AIRCRAFT ACCIDENT INQUIRIES

HL Deb 23 May 1973 vol 342 cc1284-313

7.0 p.m.

LORD BESWICK rose to ask Her Majesty's Government whether they will consider amending the regulations governing inquiries into air accidents to provide for adequate protection of public interest without the immediate publicity which can cause unnecessary pain to individuals; and to provide for deeper technical investigation into causes without expensive time-consuming legalistic presentations. The noble Lord said: My Lords, may I first express my thanks to the noble and learned Lord who sits on the Woolsack for sparing time out of his extremely busy life to reply to my Unstarred Question. I am putting the Question because I want to change the regulations governing aircraft accident inquiries. I want, equally with the rest, to establish causes and get at the truth; but I believe that we ought to be able to achieve these objectives without causing unnecessary pain to persons involved in accidents or to the relatives of those killed. We need to work towards a form of inquiry which will protect proper public interests without the kind of damaging, hurtful publicity which we saw following last year's Trident tragedy. We want the first concern of any inquiry to identify causes rather than to allocate blame. That is the declared purpose of the 1969 regulations (No. 833), but, as I hope to show, they do not always work out that way.

We are not dealing with a simple problem, or a recent one. To consider accident inquiries as aviation developed there was the Shelmardine Committee of 1943; then we had the Newton Committee of 1948; then there was the great controversy arising from the Prestwick accident, when my noble friend Lord Longford was the relevant Minister. I joined him as Parliamentary Secretary soon afterwards. We have now solved the problem which arose then of the Minister being judge and jury in his own case. The Chief Inspector of Accidents is now quite separate from the regulatory authority and is, to a point, independent of the Secretary of State.

Nothing that I say to-day is in any sense a criticism of the Accidents Investigation Branch. I know the Chief Inspector and his staff to be of unquestionable skill, experience and integrity; but as events have developed new difficulties have emerged. I believe that we can develop still further to meet those difficulties. They arise when an accident investigation moves from the direct responsibility of the Chief Inspector and his professional technical team to the court of inquiry established by the Lord Chancellor, remitted to the Attorney General and conducted by the Treasury Solicitor according to the 1969 regula- tions. It is then that the carefully assembled technical evidence and the scientific method is overshadowed by the advocates' speculations—and the raw material which they provide for the popular Press headlines. I am here not criticising the Law Officers, but counsel appearing for other parties and, especially I might say, counsel who are not members of the Bar of this country.

I know that it can be said that in the Trident case the headlines started before the public inquiry began. The Minister for Aerospace made a Statement the day afterwards about the crash and gave premature droop retraction as the cause. I understand the wish of the Minister to establish confidence and to eleminate any fear of unknown defects in the aircraft or its operation, but I still wonder whether that Statement was altogether advisable. In any event, one newspaper covered half its front page with the four words: "One Man's Fatal Error" and there were photographs of two young men, two killed co-pilots, one of whom it was said, must—and I emphasise "must"—have made "the fatal mistake"—and I emphasise the singular "mistake". The truth is that an airline accident—and I speak with some little experience—is very seldom the result of a single, simple cause. As the noble Earl, Lord Selkirk, said the other day, secondary causes are often also important. He has much experience in these matters of accident inquiries; and he is right. However, it is sometimes difficult to say which are primary and which are secondary causes.

My Lords, there are two major advantages claimed for the legalistic approach. One is the capacity of counsel to probe areas which otherwise might be inadequately examined, and the other is their skill in presenting a complicated case in simple terms. The trouble is that these two undoubted attributes carry certain penalties. This ability to probe and to suggest possibilities means that an alleged sensational cause can be given full treatment by the Press, and the sober technical evidence which next day shows that the speculation is unfounded goes quite unreported. As to the gifts of simplification, as I have said already, simple, straightforward causes are seldom to be found.

In this particular Trident tragedy we had an aircraft which was overloaded—only slightly so, but still over rather than under the limit of, I believe, 28 kilogrammes. There had been a frustrating delay due to load readjustment on take-off, the centre of gravity was still outside the operator's limit—not outside the manual limit but beyond rather than within the limit laid down by the operators. The aircraft went into "eight-eighths" cloud and there was considerable turbulence. In these turbulent conditions, regulations required the noise abatement procedure to be followed. Add to all this the fact that there was no physical impediment to the premature retraction of that critical droop.

In these complex and difficult circumstances one newspaper headed its report of one day's proceedings of the inquiry that one of the co-pilots had once been reported as "slow". He was a young man about whom it was said in the Commission's eventual report that he dealt satisfactorily with one real emergency in his line training. It also said that he was desperately keen to succeed in his chosen profession and that he undoubtedly would have so succeeded had he lived. But to the readers of one mass circulation newspaper, that pilot was "slow". The report of the court of inquiry was eminently fair about the part played by those young co-pilots. It commended both their skill and character; but in the meantime the headlines had been written and the pain had been caused.

It may be said that in the interests of truth and of air safety a penalty must be paid, and that these speculations by counsel representing interested parties are an essential element of any effective inquiry. But I put it to the noble and learned Lord the Lord Chancellor: Are these speculations an essential element? Flight International, in a most interesting leading article in last week's issue, said that the present inquiry procedure enables lawyers to trap witnesses into self-incrimination. Some counsel, they said, play to the Press table with tomorrow's headlines in mind. It is difficult to dissent from that criticism. Most observers—and some of us followed that inquiry with great care—would agree with it. But is this the way to the truth?

Might it not hinder the search for truth if great play is made of incidents which suit a particular legal case but have no significance as to causes?

Take, for instance, the part played by weather in that Trident accident. No reference was made to it in the court's findings as a contributory cause; no counsel pressed the essential importance of the weather. Yet the evidence before that court and, surely, all pilot experience, points to the difficulty of maintaining forward speed in serious turbulence. Much of what happened in those critical seconds in the cockpit could be explained by severe gusting.

