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Aviation History
1960
1960 - 0448.PDF
448 FLIGHT, 1 April i960 After an Accident . . . light to a layman president of the court who will often be sittingin that capacity for the first time? Yet there must be few inquiries whose relevant facts could not be spotted in a day and sifted in aweek under experienced direction. Instead of the court taking its pace from counsel, as it does today, it should take it from itspresident, which under the existing system it cannot do. That is the first point on which reform is needed, and this will be dealtwith in Recommendation 2. ? The second weakness stems from the first: this is the slavishemulation of the proceedings of the High Court: Certificates of Airworthiness, load sheets, crew and engineers' licences, log books,and so on, are all exhibited and proved in legal fashion. The same time would be taken up with these procedures after a mid-aircollision—in which the relevance was slight—as would be applied in a case involving engine failure, in which the relevance is verymuch greater. Someone, of course, must check on such documents in all cases. But does it have to be done by a court of a hundredhighly paid men? A solution is offered in Recommendation 1. The third weakness of the public inquiry is, in my view, moreimportant in that it can affect the findings. Again it stems from the unfamiliarity of the president with the make-up of the industry.I refer to the fact that, when aircraft performance has been in question, the court has never called for a performance test.Examples of this are the Viking at Blackbushe on May 1, 1957; the Viking at Southall on September 2, 1958; and the York inMalta on February 18,1956 (the latter inquiry under the Govern- ment of Malta, but following UK procedures). In all these casesthe evidence of the Air Registration Board has been accepted by the court without any form of cross-check. ARB Evidence -A V; ^ YY' •••- Y ' Y. • Y ' "'•"• Now I have no quarrel with the ARB in this. But I cannotpossibly regard the Board as entirely independent witnesses in the matter of aeroplane performance. After all, they recommendedthe granting of the Certificate of Airworthiness; during perform- ance tests overload gradients are not measured; and during a longlife aerodynamic efficiency falls off. Yet the ARB official, quoting a theoretical figure, is never required to prove it. The certificationof aircraft performance is carried out as something of a secret act as between the manufacturer and the ARB. At no pointdoes the ordinary pilot get an opportunity to see just how the check is carried out. Yet in spite of this secrecy it is commonknowledge among pilots that the techniques used in measuring performance are extreme (especially is the case of landing) andcannot be applied in day-to-day operations. This being so, the pilot cannot use the certificated figures for his yardstick in manycases and he therefore tends—quite reasonably—to place his faith in the thought that, if there is an accident, the court will see thatthese performance figures are substantiated. But the court never does! I have given above my main criticisms oi the two types ofinquiry. But before proceeding to the remedies we may appro- priately consider the position of the pilot, who is so often thecentral figure. ,--.-.--. Suspended Pilots After the accident a commercial pilot is normally suspended from further flying until after the result of the inquiry. Although this would seem to be a prudent measure, it is not necessarily a just one, since the cause of the accident may have had nothing to do with the pilot, who may suffer financially by reason of his suspension. But notwithstanding the above, suspension seems the only practical course to take. The possible injustice it does, however, lends emphasis to the need to conduct inquiries as quickly as possible. But if it is impracticable to avoid temporary suspension, it is not necessary to impose a further restraint on the pilot, namely access to all the evidence he can secure. Yet in the UK the pilot or his representative is denied access to the scene of the accident. Every- body else seems to go there (the operator, the manufacturers of the aircraft and of the engine, and often of ancillary equipment) to obtain first-hand evidence which may be of assistance to them in defending their reputation. Clearly, therefore, the pilot should be afforded the same facilities in defending his reputation. Turning now to the remedies, I propose here to give only the outlines, since it would take a great deal of space to work right through all the ramifications involved: — (1) I would recommend the abolition of inspector's inquiries and theemployment of the present staff as "agents of the court" to the public inquiries. (2) All accidents should be subjected to a public court of inquirycomprising: (a) A president, who should be selected from a panel of eminent lawyers; (b) A vice-president, similarly qualified, whoseduties would be to act as personal assistant to the president and, in this capacity, to gain experience for a later appointment aspresident; (c) Two assessors (more in cases of special complexity), drawn from a separate panel, representing various professional! odie—e.g., pilots, engineers, air traffic controllers. One assessor : ould normally be a practising pilot. (3) The court should be appointed by the Lord Chancellor and lot buthe Minister of Aviation, whose department may be direcdy involved (4) In cases