Closure, they call it. The kind of thing people long for after a distressing period. The emotion we yearn for after bereavement, or some kind of devastating loss. The sort of feeling experienced after a court case or a public inquiry. It's easier to talk about closure than to achieve it. That much is known by the families and friends of the 10 people who died as a result of the Police Scotland helicopter EC135 crashing into the roof of the Clutha bar on 29 November 2013. They, and the 31 injured that dark Friday night, were to wait more than five long years until the start of a Fatal Accident Inquiry (FAI) early last April.
Last week, after more than 30 days of evidence stretched over more than four months at Hampden stadium, Sheriff Principal Gordon Turnbull delivered a verdict of pilot error. His report placed the blame squarely with Captain David Traill, 51, a vastly experienced pilot. In doing so, the Sheriff echoed an Air Accident Investigation Branch (AAIB) report published in autumn 2015.
The conclusion was predictable. It does raise questions about the worth of FAIs of this type, however. The Crown declared in advance that there would be no criminal proceedings. It was to apologise at the end of the inquiry – after some prodding by families' legal representatives – for the length of time taken to get the inquiry itself going.
There is little disputing the bald facts supporting the pilot error narrative. Captain Traill seems to have acknowledged five low fuel alerts – the flashing yellow and red lights, the warning gongs – yet done little in response. He and his two experienced police air observer passengers accepted three further search operations in Lanarkshire before finally heading towards base at the Glasgow heliport. We shall never know why that decision was taken.
It was at 10.22 pm, more than quarter of an hour later, that both engines 'flamed out', within 32 seconds of each other. The aircraft crashed towards the ground from about 600 feet. Captain Traill attempted autorotation – a last-gasp rescue technique – once, then again, but to no avail. He and Constables Kirsty Nelis and Tony Collins died when the helicopter smashed into the flat roof of the Clutha, just yards from the River Clyde.
Below, 100 people were thronged into the small, bustling Glasgow pub. A live ska band was playing. The Clutha enjoyed a mixed crowd – young and old – most of them attracted by live music. One group of 10 men was typical. Gathering from the suburbs and towns around Glasgow like Rutherglen, Hamilton and Paisley, they met on the last Friday of every month. That night most would escape the roof timbers as they came down under the weight of the helicopter and its impact. But one, Joe Cusker, was trapped beneath. He never recovered from his injuries and died the following month.
Seven pub customers died. The single-storey building had once been part of a five-storey tenement, and its roof retained a century of dust and debris. Rescue services and volunteers scrambled through it, hoping to find survivors. Many people did escape the building, some hurt, others terrified, but relieved to be safe. One of them, Mary Kavanagh, realised quickly that her partner Robert Jenkins was not among them. His body was recovered later. Mary did not give evidence at the inquiry. None of the relatives did. Not one witness to the inquiry had been at the Clutha that fateful evening. As Mary's QC, Donald Findlay, remarked: 'There is a sense that those who died have not featured enough in this inquiry'.
What might have been examined by this FAI? We will never know what went on inside the helicopter cockpit during those fateful final minutes because there was no flight recorder. The timing estimates and guesswork on the fuel alerts all came from radar measurements and data found within various instruments by the AAIB.
The inquiry relied heavily on the authors of the AAIB report, as well as the report itself. Those witnesses were called early in the inquiry, as were engineers from Airbus. None of them were recalled after other evidence was heard from Bond maintenance workers, pilots and police witnesses, some of whom appeared to contradict what the inquiry had been told.
There were no questions asked about the role of the helicopter itself. Based in Glasgow and operated formerly by Strathclyde Police, senior officers were keen to emphasise its availability to the rest of the country, soon after the creation of a single force, Police Scotland. So, that morning, it had sped to Inverness and undertaken some search activities in the Highland area, before returning to base. When Captain Traill and his crew took off at 8.44pm, they immediately helped investigate reports of a man on railway lines in the Oatlands area of the city, before heading to Dalkeith for what was described as routine search operations. Then there were the three searches at Uddingston, Bothwell and Bargeddie.
Has there been any formal appraisal of the usefulness of such activity? How did our police cope before helicopters become freely available? The EC-135 aircraft are being used daily for routine, rather than specialised, work. If the Clutha incident was not a good enough reason to examine their effectiveness, when might there be such a moment?
Instead, during weeks of cross examination, there was arid discussion about safety procedures, flying hours, emails between frustrated staff of Bond Air Services, and blame-shifting between Bond and the aircraft manufacturer, Airbus. Thirteen legal teams attended each day's proceedings, plus the Crown Office representatives. In all, the number of lawyers at the inquiry was between 30 and 40 people, easily more than the total attending in the public benches.
By the end, those relatives who had continued to attend were confessing to weariness with the seemingly endless and repetitive evidence about faulty fuel readings, a problem which had clearly been acknowledged by manufacturer and operator before and after the November 2013 incident.
The main problem appeared to be one of achieving consistent accurate fuel readings. There was some evidence that in certain conditions – when aircraft pitch and roll, or bank to one side – fuel readings can become misleading. There were questions about whether water can leak into the system, causing emulsification of fuel. There were apparent disparities between what a fuel reading on the cockpit might display, compared to the reality inside a tank.
There was much at stake for Bond (now Babcock) and Airbus. It was clear that some engineers had varying views of the problem. There appeared to be a regular need within Bond for new pumps and sensors. Some pilots were uneasy about the reliability of the fuel readings within what was otherwise accepted to be a reliable aircraft model.
Despite all the cross-examination, the Crown and other legal representatives could not convince the Sheriff that faulty fuel systems had contributed to the tragedy, even partially.
One fact could not be denied or ignored. Any one of the five warnings should have prompted Captain Traill to follow procedure and initiate plans to return immediately to base, or even to land his aircraft sooner. One conclusion might have been that the experienced pilot – a former RAF airman who not only flew helicopters but trained others to do so – had dismissed the warnings because he believed they were the result of a defective system. But that has been ultimately rejected by Sheriff Turnbull.
Families refuse to accept that the pilot was solely to blame. 'I don't know any family member who wholly blames the pilot,' said Mary Kavanagh. 'There was something on that helicopter that night that made him and the two police observers think everything was okay.'
Did Captain Traill say something to reassure his crew that he need not take action? Had the pilot forgotten that he had switched off both fuel pumps at an earlier stage? Either way, until the engines flamed out, neither he nor the police observers appeared to be perturbed by the alerts. They continued with three routine searches. None of them made contact with air traffic or police controllers on the ground.
On Monday, Dr Lucy Thomas, Captain Traill's fiancée, issued a statement that took issue with the Sheriff's comment that the pilot had taken risks:
I find it distressing and incomprehensible that given months, not moments, to consider the facts, the Sheriff Principal has come to this conclusion. He chose not to concentrate on the fact that the EC135 model of helicopter has a history of faults with the caution advisory display, specifically a history of erroneous or spurious fuel indications, amongst other technical problems such as contamination of the fuel tanks, issues still never fully resolved by the manufacturer... Instead, the Sheriff Principal has opted to sully the distinguished reputation of a pilot with an exemplary record who was renowned for his sense of responsibility and his regard for the safety of his crew... The opportunity for closure and maybe some peace for so many people has been denied.