Pilot error was the main cause of the deadly Shoreham A27 air crash but controls to protect the public, including those not attending the airshow, were ineffective, the final report into the disaster has found.
Eleven people were killed in the crash in August 2015, when a Hawker Hunter jet aircraft performing at the Shoreham Airshow crashed onto the A27.
The report by the Air Accidents Investigation Branch (AAIB) identified both causal factors and contributory ones, including ‘the absence of provisions to mitigate the effects of an aircraft crashing in an area outside the control of the organisers of the flying display’.
It found that the plane was carrying out a manoeuvre that ‘commenced from a height lower than the pilot’s authorised minimum for aerobatics, at an airspeed below his stated minimum, and proceeded with less than maximum thrust’.
‘This resulted in the aircraft achieving a height at the top of the manoeuvre less than the minimum required to complete it safely, at a speed that was slower than normal.’
The report added that it was possible to abort the manoeuvre safely at this point but that it appeared the pilot did not recognise that the aircraft was too low. It suggested ‘several credible explanations’ for this, including not reading the altimeter correctly and ‘incorrectly recalling the minimum height required at the apex’.
The investigation found confusion and a lack of formal safety management systems among the parties involved in the planning, conduct and regulatory oversight of the flying display.
‘No organisation or individual considered all the hazards associated with the aircraft’s display, what could go wrong, who might be affected and what could be done to mitigate the risks to a level that was both tolerable and as low as reasonably practicable.’
‘Controls intended to protect the public from the hazards of displaying aircraft were ineffective,’ the report found.
The AAIB has published three Special Bulletins ‘highlighting areas of concern that required timely consideration’ and made a further 11 Safety Recommendations in its report.