My Lords, I have re-read the closing speech by one counsel who probably had made most impact at the inquiry and I wondered whether he had mentioned turbulence. Not a word. Why was this? Could it be, my Lords, that the chances of getting compensation from the Clerk of the Weather are distinctly limited? Is it not a fact, an understandable fact, that much of the probing and speculation and cross-questioning by counsel are designed to establish a basis for subsequent claims for compensation for their clients? The American counsel who appeared at the Trident inquiry for certain of the passengers' representatives, in his closing speech—which incidentally he was apparently allowed to make before all the evidence had been heard because he had another accident case in hand in the States—said he would like to see the British inquiry system copied in the United States. I am not surprised. It is tailor-made for his purpose. But the question is whether we can improve upon it.

I believe that Ministers responsible for and all who care for aviation would agree that we should, if we could, improve the present system. Flight International, in the leader from which I have already quoted, suggested that the answer was to change the reporting rules at inquiries; that everything that is said, including speeches by counsel, should go on the record but that the transcript should not be released until after the publication of the court's findings. I believe that this is a proposal which the noble Earl, Lord Selkirk, also was indicating the other day. That is one possible solution and it could inhibit premature publicity or hurtful speculation, but I am not so certain myself that the inhibition would be complete. There is such a thing as "leaks".

My Lords, I do not pretend to have a complete cut and dried solution, but from experience here and elsewhere we can learn. For example, from the United States National Transportation Safety Board rules in Part 431 there is much from which we could learn. I believe that the German system is worth studying; and soon, unhappily, we shall sec how the Swiss Bureau of Accident Investigation and the Swiss Accidents Board deal with an air tragedy. Certain constructive possibilities emerge, and I hope that the noble and learned Lord the Lord Chancellor will assure us that he and his colleagues will carefully consider them.

We should all agree that in certain straightforward cases the investigation can be conducted to a conclusion by the Chief Inspector of accidents. He would make his report to the Minister. Where, however, there is a major tragedy with obvious wide public interest, I suggest that the Chief Inspector's report could go to a board or commission; either a permanent body or one established by the Secretary of State or by the Lord Chancellor. In Switzerland there is a permanent body with a president, vice-president and three other members. In the United States a public hearing is ordered by the Director of the Bureau of Aviation Safety and is organised by a Hearing Officer. Under Part 431—and I stress this—at that public hearing no formal pleadings, private issues, objections or adverse parties are authorised. Could we not have the Chief Inspector's report in this country put before a similar board? The proceedings would be in public. The evidence and the technical facts and the complete report of the Chief Inspector would be tested. Interested parties could ask questions, clarify issues, seek additional information—but all through the chairman of the board. There could be no grand speeches, either opening or closing. Nobody would be placed metaphorically in the dock for grilling. The final report would be the responsibility of the board. If questions of negligence or compensation arose—and I stress this to the noble and learned Lord—they would be a matter for the customary court proceedings. Frivolous or extreme complainants would face the discipline of possible costs.

It has been pointed out to me that the Newton Committee recommended something similar in 1948 and their recommendations were turned down. The fact that such an authoritative body came to these conclusions strengthens my view. I recall the circumstances in which they were turned down and I say what my memory suggests are the circumstances in the presence of my noble friend who was Minister shortly afterwards. It was largely due to the immense influence of the Lord Chancellor of that day. But these proposals could be simplified and improved, and I am sure that the noble and learned Lord who now sits on the Woolsack would not allow an understandable disposition to favour court proceedings to override other considerations. The increasingly complicated technical character of modern aircraft strengthens the case for the changes I suggest. Something along these lines is possible. There would be no chance of sweeping anything under the carpet. Causes could be established at least as effectively, and probably more expeditiously, than under the present system and we could minimise the quite unforgivable pain and offence such as was caused at a public hearing which followed the Papa India accident.

My Lords, we have a duty to do everything humanly possible to avoid other accidents, and an improved inquiry system would discharge that duty. But if there is an accident we also have a duty to do everything possible to avoid causing additional grief to those who suffer loss in the accident, and an improved system is absolutely essential for that.

7.8 p.m.

EARL AMHERST

My Lords, I think that we are all much indebted to the noble Lord, Lord Beswick, for having raised an issue coupled with a request that the Government should overhaul the regulations for inquiries into air accidents and that they be so amended as to avoid a repetition of what happened at the inquiry into the accident to the B.E.A. Trident last year. The extent of the publicity given by the media and other interested parties amounted to a prejudiced trial by opinion long before the inquiry itself had had time to formulate its own findings. In addition to what the noble Lord, Lord Beswick, has already said so well, I would stress that under the present regulations there is a situation where dedicated and fully qualified people—pilots, engineers—are called to face as technical witnesses (their own position is not in question) a barrage of needle-sharp questions and cross-examination, sometimes by a "smart Alec" lawyer busily engaged in attempting to establish blame so that he may chisel the last new penny of compensation for his client. There are, in addition, all kinds of questions which sometimes have little to do with the official inquiry. The publication of all these questions by the media, coupled with irresponsible comment which very likely would be brushed aside by the inquiry itself when it came to publish its findings, causes great distress and also professional damage which can prejudice, even ruin, a man's career.

The problem is to turn to a procedure which would eliminate the damage and prejudice created by the uncontrolled publicity given to all these opinions and theories. As the noble Lord, Lord Beswick, has already said, this presents a really formidable problem. especially as all such inquiries must be public—there can be no two views about that. Might not some partial solution lie in a regulation to prohibit the publication of all testimony elicited from and given by witnesses until the inquiry itself publishes its final report? Does not something of the sort govern Parliamentary Select Committees?

The noble Lord, Lord Beswick, has covered the ground so well as to leave me with almost nothing further to add, other than to say that we on these Benches thoroughly support everything he said. But there are two aspects that arise from the recommendations made by the inquiry, to which I should like to take the opportunity of drawing your Lordships' attention. The first is the recommendation to install cockpit voice recorders in all commercial aircraft of over 27,000 kilos all-up weight. Why this should not apply also to smaller commercial aircraft is not stated. I understand that B.E.A. is at the moment discussing with the Civil Aviation Authority what is the most efficient type of equipment now available for this purpose. Can we assume that the result of their discussions will be passed on to other commercial operations? The object is, of course, to have a full and proper record of all that is spoken on the flight deck and not just the exchange of messages between the aircrew and the ground controls. Such records must, of course, be of paramount importance to any subsequent inquiry.

