On November 29, 2013, a police helicopter crashed onto the roof of the Clutha Vaults bar in Glasgow, Scotland. The crash killed the helicopter’s three crew members and seven customers in the popular city centre pub. Thirty-one people were injured.

Nearly six years later, the determination (verdict) of a Fatal Accident Inquiry (FAI) has pinned responsibility for the crash solely on the aircraft’s pilot, David Traill, one of those killed.

The determination, delivered by Sheriff Principal Craig Turnbull, effectively exonerates the aircraft’s manufacturer Airbus Helicopters, Babcock Mission Critical Services Onshore—successor to the helicopter operator Bond Air Services Limited—and Police Scotland. It ignores a mass of evidence making clear that the aircraft design, a Eurocopter EC-135, had multiple problems in its fuel supply system, while the aircraft’s maintenance regime was also compromised.

These failings appear to have led Traill, a highly experienced pilot, formerly a pilot and flight examiner with the RAF, to fatally misconstrue contradictory messages from the helicopter’s Caution and Advisory Display (CAD) system. As a result, the craft’s engines ran out of fuel over the centre of Glasgow, leaving the pilot no time to issue a Mayday call or attempt to land safely.

The determination was published October 30, the same day as the report on the first part of the inquiry into the 2017 Grenfell Tower disaster. Release of both reports was doubtless timed to be buried as news under a deluge of reporting on Britain’s departure from the European Union, then anticipated to be the following day.

Turnbull’s verdict was denounced by relatives of the victims. Gordon Arthur, whose son Gary was killed in the bar that evening, told a Sun reporter, “The questioning of witnesses and everything pointed towards fuel contamination. Scottish justice is absolute crap.”

He went on, “Babcock are very lucky. They’ve literally got away with murder. We’ve been waiting six years for this and this is what they give us. I wish I’d never got involved in the FAI. The 10 people killed have been let down by this report. Nothing has been solved. There had been issues with fuel for years before this tragedy and they’d done nothing about it.”

Mary Kavanagh lost her partner, Robert Jenkins. “This was meant to be the missing part of the jigsaw,” she said. “Instead we are left with more questions than answers. When I read the part about the pilot being responsible I burst into tears. It was terrible. I don’t blame him for a second and his family have all my support.”

Traill’s fiancé, Dr. Lucy Thomas, issued a statement accusing the sheriff principal of opting to “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.”

Clutha Vaults’ owner, Alan Crossan, told STV News, “I sat through most of that FAI inquiry and from what I got from it, it was a design fault with the fuel system and it was fuel, fuel, fuel. To me, there is a big issue with the fuel system in these aircraft.”

The relatives’ and survivors’ suspicions about the aircraft are borne out by the reported sequence of events on the night of the crash, by much of the contents of an Air Accident Investigation Board (AAIB) report and the FAI itself.

Aircraft registration G-SPAO, piloted by Traill and with two other police officers, Tony Collins and Kirsty Nelis, on board, took off at 20:44 hours for a series of routine surveillance operations over central Scotland. The flight path took G-SPAO from Glasgow to Dalkeith near Edinburgh, then back to Bothwell and Bargeddie in the Glasgow area.

At some point two fuel pumps, which transfer fuel from the main tank to supply tanks for the two engines, were switched off by the pilot at different points in the flight, to prevent them overheating. This is apparently a long-standing problem.

This meant that when the aircraft crashed, its main fuel tank still held 76kg of fuel, less than the recommended minimum but plenty to make the short journey to the aircraft’s base beside the Clyde.

The AAIB report noted that in the aftermath of the crash, Airbus Helicopters intended to introduce changes to “simplify the operation of the fuel transfer pumps” and provide pumps which did not overheat.

Despite this, Turnbull opined, “[I]t would not have been a reasonable precaution for the fuel tank system and fuel contents indication system of G-SPAO to have been designed in such a way that the fuel transfer pumps did not require to be switched ON or OFF during flight.”

Later in the flight, at 22:06, the first of five CAD fuel warnings were illuminated. Gongs would also have sounded. These were all acknowledged by the pilot. Evidence was given that police helicopter pilots have acute “fuel awareness” because of the non-standard character of many of their flights.

