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Analysis – Monarch Crash Coroner’s Report
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Coroner’s Report On Monarch Crash: Damning Indictment Of All Concerned
The Coroner’s report into the Monarch Airlines disaster three years ago has found that the loss of seven lives in the crash of the Piper Navajo would not have occurred if certain autopilot components had not been removed from the aircraft.
The Coroner, Mr Peter Gould, found that the absence of the autopilot computer amplifier and controller rendered two directional instruments inoperative, which led to the pilot, Wayne Gorham, to suffer “skill fatigue”, and that it was this, rather than pilot error, which caused the accident
The Coroner went on to present a damning indictment of the then Monarch General Manager, Richard Maclean. “All the evidence points to Maclean being well aware that the plane was forbidden to fly with the computer amplifier removed and that he had acted to conceal the fact of its removal from the CAA,” Mr Gould said. “The evidence before the inquest is that the CAA knew for a long time that Maclean was a person who showed scant regard to the regulations and could not be trusted to maintain proper safety standards on Monarch aircraft,” Mr Gould said.
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