SHERIFFDOM OF SOUTH STRATHCLYDE, DUMFRIES AND GALLOWAY AT LANARK
THE FATAL ACCIDENT AND INQUIRIES (SCOTLAND) ACT 1976
in Fatal Accident Inquiry
in terms of the Fatal Accidents and Sudden Deaths Inquiry (Scotland)
circumstances of the death of
COLIN STEELE McRAE;
GRAEME ARTHUR DUNCAN;
BEN TELFER PORCELLI
and JOHN GAVIN McRAE
For the Crown: Ms MEIKLE, Principal Procurator Fiscal
For the McRae family: Mr McBRYDE, QC, Mr Anderson, Solicitor, Levy &
For Eurocopter: Mrs Anwar, Solicitor, DLA Piper.
For the Civil Aviation Authority: Mr ANDERSON,
Solicitor, Simpson & Marwick WS
LANARK, 2 September 2011
The sheriff, having
resumed consideration of the evidence adduced, FINDS AND DETERMINES in terms of section 6(1)
of the Fatal Accidents and Sudden Deaths Inquiry (Scotland) Act 1976:
- In terms of section
McRae, date of birth 5 August 1968, Graeme Arthur Duncan, date of birth 14 December 1970, Ben Telfer Porcelli,
date of birth 7
and John Gavin McRae, date of birth 6 December 2001, died in the wooded area
adjacent to Jerviswood House, Bellefield Road, Lanark at 1610 hours on 15 September 2007.
- In terms of section
6(1)(b) the cause of death was:-
relation to Colin Steele McRae
injuries due to
relation to Graeme Arthur Duncan
injury due to
relation to Ben Telfer Porcelli
injury due to
relation to John Gavin McRae
injury due to
1b: aviation incident (helicopter)
- In terms of section
6(1)(c) of the Act it would have been a reasonable precaution to refrain
from flying helicopter G-CBHL into Mouse Valley wherein the pilot engaged
in low level flying when it was unnecessary and unsafe for him to do so
and whilst carrying passengers on board. The accident occurred when, due
to an unknown occurrence, the aircraft deviated from its intended flight
path and crashed into trees lining the side of Mouse Valley. The aircraft was in powered
flight at the time of the collision and attempts were being made by Mr
McRae to recover from that unknown event. These attempts were rendered
ultimately unsuccessful because of the position and speed of the
helicopter within Mouse Valley and the resultant restrictions on opportunity to land
or fly the helicopter to safety. Such options would have been available
to him had he adhered to rules of good airmanship and desisted from flying
in the valley at low height and high speed.
- This is an Inquiry
instituted by the Lord Advocate under the discretionary provisions of the
Fatal Accidents and Sudden Deaths Inquiries (Scotland) Act 1976. It was
considered expedient in the public interest that such an Inquiry should be
held into the circumstances of the deaths of Colin Steele McRae, aged 39, Graeme
Arthur Duncan, aged 36, Ben Telfer Porcelli, aged 6 and John Gavin McRae,
aged 5, which occurred when the helicopter piloted by Mr McRae and in
which they were passengers crashed on 15 September 2007.
- The Inquiry took
place at Lanark
Sheriff Court and evidence was heard over 16 days between 12 January and 26 May 2011. A locus inspection
of the crash site and points along the helicopter's final flight path took
place on 25
January 2011. Written submissions were prepared and lodged, and on 8 August 2011 parties were given
the opportunity to make additional oral submissions. The evidence,
although often complex, was in great measure uncontroversial, resulting in
fewer court days being required than originally contemplated. Whilst
parties are to be congratulated on their determination to focus attention
on the salient issues, this had the unforeseen consequence of delay being
encountered between blocks of evidence which had been carefully timetabled
in advance and which could not be re-scheduled because of the unavailability
of non-local and expert witnesses. Further delay was occasioned when, as
a result of concern voiced that eye witness accounts given in court may
have differed in important areas from statements given to Air Accident
Investigation Branch (AAIB) investigators and founded upon in AAIB report
Crown Production 34, transcripts of that evidence were made available to
investigators in order that any such discrepancies could be taken into
account by them in oral evidence.
- The McRae family
became a party to the Inquiry and were represented by senior counsel. The
families of Graeme Duncan and Ben Porcelli did not become parties and were
not represented, albeit family members were regularly in attendance during
the Inquiry, and I understand that Ms Meikle on behalf of the Crown liaised
closely with them and was careful to take their views and comments into
account in her preparation and presentation of the case. Evidence was placed
before the Inquiry from family members in the form of affidavits.
- Evidence was led from
the following witnesses.
Roslyn Douglas, Scene
Examination Branch, Strathclyde Police
Identification Bureau, Strathclyde Police
Identification Bureau, Strathclyde Police
Edward Brown, Scottish
Police Services Authority.
Murray, Strathclyde Police.
Identification Bureau, Strathclyde Police.
Constable Kevin Brown,
Sergeant John Watt,
Christine Currie Moore
William Kirk Hope
Identification Bureau, Strathclyde Police.
Fiona Brown, Strathclyde Police.
Mark Brown, Strathclyde Police.
Robert Campbell Roy.
Ann Rosemary Cooper.
Sergeant John Watt,
Constable Ian Thomson,
Fraser Lamb, Scottish Government, Police Division.
Dr Gerard Murphy,
Police Casualty Surgeon, Strathclyde Police.
Ian McLean, Strathclyde
Fire and Rescue.
Sergeant Robert Logan,
Jennings, Strathclyde Police.
Inspector Alan Bowater,
Craig Willison, Strathclyde Police.
Inspector Alan Bankier, Strathclyde Police.
Steven Bertram, Strathclyde Police.
Detective Sergeant Alex
McArthur, Strathclyde Police.
Grant McLeod, Strathclyde Police.
Mark Henderson, Strathclyde Police.
Dr John Clark, University of Glasgow.
Constable James Baird,
Paterson, Strathclyde Police.
Thomas Mathers, Prestwick International Airport.
Stephen Aspin, Scottish
Air Traffic Control Centre, Prestwick.
Brian Park, PDG Helicopters, Aberdeen.
Strathclyde Fire & Rescue.
Bond Air Services, Glasgow.
Scottish Ambulance Service, Law.
Dr Alan Downie, Paisley.
Raymond Elgy, Civil
Aviation Authority, Gatwick.
Fred Cross, Civil
Aviation Authority, Gatwick.
Mrs Alison Jane McRae.
Mrs Jenifer Dawn Love Duncan.
Neil Robert Gatt
Sloan Helicopters, Majorca.
Andrew Robinson, AAIB, Aldershot.
Ken Fairbank, AAIB, Aldershot.
Findings in Fact
I found the following
facts admitted or proved:-
- Colin Steele McRae
lived with his wife and two children at Jerviswood House, Bellefield Road, Lanark. Johnny
Gavin McRae was his 5 year old son. Mr McRae was the owner and pilot of
an Eurocopter AS350B2 Squirrel helicopter, call sign G-CBHL. Mr Graeme
Arthur Duncan lived with his wife and son at 3 Cleghorn Street, Lanark and in France. Ben Telfer Porcelli
lived with his parents at Lochside, Braidwood.
- The helicopter G-CBHL
was manufactured in 1992, used in Japan and then Canada before being
registered in the UK for the first time in January 2002. It was purchased
by Mr McRae in November 2003. Whilst it's exact number of flight hours is
not known, at an annual inspection carried out on 7 June 2007, 4158 flight hours
are recorded. A 12 Year Inspection was successfully carried out on 1 June 2006 and it had a
European Aviation Safety Agency Standard Certificate of Airworthiness,
valid until 1 May 2008. The helicopter was not fitted with flight recording
data or cockpit voice recorder and was not required to be.
- The McRae family home
at Jerviswood House was equipped with a helipad and an aircraft hanger.
It is situated above the south side of the Mouse Valley, yards from the edge of the
wooded glen with the River Mouse at its foot which comprises the Mouse Valley. The helicopter,
G-CBHL, was based at this location, and was frequently flown by Mr McRae
both for business and for pleasure. It was a common sight in Lanark and
the surrounding area.
- Mr McRae had
significant flying experience, amassing 965 hours in total, of which 490
were on this type of helicopter. He continued to fly regularly in the
weeks and months prior to this incident.
- On the afternoon of 15 September 2007, Mr McRae was at
home in the company of his daughter and some male friends. His son was
returned home in the company of his friend Ben Porcelli by Mrs Porcelli.
At or about 1400 hours Mr McRae set off in the company of Mr Graeme
Duncan, Johnny McRae and Ben Porcelli to undertake a short, 8 nautical
miles, flight to a friend's farm near Larkhall. It was not unusual for Mr
McRae to use his helicopter for short, domestic flights such as this.
Ben's parents had no knowledge of the proposed helicopter flight and had
not been asked for their consent to it.
- Mr Duncan filmed much
of the outbound and return flights on his personal camcorder. 5.3 minutes
of video and sound track were recovered in total. The video was taken
from his front passenger seat and ended approximately 55 seconds prior to
the accident. This source provides confirmation from pre-flight checks at
the start of the outbound journey that all engine and system indications
were normal and flight instruments appeared serviceable. Fuel levels were
sufficient for 1 hour 40 minutes flying time. Indicated air speed
generally varied between 110 knots and 115 knots; a typical cruise speed.
Dual flight controls were fitted but front passenger, Mr Duncan, appeared
able to sit without interfering with them. The pilot was seen to remain
in full control of the helicopter throughout, giving no sign of any
concerns about its performance. Passengers were seen and heard to be
enjoying the flight. Cabin noise levels prevented the picking up of
conversations conducted at normal levels, although louder comments were
- The outbound flight
took approximately 6 minutes in the course of which no concerns were
raised in respect of the performance or condition of the helicopter. Mr
McRae was seen piloting the aircraft in a confident and competent manner
albeit exhibiting what was described by expert witnesses as "spirited"
flying. The party spent less than an hour at Little Sunnyside Farm prior
to re-boarding the helicopter for the return journey to Jerviswood. The
helicopter took off at or about 1500 hours to commence the homeward
- The return journey
took approximately 5 minutes. In the course of it the pilot performed a
zoom climb from take off before descending into a narrow, steep-sided
valley next to Larkhall. He flew over trees at the valley's edge at speed
with a separation of less than 30 feet between aircraft and trees. The
helicopter was then pitched nose-down into the valley coming into similar
proximity to trees on either side of it, before zoom climbing out of the
valley. Passengers were seen and heard to enjoy the manoeuvre.