The helicopter’s other crew members were both experienced and qualified to intervene if they felt Traill was behaving recklessly. Radio contact was maintained with the helicopter until minutes before it crashed. No concerns were raised by anyone.

The only possible explanation for this is that Traill and his colleagues thought the aircraft had enough fuel, that the fuel alerts were erroneous and could safely be discounted.

Astonishingly, it emerged that the EC-135s have a history of faulty fuel indications. The 2013 AAIB report noted that Bond Air Services had noted “erroneous fuel quantity indications on EC-135 helicopters. … The evidence suggested that water contamination may have been the root cause but the exact mechanism was not fully understood.”

Two weeks after the crash, another of Bond Air Services’ EC-135s displayed “contradictory fuel indications and low fuel warnings.” Tests on the aircraft found fuel sensors showing a full tank even when it was empty. The G-SPAO had itself encountered similar problems three times in the preceding five months.

Holger Mendick, an Airbus engineer, told the inquiry that in the six years prior to the crash as many as 680 fuel sensors had been returned to Airbus because of “mis-readings.” Another 600 had been returned subsequently.

The AAIB report also noted a “safety action” by the operator, engine and aircraft manufacturer to improve engine washing to avoid the danger of fuel contamination and false readings.

Mendick told the FAI that any water contamination of the fuel system on G-SPAO would have rapidly evaporated. “It’s not a matter of days or weeks, it’s just a matter of maybe an hour, or some hours.”

Despite this, Turnbull found that there was “no evidence which would entitle the court to find that the fuel, the fuel tank system or both of them were contaminated with water.”

Also in question is the maintenance regime at the helicopter base provided by Bond Air Services for Police Scotland. Bond is now part of Babcock International, the British-based engineering, infrastructure and defence contractor.

The FAI heard damning evidence from helicopter engineer Paul Booth. His handover notes to management the day before the crash commented, “I am extremely concerned at the way we are having to carry out in depth maintenance on our aircraft at Glasgow … It is an accident waiting to happen.”

Booth had been told by a pilot of fuel reading fluctuations on G-SPAO on November 24, 2013. He told the inquiry he did not have time to replace the fuel sensor that week and wanted Bond management to be aware.

Turnbull makes no mention of these issues. Instead he blandly refers to the AAIB report’s assertion that “G-SPAO was maintained in accordance with the manufacturer’s recommendations and servicing routines.”

Turnbull therefore explains nothing in his conclusion: “The central question for the inquiry is why did that happen? The answer is a simple one. Captain Traill ignored the LOW FUEL warnings he received.”

It may well be that Traill and his crew made a fatal error. However, by refusing to place responsibility on Airbus, Babcock or Police Scotland in dealing with long-standing and known problems with the aircraft, Turnbull is implementing the same class justice as Sir Martin Moore-Bick deployed in his findings of Phase 1 of the inquiry into the 2017 Grenfell Tower disaster.

Moore-Bick’s report focused almost entirely on the London Fire Brigade’s response to Grenfell and not on where real responsibility for the fire lies—with the companies and authorities responsible for the building being covered with deadly flammable cladding.

There is another parallel. On June 2, 1994, an RAF Chinook crashed on the Mull of Kintyre, southwest Scotland, in foggy conditions, wiping out much of British military intelligence’s top brass. Under pressure to find a scapegoat, an RAF inquiry blamed the aircraft’s pilots despite known problems with the Full Authority Digital Electronic Control (FADEC) system controlling and balancing the Chinook’s twin engines. It was not until 2011, following a sustained campaign by relatives, that the pilots were finally cleared of gross negligence.

Many of the relatives of victims of the Clutha tragedy have already been through traumatic legal battles. John McGarrigle, whose father died in the bar, said, “I’m consulting my lawyers about what to do next because the fight isn’t over for accountability and justice.” McGarrigle won a compensation case against Babcock for his father’s death, but under harrowing circumstances. Babcock’s lawyers attempted to prove that McGarrigle “did not have a close tie of love and affection” with his own father.