenging time for the families of the victims, and our thoughts are with those affected today.
“We are confident that we made every effort to follow the CAA’s guidance. Any resulting revisions to air show regulations following this interim bulletin are an issue that must be resolved by the CAA and AAIB. As dialogue continues between these two organisations, we will offer every assistance possible to the ongoing investigation.”
Lawyers representing families of victims
Jim Morris, a former pilot and specialist aviation lawyer at Irwin Mitchell representing the victims of the Shoreham crash, said: “This special bulletin is an extremely important step forward in improving the safety of airshows across the UK.
“There are clear learning points from what happened at Shoreham which the CAA must take into account and implement into its policies and guidance asap.
“The key issues include the detail included in the risk assessments for Shoreham in relation to where potentially dangerous manoeuvres were taking place and how close the crowd would be standing.
“As we tragically saw in August last year, when something goes wrong with an aircraft near to a large group of spectators, there can be disastrous consequences
“Although we don’t want to dampen the enjoyment that many people derive from airshows, it’s quite clear that the regulations for organisers looking to put on a display have got to be improved to reduce the risk of similar issues in future.”
Clive Garner, who leads the aviation team at Irwin Mitchell said: “While the CAA’s recommendations to improve safety at airshows are welcome, we and our clients are very disappointed that it has taken this disaster and this terrible loss of life to happen before these recommendations have been made.
“Most of the recommendations are common sense, and questions have to be asked whether more should have been done to improve safety standards prior to the tragic events that occurred in Shoreham.”
Irwin Mitchell will be representing its clients at the pre-inquest review into the deaths of those killed in Shoreham on March 22 in Horsham.
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