- Weather conditions
were generally favourable for flying. Wind conditions were reported as
gusty in the Mouse Valley area with some
turbulence, although not severe in nature. It was dry and visibility was
- Both flights were
conducted at low levels of altitude, on occasion flying well within the
recognised minimum. The transponder on board the helicopter did not record
altitude but witness sightings together with video evidence enable
informed estimates of height and separation to be made.
- Ground speed of the
helicopter en route is estimated from available radar detail
together with Indicated Air Speed taken from video recorded cabin readings
and meteorological information. Radar tracking captured the majority of
the flight, but contact was lost approximately 20 seconds prior to the
helicopter reaching the accident site, as it descended out of sight behind
obscuring terrain. Speed thus recorded shows an average ground speed for
the second half of the flight, fluctuating between 100 knots and 120
knots, increasing to 122 knots in the last 30 seconds of data. Speed
further increased as it descended into the valley.
- Witnesses to the
return flight reported no visual signs of distress to the aircraft. It
appeared to be handling appropriately, under the control of the pilot,
albeit its low altitude and the resultant high level of noise generated,
attracted attention and some concern.
- Mr McRae's usual
approach to Jerviswood involved flying to the east of the helipad before
making a slow, controlled descent to land, albeit other approaches were
also utilised as appropriate. On this occasion and very unusually he
approached the area from the west, initially flying across the Mouse Water Valley before making a
brief right hand turn then banking steeply to the left and descending into
the valley. The helicopter adopted a marked nose-low, banked attitude as
it descended and was described as flying faster than normal. Its
indicated air speed as it entered the valley was reliably estimated at
approximately 130 to 135 knots which together with a 20 knot tail wind,
would have resulted in a ground speed of approximately 150 knots. Having
entered the valley the helicopter was not seen again by witnesses. Prior
to it disappearing from view the aircraft was not seen to be in obvious
difficulty. There were no witnesses to the crash itself.
- The helicopter
crashed into the steeply sloping, heavily wooded ground on the south bank
of the Mouse Valley water. An extensive
post-accident fire consumed a large part of the aircraft structure.
- Post mortem findings
in respect of the deceased found no evidence to suggest that any of them
were alive when the helicopter was ablaze, death in respect of all
occurring at impact. All four sustained severe multiple injuries in the
impact which were immediately fatal.
- The helicopter
impacted initially with the upper branches of 2 large trees growing on the
south bank: the left side of the rotor disc impacted with the trunk of a
fir approximately 30 feet from its top, whilst the fuselage and the rest
of the rotor disc struck an oak tree. The damage thus sustained to the
rotor head resulted in the release of the main rotor blade, which was seen
to fly above the height of the trees and land in an adjacent field,
approximately 150 metres beyond the initial impact point. The main
gearbox was torn from its mountings on impact and fell to the ground
nearby. The tail boom separated into two major sections on impact, and
the cabin section together with the engine struck the rising valley side,
coming to rest approximately 45 metres from the initial impact point.
Most of the cabin structure, furnishings and instruments were destroyed in
the fire which broke out in the cabin section. The aft section of the
tail boom, including the tail rotor assembly and horizontal stabiliser,
remained lodged in the upper branches of a tree immediately down track
from the fir tree initially struck.
- Damage to the trunk
of the fir tree which took the initial impact and to one of the main rotor
blades is consistent with contact between the two. Examination of the
orientation of a broad horizontal scar on this tree, together with the
general disposition of the wreckage, suggests that the helicopter struck
the tree in an upright attitude with no significant bank angle. The pitch
angle was estimated to be nominally level or slightly above the
horizontal. The main impact area was at a similar elevation to that of
the initial tree strike, at or about 550 feet above sea level, indicating
an almost level trajectory. The high degree of airframe break up
suggests a relatively high impact speed.
- The high speed of the
aircraft as it entered the valley, the high energy nature of the impact
together with the nature of the manoeuvres carried out by Mr McRae in the
approach to and descent into the valley indicate that he was not making an
approach to land at Jerviswood at the time of the accident. In any event,
such an approach to the helipad was not open to him as all necessary
points of reference would be obscured by the topography. All indications
point to an intention to descend into the valley before executing a steep
right turn, possibly with a planned zoom climb out of the valley
- All wreckage
recovered in the course of a comprehensive and detailed police operation
was sent to the Air Accident Investigation Branch ("AAIB") facility at
Farnborough where it was subjected to painstaking inspection and technical
examination, assisted where necessary by representatives from the engine
and airframe manufacturers and from the French Air Accident Investigation
- All the extremities
of the helicopter were accounted for and there was no evidence of any
pre-impact failure or detachment. All failures in the structure, the
rotor head and the main rotor blade attachments were consistent with
violent impacts with the trees and ground.
- The engine had been
extensively damaged in the accident. Detailed testing revealed that the
engine was delivering power at the time of the impact and there was no
evidence of an engine malfunction. The hydraulic system had also sustained
significant impact damage but examination and testing of its component
parts effectively ruled out hydraulic failure. Many of the flying
controls components had been severely affected by the post-impact fire
which made verification that the entire system was intact and operative at
the time of impact difficult. Further testing discounted concerns that a
server rod eye end may have become disconnected prior to the accident and
it was concluded that there had been no failure of the internal
components. These tests did reveal that some of the flying control servos
operated in a less than satisfactory manner but on further investigation
it was concluded that this was consistent with damage sustained in the
impact, together with the likelihood of contamination of the valve
components with dirt from the accident site. The possibility of a
pre-impact seizure of the valve in the forward cyclic actuator cannot be
entirely discounted. However, such a failure is unknown in practice and is
an extremely remote possibility. Were it to occur, the pilot would probably
experience some prior stiffness in the controls and would therefore be
alerted to a difficulty in advance of failure and be able to return to
- The autopilot system
had been damaged in the fire, allowing only partial examination of the
system. Whilst the theoretical possibility of a fault developing in the
final moments of flight cannot therefore be discounted, the system has
only limited effect on the range of movement and force on the flying
controls, which could be easily overcome by the pilot even in the event of
a major fault developing.
- The thorough
examination carried out under the auspices of the AAIB therefore failed to
indentify any unrectified defects affecting the helicopter. It did not
discover any structural or system failure responsible for the accident.
The helicopter was functioning appropriately as it entered the valley.
Had it not been, Mr McRae would have had the opportunity to seek a safer
option than a rapid descent into a heavily wooded valley and a pilot of his
experience is likely to have taken it.
- The video recording
provides detailed information as to the manner in which Mr McRae piloted
G-CBHL that day. He consistently flew the helicopter at unnecessarily low
heights. He clearly breached the 500 feet minimum separation requirement
on at least one occasion when he detoured to fly at 275 feet over farm
buildings and may well have done so on others. He undertook significant
manoeuvring at low level and the helicopter seems to have encountered
significant g-loading as a result, to the evident enjoyment of his
- The episodes of
extremely low level flying and the excessive manoeuvre parameters,
particularly the descent into the valley by Larkhall, all as captured on
the video recording, are indicative of an aircraft being flown
imprudently, without due regard to the principles of good airmanship, and
in such a way that normal safety margins would be reduced.
- The video recording
ends an estimated 3500 mm from the accident site, approximately 55 seconds
flying time and prior to its entry into the Mouse Valley. At that time Mr McRae appears
to be relaxed and in control of the aircraft which seems to be operating
satisfactorily. The manner in which he handles the aircraft suggests he
continues to have no concerns about its serviceability.
- There was no evidence
of passenger interference with the aircraft controls. The helicopter was
fitted with dual controls which could be simply removed by maintenance
crew or by the pilot himself. They were in situ at the time.
There was no evidence of loose objects interfering with the controls. The
video recorder was the only substantial loose object recovered at the site
and it bore no signs of damage from such interference.
- The trajectory of the
helicopter as it entered the Mouse Valley would not have brought the helicopter to the impact
site. As the valley changes course eastwards it is likely that the
helicopter would follow the line of the river, undertaking a 90 degree
right turn as it did so. The high speed of the helicopter as it entered
the valley necessitated a rapid rate of descent into the valley.
Executing such a right turn in ideal conditions would require a steady
loading of 2 g. Conditions on that day were not ideal and the manoeuvring
required to execute such a turn would have placed considerable demands
upon pilot and machine. Accurate judging of the point of turn would be
hampered by high speed, strong tailwind, lack of a horizon and the nature
of the valley. Misjudgement or delay would have brought the helicopter
within dangerously close proximity to the terrain. Any transitory
handling difficulty with the helicopter would have had the same effect.
Recovery would involve manoeuvring the helicopter at maximum performance
and in turn increase the risk of deviation from the intended flight path.
- The helicopter struck
the trees on the south slope of the Mouse Valley as a result of a significant
deviation from its flight path. What caused that deviation cannot be
positively determined. The possibility of a sudden onset technical
malfunction cannot be entirely ruled out albeit scrupulous investigation
renders such a fault unlikely. Accidental interference with the flying
controls cannot be entirely ruled out but in the circumstances would seem
to be unlikely. There was no evidence of bird strikes but such an event
cannot be entirely ruled out. Pilot disorientation or misjudgement as a
result of low flying at speed in difficult terrain cannot be discounted.
The servo transparency phenomenon if encountered at these low levels,
could have delayed pilot response and efforts to avoid collision. Servo
transparency leading to or contributing to deviation cannot be ruled out
in circumstances such as these when a pilot is undertaking unexpectedly
high performance manoeuvres. All of these possibilities could have been
avoided or mitigated had the decision to fly G-CBHL into Mouse Valley not been taken.
