Rank: Super forum user 
|
There was a topic on the Shoreham air show plane crash where is was stated there was a deficiency in the risk assessment. I turned to my long suffering wife and said "I wish I had a pound for every poor risk assessment I have read, I would have retired by now".
These and other documents are just rolled out whit often no real thought to the process and contents. I would like to see either RAs scrapped altogether or the regulators taking action BEFORE a serious accident occurs.
|
|
|
|
|
|
Rank: Super forum user 
|
Wish I ahd a pound for every risk assessment written but not shared. It's become a paper exercise with no real relevance.
|
|
|
|
|
|
Rank: Forum user 
|
The biggest issue with risk assessments is that you won't know if they are sufficient enough until something goes wrong and you end up in court.
I personally don't think that they have any worth on there own. To me a safe systems of work or method statement is much more of a useful document
|
|
|
|
|
|
Rank: Super forum user 
|
Too many people think that if a risk assessment has been written then job done, file that away somewhere and carry on regardless. On this occasion eleven people died and the repercussions will be felt for years.
|
|
|
|
|
|
Rank: Super forum user
|
By saying Shoreham had a deficiency in the risk assessment they are not just talking about a piece of paper, they are (presumably) saying that there is evidence to suggest that the details of the flying stunts had not been fully discussed with the pilot and it was not agreed in writing what geographical areas were prohibited and what altitude had to be maintained at all times.
As well as the Shorehammanagement, I would also expect the self-employed pilot to have a safety policy that explained his stunts should not put people on the ground at significant risk.
|
|
|
|
|
|
Rank: Super forum user
|
Media tends to be selective.
The most recent report on the basis of which we have had latest media interest si at:-
https://assets.digital.c...0001b/S1-2016_G-BXFI.pdf
The first recommendation in the report as 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
|
|
|
|
|
|
Rank: Forum user
|
...and going back to the OP, yes, a good regulator should be taking action by reviewing these assessments (at least sometimes) before the event, so to speak. In safety critical industries this is often the norm, for an airshow I would have thought the CAA (or would it be the HSE?) would review the RA, flight-plans, emergency arrangements, etc before the show......
Apparently some manoeuvres were carried out over residential areas at previous shows.
|
|
|
|
|
|
Rank: Super forum user
|
BBC Radio 4 discussed last night.
One interesting point, if correct, that the American authority for aviation attends every show to check that risk assessments are followed. In the UK the authority only attended 8 shows in the last 12 months.
|
|
|
|
|
|
Rank: Super forum user
|
The AAIB report also covers Monitoring of safety standards--I need not copy it
Determining the appropriate level of regulatory oversight of an activity requires an understanding of the level of risk it presents. Therefore the following Safety Recommendation is made:
Safety Recommendation 2016-044
It is recommended that the Civil Aviation Authority establish and publish target safety indicators for United Kingdom civil display flying
|
|
|
|
|
|
Rank: New forum user
|
Air shows are quite specialised, but as far as risk assessments for general events are concerned, I worked at a prestigious organisation that often had high-falutin' events on-site. I produced and promoted an Event Plan document which would summarise the main aspects that everyone involved would need to know (key personnel contacts, activities, time tables, first-aid, parking, security etc).
On the back of this I used to sneak a section in that would contain all of the things that could go wrong and how it would be approached, avoided, mitigated and controlled. So basically, a risk assessment by stealth!
This way, people had the info to keep them in the picture and also the risk info. No one used to bat an eyelid and actually liked having the document to hand. It certainly avoided the inevitable groans that came if the term 'risk assessment' was uttered!
I'm also a big fan of combining SOPs, RAs and Environmental aspects in one document, especially if it has to fit a formal management system or GMP structure. Probably fits technical/manufacturing/lab operations best though...
|
|
|
|
|
|
Rank: Super forum user
|
You can have as many risk assessments as you want or any other paperwork - but if a pilot isn't going to fly a manoeuvre properly, then a crash is always possible.
