Safety Mat­ters

Safety Mat­ters and Safety Briefs are based on the AAIB Bul­letin and UK Air­prox Board re­ports, with ad­di­tional ma­te­rial from the US Na­tional Trans­porta­tion Safety Board

Pilot - - CONTENTS -

Tur­bu­lent tip-up, close kite en­counter, be­ware props and Air­prox re­ports

Tur­bu­lent wa­ters

Air­craft Type: Rol­la­son/ Dru­ine Tur­bu­lent Date & Time: 14 August 2016 at 1430 Com­man­der’s Fly­ing Ex­pe­ri­ence: PPL, 922 hours, 360 on type Last 90 days: 8 hours Last 28 days: 2 hours The air­craft was one of three from the Tiger Club’s Tur­bu­lent Dis­play Team tak­ing part in an air­show at Herne Bay, Kent. The pi­lots briefed for their show, walked through the planned rou­tine and, given that the dis­play was tak­ing place just off­shore and ad­ja­cent to a con­gested area, agreed that in the event of an en­gine fail­ure the best op­tion would prob­a­bly be to ditch in the sea. The dis­play rou­tine pro­ceeded nor­mally un­til the bal­loon-burst­ing seg­ment, for which the air­craft adopted a race­track pat­tern along the dis­play line. A mem­ber of the team’s ground crew, po­si­tioned in a small boat, then re­leased bal­loons so that the team could burst them by fly­ing into them at 500 feet.

On his first run the pilot of the ac­ci­dent air­craft did not make con­tact but on his sec­ond he hit a bal­loon ‘dead cen­tre’ with the pro­pel­ler and con­tin­ued around the race­track. When es­tab­lished on the down­wind leg, how­ever, the Tur­bu­lent’s en­gine power much re­duced. A check of in­stru­ments and con­trols re­vealed noth­ing amiss, but the en­gine con­tin­ued to run at low power. Judg­ing that it would not be pos­si­ble to glide as far as open land in­land from the seafront for a forced land­ing, he con­tin­ued to­wards an area just off the beach, be­yond the dis­play area, where there were fewer spec­ta­tors. He planned to stall the air­craft onto the wa­ter, touch­ing tail-first, fol­lowed by the un­der­car­riage, so that it re­mained up­right.

In the event the main­wheels touched first and their drag caused the air­craft to pitch for­ward rapidly onto its back.

Al­though the pilot was able to un­fas­ten his straps, he found him­self trapped with his head close to the seabed and in­suf­fi­cient space to ma­noeu­vre him­self out of the cock­pit. His au­to­matic life­jacket had in­flated and its bulk and buoy­ancy were press­ing him up into the in­verted cock­pit. Mem­bers of the pub­lic ran into the wa­ter, lifted the air­craft up­right and helped the pilot out of the cock­pit and onto the beach. He had been un­der wa­ter for about twenty sec­onds, but had re­mained con­scious, and apart from a small cut on his face from strik­ing the canopy sur­round was un­hurt.

The air­craft was re­cov­ered in­tact but with some dam­age to the wing lead­ing edge. It could not be es­tab­lished whether this was caused dur­ing the ditch­ing or sub­se­quent re­cov­ery. Ini­tial in­ves­ti­ga­tion did not iden­tify any other dam­age, but de­tailed ex­am­i­na­tion of the en­gine found a piece of bal­loon, ap­prox­i­mately 50mm in di­am­e­ter, lodged in the air path of the car­bu­ret­tor. The op­er­a­tor of the air­craft has sub­se­quently de­vel­oped a mod­i­fi­ca­tion to fit a screen to the en­gine’s car­bu­ret­tor in­take so as to pre­vent ingress of de­bris sim­i­lar to the bal­loon frag­ment. Should this screen be­come blocked, air can still be supplied to the car­bu­ret­tor via the al­ter­na­tive hot air sup­ply, thereby al­low­ing the en­gine to op­er­ate nor­mally.