Each, whether encountered singly or together, were capable of safe
resolution had the pilot been flying in an environment which increased the
margin for error and offered the opportunity of safe landing or
- The deaths and the
accident resulting in the deaths might have been avoided had Mr McRae not
flown his helicopter into the Mouse Valley. Such a precaution would have been entirely
reasonable. There was no necessity to enter the Mouse Valley. There were no operational or
logistical reasons to enter the Mouse Valley. Mr McRae chose to fly the helicopter into the
valley. For a private pilot such as Mr McRae, lacking the necessary
training, experience or requirement to do so, embarking upon such
demanding, low level flying in such difficult terrain, was imprudent,
unreasonable and contrary to the principles of good airmanship.
- In order to pilot an
aircraft in the UK it is necessary to hold a pilot's licence, a valid
relevant medical certificate, to have had the pilot's licence validated
with the type of aircraft to be flown and to hold a Licence Proficiency
Check ("LPC") in respect of the type of aircraft to be flown. On the date
of the accident Mr McRae possessed the necessary medical certificate.
- On the date of the
accident Mr McRae did not hold a valid flying licence or a valid AS350B2
type rating. He was accordingly in breach of Article 26 of the Air
Navigation Order 2005 when he flew his helicopter on 15 September 2007 and should not have
flown that machine at that time.
- His private pilot's
licence was first issued on 15 February 2000 and expired on 14 February 2005. It bore a five
year validity period on its title page. Mr McRae qualified to fly type
AS350BS helicopters on 17 November 2003. Type rating is valid for one
year and is a test of competency to fly that particular type of aircraft.
In order to revalidate type rating a pilot is required to pass a Licence
Proficiency Check in the same helicopter type. Mr McRae had last completed
a "LPC"on 21 March 2006 which expired on 21 March 2007. No application had
been made by or on behalf of Mr McRae to renew it. Mr McRae had previously
allowed his type rating to expire on two occasions and continued to fly
the helicopter during periods of invalidity.
- It is clear from the
evidence of all who taught Mr McCrae to fly, who tested him on his ability
and who flew wi th him, that he was a technically competent pilot. Many
spoke highly of his abilities and of their confidence in flying with him
and no witness within this category offered criticism of his skills.
- Weather conditions
that afternoon were generally good for flying, albeit a moderate south,
south west wind was described with moderate turbulence being experienced
in the valley area.
- There were no
eye-witnesses to the accident and no flight recorder on board. Air
Accident investigators therefore required to undertake extensive and
comprehensive investigations in order to piece together the aircraft's
final moments by building up a picture of all known or deducible facts and
by eliminating where possible all factors which could have brought about
such a sudden catastrophic event. They were assisted in this by eye
witness accounts of the final flight, by radar data of the flight
collected by the Lowther Hill radar and by video evidence recorded in a handheld
camera operated by Mr Duncan. which survived the crash.
- The Inquiry heard
from a number of eye witnesses who viewed the helicopter flying overhead
at different stages of its final journey. AAIB investigators spoke to all
such witnesses at an early stage in their investigation. Whilst many gave
useful information of location and height which was supportive of other
evidence, such as the onboard video film and radar plotting, some raised
concerns as to the noise coming from the engine, which was at odds with
other evidence in the case.
- Some evidence given
during the Inquiry differed markedly from evidence the same witnesses had
given in the immediate aftermath of the accident when, it may be thought,
recollections would be at their freshest and most acute. Others were
internally consistent but conflicted with other accounts of similarly
located witnesses. Mr Fairbanks explained that in his experience of
accident investigation adult witnesses try to make sense of what they see
and in so doing may inadvertently alter or place undue stress on aspects
of their sightings and thus simply get it wrong. To guard against this
tendency he looks for evidence of what they have seen as opposed to what
they think they have seen and asks them to reproduce what they have seen
using a model. He also personally goes to the location of such sightings
to get a feeling for their position at the time, the topography of the
- Importantly, no
witness spoke to seeing any parts of the helicopter falling off, of flames
coming from it, of uneven flight or any other visual indicators of machine
breakdown or difficulty.
- Mr Lowrie, who had a
panoramic view of the helicopter in its approach to the valley, had seen
it in flight often, albeit only once flying into the Mouse Valley. He described
hearing no unusual noises coming from it as it made a slight turn to the
right then a significant roll to the left prior to descending into the
valley. He was supported in his account by Mr Henderson, an off-duty policeman,
and, to an extent, by Mr Scrambler.
- Mr Scrambler gave
evidence in court that he was concerned at the helicopter's closeness to
housing at the periphery of Lanark which, with hindsight, he suggested
must have been indicative of the pilot struggling to get control so as to
avoid collision with the houses. Examination of his account given
directly to Mr Fairbanks within days of the accident showed, however, that
at that time he had spoken of his anger that the helicopter was so close
to houses and made no mention of any concern that it might be in trouble.
This, suggested Mr Fairbanks, was indicative of the phenomenon he had
spoken of whereby witnesses in good faith with the operation of hindsight
try to deduce from what they have seen rather than simply recording what
they did see. Experts were agreed that a four-second glimpse of a
helicopter, occurring unexpectedly, was insufficient to allow the formation
of any coherent or useful view of its condition or performance. Mr
Scrambler does however agree with other witnesses that the helicopter
descended into the valley in a left banking manoeuvre. He describes a
steady flight path without any significant changes.
- Eye witnesses in
Lanark thus confirmed the radar tracking of the helicopter as it turned
left at a steep angle of bank into the Mouse Valley, where it went out of sight,
rolling to the left when last seen.
- Whilst some eye
witnesses, such as Cathleen Anderson, describe hearing the helicopter make
a different noise - "a labouring chugging"- Mr Fairbanks thought this was
consistent with the blade slap which occurs when a helicopter is being
manoeuvred, the "swoosh" heard 2 or 3 minutes later being the explosion on
collision. Mr Connolly, the expert witness for the McRae family, agreed.
- Radar data was
available for most of the flight and from this the flight path could be
plotted and an estimate of the speeds at which it was travelling obtained.
The data tracks all but the final 20 seconds of the flight, when the
aircraft's position becomes obscured by the topography of the landscape.
- The average ground
speed of the aircraft in the early part of the flight is between 90 knots
and 100 knots, increasing to between 120 knots and 130 knots as the flight
continues. In the last 30 seconds of data, up until the point it goes off
radar at Lockhart Mill, and just before it descends into the Mouse Valley, speed is increasing
to 122 knots As the helicopter turns down wind into the valley, its
ground speed increases due to the effects of tailwind. Flight trials
based on the helicopter's radar profile, witness accounts and expert experience
of trying to reproduce the flight pattern, suggest a figure of
approximately 150 knots: that is, an airspeed of 120 -135 knots overlaid
with wind speed of 15 -20 knots.
- The outbound and
return flights were captured in part on film. Mr Graeme Duncan used his
Sony RDC-DVD106E Handycam
recorder to record portions of each flight. In total approximately 5
minutes of recording showed scenes from the two flights undertaken that
- From the video it is
clear that on the return flight to Jerviswood Mr Duncan was in the
passenger seat with Ben Porcelli occupying the right hand outboard or
window seat and Johnny McRae occupying the right inboard seat. All were
appropriately restrained by the fitted safety belts and wearing
- The video footage
ends 55 seconds before impact. A soundtrack accompanies the video
footage. Whilst much of the conversation carried on at normal
conversational level is drowned out by normal engine noise, occasional
snippets of raised voice remarks and exclamations from the passengers can
be heard. The video footage also provided accident investigators with
useful access to the majority of control panel instruments, from which the
lack of any concerning or abnormal readings could be confirmed. The
helicopter is seen to suffer no apparent technical defect, flight
instruments are functioning normally and Mr McRae appeared at all times to
be relaxed and in control of the helicopter.
- The outbound flight
was conducted at low heights, never in excess of 500 feet and probably
considerably below this altitude for much of the time. The video also
revealed significant low-level manoeuvring. At one point Mr McRae deviates
slightly from his route to pass over a farm building, descending to an
altitude of approximately 205 feet to do so. This is in conflict with the
universally recognised good practice of maintaining a minimum separation
of 500 feet between aircraft and any structure, person or vessel and constitutes
a contravention of Rule 5 of the United Kingdom Rules of the Air
Regulations 1996. There appears to be no operational reason for doing so.
- The video reveals
what was described as a "spirited approach" to land at Little Sunnyside
Farm involving the undertaking of a number of simultaneous manoeuvres.
All experts described this as showing a level of competence on the part of
Mr McRae. Mr Fairbanks made specific reference to the soundtrack at this
point, where Mr Duncan was heard to say,
"Ah yes -feel the G force!"
- The return flight
commences with a zoom climb, whereby the forward motion of the aircraft is
converted to height, the helicopter rolling left as it climbs to about 40
degrees of bank. Whilst this is competently carried out, Mr Fairbanks
explained the increased risks attached to such a manoeuvre when compared
to a more normal, gradual transition to height. He also described the
method used by Mr McRae as not following the recognised method taught to
pilots. Passengers are heard to respond to this manoeuvre with laughter
- In the next segment
of film, the helicopter is seen to fly at considerable forward speed and
at extremely low height along the Avon valley, coming within 30 - 40
feet of trees at the valley edge. The helicopter pitches forward into the
valley along the line of the river and descends below the level of the
surrounding terrain, coming into close proximity of a number of tall trees
growing on the valley sides. Minimum separation is thought to be less
than 100 feet and probably much less, of the order of between 20 - 30
feet. It then climbs quite steeply out of the valley, coming close to
houses at the top of the valley. Throughout this sequence, Mr Duncan and
the children are heard to shout with enjoyment.
- Mr Fairbank commented
that when he flew the same route with a CAA examiner on board both agreed
that they would not have come close to repeating these manoeuvres on
safety grounds. He explained that apart from the proximity of the houses,
the danger of flying into a wooded valley is that you get trees of
different heights, increasing the work load on the pilot who requires to
be super-sensitive to what lies ahead. As he explained,
have the luxury of time and space because of the hazards all around you."