It was obvious as soon as the crash happened, that pilot error was very likely to be the cause. Anything else is secondary. It is quite rare for an aircraft to crash due to technical failures.
|
|
|
|
|
|
Rank: Super forum user 
|
can I be a pedant here. A risk assessment is not a form, it is not written, it is not a piece of paper, it is not an electronic record. The form is the record of risk assessment. Risk assessment is a process, which includes implementing, monitoring and reviewing the control measures used. The recent judgment in Kennedy vs Cordia used this (correct) definition of risk assessment, as did L21, as does HSG65. Risk assessment includes your SSOW, and it includes checking your SSOW is followed.
I feel quite strongly about this, thinking of risk assessments as pieces of paper is behind numerous incidents, some of them quite serious,
John
|
|
|
|
|
|
Rank: Super forum user
|
JohnW wrote:By saying Shoreham had a deficiency in the risk assessment they are not just talking about a piece of paper, they are (presumably) saying that there is evidence to suggest that the details of the flying stunts had not been fully discussed with the pilot and it was not agreed in writing what geographical areas were prohibited and what altitude had to be maintained at all times.
As well as the Shorehammanagement, I would also expect the self-employed pilot to have a safety policy that explained his stunts should not put people on the ground at significant risk.
"The Shoreham FDD was an experienced display pilot but was not provided with, or was not
aware of, the sequence of display manoeuvres that the pilot of G-BXFI intended to perform.
Without prior knowledge of G-BXFI’s display routine or the ground area over which the pilot
intended to perform it, it was not possible for the FDD to identify the specific associated
hazards, where the various aerobatic manoeuvres would be conducted, and therefore to
determine which groups of people would be exposed to those hazards and to what extent"
"You can have as many risk assessments as you want or any other paperwork - but if a pilot isn't going to fly a manoeuvre properly, then a crash is always possible.
It was obvious as soon as the crash happened, that pilot error was very likely to be the cause. Anything else is secondary. It is quite rare for an aircraft to crash due to technical failures"
Watching the video, the pilot failed to complete the manoeuvre until quite late in its execution, pulling-up quite sharply immediately prior to impact.
|
|
|
|
|
|
Rank: Forum user
|
jwk wrote:can I be a pedant here. A risk assessment is not a form, it is not written, it is not a piece of paper, it is not an electronic record. The form is the record of risk assessment. Risk assessment is a process, which includes implementing, monitoring and reviewing the control measures used. The recent judgment in Kennedy vs Cordia used this (correct) definition of risk assessment, as did L21, as does HSG65. Risk assessment includes your SSOW, and it includes checking your SSOW is followed.
I feel quite strongly about this, thinking of risk assessments as pieces of paper is behind numerous incidents, some of them quite serious,
John
Absolutely!
Thanks John
|
|
|
|
|
|
Rank: Super forum user
|
For some aspects of this tragic incident I wonder if the term 'risk assessment' has been misplaced. Doing acrobatics or manoeuvres over populated areas surely does not need a RA but planning supported by a policy.
|
|
|
|
|
|
Rank: Super forum user
|
It doesn't!!
It requires good airmanship skills - to reject a manoeuvre if the aircraft height/speed/altitude/position does not meet the criteria for the intended manoeuvre.
If these weren't correct, a simple straight and level flypast could have been carried out, before setting up the aircraft for the manoeuvre on the next pass.
As previous, it was obvious that pilot error/poor decision making was the most likely immediate cause of the accident.
I once saw a guy in a Spitfire kill himself because he had simply started a vertical loop from too low a level - as he descended on the down side of the loop he couldn't do anything except impact the ground. Poor decision making. He should have 1/2 rolled at the top of the loop and returned to straight and level flight.
|
|
|
|
|
|
Rank: Super forum user
|
Indeed, but the human error aspect of it is part of the challenge both the pilot and the watching crowd. The pilot does not intend to make a mistake. However, carrying out risky manoeuvres over populated areas is the crux of the matter, not the manoeuvre per se.
|
|
|
|
|
|
Rank: Super forum user
|
I refer to my earlier comment.