The pilot was wear­ing a 150N (New­ton) life jacket in­tended for

use in boats. He had se­lected an au­to­matic de­sign as he be­lieved that this was a de­sir­able fea­ture, and wore it when­ever fly­ing over wa­ter. How­ever, the CAA’S Gen­eral Avi­a­tion Safety Sense Leaflet 21d Ditch­ing ad­vises: ‘Many au­to­mat­i­cally in­flated life­jack­ets, used by the sail­ing com­mu­nity, are ac­ti­vated when a sol­u­ble tablet be­comes wet. This type is to­tally un­suit­able for gen­eral avi­a­tion use as it will in­flate in­side a wa­ter-filled cabin, thus se­ri­ously hin­der­ing es­cape.’ The leaflet also pro­vides guid­ance on suit­able life­jack­ets, where to ob­tain them, and in­for­ma­tion and ad­vice on the prepa­ra­tion for and prac­tices to em­ploy in the event of hav­ing to ditch an air­craft in wa­ter.

This ac­ci­dent calls to mind a pre­vi­ous ditch­ing in­volv­ing a Tiger Club Tur­bu­lent when club mem­ber Robin d’er­langer was forced to put down in the English Chan­nel in the sum­mer of 1964 whilst re­turn­ing from a trip to France. The Turb floated, and when a pass­ing Nor­we­gian freighter res­cued him (and the air­craft) d’er­langer was calmly sit­ting on top of its fuse­lage smok­ing a cig­a­rette. Robin was later to win the King’s Cup Air Race while fly­ing an­other Tiger Club Tur­bu­lent — MJ

(Too) high as a kite

Air­craft Type: Bell Jetranger III Date & Time: 19 February 2017 at 1045 Com­man­der’s Fly­ing Ex­pe­ri­ence: ATPL, 6,800 hours, 350 on type Last 90 days: 118 hours Last 28 days: 17 hours The pilot was car­ry­ing out a series of sight­see­ing flights from Manston. The first trip de­parted to the south along the coast at Sand­wich Bay to Dover be­fore turn­ing in­land to­wards Can­ter­bury, then back to Manston. As he was fly­ing along the coast at around 700ft he no­ticed a kite very close by and took avoid­ing ac­tion. He was not aware of any con­tact. Dur­ing a sec­ond flight in the same area, at 1,500ft amsl he no­ticed a num­ber of kites in the sky at lev­els that he es­ti­mated to be above 1,000ft amsl. Fi­nally, there was a short (third) flight in a dif­fer­ent di­rec­tion after which ground staff no­ticed a scuff mark on the Jetranger’s wind­screen. In­spec­tion re­vealed fur­ther dam­age to the right for­ward door screen, the main ro­tor pitch change links, one ro­tor blade and the ver­ti­cal fin.

The lo­ca­tion where con­tact with the kite line most likely oc­curred was on the coast in Sand­wich Bay, where the ter­rain con­sists of low ly­ing coastal plain and sand dunes from which high level kite fly­ing ac­tiv­ity has been ob­served, both on the day of the in­ci­dent and on pre­vi­ous oc­ca­sions. On­line footage of ac­tiv­ity at this lo­ca­tion shows a num­ber of peo­ple fly­ing kites with 700m line spools, with adapted power drills and winches be­ing used to wind in the lines after fly­ing.

The op­er­a­tor of the he­li­copter car­ries out char­ter flights and or­gan­ised sight­see­ing tours in the lo­cal area around Manston, and No­tam are rou­tinely checked be­fore flight. None were ap­pli­ca­ble to the area on the date of the in­ci­dent flight. The pilot had flown sight­see­ing tours on be­half of the op­er­a­tor on a num­ber of oc­ca­sions and was fa­mil­iar with the routes and had not pre­vi­ously ob­served kite-fly­ing ac­tiv­ity. He re­ported the in­ci­dent and no­ti­fied the lo­cal Coast­guard SAR he­li­copter fa­cil­ity at Lydd Air­port of the hazard. Later that day two of the op­er­a­tor’s per­son­nel vis­ited the beach from which the kites were be­ing flown and ad­vised the peo­ple fly­ing them that they were caus­ing a risk to air­craft.