Subject to correction, I would hazard the guess that the most critical periods when such monitoring is vitally required are those from the time when an aircraft has started to taxi out to the take-off point, during and after take-off, until it has reached its allotted cruising height and proceeds to fly on its pre-determined course, and then again when it starts to enter the controlled pattern of descent and until it has landed, taxied to its unloading point and the engines have been switched off. One remembers that in the patterns of descent can come those agonising moments when several aircraft are stacked one above another, seeing nothing in total cloud, waiting to be given a turn to land. I think it is true to say that the majority of accidents have occurred during these periods. It is therefore of the greatest importance to have a full record of all that is said at those times on the flight deck. But I am wondering whether it would be wise to insist on a complete monitoring for the whole flight, especially long flights involving many hours between take-off and landing. Could not this tend to build up some sort of neurosis among the aircrew, something of the nature of "Keep guard on what you say; Big Brother is for ever listening to you"? I do not know whether this aspect has been considered, but I suggest that if it has not it might be worth while drawing the attention of the Civil Aviation Authority to it.

My second point is the reviewing of the present medical aspects, with special reference to the stress test electrocardiograms. This is a field in which I know nothing and am certainly not qualified to discuss, but I understand that the Civil Aviation Authority is already initiating a long-term research programme on the prediction of coronary diseases in healthy pilots. Can the noble Lord, Lord Beswick, say when the result of this research can be expected? And when it is received, will it be made public?

7.24 p.m.

LORD HARVEY OF PRESTBURY

My Lords, I am sure that the whole House is grateful to the noble Lord, Lord Beswick, for initiating this debate. He has had long experience as a practical aviator and Minister and I must say that I agree with almost everything he said. If I may, I should like to amplify some of the points. The Regulations governing the investigation of accidents are laid down in Statutory Instrument 1969 No. 833, the Civil Aviation Authority Investigation of Accidents Regulations 1969. The main purpose of investigating accidents as set out in these Regulations is, To determine the circumstances and causes of the accident with a view to avoiding accidents in the future rather than to ascribe blame to any person". My Lords, I have a small interest to declare in that I am honorary Vice-President of the Airline Pilots Association, as is the noble Lord, Lord Beswick. He and I spend a fair amount of time doing what we can for the welfare and the future of air crews. They have their problems, and I think the views I put forward broadly represent BALPA'S point of view on this. BALPA recognises that public inquiries are instrumental in providing an effective demonstration of public accountability and may at times be necessary in the public interest. The Association is nevertheless concerned that under the present system it creates an atmosphere similar to a court of law, with prosecution, defence and the accused. This arises largely out of the procedure of opening and closing addresses, the cross-questioning of witnesses and the objective in some cases of counsel to establish legal grounds for subsequent action for damages. The noble Lord referred to the American lawyers. If what we read is correct, ambulance lawyers, as I believe they are known—though I do not want to be disrespectful to them—when accidents take place are in on it and share out the spoils. That does not lead to good methods of law and inquiry into these matters, particularly in a sad case like the Trident accident.

It follows that there will always be a certain amount of speculation and conjecture in such a form of investigation, and, as the noble Earl, Lord Amherst, said, the television, radio and the Press will make the most of any sensationally newsworthy items arising from day to day. Unfortunately, none of the mass media gives the same coverage to the correction of speculative and misleading statements arising from the evidence on subsequent days. The damage is done. Such treatment of evidence is liable to mislead the public rather than allay their concern on any particular matter.

It follows, furthermore, that the nature of British public inquiries, with all their legal ramifications, is an extremely heavy expense to the public. That is not really so very important when dealing with the Trident accident, the worst in British history. Nevertheless, to other concerns and to individuals involved, for example BALPA, this inquiry cost something over £16,000. That is a great deal of money to a small set-up such as BALPA with comparatively few members. No consideration is given to the protection of the names of the crew members and others against speculative imputation; and in the case of deceased crew members it is left entirely to the next of kin and relatives to fend for themselves in protecting the good name and professional integrity of the crew members. Were it not for the support given by such organisations as BALPA, in these cases next of kin would not always be adequately represented because the legal expenses would be beyond many people's financial means. I would say, my Lords, that in my experience over many years in our country the Accidents Investigation Branch has a very creditable record. It is second to none. One saw how they pieced the Trident together at Farnborough, built it up from a lot of wreckage which must have helped enormously in some of the findings that they made. But they are completely fair and we can trust them 100 per cent. Inquiries or hearings can be and are held in public without the disadvantages seen in the British system.

The noble Lord, Lord Beswick, has given examples of inquiries in other countries, and I should like to refer to Switzerland. My Lords, this might be the right time to say that, after the unfortunate Vanguard accident a few weeks ago at Basle, the City of Basle raised £55,000 from public subscription for the dependents. We have heard much criticism about the Swiss in other respects, but perhaps we should express our thanks from this House to that great city for what they have done. In Switzerland, it appears that an accident is investigated, as it would be in the United Kingdom, by members of the Accident Investigation Branch and that the chief investigator of the Bureau of Accident Investigation submits his report to the President of the Swiss Accident Board. Before doing so, however, interested parties are given the opportunity to make a submission or representation on the content of the Report, and this is submitted to the Accidents Board along with the Report. The Swiss Accidents Board is a permanent body comprising, as has already been said by the noble Lord, a President, a Vice President and three other members. In the case of a major accident a public hearing is conducted by the Board during which witnesses are taken through their evidence and questioned by the President. There are evidently no opening or closing addresses by counsel, and there is no cross-questioning of witnesses. All the proceedings are conducted through the President, and any questions related to the evidence are addressed to him.