- As the helicopter
flies at a separation of approximately 400 feet from a major roundabout,
Mr Fairbanks comments that the pilot has no margin for error if anything goes
wrong, that one normally flies a single engine aircraft in such a manner
that it can be landed if a problem arises but that here it would not even
be possible to do a zoom climb to get out of it because of housing
- The next segment of
film shows the aircraft coming out of a steep right hand turn just north
of Crossford. Mr Fairbank commented that there seemed to be no necessary
reason for that turn in terms of the overall flight.
- In the final segment
of film the helicopter is following Auchenglen Burn in the Lee Castle
valley. It again starts with the helicopter in a steep right bank which
it rolls out of and the beginning of a left turn is seen. Again, Mr
Fairbanks regards the right hand turn as an unnecessary manoeuvre towards
rising ground and suggests it is for the benefit of the passengers. As
the camera pans aft, Mr McRae appears to be in full control of the
aircraft and to be handling the controls normally. His spirited handling
of the aircraft is indicative of his confidence in its serviceability at
that time. There is no air of concern apparent from the adults or the
children. It is clear from the instruments that there continues to be
adequate fuel on board, no warning lights are illuminated and the
passengers all appear to be clear of the controls. The helicopter is
flying at 110 knots at a height of approximately 440 feet, reducing as it
rolls into the turns.
- The video ends
approximately 1.119 km from the landing site, 55 seconds from impact.
- Mr Fairbanks
considered as notable the spirited handling of the aircraft as seen in the
5 segments of the accident flight, accompanied in each case by laughter,
screams and shouts from the passengers. Mr Duncan is the source of much
of this banter and seems to address his comments to the boys. Mr
Fairbank reiterated in evidence, the terms of his note (Crown Production
number 52) in which he observes that:
operation at extremely low level and the excessive manoeuvre parameters,
particularly the descent into the valley by Larkhall, is indicative of an
aircraft being flown without due regard to the principles of good airmanship,
and in such a way that normal safety margins would be reduced"
giving evidence on behalf of the McRae family, agreed that "it was imprudent to
fly lower than necessary."
- No contradictory
position was put and accordingly I have no difficulty in accepting their
- The licensing
prerequisites for a private helicopter pilot are three-fold: A pilot must
hold a current Private Pilot's Licence certifying his qualification to fly
helicopters; he must also pass annual Licence Proficiency Checks to renew
his type rating on the type of helicopter flown by him; and he must hold a
valid medical certificate. At the time of the accident Mr McRae's licence
had expired as had his AS35OBS type rating. He did hold a current medical
- Mr McRae was one of a
group of pilots who gained their licences in a period of transition
between different licensing regimes. Whereas pilots qualifying prior to 1 January 2000 held them for life,
Mr McRae's licence was issued on 15 February 2000 and was therefore
only valid for a 5-year period. Whilst his licence itself made it clear
on at least five pages, all of which bore Mr McRae's signature, that it
remained in force until/was to be reissued not later than 14 February
2005, there was at this time no external system of reminder to such
licence-holders that their licences were about to run out.
- In 2005 only 30% of
those pilots whose licences required renewal, applied for renewal. Becoming
aware of this, the Civil Aviation Authority (C.A.A.) in late 2006 began
notifying those whose licences were approaching expiry of the need to
renew. Mr McRae did not receive such a reminder as his licence had
already expired by then. Whilst the need for renewal featured in
specialist magazines Mr McRae did not receive any individually-targeted
prompting to renew. Mr Sutherland, who prepared and examined Mr McRae for
his pilot's licence, told the court that he had advised his client that he
thought he would get a lifetime licence.
- Revalidations tests,
in the form of Licence Proficiency Check's (LPC's) require to be carried
out annually in respect of the type of helicopter a pilot wishes to fly.
This is an ongoing competency check involving a flying test and minimum
flight hours in order to test the applicant's ability to handle the
aircraft in normal flight and in emergency situations. Mr McRae's type
rating had been due for renewal on 20 March 2007 and by 15 September 2007 he had failed to
undertake the necessary LPC or to apply to renew it. The onus was on him
to do so. He had failed on three previous occasions to carry out LPC's in
respect of G-CBHL within the one year period and evidence was led to show
that despite the lapse of his type validation during these occasions, he
had logged many flying hours and had flown alone on at least one occasion.
- The law is clear in
respect of the requirement. It is an offence punishable by imprisonment
or unlimited fine to fly without a valid pilot licence, either because it
has expired or because it does not have the relevant current type rating.
It appears to be less clear in respect of its system of enforcement. Mr
Gwilt gave evidence that he neither checked Mr McRae's pilot's licence
prior to issuing a renewal of the LPC on either of the two examinations
carried out by him, nor brought the lapses to McRae's attention and was not,
at that time, bound to do so, although is now. Mr Fairbanks expressed his
concern that at the time of the accident Mr McRae was flying despite not
having demonstrated his fitness and competency to fly that aircraft in the
prescribed period. This failure impacts upon insurance as well as competence.
- As a result of the
AAIB investigation into this accident, and their issuing of a Safety
Recommendation (2008-070) the CAA now require all authorised examiners to check
the licence and other applicable documentation of candidates for
proficiency checks and skills test.
- At the time of the
accident Mr McRae did hold a current medical certificate. However, on
two previous periods totalling 110 days he continued to fly despite not
holding a valid medical certificate. Whilst there is no suggestion that
he was in fact unfit medically to fly during these periods, he was in
breach of regulations at these times. As indicated above, he had
previously failed to renew his type rating on another two occasions but
continued to fly during these periods also. Again, there was no evidence
to suggest that he would not have satisfactorily renewed his type rating
had he applied to do so. The Crown did not suggest any causal connection
between Mr McRae's failure to meet timeously the licensing requirements
and the accident. The evidence would not support such a proposition. Mr
McRae had considerable flying experience. He had logged 965 hours, 490 of
which were on the Eurocopter AS350B2 Squirrel helicopter. His flying
experience was current, having flown an estimated 50 hours in the three
months prior to the accident. He was a competent and confident pilot and
would have experienced no difficulty in renewing the required licences.
There was nothing in the tests he would have had to pass which is likely
to have better prepared him for the last flight. However, his tolerance
of such lapses in licensing, some of which he must have become aware of
and therefore should have been on guard against on future occasions,
indicates a somewhat cavalier attitude to the safety regime imposed by the
Civil Aviation Authority. Doubtless he put faith in his own ability, as
did others, however the legislation requires an objective, external check
of continuing knowledge and skill and to fail to engage with that assessment
may be seen as reckless.
AIR ACCIDENT INVESTIGATION BRANCH ("AAIB")
- Mr Andrew Robinson,
Senior Inspector of Air Accidents responsible for the engineering aspects
of the AAIB investigation, attended the accident site on Sunday 16 September 2007 and viewed the
wreckage. He noted the extent of the physical damage to the air frame,
and to surrounding trees. He concluded that these signs pointed to a high
energy impact, with disintegration of the aircraft occurring after impact
with two tall trees. The aircraft was travelling fast at impact. The main
strike on the fir tree occurred at the same height above sea level as the
main wreckage was found suggesting it was travelling at speed. Scrutiny
of the point of impact on a fir tree, the shape of the mark and
distribution of branches suggested that the aircraft struck it in an upright
attitude with no significant bank angle. The pitch angle was estimated to
be nominally level but the detachment of the tail boom suggests that the
nose may have been pitched above the horizontal. The aircraft, at point
of impact, was flying virtually at right angles to the valley and not on a
diagonal trajectory. Such a trajectory did not make sense since it
brought the aircraft into contact with the hillside. All major parts of
the aircraft were accounted for at the crash site, indicating that there
had been no structural failure and it had been intact on impact
- It was immediately
apparent to AAIB investigators that the helicopter was not making an
approach to land at the landing pad at Jerviswood at the time of the
accident, albeit the point of impact was only about 150 metres from the
helipad. Whenever possible, helicopters land into the wind and the
direction of travel was downwind and with any view of the landing site
being impeded by trees. The impact speed was faster than that for an
approach for landing.
- AAIB investigators carried
out an admirably thorough investigation into all aspects of the incident,
including a detailed examination of the wreckage, an analysis of the
flight, ingathering and examining meteorological information, recorded
data in the form of radar data and video recording and attempting to
reproduce its final flight path and establish its flight parameters. Where
initial investigation revealed any ambiguity, further detailed
exploration, sometimes involving the expertise of others, was undertaken
until a definitive position could be safely adopted. This scrupulous
approach allowed them to dispose confidently of the vast majority of
potential causes. It is a mark of the meticulous nature of their inquiry
that where they are unable to dismiss utterly a potential cause, however
remote, they rehearse clearly how it could impact upon events whilst also
attempting to set in context the improbability of it in fact featuring.
- Recovery of the
wreckage by police and emergency services was painstaking and thorough.
It was carefully logged and taken to the AAIB facility at Farnborough
where a detailed inspection was carried out, assisted by the airframe and
engine manufactures and by experts from the French air accident investigation
- Examination of the
structure confirmed there was no evidence of a pre-impact failure, all
damage being referable to impact.
- The engine had been
extensively damaged in the impact, resulting in distortion of the engine
casing and the seizing of the rotating components as a result.
Disassembly of the free turbine module revealed that the drive nut had
slipped rotationally relative to the turbine shaft and the direction of
slippage indicated that the shaft was being driven and that therefore the
engine was delivering power at the time of the impact, sufficient to
maintain flight. There was no contamination of the magnetic plugs and no
sign of clogging in the oil filter. Examination of the engine revealed no
reason for the crash.
- The hydraulic system
had sustained damage on impact but examination of its component parts
revealed that the pump mechanism remained functional, there was no sign of
in-service deterioration of the drive belt which had snapped cleanly on impact,
the hydraulic reservoir although holed on impact, still contained 50% of
its contents suggesting there had been no pre-impact leaks and whilst the
pressure regulator could not be subjected to a full production test due to
damage on impact, its regulatory function was operating correctly without
contamination or interference. Accordingly it was extremely unlikely that
there had been any form of hydraulic failure.
