Report on the accident to Hawker Hunter T7, G-BXFI near Shoreham Airport on 22 August 2015

452 Pages·2017·28.08 MB·English

AIRCRAFT ACCIDENT REPORT 1/2017
A AIB
Air Accidents Investigation Branch
Report on the accident to
Hawker Hunter T7, G-BXFI
near Shoreham Airport
on 22 August 2015

AIRCRAFT ACCIDENT REPORT 1/2017
Air Accidents Investigation Branch
Report on the accident to
Hawker Hunter T7, G-BXFI
near Shoreham Airport
22 August 2015
This investigation has been conducted in accordance with
Annex 13 to the ICAO Convention on International Civil Aviation,
EU Regulation No 996/2010 and
The Civil Aviation (Investigation of Air Accidents and Incidents) Regulations 1996.
The sole objective of the investigation of an accident or incident under these Regulations
is the prevention of future accidents and incidents. It is not the purpose of such
an investigation to apportion blame or liability.
Accordingly, it is inappropriate that AAIB reports should be used to assign fault or blame
or determine liability, since neither the investigation nor the reporting process has been
undertaken for that purpose.
© Crown Copyright 2017
This report contains facts which have been determined up to the time of publication. This
information is published to inform the aviation industry and the public of the general
circumstances of accidents and serious incidents.
Extracts may be published without specific permission providing that the source is duly
acknowledged, the material is reproduced accurately and it is not used in a derogatory manner
or in a misleading context.
Published 3 March 2017
Printed in the United Kingdom for the Air Accidents Investigation Branch
ii
Department for Transport
Air Accidents Investigation Branch
Farnborough House
Berkshire Copse Road
Aldershot
Hampshire GU11 2HH
February 2017
The Right Honourable Chris Grayling
Secretary of State for Transport
Dear Secretary of State
I have the honour to submit the report on the circumstances of the accident to
Hawker Hunter T7, registration G-BXFI near Shoreham Airport on 22 August 2015.