The AAIB report con­cludes: ‘Ev­i­dence from the na­ture of the dam­age to the he­li­copter and pho­to­graphs taken at the prob­a­ble kite fly­ing lo­ca­tion sug­gest that the kite string was coated with an abra­sive sub­stance. In a num­ber of other coun­tries, kite fight­ing is a com­pet­i­tive sport where the ob­jec­tive is to cut the string of an op­po­nent’s kite. To fa­cil­i­tate the cut­ting ac­tion, the up­per parts of the kite string may be coated with [such] an abra­sive sub­stance. There is ev­i­dence that a num­ber of dif­fer­ent coastal lo­ca­tions in the United King­dom are used for kite fly­ing at heights above 60m but the ac­tiv­ity is not be­ing no­ti­fied. The AAIB re­ported on an­other in­ci­dent in June 2016 in which a light air­craft was also dam­aged when it came into con­tact with kite string (see ‘Safety Mat­ters’, January 2017 — Ed).

‘The Air Nav­i­ga­tion Or­der 2016 Ar­ti­cle 92 (c), which is ap­pli­ca­ble to kites, states: A rel­e­vant air­craft which is launched, moored, teth­ered or towed must not be op­er­ated in such a man­ner as to rep­re­sent a hazard to other airspace users or with­out the per­mis­sion of the CAA re­sult in any part of the rel­e­vant air­craft whilst it is be­ing launched or towed, or its tether, moor­ing or tow­ing equip­ment, ex­tend­ing more than 60 me­tres above ground level.

‘Per­mis­sions for ex­cep­tions to Ar­ti­cle 92 of the ANO can be ob­tained through the CAA. On re­ceipt of an ap­pli­ca­tion, the lo­ca­tion of the ac­tiv­ity is checked with re­gards to the sur­round­ing airspace and the ac­tiv­ity’s im­pact on that airspace. Spe­cial con­di­tions may be im­posed for a per­mis­sion to be granted, such as at­tach­ing stream­ers to the line to aid con­spicu­ity, and a No­tam will be is­sued.

‘The ev­i­dence in­di­cated that the he­li­copter en­coun­tered a kite at high level [which was] not be­ing flown in ac­cor­dance with Ar­ti­cle 92 of the ANO, and the ac­tiv­ity had not been no­ti­fied… Al­though the dam­age [to the Jetranger] was re­pairable, the po­ten­tial ex­ists for the re­sult of such an en­counter, on air­craft and/or its oc­cu­pants, to be more se­vere.’

Painful prop strikes

Air­craft Types: 1 Piper Warrior II 2 Mer­cury flexwing mi­cro­light Dates & Times: 1 26 March 2017 at 1450 2 9 April 2017 at 0810 Lo­ca­tions: 1 Half­penny Green Air­field 2 Other­ton, Stafford­shire Com­man­ders’ Fly­ing Ex­pe­ri­ence: 1 PPL, 56 hours, 42 on type 2 NPPL, 33 hours TT Last 90 days: 1 5 hours Last 28 days: 1 3 hours The Warrior’s pilot fol­lowed his check­list to start the en­gine, in­clud­ing prim­ing the fuel sys­tem, but it did not turn over when the key was turned. Two fur­ther at­tempts also failed. He closed the throt­tle, turned fuel and electrics off and re­moved the keys, then turned the pro­pel­ler by hand to check if the en­gine had seized. He no­ticed that it was stiff, ap­plied more force and the pro­pel­ler sud­denly started to spin, turn­ing over some five revo­lu­tions. It struck his right el­bow, caus­ing a small punc­ture wound, swelling and bruis­ing, but no long-term dam­age.