- In the event of a
hydraulic system failure, the aircraft retains 30 seconds of hydraulic
power as a safety feature. Such a failure would result in the tripping of
a cockpit red warning light, notifying the pilot that he has 30 seconds to
reduce speed, return the aircraft to manual control and get the aircraft
to safety. This is sufficient for the pilot to fly the aircraft to a
safer environment. Pilots receive mandatory training in respect of
approaches and landings in the event of such a failure within the AS350B2
- Examination of the
flying controls threw up some challenges to investigators. As any
disconnection or failure of the flying control components could have
caused the pilot to lose control of the aircraft it was important to
establish that they were in fact connected pre-impact. Fire damage to
many of the components resulted in difficulty in identifying the specific
airframe location of some of them. Careful forensic examination of the
remaining components confirmed that the servo operating rods were intact
at the time of the accident.
- Apparent lack of
damage to the lower eye end of one of the servo operating rods which
remained attached to the servo input linkage on the gearbox, combined with
uncertainty as to whether the original aluminium rivets connecting them
had melted or failed or been replaced with bolts resulted in extensive
investigation to try to ascertain whether a bolt or a rivet had been
present at the time of the impact and thus whether the component was under
load at the time. Tensile tests, in conjunction with examination of brinelling
marks on the forward servo input rod lower eye end conclusively proved
that the rod end and bellcrank components had been attached with an
aluminium rivet, which failed on impact, preserving the intact servo
operating rod from the tensile loads which led to failures in the
remaining two rods. Investigators concluded therefore that this area of
the flying control linkage was intact at the time of the accident.
Flying control servos
- The four flying
control servos were subject to intensive testing by their manufacturers
under AAIB supervision. Initial problems were identified in the three
damaged cyclic servos, but these responded to removal from their damaged
location and being cleaned of accident site contamination, giving rise to
the conclusion that there had been no failure in the internal components
of these servos. The critical components would have been protected in
service by dust covers which had been ripped off in the crash, permitting
contamination at that point, together with distortion as a result of the
- Examination of the
forward cyclic servo, which controlled the tail rotor, initially resulted
in no actuator movement being detected. Stripping of the valve body
proved difficult as it was found to be almost seized. Since any distortion
caused by the gumming-up of the moving parts of the servo by swarf or
other contaminants could prevent a pilot being able to control the
direction of flight, it was important to investigate carefully the nature
of the seizure noted in that component. Stripping of the spool valve
revealed no internal debris but a slight discolouration in the fluid wiped
from the spool stem. Cleaning of this resulted in satisfactory operation
on retesting. Whilst it was concluded that the initial unsatisfactory
operation was consistent with accident damage and accident-site contamination,
its existence means that it was not possible to entirely rule out a
pre-impact seizure of the valve in the forward cyclic servo. Despite the
existence of this theoretical possibility, the operational history of this
aircraft made this very unlikely to have in fact occurred, no such seizure
having come to the attention of manufacturers or the authorities in many
millions of servo operating hours.
- The flight manual
contains procedural advice to be followed in the event of a main servo
actuator valve seizure, whereby a return to manual control is recommended.
Any such seizure would be preceded by stiffness resulting in resistance in
the cyclic controls.
- An autopilot system
had been fitted of which only the pitch and roll actuators were recovered
and examined. It was established that they were in the mid point
position, which is where they would be expected to be. Investigators
encountered an initial problem getting the roll trim actuator to function
but concluded it was most likely to be a consequence of accident damage.
Other parts of the system were not recovered and therefore it is not
possible to confirm that the entire system was functional.
- However, even were a
major fault to have developed in the autopilot system, the pilot could
have easily regained control by moving the cyclic stick and breaking the
weak links in the trim actuators. The weak links had indeed failed but it
is probable that this was associated with impact.
- Video evidence showed
that the auto pilot yaw channel was disengaged. The yaw channel is an
optional extra and it was not clear whether this disengagement was as a
result of a fault or simply because Mr McRae had chosen not to engage it.
There was no suggestion that this disengagement played any part in the
SERVO TRANSPARENCY PHENOMENON
- Some time was spent
by investigators and by witnesses exploring the "flight control servo
transparency phenomenon", also known as "jack stall".
- A helicopter
operating within normal flight conditions is protected from the
aerodynamic forces which act upon the main rotor blades by means of servo
actuators within the hydraulic system. If a helicopter is manoeuvred in
such a way that its airspeed and/or g -loading becomes excessive,
aerodynamic forces on the rotor blades become greater than the hydraulic
forces used to control them and can be fed back to the flying controls
which then feel heavy to operate. A pilot who is not expecting to
encounter this phenomenon, may have the impression that his controls have
- If appropriate action
is not taken to combat this, then the helicopter will roll to the right
and may pitch up. If a helicopter is already in a right turn when servo
transparency occurs, then the resultant further roll to the right and
pitch-up will cause an increased rate of turn. To overcome and counter
this phenomenon the pilot will require to use increased force on his
controls. At no time does an aircraft thus affected become inoperable or
the pilot lose control. It does however become more difficult to fly
accurately as it is more difficult to move the controls. It may also
cause a pilot who does not recognise the phenomenon to panic that the
aircraft is malfunctioning and the controls have jammed and thus fail to
respond appropriately. If it occurs during a right turn, such a pilot may
delay in recognising the increased angle of bank. A helicopter
experiencing this phenomenon will respond automatically to correct by
reducing collective pitch. A pilot seeking additional power at this point
may be denied it.
- This is a rarely
encountered phenomenon with very few documented examples of it in the
literature but is sufficiently recognised to feature in Eurocopter's
published advice to AS350 series helicopter owners together with advice as
to how to respond should it occur. It is a feature of this phenomenon that
it only lasts less than 2 seconds before the aircraft reacts in response to
reduce the factors contributing to it by slowing down and reducing control
loads. It is therefore self-correcting. Pilots are told to immediately
reduce the severity of the manoeuvre which caused it in the first place.
- Helicopters which are
flown within the normal flight envelope will not encounter this
phenomenon. Those flown at or beyond it may. By definition therefore,
the phenomenon can only be present when a pilot is performing manoeuvres
which reach and exceed several aircraft limitations simultaneously.
- The Eurocopter
Service Letter SL 1648-29-03 indicates that,
airmanship should prevent encountering this phenomenon by avoiding combinations
of high speed, high gross weight, high density altitude and aggressive manoeuvres
which exceed the aircraft's approved flight envelope."
advises that the pilot should immediately reduce the severity of the manoeuvre
on becoming aware of control forces feedback. This advice was first published
in a service letter published in December 2003 and subsequently in a revision
to the flight manual which was sent out to pilots and maintenance contractors
in October 2004. The revision does not appear to have been inserted in this
helicopter's flight manual and the service letter appears to have been sent only
to the helicopter's maintenance engineers and not to Mr McRae. No attempt was
made by PDG Helicopters, the helicopter's
maintenance engineers, to forward it to Mr McRae or to update the manual during
maintenance of G-CBHL. Whilst this information was available on the Eurocopter
web site, there is no evidence that Mr McRae had accessed it or was aware of
the contents of it.
- Mr McRae should have
been aware of the advice contained within his helicopter manual as part of
his responsibility as a pilot, but that advice was out of date. The
responsibility for keeping the flight manual current rested with Mr McRae
as owner and pilot of the aircraft, albeit there is no evidence that he
was aware that updates were available. The advice noted in the manual
recovered at the accident site in respect of manoeuvring limitations
contained a prohibition on exceeding "the load factor corresponding to the
servo-control reversibility limit" and described servo-control
transparency as being a smooth phenomenon which "presents no danger". It
power configurations, it is advisable to decrease collective pitch slightly
before initiating a turn, as in this manoeuvre power requirement is increased"
- Whilst this original
advice remains generally correct, the revisions to this entry give much
greater information about how to avoid encountering the phenomenon and its
effect once encountered, together with detailed advice on how to counter
reduce the severity of the maneuver (sic)...; follow the aircraft natural
reaction to pitch up and induce a down collective movement; reduce overall load
on the rotor system and smoothly counteract the right cyclic tendency to
prevent an abrupt left cyclic movement as hydraulic assistance is restored.
Transparency will disappear as soon as excessive loads are relieved."
clarifies that the phenomenon is not dangerous, "if properly anticipated by a
pilot during an abrupt or excessive high load maneuver such as a high positive
g-turn or pull-up".
- The recommendations
made in the AAIB report number 34 of process that:
Aviation Authority should circulate, by the most appropriate means, the content
of Eurocopter's Service Letter SL-1648-29-03 to owners and operators of
applicable helicopter models, with a view to reminding them of the causes,
symptoms, hazards and recovery actions relating to "servo transparency" or
"jack stall encounters" (Safety Recommendation 2008-068); and
"... that the
Civil Aviation Authority, in conjunction with the European Aviation Safety
Agency, require an awareness of the causes, symptoms, hazards and recovery
actions relating to "servo transparency" or "jack stall" encounters to be
covered as a ground study item as part of the mandatory training for aircraft
type ratings for those helicopter types likely to be affected" (Safety
Recommendation 2008 - 069).
have been accepted and
implemented by the C.A.A..
FLIGHT PATH ANALYSIS
attempt to more fully understand what happened once the helicopter was out of
radar and eyewitness sight, an attempt was made by the AAIB to piece together
its likely flight plan.
- Witnesses describe an
initial right turn quickly followed by a steeply banked, descending
manoeuvre into the valley. Albeit that left roll to a high bank angle attracted
the notice of witnesses, the helicopter could not have actually turned
very dramatically or it would have flown out of the valley to the north.
It maintained this left bank as it descended into the valley and
disappeared out of sight. This track would not have led to the impact
site. To arrive there, the helicopter would have had to undergo a right
turn through 90 degrees, probably following the line of the river as it
followed the valley eastward.
