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Full story: Air traffic control mistakes cited among causes for plane crash
MISTAKES by air traffic control have been identified by jurors as key reasons for a mid air crash in which a Marlow pilot died.
Five people including James Beagley, who lived in Marlow, lost their lives in August 2008, when two planes collided near Coventry Airport.
An inquest, finally held in Warwickshire last week after pressure from the families of the victims, concluded yesterday afternoon.
Jurors returned a narrative verdict and were not able to specifically allocate blame to any individuals or company involved.
However, they highlighted certain significant factors in what occurred.
They concluded that poor communication between the airport operator and air traffic controllers about the kind of training exercise to be carried out in the Cessna, in which Mr Beagley was a passenger, contributed to the accident.
The Cessna crew, all employees of Baginton-based Reconnaissance Ventures Ltd (RVL), had been carrying out specific training which saw their plane travel 40 knots faster than usual.
However, the inquest heard that when the crew had informed air traffic control of their intention the night before, the information was incorrectly categorised by a staff member.
In their verdict jurors said the lack of a prior meeting between air traffic control and the operators to discuss the type of flight the Cessna would be doing was one cause for the crash.
Although the airport operator considered the risks associated with the type of flying to be conducted that day, air traffic controllers did not have the opportunity to establish and plan for potential dangers, jurors decided.
Information given to tower control immediately before take off by Mr Beagley's Cessna crew was enough for officials to understand, jurors said, yet, this was not taken fully into account for devising the landing plan.
Another factor for the tragedy, identified by the jury, was that the second plane had been given no information about the speed or location of the Cessna.
Their conclusions broadly followed the same lines as an official air accident report, published some time ago.
Coroner Sean McGovern said: "In August four years ago, on a sunny day, bad news came to each one of those families.
“It was unexpected and I'm quite certain it has changed their lives.”
Turning to the jury, he said: “I hope you will want to join with me to offer your condolences to the families and all of those who have been affected by this incidents.”
Addressing the families, he said: “My personal condolences to you. Very unusually, I went to the scene of this incident when it occurred. This case particularly stuck in my mind within the last four years and it's very nice to see you all today.
“I'm very aware, at lease to some extent, how difficult it has been.
“You may find it of some interest that the first time I came to an inquest I was sitting on that side where you are.
“I was there as a family member many years ago."
The narrative verdict in full:
A Cessna 402C aircraft G-Eyes was engaged in flight calibration training and was making an ILS approach to runway 23 at Coventry Airport when it was involved in a mid-air collision with a Rand KR-2 aircraft, G-Bolz, operating in the visual circuit. The collision occurred in class G airspace.
Our factual findings as to what probably caused or more than minimally contributed to the collision are as follows:
1) Whilst the operator considered the risks associated with the planned activity in advance he did not discuss the planned calibration training with air traffic control management prior to 17 August 2008. The absence of an advance meeting or written explanation held with air traffic control prior to the flight calibration activity did not give air traffic control the opportunity to identify and plan for any associated risks.
2) The information given to the tower controller by G-Eyes immediately prior to take off was sufficiently comprehensive to enable air traffic control to understand the nature of the flight but was not fully taken into account by the tower control when devising the landing sequence, which was unlikely to succeed. Further, the tower controller did not monitor or adjust his landing sequence plan in order to minimise the risk of G-Eyes and G-Bolz coming into conflict.
3) No information was provided to G-Bolz about the presence, location, and speed of G-Eyes which compromised G-Bolz's ability to see and avoid G-Eyes.
4) The tower controller provided G-Eyes with inaccurate information about the presence and position of G-Bolz which had an adverse effect on G-Eyes' ability to see and avoid G-Bolz.
In conclusion: The two aircraft collided because their respective pilots either did not see the other aircraft or did not see them in time to take effective avoiding action.