The situation in the United States is somewhat similar, in that an inquiry is much more a review of the accident investigators' findings than a de novo inquiry in which the court starts from scratch. The emphasis is technical rather than legal, although proper attention is paid to legal aspects, and there is no cross-examination. In the case of a public hearing, the facts determined in the investigation are presented as sworn testimony. Opponents of change in the British system cite the L.1011 public hearing as an example of worse treatment by the American news media than by the British in the case of the Trident or the Vanguard accident at Heathrow in October, 1965. Possibly the answer to this is that mishandling of the proceedings is encouraged by the full television coverage given by American TV, as also in many other inquiries, To summarise, my Lords, BALPA has not advocated that proceedings should be held in camera when a public investigation into an accident is called for. The Association, however, maintains that the aims of accident investigation are not well served by permitting inquiries to be unduly influenced by legal considerations, which are not always directed at the determination of the causes of the accident.

I should like to make one reference to the condition of Captain Key's health at the time of the Trident accident. We have read the report, and we understand that the poor wretched man had heart trouble. I want to put this point to the Government. I understand that the medical boards carried out on pilots and aircrew every six months for the renewal of their commercial licence vary enormously in different parts of the country. Some boards are much more stringent than others. I recall when I was flying on a commercial licence in Hong Kong some years ago I had quite a bad accident, and I was sent before the doctor. He took my pulse and my blood pressure, but did very little else. I thought that I had got away with it very lightly, but I discovered afterwards that he was examining me as a harbour pilot, not as an air pilot. I hope that this question of medical examinations can be looked into carefully, because when men get to a certain age their health can deteriorate rapidly. May we perhaps be told by the noble and learned Lord on the Woolsack whether a committee could be set up to look into the whole matter of the investigation of these accidents. We have a real problem on our hands in this country. Unfortunately, as was said a few years ago, in the nations' league of safety Britain stands only ninth. The Dutch, KLM, are top. This is something that has to be remedied, and with all our technological know-how in this country, I am sure that that position can be improved upon. I hope that this can be done in the fairly near future.

7.33 p.m.

THE EARL OF KINNOULL

My Lords, I, too, should like to congratulate the noble Lord, Lord Beswick—I think it is quite a rare thing for him to introduce an Unstarred Question—for raising a very sensitive issue, and one which I believe has been the cause of mounting criticism over the years and, as other noble Lords have said, has come somewhat to a head with the proceedings over the recent Trident disaster. If I may say so, the subject could not have been diagnosed with more clarity than it has been by the noble Lord, whose authority in aviation I believe takes precedence over the many other subjects that he covers: indeed, his experience in the air and on the ground is, I believe, unrivalled in this House, save perhaps for the pioneering exploits during his career of my noble friend Lord Balfour of Inchrye. The noble Lord's Question, in my view, expresses in a nutshell the two facets of the crux of the criticism of the present proceedings; namely, the sensational and often irresponsible Press reports surrounding air disasters, with all the accompanying speculative innuendoes that go with them; and secondly, the manner, as other noble Lords have said, of the cross-examination at the inquiry of the expert technical witnesses by astute counsel, often it appears more anxious to promote a subsequent claim for their clients than to assist the tribunal.

The wording of the noble Lord's Question seems to suggest that on publicity, he would favour a ban on any immediate publicity surrounding an inquiry in the hope that it would restrict or eliminate the sensational element of the Press coverage. Although this is perhaps the best alternative to any direct Press control, I find myself disagreeing with the noble Lord here, because I feel that at the very time of an accident, as in the case of the "Papa India" tragedy, there is instantly a feeling of shock, uncertainty and worry among a great number of air travellers, and the sooner confidence can be restored, obviously the better. The element of irresponsible reporting at this stage is, I believe, far more preferable than no reporting at all, particularly since in many of these tragedies many lives are lost. I also hold the view, which I believe the noble Lord shares, that it would be quite impossible, if the overriding public interest is to be fully protected, either to ban reporting on proceedings altogether, or to delay publication until the end of the inquiry. Both alternatives, in my view, could lead, however wrongly, to the thought that some cover-up operation was going on, and nothing could be more harmful to aviation or to public confidence in it.

My Lords, the solution that I would put forward to my noble and learned friend the Lord Chancellor—I hope it may be a practical solution, although probably it is not—is that the Press Council should be asked to consider introducing a stricter code of reporting in cases of accident inquiries. It would not be difficult, I think, to demonstrate to the Council the example of the Trident disaster coverage and some of the wholly irresponsible and deplorable reports published, to which the noble Lord, Lord Beswick, referred.

Taking the other side of the coin, again in the case of the "Papa India" tragedy, the value of the informed and factual reporting of the inquiry that went on, and the swift publication of the findings, followed by B.E.A.'s immediate announcement of certain remedial action that was to be put in hand to correct certain aspects that came to light, undoubtedly helped to restore public confidence in what must have appeared to be a rather disturbing set of circumstances surrounding B.E.A.'s own management. In that sort of case, to have banned immediate responsible Press reports would, in my view, have been very harmful in the public interest.

Turning to the present procedure of accident inquiries, I would very much support Lord Beswick's argument. The current procedure appears to offer quite unnecessary scope for a skilful barrister, set on achieving, as other noble Lords have said, something outside the main purpose of the inquiry. At the same time—and I do not think this has been sufficiently emphasised—it inhibits evidence given by professional witnesses, because so often they are worried about exposing themselves unnecessarily. I say this with no personal knowledge, but from having sought the views of those professionally employed in flight accident investigations. The noble Lord's suggestion of adopting the American, German or Swiss procedure is, I am sure, well worth looking into. I hope that my noble and learned friend will be able to say that at least this will be done.

My Lords, I support the general theme of the noble Lord's Question. I hope that the suggestion of referring the matter to the Press Council may be considered. I hope that the procedures also may be looked at, and possibly altered, to encourage and not inhibit the expert technical evidence being given in an atmosphere that will be to the benefit of what is, after all, a highly complicated and technical investigation—an investigation which so often is vital to the future safety of flying and the travelling public.

7.40 p.m.