The pilot later said that the en­gine had al­ready been primed with fuel from a pre­vi­ously failed start at­tempt and that he be­lieves that fuel in the cylin­ders may have det­o­nated when he turned the pro­pel­ler, caus­ing the en­gine to ‘run’ for a few revo­lu­tions. Al­though he had re­moved the ig­ni­tion key prior to leav­ing the air­craft, and as on most types it had to be in the ‘both mag­ne­tos off’ po­si­tion be­fore it could be re­moved, it is pos­si­ble that one, or both mag­ne­tos were not prop­erly earthed when the ig­ni­tion switch was in the off po­si­tion.

In the sec­ond in­ci­dent the mi­cro­light’s pilot-owner was run­ning its en­gine to in­ves­ti­gate a mis­fire that had oc­curred in flight on the pre­vi­ous day. He did not in­tend to fly: the wings had been re­moved from the trike, a chock placed in front of the nose­wheel and he had ap­plied the foot­brake. Al­though the pilot’s rec­ol­lec­tion of the se­quence of events is hazy, he be­lieves he may have re­laxed pres­sure on the brake pedal, caus­ing the air­craft to move for­wards by about ten feet. He im­me­di­ately ap­plied full brake, throt­tled back to idle power and the air­craft stopped mov­ing. Pre­oc­cu­pied with the fact that the nose­wheel had jumped over the chock, he stepped out and reached down to pick it up, at which point he was struck in the face by the pro­pel­ler, sus­tain­ing a se­ri­ous in­jury.

A by­stander ren­dered first aid and the pilot was sub­se­quently air­lifted to hospi­tal. The pilot recog­nised that the ac­ci­dent could have been averted sim­ply by turn­ing the en­gine off or not be­ing dis­tracted by his per­ceived ur­gency to re­trieve the chock. He ad­di­tion­ally com­mented that he had not been wear­ing a hel­met as he was not in­tend­ing to fly, but be­lieved in­juries might have been less se­ri­ous or even elim­i­nated had he been wear­ing one. Al­though he was an in­ex­pe­ri­enced pilot, he had served for thir­teen years in the Royal Air Force work­ing as ground crew and was thus well aware of the dan­gers as­so­ci­ated with run­ning en­gines, yet still made a ba­sic er­ror.

The AAIB com­ments: ‘[These events] serve as a stark reminder of the po­ten­tially lethal power of a pro­pel­ler, em­pha­sise the im­por­tance of al­ways treat­ing mag­ne­tos as “live” even when they ap­pear to be switched off… [and] also un­der­line the need to treat pro­pel­lers with re­spect at all times, even when at­tached to a small en­gine run­ning at idle.’

Pas­sen­ger han­dling of a dif­fer­ent kind

Air­craft Type: Jodel DR100A Am­bas­sadeur Date & Time: 23 January 2017 at 1600 Com­man­der’s Fly­ing Ex­pe­ri­ence: LAPL, 1,950 hours (of which 155 were on type) Last 90 days: 11 hours Last 28 days: 5 hours Dur­ing take­off after the sev­enth touch-and-go land­ing of a fa­mil­iari­sa­tion flight at Dunkeswell, the han­dling pilot lost con­trol as power was ap­plied. The air­craft ground looped, its un­der­car­riage col­lapsed and the pro­pel­ler struck the ground. The han­dling pilot, who had no pre­vi­ous ex­pe­ri­ence of tail­wheel types, had re­cently pur­chased the air­craft. He was ac­com­pa­nied by a Light Air­craft As­so­ci­a­tion in­spec­tor who was ex­pe­ri­enced on type and had of­fered him some fa­mil­iari­sa­tion flights, of which this was the third. The han­dling pilot sat in the right seat for the first gen­eral han­dling flight and in the left seat for the next two, dur­ing which cir­cuits were flown, some by the air­craft’s new owner.