where blame is attached to an individual or to individualsan Appeals Board should conduct a further hearing. The Board should be drawn from three members of the presidents' panelleast two of whom should have previously sat as president. '•hese members of the Board should be appointed permanendy. Assessorsshould be co-opted by the Board according to the grounds if the appeal. The role of the assessor is slightly diminished on the AppealsBoard. The reason for this is that, in the sort of case taken to appea] the judicial element should predominate over the expert. f ' (5) Any party to whom blame might be attached should have the rightto be represented by a legal adviser, a trade union official, or a friend However, the tradition should be established that it would be excepttional for legal advisers to attend. If they did so, they would be given no special position vis-a-vis any other adviser; moreover, insuch cases due notice should be given to all parties, so that others could decide whether or not they should be legally represented. (6) The usual rules of evidence should in general govern the proceedingsbut they need not be too rigidly applied. Hearsay evidence should definitely be excluded, but the proceedings should, nevertheless, no!be too formal. On this the Franks Report probably strikes the right note : " The aim should generally be to combine an orderly procedurewith an informal atmosphere. . . . Parties should be free to question witnesses directly and not only through the chairman." (7) Parries to whom blame is attached in the findings of the court, andadvisers to those parties, should have the right to see the findings before publication and to raise any question of fact. This is in linewith the recommendations of the Franks Report. They should, however, not have the right to hold up publication indefinitely eventhough all the facts may not be ascertainable. (8) A suitable system should be devised, in association with the appro-priate professional bodies, for a number of "approved pilot observers" to be appointed. These should be pilots of proven experience.Arrangements should be made for them to have a brief course in the principles of accident investigation. They should then be permittedto attend all "on-the-scene" phases of inquiries. (9) The principles outlined above should also be applied, so far as prac-ticable, in the case of foreign inquiries. In particular, the right to withhold evidence at any point should not be permitted; evidenceshould, indeed, be volunteered. In this connection, it may be neces- sary to give the agents of the court authority to obtain evidence froma manufacturer or operator and to transmit it to a foreign court of inquiry. Only by such means can confidence be placed in thereciprocal arrangements outlined in ICAO Annex 13, para. 5.1, and only by such means can a British national, falling under a foreigncourt of inquiry, enjoy as great a proportion as is practical of the rights to which he would be entitled in the United Kingdom. Time for Reappraisal Finally, it may not be inappropriate here to comment on thegeneral setting in which aircraft accident inquiries take place. Because of the small circle among whom adequate knowledgeexists, as compared with the case of railway or road accidents, there is a tendency for the inquiry to assume a unique character.The discussions are a hunting ground for the specialist, and there is a tendency, from the Government downwards, to assume theresponsibility of "protecting the industry." By this it is hoped to minimize public alarm and thereby to maintain the prosperity ofthe industry. This is all very well, but this policy can be applied only at the expense of the individual or at the expense of notpublicizing the error (and thereby inviting a recurrence). While the industry was growing up—in, say, 1925-45—it was difficultto strike a balance. Civil flying tended to be regarded on much the same basis as military flying: there were known risks but oneplayed them down, as one does the casualties of military engagements. I would say, however, that we have now passed that stage.There is a very large, adult and sophisticated industry. Moreover, there are some very good aeroplanes and operations; the risks arewithin our day-tonday experience in other walks of life. There- fore, whatever justification there might have been in the past forthe protection of a young industry, this no longer applies and the privilege which the industry has hitherto enjoyed should bemore closely regulated and brought into equality with the privilege of the individual. It must face its disasters just as it is free toprofit by its triumphs. It should therefore be prepared, in the event of an accident, to "see the chips on the table." But, to put the matter in perspective, I should say that theposition on accident investigations in the United Kingdom is no worse than in many other countries. It is fairly common to findinadequate inquiries, safeguarded commercial interests, a playing- down of facts which might lead to criticism of the aeronauticalauthorities, or the entire suppression of reports. However, in the leading aeronautical countries of the world this phase is rapidlybeing discarded, and it is timely for the United Kingdom to make its reappraisal and so prevent the interests of a small but importantgroup from slipping under the cloak of a technocracy which lacks the checks and balances applied in other fields of our public ute.
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