THE EARL OF SELKIRK

My Lords, I should like to congratulate the noble Lord, Lord Beswick, on raising this very important point; and he has done so on what I would describe as a first class, a very well documented and very well presented report. I should also like to endorse what the noble Lord, Lord Harvey, said about the Accident Investigation Branch which we have had in this country and which has long performed a task of the first order. I do think it is very dangerous to allow what the media inevitably want to do, namely to present simple, sensational facts to their readers. This is the way it is done and we cannot complain about it. I am afraid I have very little doubt, on what the noble Earl, Lord Kinnoull, says, whether the Press Council could exercise a great deal of influence on this aspect. I think that if there are sensational facts the Press will use them, and we really cannot complain too much about this. It may be regrettable, but it will simply go on happening and it will lead inevitably to certain rather serious effects, for instance, in regard to the quality of the aeroplane, whether the aeroplane failed, quite apart from the question of pain which the noble Lord, Lord Beswick, has mentioned. Not only is that so, but the quality of the final report is undermined. The final report may indicate something different, but the rumours which have gone out have given an entirely different picture. I had occasion once in my life to look at a very large number of accident cases, I am afraid running into thousands rather than hundreds. I was not, however, concerned with the subject of compensation which is mentioned here; but every one of those cases is delicate to a degree and terribly difficult to assess. We were primarily of course concerned with avoiding future accidents and with what common link there lay through accidents of one kind and another.

I would say that the noble Lord, Lord Beswick, did not go far enough in saying that most accidents have more than one cause. Every accident, practically without exception, is a coincidence of factors; each one of those factors may well be an effective cause of the accident, and if one of those factors had not taken place the accident would not have happened. I looked through this report and it seemed to me that there were at least six factors listed and if any one of those had not been there, there would not have been an accident. If anyone were to take a short account of what happened and to emphasise one of those factors he would be quite wrong. May I give a very small example of what I have in mind? When the blackout was introduced in the war, we had a number of accidents with pupil pilots who had to move straight from the flarepath on to their instruments. It was quite a difficult manoeuvre and many of the pilots were killed. A very simple answer was that they tumbled their instruments. But that was not the answer; the answer was having a better system of lighting, which in fact was invented by Air Marshal Sir Richard Atcherley at Drem and has now become more or less the standard system. In other words, the immediate cause had nothing at all to do with the basic cause. This is where I think it is so important that little bits of information should not emerge.

My Lords, if I may mention this, the Lord Chancellor, knows very well that in divorce actions it has long been the case that the reporting of evidence is not permitted, and that the only reporting is of what is said by the judge from the Bench. I think that is still the practice, though I cannot remember the exact details. I see no reason why that should not happen in a public inquiry of this character. I see no reason why it should not be just as effective and why no sort of covering should in fact be considered at all. I think it is really important that these cases should be examined thoroughly, possibly with the initial safeguards which have been mentioned already, and should not be reported with glaring publicity before a full and careful decision is come to.

7.44 p.m.

LORD TREFGARNE

My Lords, before the noble and learned Lord the Lord Chancellor answers, I apologise for the fact that I did not expect to be here to-day and therefore do not intend to make a full speech. But I should like to say that I think the system of public inquiry into these accidents is in general a good system, particularly in the case of accidents to large transport aircraft involving many people, and also in the case of accidents to aircraft operated by the State corporations, which after all have in the main been financed from the public purse.

Having said that, there are three possible reservations which I have, particularly about the "Papa India" accident. First, I think it might be wise to consider whether we could prohibit from appearing before the council those who have only a financial interest in the outcome of the inquiry. I do not think that the spectacle of the American lawyers with their so-called expert heart specialists, flown in specially from America, was very edifying; and the evidence that I have read in Mr. Justice Lane's report suggested that the evidence put forward by those witnesses was not very reliable and was intended only to increase their clients' claims to compensation. The second point I make is that it might be wise to prohibit publication of the names of the crew of the aircraft until the publication of the report itself. That would go some way to answering the very real grounds of Lord Beswick's complaint about the pain that was caused to the pilots in this particular accident. Finally, my Lords, I should like to support my noble friend Lord Kinnoull in his suggestion that the Press Council might be asked to apply a more stringent code of conduct to the reporting of these accident inquiries. With that I look forward to listening to the noble and learned Lord the Lord Chancellor.

7.47 p.m.

THE LORD CHANCELLOR

My Lords, if I were to reply fully to the several speeches which have been made from all corners of the House, I think I should detain your Lordships rather longer than the House would desire. I had come armed with a considerable bundle of material which I had intended to use. If I added that to the detailed reply I could then give I should detain your Lordships longer still. I will, however, attempt to reply in general to the debate, and in particular only to some of the points which have been raised. But let me say by way of preface that I have taken careful note, and I know others more skilled in note-taking than I have taken careful note, of various suggestions which have been made by noble Lords. They will be carefully considered by the Department for which I in part speak this evening, and I will see whether letters cannot be written dealing with the several points raised, including the suggestions that came from my noble friend Lord Trefgarne and my noble friend Lord Kinnoull. I think I am right in saying that it is not possible to give a direct answer to the noble Earl Lord Amherst, about the state which the research has reached into the heart matter. I had an answer about that almost as he sat down, and I am told that nothing sufficiently reliable has yet emerged to give him the answer to that matter but I will check on that again after I have resumed my seat.

My Lords, that brings me back to the Question of the noble Lord, Lord Beswick, for which I should like to thank him as I think every speaker has done. It is a Question I have found intensely interesting and intensely difficult, for reasons which I will attempt to give. I think I ought to explain why, in principle, I thought it right that the Lord Chancellor should answer this debate on behalf of the Government. Every speaker, I think without exception, who has posed the question or supported it has been primarily interested in the "Papa India" inquiry in particular, and in the aviation accident problem in general. I do not view it in quite the same light. I think this is an important part of the administration of public justice in this country, and I think it raises questions of importance covering a much wider range than noble Lords have indicated.