- Flight trials were
undertaken under the auspices of the AAIB in an attempt to establish the
maximum speed and rate of descent of G-CBHL as it entered the valley. To
increase accuracy of results, parameters were applied to each flight
profile, based on known information as to helicopter mass, the limitations
of the terrain, the position of the accident site and radar and witness
information. Three different pilots were involved in flying these
profiles, a Eurocopter test pilot, the C.A.A chief examiner and Mr
Fairbanks and they obtained a consistent, repeatable result of an airspeed
of 135 knots, with a rate of descent of 1500 ft/min to 2000 ft/min from a
starting height of approximately 300 feet. Mr Fairbanks expressed his
confidence that these figures were accurate. No direct challenge to these
figures was taken in evidence, despite this estimate of airspeed featuring
in Crown Production 34 (page 99).
- In submission Mr
McBryde for the first time, seeks to rely upon the last recorded airspeed
of 100 knots based on the radar data as being reflective of speed in the
final seconds and appears to cast doubt upon the AAIB figures of 135 knots.
He did not deal in submission with Mr Fairbank's evidence that the
recorded groundspeed of 122 knots in the last 30 seconds of radar data
occurred at a point prior to entry to the valley, when the aircraft was
flying across the valley and had not yet encountered the full force of the
tail wind. A 15 -20 knot tailwind would accordingly have to be added to
this as it flies up the valley. At that time airspeed was increasing. I
prefer Mr Fairbanks assessment of speed.
- A 90 degree right
turn at a 60 degree bank angle, at an airspeed of 130 knots is calculated
to require a steady loading of 2g in calm air and in level flight.
Conditions were not ideal in the valley, with gusty winds of between 15 -
20 knots with some turbulence and such a turn would not have been
sufficient to keep the helicopter within the narrowest part of the valley,
suggesting a tighter turn would have been attempted.
- The main rotor disc
hit the fir tree approximately 30 feet from its top, suggesting that Mr
McRae had not simply misjudged the height of the tree line but had rather
collided with it in the course of another manoeuvre. Had the aircraft
continued on a trajectory consistent with the impact track, it would have
headed towards rising wooded ground, suggesting that the aircraft was not
on its intended path at the time of impact. The fact that it hit the tree
in an upright, nose up attitude is suggestive of an attempt by Mr McRae to
arrest a rate of descent into rising terrain.
- Mr Fairbanks was of
the view that the flight path analysis carried out by him is key to
understanding the accident.
to fly in the valley at relatively low height and high speed, the pilot was
undertaking a demanding manoeuvre. With the aircraft initially banked steeply
in the opposite direction of the intended turn, descending at relatively high
speed and rate of descent and with a strong tailwind, accurate judgement of the
required turn point would have been very difficult. The risk was that the
pilot would start to turn late, come into unexpectedly close proximity of the
terrain immediately ahead, and need to fly a harsh manoeuvre to avoid it. Even
had the turn started in the correct place, it would have been difficult to
judge, given the helicopter's speed, the nature of the valley, the lack of a
good horizon reference, and the effect of the wind" (page 99)
- So, it seems likely
that Mr McRae found himself having to manoeuvre at speed, without height
and all within a challenging environment. In doing so he would be pushing
his aircraft towards maximum performance.
- The conditions
precedent for the occurrence of servo transparency include excessive speed
and/or g-loading. The transparency may be reached, according to Rush
Revision 3A to the AS350B2 Flight Manual, "during manoeuvres such as steep
turn, hard pull-up or when manoeuvring near V 6" (the never exceed speed
of 155 knots).
- If, as I accept, Mr
Fairbanks analysis of the final flight path is correct, then G-CBHL was
indeed operating at or towards the limit of its flight envelope and servo
transparency becomes a possibility, albeit not a probability. We simply
do not know whether Mr McRae increased the g-loading beyond 2, albeit he
may inadvertently have done so in circumstances where he could have
encountered turbulence, required to respond to circumstances and increase
power or intensify a manoeuvre. If he encountered it we know that he was
aware of the phenomenon, having studied it, at least as set out in his
manual in its pre-2003 form, and should have been in a position to
recognise it and even take steps to assist his aircraft to overcome it.
However, in such extreme conditions, even momentary hesitation or recovery
time could have proved fatal.
- As indicated, this
phenomenon is short lasting and self correcting, but could be extremely
disconcerting for any pilot unexpectedly encountering it and, if it occurs
in a situation where reaction time and manoeuvring space is already
limited, catastrophic. Flying within the Mouse Valley, at low level, at high speed,
executing tight manoeuvres could constitute such a situation.
- Investigators wanted
to explore the necessary preconditions for the phenomenon arising in the
present case. Using known data such as altitude of the crash site,
temperature, weight of the helicopter and estimated data such as speed
Eurocopter were able to produce a graph (reproduced at Figure 9 on page 92
of Crown Production 34) demonstrating predicted conditions for the onset
of servo transparency in this machine. It shows that the faster the
airspeed, the less g loading required to encounter it and at 130 knots,
the onset of servo transparency is predicted to occur at a load factor of
2.1g. G-CBHL would, on the basis of the estimates of speed, rate of
descent, angle of bank and the known components of gross weight etc, be
nearing such load factors as it carried out the corrective right hand
turn. Figure 10 of Crown Production 34 indicates the path such a turn
would follow given the prevailing wind speeds. That path would have to be
further corrected to keep the helicopter within the narrowest part of the
valley. The more dramatic the manoeuvring, the closer to maximum
performance the helicopter would be and the less needed to exceed it. Any
sudden dramatic attempt to correct a slight misjudgement on a turn, or
pull up to avoid oncoming terrain would make servo transparency more
- Attempts to induce
servo transparency in flight trials carried out by Mr Connolly were
unsuccessful, supporting other evidence that this aircraft has not so far
proved particularly susceptible to the phenomenon., albeit Mr Connolly was
restricted in his attempts to push beyond the flight envelope because he
was not engaged in an authorised flight trial, limited his speed to below
that estimated in this case, and was reluctant to be more aggressive.
- Mr Fairbanks believes
that if servo transparency occurred in this case, it did not persist for
long. The reason for this conclusion is that the aircraft was notionally
upright, perhaps with its nose up at the time of impact, suggesting that
the pilot was flying the aircraft, and trying to fly out of the position
he found himself in, when he hit the tree, not rolling to the right as a
result of the phenomenon. Servo transparency is, however, a possible
explanation for the strange deviation from the flight path taken in the
final seconds when the helicopter flew at right angles to the valley.
- Other explanations
for this deviation can also be suggested, but not factually established. As
Mr Fairbanks commented,
- "We felt it looked
that he was trying to get himself out of danger. Because the helicopter
had turned more degrees than we would have expected, we felt something
unusual had happened. But, because of the upright nature of the
helicopter we feel he was trying to recover it."
- Dual controls were
fitted to the helicopter with the result that duplicate controls were
located at both the pilot and front passenger positions. These were
active and working on this flight. The passenger side controls can be
removed. The general advice from the Civil Aviation Authority is that it
is advisable to remove such controls if the passenger is not a qualified
pilot. There is no requirement to this effect but it is good practice to
- According to Mr Hugh
Sutherland, whose firm was responsible for the maintenance of G-CBHL, the
passenger side controls were simple to disconnect by pulling out a spring
loaded pin and removing them. The pilot can do this himself, albeit 90%
of his customers have the dual controls in their aircraft fitted at all
times. Mr McRae's were in most of the time.
- In his submissions on
behalf of the McRae Family, Mr McBryde takes issue with this. He founds
upon Mr Connolly's evidence that the signature of a second licensed pilot
or engineer would be required to verify the controls being removed or
refitted. He also quotes Mr Alastair Sutherland's evidence that he was
familiar with Mr McRae's helicopter and he would not attempt to remove the
dual controls. Not much may hang on this discrepancy, albeit I would
prefer Hugh Sutherland's evidence as the man responsible for the
maintenance of the helicopter since its purchase by Mr McRae in 2003. It
is backed up by Mr Fairbanks account of receiving training in removing and
refitting them using the screw type fixings, when he trained on that
model. Mr Connolly agrees that removal is physically an easy operation to
carry out, but maintains that Mr McRae would technically have been in
breach of requirements had he done so without inspection.
- Clearly had Mr McRae
wished to have them removed the opportunity was there for him to do so,
either personally or involving others, and having that certified if
necessary. Had they not been in place, then any possibility of accidental
interference with them would have disappeared.
- The video shows that
Mr Duncan's right foot is positioned forward, under the right pedal at the
start of the outbound flight. There is no such evidence that it was in the
same position during the return flight. There is no suggestion from the
video footage that Mr Duncan interfered with the controls, even during
bouts of "spirited" flying.
- In an aircraft such
as this, fitted with dual controls, if a passenger touches the collective
lever unexpectedly, with sufficient force, the aircraft would deviate from
its flight path. Any such accidental interference could be rapidly
countered by the pilot but until he regained control, the aircraft would
go into freefall.
- Mr McBryde suggests
as a possibility the sudden accidental lowering of the collective lever by
Mr Duncan as he adjusted his position in his seat or sought to stow or
recover the video camera. That, he suggested, would cause a reduction of
power, a nose down pitch resulting in increased airspeed. It could also
result in a yaw to the right. Whilst this is capable of correction, by
the pilot using the left yaw pedal to correct the yaw, if Mr Duncan's foot
was under the right yaw pedal his ability to do so would be impeded.
Recovery from the induced high speed dive may then have been impeded by
the onset of servo transparency and further height would be thus lost with
further disorientation occurring to the pilot.
- To cause lowering of
the collective lever the passenger would require to apply a lot of
pressure to it - to lean on it. Whilst this cannot be entirely ruled out,
there is no evidence that it in fact occurred. Mr Duncan is seen from the
video to be properly strapped in, to be behaving appropriately and at no
time in contact with the controls. As a former quad bike racing champion
and mechanical engineer with experience working with an aeronautical
company, he would have some familiarity with and respect for the helicopter
controls and their vulnerability. Had he uncharacteristically come into
contact with the controls with sufficient force to interfere with the
pilot's control, Mr Sutherland indicated he would expect a pilot in such circumstances
to make a very rapid recovery - in less than 2 seconds, albeit meantime if
the aircraft was flying horizontally it would continue forward at speed
but drop rapidly and roll a bit.