Aerobatics are of limited risk to anybody when carried out correctly.
This includes positioning the aircraft such that the manoeuvre can be carried out within the safe envelope of the display area and always away from the crowd line/public areas/populated areas.
Poor airmanship.
|
|
|
|
|
|
Rank: Super forum user
|
Ian Bell2 wrote:I refer to my earlier comment.
Aerobatics are of limited risk to anybody when carried out correctly.
This includes positioning the aircraft such that the manoeuvre can be carried out within the safe envelope of the display area and always away from the crowd line/public areas/populated areas.
Poor airmanship.
Is that not the starting point for a risk assessment then?
Since when did we say we don't need to identify and mitigate the risks as the only way a crash can happen is by poor airmanship? Do we carry out RAs without thought for human error?
We might just as well say its down to common sense and leave it at that
|
|
|
|
|
|
Rank: Super forum user
|
Seems to be quite a few things that contributed to the accident, not just the pilot error.
It is in the report that the person completing the risk assessment didn't have an understanding of what risk assessment was for, there was no site visit or inclusion of local knowledge, so they could not see what obstacles etc are in the way, this would include the roads proximity to event, etc. Again probibly to much relience on the competency of the Risk assessor and his findings than actually regarding through the document and holding a meeting to ensure that all understood the assessment and it's contents.
|
|
|
|
|
|
Rank: Super forum user
|
WatsonD wrote:
Is that not the starting point for a risk assessment then?
Since when did we say we don't need to identify and mitigate the risks as the only way a crash can happen is by poor airmanship? Do we carry out RAs without thought for human error?
We might just as well say its down to common sense and leave it at that
Its called airshow/flight planning and briefing and being an authorised/qualified pilot.
But again if a pilot isn't going to a fly a manoeuvre within the safe envelope for the display at the actual time of a display then it can all go wrong.
In occupational safety terms...lets use the example of a scaffolder
Writing a risk assessment and method statement, having a safety plan, briefing involved workers, checking someone's experience and qualifications...
If a scaffolder then wilfully fails to clip on or use a fall arrest device then if he falls, he may end badly.
|
|
|
|
|
|
Rank: Super forum user
|
As per post#13. No-one had checked the sequence of manouevres the pilot was intending to perform.
In your example, you assume that everything had been checked and planned - in this instance it appears it hadn't.
|
|
|
|
|
|
Rank: Super forum user
|
Ultimately with any work activity that is in essence a solo activity - the person can be checked and verified and assessed as competent as much as you like - but can still not perform correctly.
A pilot may display 100 times within the display parameters - what happens at the 101st display when he is allowed to display to the public?
Quite obviously by the vary nature of a single seat aircraft, there is very little anybody can do once airborne. The human factors/decision making process seems key to this accident.
What would I know - 150hrs fast jet flying and over 3yrs working with our boys in red - so I do have some knowledge of aviation display flying.
|
|
|
|
|
|
Rank: Super forum user
|
Ian Bell2 wrote:Ultimately with any work activity that is in essence a solo activity - the person can be checked and verified and assessed as competent as much as you like - but can still not perform correctly.
A pilot may display 100 times within the display parameters - what happens at the 101st display when he is allowed to display to the public?
Quite obviously by the vary nature of a single seat aircraft, there is very little anybody can do once airborne. The human factors/decision making process seems key to this accident.
What would I know - 150hrs fast jet flying and over 3yrs working with our boys in red - so I do have some knowledge of aviation display flying.