By a curious coincidence—and it was only coincidence—it was only yesterday that the Government issued a White Paper on Public Inquiries, giving their considered view of the Salmon Report of 1966 on public inquiries. It happened, therefore, that in addition to having read every word of the Lane Report on the "Papa India" disaster for the purposes of this Question, I also had very freshly in my mind the findings of Lord Salmon's Report and of the White Paper, commenting upon it. I should like to say to noble Lords who have taken part in this debate that literally not one of the criticisms they have made about this type of public inquiry into air accidents was not canvassed in relation to the wider canvas by the noble Lord, Lord Salmon, in his Report and in the White Paper just issued. It is because I think this is part of the administration of public justice in this country that I felt it proper that the Lord Chancellor should reply. I believe much wider questions of public policy are involved than simply inquiries into air accidents.

On the accident report itself I would only say in brief that, having read it, I think it is an absolutely masterly document of its kind. I believe that if the noble Lord, Lord Beswick, would refer to it again he would find that he is wrong in saying that the Report contains no reference to the weather. I can give him the reference if need be.

LORD BESWICK

My Lords, may I say it is not necessary: I have the reference. I said carefully that it made no mention of the weather in its conclusions.

THE LORD CHANCELLOR

There again, my Lords, I do not quite agree with the noble Lord. All the factors which he mentioned—the overloading, the weather and the turbulence—were all evaluated in the report. The overloading was expressly discounted as a contributing factor to the accident; and the weather and turbulence were, by implication, also discounted quite clearly as contributory factors in the accident. Although I would absolutely agree, both with the noble Lord, Lord Beswick, and with my noble friend Lord Selkirk, in saying that accidents always have complicated causes and a background of human contributory factors, my own reading of this report was that this accident had fewer than most. If you took three factors only—premature retraction of the droops, the overriding of the stick-shake and stick push mechanism by one of the pilots and the cardiac condition of Captain Key—you would find that those were factors quite disproportionately large as causes of the accident, compared with any others that could be mentioned; and, as the noble Lord, Lord Beswick, rightly observed, a number of other factors emerged as factors which ought to be taken into consideration.

May I now come to the composition of this particular inquiry, because it is relevant to the way in which the Question has been presented by noble Lords who have spoken. The Question itself suggests, and I think that each speaker in different ways has suggested, with the possible exception of my noble friend Lord Trefgarne, first, that this public inquiry was open to criticism in various ways and, secondly, that the criticisms could be met in the future by alterations in the regulations, either restricting or inhibiting altogether the activities of counsel or the activities of the media—by which I mean the Press, television and sound radio.

It is these two propositions which I want to examine rather carefully, because I think it is these two propositions—inherent in the way in which the Question has been presented—which raise the question of principle concerning public reports and which ought to be considered rather carefully before being accepted uncritically. Therefore I return to the composition of the board. It consisted of a High Court Judge, Sir Geoffrey Lane, in the Chair. This was unusual. Normally a Queen's Counsel takes the chair in these inquiries. I was asked for a High Court Judge because of the extreme importance of the inquiry. I thought it right to accede to the request of my right honourable friend in that respect, and it was on my recommendation that that particular Judge was chosen—because, as the noble Lord, Lord Beswick, will be aware, he was himself a pilot and had been decorated during the war in 1943 for his gallantry in that capacity. The other two members were Sir Morien Morgan, who is a Fellow of the Royal Society, and Captain Jessop, whose technical expertise speaks for itself. I mention these facts not in order to pay empty compliments to the persons concerned, but because of the criticisms that have been made. I should have thought that if it was possible to find three people in the country who were less inclined to listen to wild allegations by counsel, or less unable to control cross-examination by counsel within reasonable limits, it would be a High Court Judge with Common Law Bar experience who had express experience of flying, a Fellow of the Royal Society who gained his distinction very largely in aeronautics and Captain Jessop. In fact, I would say with respect, bearing in mind what my noble friend Lord Trefgarne said, that not only does the report not bear the smallest trace of their having been influenced by such allegations but, as my noble friend also pointed out, where those allegations have come under particular scrutiny from your Lordships this evening, they have been expressly rejected in the most uncompromising way.

LORD BESWICK

My Lords, I wonder whether the noble and learned Lord would permit me to say that I have on an earlier occasion paid my tribute to the composition of the board. Nothing I said was a criticism either of the President or of the two assessors, and I am glad to be able to make that clear. My criticism was directed to what was said and done in that court, not by the Commission, nor indeed in their findings.

THE LORD CHANCELLOR

My Lords, I was quite aware of that, though I am grateful to the noble Lord, Lord Beswick, for having re-emphasised it. I was not in any way imputing to him anything in the way of improper criticism. The point I was on was a slightly different one. I was replying to the criticism which was made as to what took place in the court. I am saying only two things: first, that there is nobody who can control counsel better than a High Court Judge; and, secondly, that this particular board was slightly higher-powered in the way I have described than perhaps others have been. All such boards are, in general, designed to counter any ill-effects which may come from the use of advocacy—and it is their business to control advocates—and although the noble Lord quite rightly said that he did not intend it as a criticism, I would regard it as a serious criticism of a High Court Judge or of anybody in charge of an inquiry, with any kind of expertise, if counsel had been allowed to go too far. I said that in relation to bankruptcy law when I was answering another of these Unstarred Questions some time ago, and I say it now in relation to these inquiries.

LORD BESWICK

My Lords, I wonder whether the noble and learned Lord can help me. Is it possible in this kind of court for the chairman of the board to control counsel in the same way as a judge can control the behaviour of a counsel in an English court, where counsel are themselves bound by certain codes laid down by the Bar of which they are members?

THE LORD CHANCELLOR

My Lords, it is perfectly possible, and I should consider it a very serious criticism of such a chairman if he did not succeed in doing it. That leads me on to the next thing that I wanted to say about these inquiries—I am sorry to be so slow, but I am trying to take this extremely seriously because I consider it seriously. The noble Lord, Lord Beswick, and my noble friend Lord Harvey of Prestbury talked about legalism and legalistic approaches. Please do not talk about the law or legalistic approaches in relation to these inquiries; there is no such thing. The only expertise which has been used, either by the chairman or by counsel during the whole of these inquiries has been expertise in probing facts, in knowing how to frame questions and how to present evidence. Those were factors to which the noble Lord, Lord Beswick, quite rightly, drew attention. There is no legalism about this. This is an expertise acquired in the hurly-burly, the rough and tumble of life at the common law Bar and on the Bench with accident cases of one kind or another, varying from the motor to the airliner, being the bread and butter of the common law barrister's background and experience. So that is a false line of approach to take.