- Investigation of the
contents of the cockpit, using the video and the search of the accident
site, reveals that there were no loose items in the cockpit prior to the
crash which could have interfered with the controls, with the exception of
the camcorder and a soft cover book. The camcorder when found was
intact. There is no evidence that it was dropped or otherwise became
loose. The soft book cover could not bring to bear sufficient force to
- In submission, Mr
McBryde suggests that Mr Duncan is likely to have recorded the aircraft
landing at Jerviswood at the conclusion of the flight since he recorded
the earlier landing at Larkhall and since he didn't it is possible that an
incident or event could have occurred within the aircraft resulting in Mr
Duncan ceasing filming.
- It is possible, but
there is no evidence to support this. Those responsible for recovering
the video footage were unable to assist the Inquiry as to whether the
video recording ceased due to the battery running out or the space to
record footage becoming full. The recording was not a continuous record
of the two flights. Mr Duncan clearly chose to cease recording at times.
He may well have chosen not to record a final segment. There is no
evidence that his recording was in any way interrupted.
- Mr McBryde thus
enumerates a number of potential causes. None can be conclusively ruled
out, but there was no evidence capable of establishing any of them.
Having considered them, I remain firmly of the view that whatever occurred
in the final seconds to prevent Mr McRae using his undoubted skills to
avoid colliding with the trees, the accident would have been avoided had
he not chosen to fly down into Mouse Valley.
- Had he encountered
handling difficulties, by reason of servo transparency or any other
temporary cause, there is every likelihood that he could have overcome
them had he not been attempting to do so in a heavily wooded, restricted
environment. Had such difficulties occurred during a routine approach to
land at Jerviswood, although it is difficult to see how servo-transparency
would in such circumstances, he would have had the opportunity and time to
gain height and take stock, or to put the helicopter down quickly on the
open fields nearby.
- Had the dual flight
controls been inadvertently operated, he would have had the time and
opportunity to overcome any momentary deviation. Open airspace and the
availability of landing opportunities would militate against pilot
misjudgement, and give opportunity to correct any that might arise.
Likewise distractions are limited and can be overcome. Bird strikes were
not investigated in evidence, but it is safe to assume, given the
meticulous police retrieval operation and forensic examination of the
scene and helicopter that there was no such evidence to place before the
Inquiry. They cannot be entirely discounted however, particularly in the
heavily wooded valley area.
- The AAIB report also makes
the point that,
aircraft at low height in the valley and turning steeply to the right, an
accurate assessment of the true horizon would have been difficult, as attention
would primarily be focussed on the valley itself. There were several isolated
trees in the immediate vicinity of the impact site, of which the fir tree that
G-CBHL struck was not the most obvious. It was considered possible that shadow
on the south side of the valley at the time of the accident could have further
hindered an accurate assessment of flight path and hence separation from the
in such an environment is a very real risk.
- If Mr McRae did
indeed encounter some event which temporarily disrupted his flight plan,
he, or the helicopter, almost managed to recover from it. The tree was
hit 30 feet from its top branches. Had Mr McRae managed to gain a little
more height they may well have survived the event. Equally, had there
been no obstacle to encounter in the path of the helicopter any such event
could have been overcome without incident.
- Whilst, therefore, it
is accurate to state, as Mr McBryde invites me to do, that the proximate
cause of the accident cannot be positively determined, it is possible to
determine that this tragedy would not have occurred had Mr McRae not flown
his helicopter into Mouse Valley. Whether that proximate event resulted from the
difficult manoeuvring involved in flying within that environment or from
an unconnected event which occurred when the aircraft was within a
difficult flying environment, the common and fatal feature is the
unforgiving nature of the valley.
- Mr McBryde submits
that it is not known whether he deliberately flew into the valley or
whether there was a problem or incident within the aircraft that caused or
contributed to it flying into the valley.
- The evidence does not
support this. The decision to descend into the valley was a deliberate
one. He was seen to do so in a controlled manner. Mr Fairbanks is clear
that Mr McRae could not have carried out such a tight manoeuvre into the
valley had he not been in control of the aircraft. Further, if he had no
control at a later stage of the flight, then how could he perform a tight
manoeuvre to the right and then adopt an upright attitude as suggested by
the evidence at the accident site? Had there been a control fault, Mr
Fairbanks would have expected to see signs of it earlier that day. Had
there been anything wrong with the handling of the aircraft, the pilot
would simply not have flown into the valley. It would go against all
instincts to do so, as well as all training. Had he suffered engine
failure, one would expect to see an attempt to manoeuvre out of the valley.
No such attempt is made and for all these reasons, Mr Fairbanks concluded
that the flight into the valley was deliberate. He believes that Mr
McRae's intention was to descend into the valley before executing a steep
right turn, possibly with a planned zoom climb.
- Since no witness
viewed or recorded the final seconds of the flight what caused an
apparently fully functioning machine, flown by a competent pilot to make
contact with trees within that valley cannot be positively determined.
Whatever occurred did so within those final seconds. Had it been
otherwise, had a fault developed prior to entering the valley, Mr McRae
would not have flown into it. That is the universal judgement of all
expert witnesses and pilots. Had he become aware of any technical problem
during his descent into the valley, he would have aborted that descent,
tried to achieve height or set up a controlled descent to a safe area.
The valley is surrounded by fields and open ground which would have
provided an opportunity for landing had that been required.
- Whatever happened was
sudden, unexpected and took place in circumstances where Mr McRae did not
have scope to recover.
- Why then did Mr McRae
decide to fly G-CBHL into Mouse Valley? The suggestion from Mr McBryde is that he may have
been flying a flight path to avoid overflying his own house and a noise
sensitive neighbour, extending his flight path eastbound before turning
into wind to make his approach to the helipad. He bases this on evidence
from Robert Campbell Roy that the routes he would take leaving and
returning to the helipad related in part to a neighbour's sensitivity to
- If so, why did he so
rarely take this approach? His housekeeper, Mrs Katherine Anderson,
reported that she had heard him go in front of the house before, but not a
lot. Mr Lowry who farms nearby and who regularly saw him flying, spoke to
only once before seeing him using this approach . Mr Iain Ross had never
seen the helicopter coming in from that direction before. Mr Roy, a passenger
in the helicopter as often as once or twice a week, had never flown up Mouse Valley and Mr McRae had
never done it to his knowledge. His usual route returning to the helipad,
he stated, would be coming from the north and swing round to the west into
- In any event, any
concern about neighbours does not explain why he descended into the
valley. He presumably could have made that approach without losing so
much height. Mr Connolly took the view that it was a practical route, if
we leave aside the question of height. However, it is the height which is
the critical factor and it cannot be left aside. Stewart Kitchen, police
helicopter pilot who attended that day, was clear that he would not have
flown that aircraft into the valley as a civilian pilot because to do so
would be in contravention of the rules of flying and he would deem it
unsafe. He had been trained to minimise flying time over inhospitable
areas such as this for the very reason that landing is problematic in the
event of an aircraft malfunction. Stewart Anderson, air ambulance pilot
and former military helicopter pilot and instructor, was of the same
opinion. He would only go into a valley if he had to pick up a casualty.
He assessed the 500 feet clearance rule as operating from the top of the
valley, not from the river running along its floor. Even Mr Connolly
agrees that he was flying lower than was prudent.
- Mr Fairbanks
indicated that he found the video evidence of the two flights to be
instructive in this regard. He referred to the segments which featured
the helicopter flying low into the Avon valley, followed by a zoom
climb out and 3 hard turns, all to the evident enjoyment of the
passengers. Based on this prior pattern and on the high speed maintained
by him as he entered the valley, he formed the opinion that Mr McCrae was
seeking to conclude the journey to the enjoyment of his passengers, by
descending into the valley, executing a steep right turn prior to a zoom
climb out of the valley.
- If it is accepted,
and it is, that Mr McRae flew voluntarily into the Mouse Valley, then no other
explanation so neatly fits the established facts. He was not making an
approach to land for the reasons stated above. He did not require to
descend into the valley in order to approach the helipad from this
direction, even had he decided that this direction of approach was
appropriate. To do so required a series of manoeuvres and stresses which
could easily have been avoided had he chosen a more direct or familiar route
to the helipad. In short, there was no operational or logistical reason
for him to descend into this difficult environment at all, never mind at
speed. It is difficult to avoid the conclusion that his intention was to
conclude the flight as he had started it, with a spectacular and dramatic
fly-past of the valley and its vegetation, followed by a steep climb out
prior to coming into land, all for the benefit of his passengers.
- Ben Porcelli was
dropped off by his mother to play with school friend Johnny McRae at
Jerviswood on that Saturday afternoon. It is clear from Mrs Porcelli's
affidavit, and that of her husband, that their understanding was that the
boys would spend the afternoon playing together at Jerviswood. Whilst they
were aware that Mr McRae had a helicopter, there had never been any discussion
involving Ben going in it. At no point did Mr McRae seek their permission
to take Ben on that helicopter flight. The pain and anguish resulting
from Mr McRae's decision to take the boys on board is unimaginable.
- I am asked by the
Crown to determine that it would have been a reasonable precaution,
firstly, in relation to Ben, that the accident and subsequent death might
have been avoided if parental consent had been sought by the pilot prior
to the child being carried as a passenger in the aircraft and secondly,
that the Civil Aviation Authority be invited to consider regulation of
- As a matter of
simple, awful, logic, if Ben had not been on board the helicopter that
day he would not have died in the accident. I do not doubt that his
parents' suffering is compounded by their lack of knowledge that he was on
board and their lack of opportunity to give or refuse informed consent to
his being a passenger. I do not know what their decision would have been
had they been asked for their consent. Their affidavits do not tell me.
