AAIB report on Shoreham airshow accident produces 14 Safety Recommendations

The aircraft was taking part in a flying display at Shoreham Airport during which it conducted a manoeuvre with both a vertical and rolling component, at the apex of which it was inverted. Following the subsequent descent, the aircraft did not achieve level flight before it struck the westbound carriageway of the A27. Eleven people on the ground were fatally injured. Special Bulletin S3/2015 was published on 4 September 2015 to provide preliminary information about the accident gathered from ground inspection, radar data, recorded images and other sources.

A further Special Bulletin, S4/2015, was published on 21 December 2015 to highlight findings of the AAIB investigation regarding ejection seat safety and the maintenance of ex-military jet aircraft, and to assist the Civil Aviation Authority in its ‘Review of UK Civil Air Displays’ (the CAA Review) announced on 9 September 2015. On 28 October 2015 the Civil Aviation Authority (CAA) published Civil Aviation Publication (CAP) 1351 - ‘CAA Review of Civil Air Displays: progress report’, setting out the progress it had made in its review to date, and explaining the next steps it would be taking.

On 26 January 2016 the CAA published CAP 1371 - ‘UK Civil Air Display Review: Actions that impact on UK civil air displays in 2016’. The AAIB investigation of the accident to G-BXFI is an independent process but it has and will continue to inform the CAA Review. The AAIB recognises that as well as being enjoyed by large numbers of spectators and participants, flying displays are also considered to provide important economic and educational benefits1 .

The sole purpose of an AAIB investigation is to improve aviation safety by determining the causes of accidents and serious incidents to make Safety Recommendations intended to prevent recurrence. It does not therefore consider the balance between those benefits and improvements. This Special Bulletin considers public protection and safety management at flying displays.

A final report will be published in due course.

Fourteen Safety Recommendations are made and are listed below.

Safety Recommendation 2016-031 It is recommended that the Civil Aviation Authority review and publish guidance that is suitable and sufficient to enable the organisers of flying displays to manage the associated risks, including the conduct of risk assessments.

Safety Recommendation 2016-032 It is recommended that the Civil Aviation Authority specify the safety management and other competencies that the organiser of a flying display must demonstrate before obtaining a Permission under Article 162 of the Air Navigation Order.

Safety Recommendation 2016-033 It is recommended that the Civil Aviation Authority introduces a process to ensure that the organisers of flying displays have conducted suitable and sufficient risk assessments before a Permission to hold such a display is granted under Article 162 of the Air Navigation Order.

Safety Recommendation 2016-034 It is recommended that the Civil Aviation Authority specify the information that the commander of an aircraft intending to participate in a flying display must provide the organiser, including the sequence of manoeuvres and the ground area over which the pilot intends to perform them, and require that this be done in sufficient time to enable the organiser to conduct and document an effective risk assessment.

Safety Recommendation 2016-035 It is recommended that the Civil Aviation Authority require operators of Permit to Fly aircraft participating in a flying display to confirm to the organiser of that flying display that the intended sequence of manoeuvres complies with the conditions placed on their aircraft’s Permit to Fly.

Safety Recommendation 2016-036 It is recommended that the Civil Aviation Authority remove the general exemptions to flight at minimum heights issued for Flying Displays, Air Races and Contests outlined in Official Record Series 4-1124 and specify the boundaries of a flying display within which any Permission applies.

Safety Recommendation 2016-037 It is recommended that the Civil Aviation Authority require that displaying aircraft are separated from the public by a sufficient distance to minimise the risk of injury to the public in the event of an accident to the displaying aircraft.

Safety Recommendation 2016-038 It is recommended that the Civil Aviation Authority specify the minimum separation distances between secondary crowd areas and displaying aircraft before issuing a Permission under Article 162 of the Air Navigation Order.

Safety Recommendation 2016-039 It is recommended that the Civil Aviation Authority require the organisers of flying displays to designate a volume of airspace for aerobatics and ensure that there are no non-essential personnel, or occupied structures, vehicles or vessels beneath it.

Safety Recommendation 2016-040 It is recommended that the Civil Aviation Authority require Display Authorisation Evaluators to have no conflicts of interest in relation to the candidates they evaluate.

Safety Recommendation 2016-041 It is recommended that the Civil Aviation Authority require a Display Authorisation to be renewed for each class or type of aircraft the holder intends to operate during the validity of that renewal.

Safety Recommendation 2016-042 It is recommended that the Civil Aviation Authority publish a list of occurrences at flying displays, such as ‘stop calls’, that should be reported to it, and seek to have this list included in documentation relevant to Regulation (EU) No 376/2014.

Safety Recommendation 2016-043 It is recommended that the Civil Aviation Authority 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 reevaluation by a Display Authorisation Evaluator who was not involved in its issue or renewal.

Safety Recommendation 2016-044 It is recommended that the Civil Aviation Authority establish and publish target safety indicators for United Kingdom civil display flying.

The full report can be viewed here https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/519513/AAIB_Bulletin_5-2016.pdf