Indeed you do, but with respect I think it is also blinding you to the obvious which has been articulated by me and others. For example, the pilot error is one thing, but the precaution which should have been adopted as I understand is failing to do the acrobatics in an unpopulated area. Whether this was down to pilot error, or I suspect a lack of proper planning is the crux of the matter.
|
|
|
|
|
|
Rank: Super forum user
|
I accept the point about not flying over populated areas, but in this case isn't that a bit of a red herring? The jet came down on a road, not on buildings. I can conceive of an air-show that doesn't have road access, but it would be hard to organise... and to visit...
Now, I do accept Ray's point that the planning may well have been faulty, but I also accept Ian's point that once the plane is in the air the pilot is on their own. It seems to me that had the route been properly planned so as to avoid built-up areas the jet could still have come down on the road. In other words, would route planning have avoided or mitigated this particular incident, rather than incidents in general?
Better decisions by the pilot might have avoided the incident (Ian's point), and advance notice of what was intended might have helped (Ray's point). But the plane did hit a road, not houses.
We were there, providing event 1st aid cover for the airshow, and we did get involved in helping with the incident,
John
|
|
|
|
|
|
Rank: Super forum user
|
jwk
Fair point - avoiding all roads may not be practical when doing flying displays. However there may be scope for trying to ensure that critical manoeuvres are not within the envelope of main roads to reduce the severity of an incident if there should be a mishap.
|
|
|
|
|
|
Rank: Super forum user
|
RayRapp wrote:jwk
However there may be scope for trying to ensure that critical manoeuvres are not within the envelope of main roads to reduce the severity of an incident if there should be a mishap.
I think I have already said this.
By the way aerial manouvres of this nature are called Aerobatics NOT ACROBATICS - that's is what they do in a circus!!
|
|
|
|
|
|
Rank: Super forum user
|
Ian Bell2 wrote:RayRapp wrote:jwk
However there may be scope for trying to ensure that critical manoeuvres are not within the envelope of main roads to reduce the severity of an incident if there should be a mishap.
I think I have already said this.
By the way aerial manouvres of this nature are called Aerobatics NOT ACROBATICS - that's is what they do in a circus!!
Actually I worked as one of the little people in the circus and we called them 'whoops a daisies'!
|
|
|
|
|
|
Rank: Super forum user
|
RayRapp wrote:jwk
Fair point - avoiding all roads may not be practical when doing flying displays. However there may be scope for trying to ensure that critical manoeuvres are not within the envelope of main roads to reduce the severity of an incident if there should be a mishap.
Sometimes maybe, but quite often probably not,
John
|
|
|
|
|
|
Rank: Super forum user
|
Is it the pilots fault - most likely
Can those in charge prove that they had done everything they could to prevent the accident - most likely not
And if so, have they not given the pilot a free pass?
They will be taking the blame for their failings as they cannot prove it was all down to the pilot
|
|
|
|
|
|
Rank: Super forum user
|
Right at the end:
"Many display pilots either fly, or have flown, multiple types or classes of aircraft. Renewal
of a DA on one type or class of aircraft renews the DA on all the types that the pilot’s DA
has listed. Therefore a display pilot may be assessed to renew their DA on single-engined
piston aeroplanes and this would also renew their DA for a fast jet that they had not
flown for several years. There can be significant differences in flying techniques and in
particular energy management, between different types or classes of aircraft. This policy
is different from common CAA aviation practice where a proficiency check for one type or class is only valid for that type or class and pilots must therefore be assessed separately
for aircraft requiring different flying techniques. The pilot of G-BXFI had last renewed his
DA in a different aircraft type"
"In 2014 a display by the pilot of G-BXFI, in another aircraft type and at a different venue, was
stopped by the FDD of that display following concerns about the execution of a manoeuvre"
|
|
|
|
|
|
You cannot post new topics in this forum.
You cannot reply to topics in this forum.
You cannot delete your posts in this forum.
You cannot edit your posts in this forum.
You cannot create polls in this forum.
You cannot vote in polls in this forum.