The LAA in­spec­tor stated that, prior to these flights, the han­dling pilot was made fully aware that he was not an in­struc­tor, and the han­dling pilot was un­der the im­pres­sion that the in­spec­tor would be pilot-in-com­mand. The han­dling pilot was also aware that he would have an op­por­tu­nity to take the con­trols dur­ing the flights but as the PIC was not an in­struc­tor he would not be able to of­fer any tu­ition. Con­se­quently, as the han­dling pilot was not be­ing trained, nor was he PIC (and thus was ef­fec­tively a pas­sen­ger), he would have been un­able to log hours for any of the flights.

The AAIB com­ments: ‘The han­dling pilot had no pre­vi­ous ex­pe­ri­ence of tail­wheel/ drag­ger air­craft and the ac­ci­dent oc­curred whilst car­ry­ing out fa­mil­iari­sa­tion train­ing, but this was not with an in­struc­tor. This event has high­lighted that, when con­vert­ing to an­other vari­ant of an air­craft than the one used for the skill test, pi­lots must un­der­take ap­pro­pri­ate train­ing with an in­struc­tor.’

Lat­est Air­proxes

The UK Air­prox Board dis­cussed six­teen air­craft-to-air­craft and fif­teen air­craft-to-drone in­ci­dents dur­ing its June meet­ing. Five of the for­mer were as­sessed as hav­ing a def­i­nite risk of col­li­sion (three Cat­e­gory A and two Cat­e­gory B), and the main theme was the num­ber of in­ci­dents brought about by on­go­ing mil­i­tary ATC con­troller man­ning prob­lems at their busy units. ‘Al­though not all of these in­ci­dents in­volved GA air­craft, there is much that the GA com­mu­nity can do to as­sist mil­i­tary ATC units by calling at an early stage and be­ing clear in in­ten­tions,’ says UKAB. ‘Even an ex­tra cou­ple of min­utes can help the con­trollers as­sim­i­late what you want and find time to

re­spond in the in­creas­ingly busy mil­i­tary en­vi­ron­ment, es­pe­cially in Lincolnshi­re and East Anglia.’

Other Air­prox themes were ‘a mixed bag’ that in­cluded five late- or non-sight­ings, four con­flicts in Class G Airspace, and seven air­man­ship is­sues vary­ing from fly­ing too close, poor se­lec­tion of ATS for the con­di­tions, in­ac­tion, and sub-op­ti­mal avoid­ance or in­te­gra­tion with other air­craft al­ready in the vis­ual cir­cuit. ‘Just to clar­ify,’ says UKAB, ‘the dif­fer­ence be­tween non-/ late-sight­ing and a con­flict in Class G is that for the non-/late-sight­ing in­ci­dents the pi­lots had the op­por­tu­nity to see the other air­craft ear­lier but did not, whereas for the con­flict in Class G in­ci­dents the pi­lots saw the other air­craft as early as could rea­son­ably be ex­pected given the con­di­tions at the time.’

The Board’s ‘Air­prox of the Month’ fo­cuses on in­te­gra­tion prob­lems in the vis­ual cir­cuit caused by fly­ing non-stan­dard pat­terns and joins. This in­ci­dent oc­curred when a Piper PA-28 and a Cessna 152 came into con­flict at North Weald.

‘The C152 was down­wind, but very far out com­pared to the nor­mal cir­cuit width, whilst the PA-28 ini­tially wanted to join left-base,’ says the Board’s report. ‘But, on hear­ing the C152 was down­wind [the PA-28 pilot] con­verted to a down­wind join of sorts that saw him route the op­po­site di­rec­tion for a while be­fore turn­ing to try to in­ter­cept a base leg. Al­though there is no spec­i­fied cir­cuit width in the UK, North Weald has a no­tional track, and, not ex­pect­ing the C152 to be that far out and there­fore not see­ing it as he looked into the cir­cuit, the PA-28’S pilot turned and came into con­flict as it rolled out onto base leg. A com­bi­na­tion of the C152’s wide cir­cuit and the PA-28’S non-stan­dard join, this Air­prox demon­strated the need to fly pro­ce­dures ac­cu­rately and state your in­ten­tions clearly in the cir­cuit, es­pe­cially when there is only a FISO to as­sist.’ Full de­tails of this in­ci­dent and all oth­ers can be found at air­prox­