That brings me to the second point to which the noble Lord, Lord Beswick, has just reverted. It is true that all members of the English Bar are bound by professional rules and by a strict code of behaviour. I do not want to expatiate on this—the noble Lord, Lord Beswick, said that he was making no specific complaint of the members of the English Bar—but it is right that I should re-emphasise it from my side. The extreme jealousy with which the profession regards its honour in matters of this kind is something which we have all known and lived with, with pride, over a whole lifetime. Noble Lords can be quite certain that this code is rigorously enforced by more sanctions than one. One of my noble friends referred to "ambulance lawyers". They do not exist at the English Bar. Although there may have been a small number of them before the war, before legal aid, they were universally condemned, and nowadays that practice is wholly divorced from the realities of those with professional qualifications.

LORD HARVEY OF PRESTBURY

My Lords, I believe my noble and learned friend is referring to me. If that is so, I should say that I was referring to American lawyers and not to British lawyers at all.

THE LORD CHANCELLOR

My Lords, I want to be extremely careful what I say about a foreign profession which contains very many able and learned men. It does not play to the same rules as we do. I am perfectly sure, from having read the report, that whatever rules they may have been playing to—and I make no kind of imputation against them—there was nothing improper which influenced, or could have influenced, a court of that calibre; and it is clear that a number of the arguments and expert witnesses, to one of whom my noble friend referred, were expressly rejected by the court after considering them. In my opinion, if you do not want pain, suffering and distress to people who may be influenced or interested in the result of an inquiry, I am perfectly sure that the right and best course is to allow a man to say his say within the limits of propriety and then to reject what he says if it is not wholly persuasive.

I must say, in passing, to my noble friend Lord Trefgarne that when you get an air disaster in which over 100 people are killed it is not contemptible in the relatives either to want compensation, if they are legally entitled to it, or to employ a lawyer at the public inquiry which results, strictly to cross-examine witnesses with a view to ensuring, if it is possible, that the causes of the accident and the degree of negligence involved, if any, are properly ascertained. The noble Lord, Lord Beswick, referred to the view of Flight International, to which I will revert in a moment. Having read their leading article, I thought it gave a superb example of exactly the thing which a public inquiry of this kind does elicit and which probably could be elicited in no other way. I refer in particular to the "Foxtrot Hotel" episode, as I think it was called, and the "Orly" episode, both of which were buried in the files of of B.E.A. and were extracted by counsel in the course of the inquiry. I should have thought it extremely improbable that these facts, which were extremely suggestive and might lead to a prevention of similar accidents in the future as a result of what the board found out about them, would have been elicited by any other means, or dragged out by any other means, than the particular method adopted.

Of course in all these cases the Press, media and counsel are the whipping boys. I want to look at this squarely in the face: it was the subject of two extremely wise paragraphs by Lord Justice Salmon (as he then was) in his Report on the Tribunals of Inquiry in 1966, every word of which I should have thought applied to an inquiry of this kind. He said—and I share his view—that attempts to inhibit or restrict publicity in a matter which gave rise to the extent of public disquiet which was felt at the appalling nature of the disaster always rebounded on the heads of those who attempted them. He said that rumour, distorted reports; leaks—I think my noble friend referred to them—and sensational gossip were far more damaging than anything that the most sensational banner headlines could do, and that these things were only encouraged by attempts to inhibit or postpone publicity.

I took particular notice on both occasions when my noble friend Lord Selkirk suggested that there might be an analogy between the procedure adopted in 1926 as a result of statutory interference in divorce cases and the present kind of situation. I venture, with respect, to think that the analogy is a misleading one. I think that though in a divorce case the public must be interested in the result, because marriage and divorce, being questions of status, are matters of public law which ought to be publicly known, the intimacies of the marriage bed in cases where parties have lost their marital happiness are something the privacy of which the public are willing to accept. I do not believe they would apply the same kind of criteria to a case where what was in examination was not marital cruelty or infidelity but a question of a public airline using an aircraft which was the glory of a nation's aviation and which has, I believe, as a result of this report, been fully vindicated.

The accident resulted in the loss of 118 lives—I think it was 118, but certainly over 100 lives—of passengers and crew coming from a number of different nationalities. I am bound to say to my noble friends that, even if we tried to inhibit the Press here, which we could do, I suppose, by legislation but could only enforce by something analogous to the law of contempt, what could we do about the American Press? The American lawyer came here. He was allowed to cross-examine witnesses; he was treated with courtesy. He went back, many of his arguments having been rejected, but at least he claimed to be—and as I believe he was—full of admiration for our system. Supposing he had been refused admission. Supposing he had been compelled to keep silence. Supposing that his arguments had been stifled. What would the American Press have said and what would he have said to the American Press?

LORD BESWICK

My Lords, is it not possible, may I put to the noble and learned Lord, that the American Press would say he was being treated here exactly as he would be treated in the United States of America?

THE LORD CHANCELLOR

I think probably not, my Lords; I think they would have said something very different. What I am suggesting is that he would have told the United States Press—I was not thinking so much of comment as of sensational headlines—exactly what he was going to have put to the witnesses if he had been allowed to put it, with the added point and the added sensationalism that he had been inhibited by law from doing so. That is what I think would have happened, and I do not think they would have said at all that in the United States it would have been much the same, because I do not think it would. There are other features of United States' practice which I think he could have made use of.