Yours sincerely
Crispin Orr
Chief Inspector of Air Accidents
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Contents
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Introduction ......................................................................................................................1 n
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Summary ..........................................................................................................................2 o
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1 Factual Information ...............................................................................................7
1.1 History of the flight .........................................................................................7
1.1.1 Background .......................................................................................7
1.1.2 The display – general preparation ....................................................7
1.1.3 The accident flight ............................................................................8
1.2 Injuries to persons .........................................................................................11
1.3 Damage to the aircraft ..................................................................................11
1.4 Other damage ...............................................................................................11
1.5 Personnel information ...................................................................................12
1.5.1 Commander ....................................................................................12
1.5.1.1 Career history ...............................................................12
1.5.1.2 Use of speed and height ‘safety gates’ in military
flying .............................................................................13
1.5.1.3 Hunter flying .................................................................14
1.5.1.4 Pilot’s display authorisation ..........................................16
1.5.1.5 Displays and display practices .....................................18
1.5.1.6 Minimum display heights .............................................20
1.5.1.7 Flying display emergency manoeuvres .......................20
1.5.1.8 Pilot recency requirements ..........................................21
1.5.2 The Flying Display Director .............................................................21
1.5.3 The Flying Control Committee ........................................................22
1.6 Aircraft information ..............................................................................................22
1.6.1 General ...........................................................................................22
1.6.2 Aircraft description ..........................................................................23
1.6.3 Standard configuration ....................................................................23
1.6.4 Flying controls .................................................................................24
1.6.5 Flaps ...............................................................................................24
1.6.6 Hydraulic system .............................................................................25
1.6.7 Electrical system .............................................................................25
1.6.8 Instruments .....................................................................................25
1.6.8.1 Accelerometer (g-meter)...............................................25
1.6.8.2 Pitot-static sensors .......................................................26
1.6.8.3 Airspeed indicators ......................................................26
1.6.8.4 Altimeters .....................................................................26
1.6.8.5 RPM indicator and tacho-generator .............................29
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1.6.8.6 Engine exhaust gas thermometer ...............................30
1.6.8.7 Transponder .................................................................30
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1.6.9 Rolls-Royce Avon Mk 122 engine ...................................................30
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1.6.10 Aircraft fuel system .........................................................................32
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n 1.6.11 Pilot escape system ........................................................................32
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1.6.12 Pilot anti-g system ...........................................................................33
1.6.13 Mass and centre of gravity ..............................................................34
1.6.14 Maintenance records .....................................................................34
1.6.14.1 General maintenance and CAA audits .........................34
1.6.14.2 Altimeter maintenance records .....................................36
1.6.14.3 Engine maintenance records ........................................37
1.6.14.4 Ejection seat maintenance records ..............................37
1.7 Meteorological information ............................................................................37
1.8 Aids to navigation ..........................................................................................38
1.9 Communications ...........................................................................................38
1.10 Aerodrome information .................................................................................38
1.11 Recorded data ..............................................................................................39
1.11.1 General ...........................................................................................39
1.11.2 Air Traffic Control radar ...................................................................40
1.11.3 Action cameras ...............................................................................40
1.11.4 Flying display videos and photographs ...........................................42
1.11.5 Smartphones ...................................................................................42
1.11.6 Data recorded during the accident flight .........................................43
1.11.7 Data recorded during previous flights .............................................48
1.11.7.1 General .........................................................................48
1.11.7.2 Shoreham – August 2014, G-BXFI ...............................48
1.11.7.3 Duxford – September 2014, G-BXFI ...........................49
1.11.7.4 Recent Jet Provost display flying..................................50
1.11.7.5 Imagery from a previous flight ......................................51
1.11.8 Engine performance ........................................................................51
1.11.8.1 JPT and rpm ................................................................51
1.11.8.2 Engine speed during manoeuvres ................................52
1.11.8.3 Engine speed indicator .................................................54
1.11.9 Recorded information from other aircraft and other flying displays .54
1.12 Wreckage and impact information ................................................................54
1.12.1 Accident site examination ...............................................................54
1.12.2 Aircraft on-site examination ............................................................55
1.12.2.1 Structure .......................................................................55
1.12.2.2 Cockpit..........................................................................55
1.12.2.3 Ejection seats ...............................................................57
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1.12.3 Further examination ........................................................................59
1.12.3.1 Flying controls .............................................................59
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1.12.3.2 Hydraulic system ..........................................................59
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1.12.3.3 Electrical system...........................................................59 e
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1.12.3.4 Pitot-static system ........................................................59 o
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1.12.3.5 Airspeed indicators ......................................................59
1.12.3.6 Altimeters .....................................................................60
1.12.3.7 Accelerometer (g-meter)...............................................62
1.12.3.8 RPM indicator and tacho-generator .............................62
1.12.3.9 Anti-g system ................................................................63
1.12.3.10 Engine examination ......................................................63
1.12.3.11 Fuel system ..................................................................68
1.13 Medical and pathological information ............................................................68
1.13.1 Pilot .................................................................................................68
1.13.2 Third parties ....................................................................................68
1.14 Fire ................................................................................................................69
1.15 Survival aspects ............................................................................................69
1.15.1 Fire and rescue services .................................................................69
1.15.2 Pilot’s helmet ...................................................................................69
1.15.3 Aircrew equipment assemblies (AEA) ............................................69
1.15.4 Survival equipment ........................................................................70
1.16 Tests and research ........................................................................................70
1.16.1 Flight trials .......................................................................................70
1.16.2 Radar Mode C validation ................................................................72
1.16.3 Radar detection of peak altitudes ...................................................73
1.17 Organisational and management information ..............................................74
1.17.1 Operation of ex-military aircraft on the UK civil register .................74
1.17.2 Record of flight training ..................................................................74
1.17.3 Safety management systems ........................................................75
1.17.3.1 Introduction ...................................................................75
1.17.3.2 International Civil Aviation Organisation ......................76
1.17.3.3 CAP 632 – ‘Operation of ‘Permit-to-Fly’ ex-military
aircraft on the UK register’ ............................................76
1.17.3.4 Safety culture................................................................79
1.17.4 Approval process for UK civil flying displays in 2015 ......................79
1.17.4.1 The Air Navigation Order ..............................................79
1.17.4.2 Ownership of risk ..........................................................81
1.17.4.3 Risk assessment of flying displays ...............................82
1.17.4.4 Hierarchy of control ......................................................83
1.17.4.5 Hazardous materials risk assessments ........................83
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1.17.5 Organisation of the Shoreham Airshow ..........................................83
1.17.6 Independent review of risk assessment ..........................................87
C 1.17.7 Sequential listing of manoeuvres ....................................................90
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n 1.17.8 Airworthiness and national permits to fly .......................................90
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n 1.17.9 Acceptance and maintenance of ex-military aircraft on
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the UK civil register ........................................................................92
1.17.10 Maintenance organisation approval ................................................94
1.18 Additional information ...................................................................................94
1.18.1 The accident manoeuvre ...............................................................94
1.18.2 Aircraft handling ..............................................................................96
1.18.2.1 Flying a loop .................................................................96
1.18.2.2 Flying a ‘bent loop’ ........................................................97
1.18.2.3 Technique for a loss of thrust during the upward
half of a loop .................................................................98
1.18.2.4 Entry speed ................................................................98
1.18.2.5 Minimum apex (‘gate’) height ......................................99
1.18.2.6 Entry criteria for low-speed aircraft such as the RV-8 ..99
1.18.2.7 Correct use of gate heights ........................................100
1.18.3 Review of recorded imagery by the Test Pilot ...............................100
1.18.3.1 Background ................................................................100
1.18.3.2 Flying display at Duxford in 2014 ...............................100
1.18.3.3 Flying display at Shoreham in 2014 ..........................102
1.18.3.4 Flying display at Shoreham in 2015 ...........................103
1.18.3.5 Manoeuvres analogous to escape manoeuvres ........104
1.18.3.6 Other observations .....................................................105
1.18.4 UK flying display statistics .............................................................106
1.18.4.1 Fatal accidents at UK flying displays 1996-2015 ........106
1.18.4.2 UK flying display accidents where the aircraft
crashed in the area below its display .........................108
1.18.4.3 Accident rates at flying displays ................................109
1.18.4.4 Scale of UK flying displays in 2015 .............................110
1.18.4.5 UK flying display activity in 2015, by month ................110
1.18.4.6 Other aircraft accidents in the UK involving
third-party fatalities ......................................................112
1.18.5 Monitoring of safety standards at flying displays ...........................112
1.18.5.1 CAA staff competencies and resources .......................112
1.18.5.2 UK Display inspections ................................................114
1.18.6 Separation between the primary crowd and displaying aircraft .....115
1.18.7 Non-participant third parties and secondary crowds ......................116
1.18.7.1 A27 vehicular traffic ...................................................116
1.18.7.2 Secondary spectators ..................................................116
1.18.7.3 Other non-participant third parties ...............................118
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