Airspace In­fringe­ment Safety Aware­ness Course of­fered

The CAA and the Gen­eral Avi­a­tion Safety Coun­cil (GASCO) have jointly de­vel­oped a train­ing pack­age tar­get­ing pi­lots who have in­fringed con­trolled or no­ti­fied airspace. The CAA will rec­om­mend, where ap­pro­pri­ate, that these in­di­vid­u­als un­der­take the course as part of any li­cens­ing ac­tion. GASCO will be re­spon­si­ble for de­liv­er­ing the cour­ses at var­i­ous lo­ca­tions around the UK.

The course en­hances the options avail­able to the CAA when de­cid­ing if any ac­tion is re­quired fol­low­ing an airspace in­fringe­ment. Each case is as­sessed in­di­vid­u­ally based on the in­ci­dent, the pilot’s ac­tions and whether the pilot has pre­vi­ously been in­volved in airspace in­fringe­ments.

“We have al­ways tried to pri­ori­tise pilot ed­u­ca­tion as the way to deal with airspace in­fringe­ments,” says Rob Grat­ton, Prin­ci­pal Airspace Reg­u­la­tor at the CAA. In the past, in­fringers were in­vited to take an on­line test that, as Pilot’s ‘Air­mail’ pages have re­vealed, some felt was ar­cane or even ir­rel­e­vant to GA. The new course “pro­vides an ex­cel­lent, in-depth op­tion to help pi­lots learn from an in­fringe­ment to both avoid fu­ture in­fringe­ments and also to im­prove their gen­eral air­man­ship and plan­ning skills.”

Mike O’donoghue, GASCO Chief Ex­ec­u­tive, said: “We are told that the na­tional speed aware­ness course used for driv­ers has proved very suc­cess­ful and so we looked at the key el­e­ments of a typ­i­cal course and de­vel­oped an en­gag­ing and ed­u­ca­tional ver­sion for pi­lots em­ploy­ing threat and er­ror man­age­ment tech­niques. The GA com­mu­nity has said that ed­u­cat­ing a pilot after an in­fringe­ment is the way for­ward. With this course the CAA and GASCO will de­liver a sig­nif­i­cant part of that work.”

The cour­ses will be run reg­u­larly through­out the coun­try. Pi­lots who are asked to at­tend a course will be given a date by which they will be ex­pected to have com­pleted it. Each at­tendee will pay £200 to cover GASCO’S ex­penses in pro­vid­ing the course and fa­cil­i­ties.

‘Airspace in­fringe­ments con­tinue to oc­cur at a high rate in the UK with over 1,000 re­ported in 2016,’ says the CAA, which of­fers this ad­vice to help to avoid in­fringe­ments:

Carry out ef­fec­tive pre­flight plan­ning and take ad­van­tage of free on­line flight plan­ning tools

Turn on your transpon­der and op­er­ate Mode Char­lie (ALT)

Use lis­ten­ing squawks when fly­ing near con­trolled airspace (see airspace­safety. com/lis­ten)

Use an airspace-alert­ing de­vice to as­sist in main­tain­ing sit­u­a­tional aware­ness

Be aware of the dan­ger of be­com­ing dis­tracted Make con­tact with lo­cal ATC ser­vices If in doubt, utilise the Flight In­for­ma­tion Ser­vice or con­tact Dis­tress and Di­ver­sion on 121.5MHZ.

The process that the CAA uses to deal with in­fringe­ments is set out at uk/cap1404.

Wonderful peo­ple: the prompt ac­tion of by­s­tanders saved the Tur­bu­lent’s pilot, trapped un­der the air­craft, from cer­tain drown­ing

The Tur­bu­lent Dis­play Team has been a fix­ture at Bri­tish air­shows for as long as many of us can remember

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