Decisions to give or refuse children a much-wanted treat are not always
easy for parents to grapple with. If asked, the Porcelli's may have had
no difficulty in saying no. They might have agreed that their child
should have this opportunity. Mr McRae was an experienced and competent
pilot. What greater reassurance can anxious parents have that the pilot's
own son is also on board? Many parents doubtless would have given consent
had the opportunity been afforded their child and could not be criticised
for doing so. However, most parents and guardians who hand their child
over into another's care for however limited a time would, in my view,
have an expectation that the adult responsible for them would seek their
consent before embarking with them upon any unforeseen, unforewarned event,
particularly if it involved risks. It may be a mark of how casually and
routinely Mr McRae regarded the use of his helicopter that he took no
steps to seek such permission, but most parents, in my view, would regard
it as appropriate to be asked before another takes their child on a car
journey, a swimming trip, or indeed any deviation from the expected play
date at home. There are good and cogent reasons behind such an
expectation: parents can give vital information about the child and his
ability to enjoy the proposed outing; there may be safety considerations;
there may be family boundaries crossed; the list goes on. Parents should
have the opportunity to say no in respect of their child. The Porcellis
were denied this.
- However, in the
absence of unambiguous evidence that Ben would have been refused
permission to participate in the flight, it is not open to me to make a
finding in terms of Section 6(1) (c). If permission had been granted, as
it could have been, Ben would have been on the flight. The granting of
that permission would not have been open to criticism.
- Nor am I in a
position to make a finding that the Civil Aviation Authority should consider
regulation of this matter. There is simply insufficient evidence before
me to entitle me to make such a finding. Regulation can be a blunt
instrument and it should only be imposed when there is certainty about its
purpose and its result, and a careful consideration of possible unforeseen
and unintentional consequences undertaken. I suspect, but do not know,
that commercial aviators require parental consent already. In the absence
of any focus on this issue during the Inquiry, except insofar as already
related, I do not have the evidential basis to determine whether there
exists a significant problem in relation to children being carried without
parental consent, whether mandatory prior consent would be a proportionate
and reasonable response, how such regulation would sit with carriage in
other forms of transport and so on. I also do not know whether or not in
this case that any such regulation would necessarily have been complied
with, in circumstances where so many other requirements were not.
FLIGHT DATA RECORDERS
- The Crown seeks a
finding that "all aircraft should be fitted with flight data recorder to
include voice and video recording together with instrumentation
recording." They are supported in this by the McRae family.
- They base this
submission upon the evidence of Mr Fairbanks and Mr Robinson of the AAIB
and of Mr Connolly. Mr Robinson explained that there is currently no
requirement in the U.K or elsewhere for any type of flight data recording
device to be installed in private aircraft of this weight. It is
compulsory in public transport operations where 9 or more passengers are
being carried. He agreed that given the uncertainty surrounding the cause
of the crash it would have been helpful if any information of this type
had been available for consideration as part of the overall investigation.
It would have been particularly helpful in considering whether servo
transparency might have occurred to have confirmation of the estimated
airspeed of 130 knots along the valley and a measurement for the g force
encountered during manoeuvres. However, he pointed out, I.T does not tell
us everything we might wish to know. Sometimes, such flight data
recorders don't work; their calibrations can be out; as they get more
complicated investigators become more reliant on manufacturers to decode
them. They are, however, becoming more reliable and the possibility of
fitting them to all aircraft in the future is probably increasing. Cost
is a problem but digital technology is bringing that down.
- Mr Connolly also
spoke of the introduction by Eurocopter and by Agusta-Westland of light
weight, low-cost system cockpit monitoring and recording systems as an
alternative to Cockpit Voice Recorder or full Flight Data Recorder
systems. The Eurocopter system, "Vision 1000" is intended as suitable for
all aircraft where flight data recorders and cockpit voice recorders are
not mandated. Such systems are, he says, available for less than $10,000
albeit lightweight audio-video recorders are available which could do the
job at less than $2,000. Costs would be driven up by certification
implications and tamper-proofing, together with routine maintenance and
inspection costs. He told the Inquiry that the Ministry of Defence has
mandated such lightweight cockpits voice recorders in all of its AS 250
helicopters following upon a recent collision.
- This was not an area
of investigation foreshadowed in any preliminary hearing or note of
issues. It emerged during evidence. Mr Anderson, on behalf of the Civil
Aviation Authority, took issue with the fact that at no time were the C.A.A.
invited to consider and provide evidence in relation to this issue.
Despite this, he was able to make helpful submissions in respect of the
impracticability of such a recommendation - a recommendation upon which
the C.A.A. would be obliged to act regardless of propriety. I précis the
points made by him, some of which are based on evidence not otherwise put
before the Inquiry, but in respect of which no point was taken or fact
contradicted in oral submission.
- His starting point
was that the C.A.A. supports the principle and the issue remains under
consideration by them. He recognised that flight recorders have a
distinct benefit in safety terms in that they provide information about
why an accident happened. They do not however, directly prevent it
occurring. Any decision to mandate flight recorders must be balanced
against possible other requirements to fit equipment with a more immediate
and tangible safety benefit.
- Such a requirement
would involve significant costs which may vary significantly according to
whether such regulations would affect existing aircraft or only new builds.
Current flight recorders are designed to be robust enough to survive high
impact accidents associated with large passenger transport aircraft. As a
result they are heavy and expensive - perhaps disproportionately so for
light aircraft use.
- This issue has been
under consideration by the C.A.A. for some time and following upon
recommendations from a number of accident investigation agencies including
the AAIB, The International Civil Aviation Authority amended their
regulations to address lightweight flight recorders for smaller commercial
and general aviation aircraft. This resulted in the development and
publication of a technical specification for such lightweight flight
recorders which designers and manufacturers can work to. However, due to
the lack of operational requirements for them, few manufacturers are
producing this type of equipment and thus it is difficult to accurately
assess likely costs and factor these into any cost benefit analysis. Mr
Anderson raised the point that even this new specification may be
excessive and thus too expensive for the lighter end of the general
- The Crown submission
seeks to apply the proposed recommendation to "all aircraft" and thus
would extend to gyroplanes and micro-lights as well as helicopters such as
G - CBHL. Apart from considerations of cost, particularly acute in
relation to such craft, such aircraft might be unable to fly under the
weight of such a recorder. Before any decision is made regarding
mandating flight recorders, consideration will need to be given to the
availability of recorders of a suitable weight, capability and cost for
the aircraft in question.
- Image recording of
the instrument panel can in some situations be used in place of a flight
data recorder, but can also sometimes be misleading when used in
isolation. All such data raises data protection issues which would
require consideration. The C.A.A. supports the use of image recording but
limited to views of the instrument panel until such time as further legal
measures can be taken to prevent the misuse of image data.
- The C.A.A. supports
encouragement rather than regulation in respect of the general aviation
community. It believes that encouraging individuals to fit flight
recorders of their own volition when able to do so has a far greater
chance of success than mandating them to do so against their will. They
are concerned that coercion can result in organised challenge and
avoidance and can be counter-productive. Mr Anderson points out that the
lack of a direct benefit to the individual in the fitting of a flight
recorder militates against an enthusiastic take up of such devices, unless
they can be combined with other practical and useful safety enhancements.
The C.A.A. welcomes the voluntary fitting of forms of lightweight
recorders to new-build aircraft by some manufacturers, including
Eurocopter, and seeks to encourage other manufacturers to follow suit.
- The C.A.A's support
for the installation of flight recorders where it is practical to do so
and where a duty of care exists has led to its support for international
and European discussions relating to new regulations for flight recorder
carriage. It also supports the principle that flight data recorders,
cockpit voice recorders and image readers can aid accident investigation
so long as they are not subject to misuse and/or misinterpretation. The C.A.A.'s
concern that it is premature to require them to implement a recommendation
in the form suggested by the Crown in the absence of further consideration
of the availability of suitable and practical recorders for all types of
aircraft, of associated costs, of competing safety- related equipment, of
privacy issues and of the potential negative impact of disproportionate and
unpopular regulation, appears to me to be well-founded.
- There is no question
but that this Inquiry, and therefore the public interest, would have
benefitted from information of the type that interrogation of a flight
data recorder might provide. Despite the very best efforts of the AAIB
there remains uncertainty about what happened in the final seconds of
flight to cause G-CBHL to come into contact with trees and disintegrate.
Such information might assist in bringing some form of conclusion to those
so affected by this tragedy and could also have safety ramifications for
the future. These are results which could only be welcomed and it is
doubtless in this spirit that the Crown and the McRae family both seek a
recommendation which would extend the requirement that aircraft be fitted
with a form of flight data recording and video and voice recording to
- However, such a
recommendation would involve the enacting of regulation. Regulation of
such matters is not solely a matter for the C.A.A. New regulations in
this field would require to be addressed to the European Aviation Safety
Agency. Given the lack of prior notice that this issue would feature in
this Inquiry, the Agency has not had the opportunity to participate. The
C.A.A's position has been admirably advocated by Mr Anderson, but I
recognise that his opportunity to do so has also been restricted by the
lack of prior notice. His submissions do, however, make very clear the
danger that a well-intentioned desire to make good a lacuna in information
could, contrarily, make for ill-informed and potentially unhelpful legislation.
- The limited evidence
produced to this Inquiry in relation to this subject is simply
insufficient in scope and depth to enable me to formulate any such
recommendation or to be satisfied that I should do so. I am reassured
that this issue remains under consideration by the C.A.A who are in a
better position than I am to consider and evaluate all aspects associated
with the introduction of flight data recorders into general aviation, and
that manufacturers are facilitating and assisting the expansion of that
market by developing and producing lighter and cheaper models.
- The principal
procurator fiscal depute has, in the public interest, thoroughly
investigated the circumstance of this accident and the deaths of Mr McRae
and his son Johnny, Mr Duncan and Ben Porcelli. Her careful and competent
preparation and presentation of that evidence, together with the high
degree of cooperation and skill and compassion displayed by all agents and
counsel involved allowed the Inquiry to focus on the relevant issues and
enabled this inevitably painful process to be as brief and as informative
as it could possibly have been. I express my profound gratitude to each
- At the heart of this
Inquiry and never far from the thoughts of those involved in the conduct
of it, were the tragically premature deaths of much loved and forever
missed family members and friends. In submissions, all representatives expressed
their sincere condolences to those bereaved. I take this opportunity to