I was, I confess, a little surprised at the praise, or the muted praise, which was given to the German and Continental systems. The object of those inquiries is different from ours. Whether we proceed under what is still, in theory at any rate, the normal procedure of a private inquiry by an inspector, which is still regarded in the regulations as the normal procedure, or whether we proceed by the public inquiry, which is the procedure under discussion here, our object is—and this is laid down in the regulations— to inquire into the cause of the accident with a view to preventing similar accidents in the future. Unlike ours, the express purpose of the Continental systems—I think without exception, but I may be wrong, but certainly of the German system—is to attribute blame. Now if that were the purpose of our inquiry here, I should be the first to say that it must be held in private. This is almost always right where you are about to attribute blame, because if the ultimate purpose and the main purpose of your inquiry is to put somebody on trial in a civil court perhaps, but in a criminal court possibly, then it is essential that the preliminary hearing at which he is compellable as a witness should be held in private, in my view, except in the most exceptional circumstances. But our object was not to do this, and in this case none of the people, I think, who could have been blamed for the accident were still alive.

I would say only this in addition with regard to the German method. I am a little surprised that the noble Lord, Lord Beswick, did not recollect the Munich air disaster of some years ago which was tried by the German method. It resulted in total ruin to the British pilot involved, who was piloting the Manchester United football team, and it took him about seven years of public campaigning to reverse the result, at the end of which he proved his total innocence. I venture to believe that if we had been allowed to conduct an inquiry into that disaster by our system it would have been very much more effective from the point of view of a man whose professional reputation was, at least for seven years, totally shattered than the system which was perforce followed according to the German code.

So far as regards the United States code, they do not in fact do more than publish, under the glare of television lights, the results of the technical investigation up to date. I am bound to say that I do not think that that would have allayed much disquiet in the present case. I am quite sure that those who suggested that there was something wrong with the aircraft would have gone on spilling their poisonous liquor into the fruitful field (I am getting mixed in my metaphors now) of international competition. I am perfectly sure that the people who attached importance to the graffiti on the pilot's desk would have gone on suggesting innumerable (and I use the word in quotes) "rows" among the air crew. I do not believe myself that by inhibiting publicity, or trying to control advocates except by those whose business it is to control them, you ultimately allay public anxiety; nor do I believe that you save relatives and other persons from distress.

May I say in conclusion—I have gone on a great deal too long but I hope the noble Lord will feel that I am taking this matter extremely seriously; and I began my speech by saying that all the suggestions will of course be examined—that we are never perfect and we can always improve. But I have I think studied more or less in depth every public inquiry in most fields, and particularly under the Tribunal of Inquiry Evidence Act, that has taken place since the Budget leak of, I think, 1936 which ruined Sir Alfred Butt and Mr. Jimmy Thomas. I do not think that many of them could have been avoided. I do not remember one of them which did not give rise to criticism of the kind we have heard to-night: the cross-examination of counsel, sometimes of the Attorney General in question; the banner headlines which come out when only part of the evidence has been given, or sometimes before any of it has been given, simply based on the opening of counsel; the distress caused to relatives and persons who may be subjected, without any fault as it subsequently turns out, to the strict discipline of cross-examination in a public court by experienced counsel. All of these criticisms have been made I believe every time. No one who heard the discussion of the V. and G. inquiry earlier this year could have failed to notice that it was made there. We remember the "Bloody Sunday"; we remember the bank rate leak, which permanently embittered, although it was found to be no leak, the relations between a particular member of the Bar, whom I will not mention, and the City of London, who never forgave him. These things have happened every time.

I must say, with candour, that I think these things are inherent in an inquisitorial method of inquiry. We have tried many models. Until the Marconi scandal discredited it, we used to have trial by Select Committee, as they are doing at the moment in the United States. Until we abolished it in 1932 we held secret trials by Grand Jury as a preliminary to an indictment. One wonders how secret the Watergate Grand Jury are being at the moment, although they are sworn to secrecy, as our grand juries were. In the aircraft field, we have tried the system of the inspector putting questions, rather in the manner suggested by some speakers this evening. It led to the Newton Report, which found that system wholly unsatisfactory. We have tried the tribunal of inquiry, only to discover that every single case as it emerges requires slightly different treatment, sometimes on fundamentals, as it varies between a shooting incident in Londonderry to an alleged breach of security, and so forth.

There was the horrible experience of the Denning Inquiry during, the Profumo affair, as to which Lord Salmon said that nothing of the sort ought ever to be held again. There has been one attempt after another. My conviction, after studying this matter deeply, is that the noble and learned Lord, Lord Salmon, was right. I wish that people who ask for public inquiries and wide-ranging inquiries would read the Salmon Report and would agree with him that such inquiries are to be avoided where possible. They are only to be used where the degree of shock to public confidence requires an inquiry of this kind. I wish they would also realise the heartbreak, the distress, and sometimes the injustice to inexperienced people who may also be involved, that these inquiries inevitably produce.

At the same time, I say in all seriousness to the House that I do not believe that in the last resort a disaster of this magnitude, with casualties of this order and scale, to an aircraft belonging to one of our national airlines of which we are justly proud could have been investigated otherwise than broadly in accordance with this method. I ask noble Lords whose interest in the matter I fully acknowledge and whose sincerity does not need acknowledgement because it was obvious, to reflect upon the more general aspects of the matter, which I have sought to bring to their attention. I know that they want publicity; so do I. I know that they want to save people distress; so do I. But in each case I believe we have to balance what are really divergent and occasionally inconsistent objectives and that where public confidence is badly shaken, strict investigation before professional people, conducted by professional advocates responsible to an English profession and with the full light of publicity upon them, is the only method of progression.

The last thing I should like to say is whether or not the suggestion made by my noble friend Lord Kinnoull about the Press Council be accepted, I am sure that the Press of this country will have read Lord Salmon's plea to them, which is reiterated in the Government White Paper of yesterday, that the greatest care should be exercised in reporting inquiries of this kind, because the premature sensationalising of bits of evidence is seldom borne out by the ultimate result and that infinite pain can be caused by sometimes quite innocent distortion. They should always say, "This has not been sifted to the bottom". I am deeply grateful to the noble Lord, Lord Beswick, for raising this subject and I can only apologise for taking so long in reply.