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 -

In­ex­pe­ri­ence, wind and weather all take a toll, plus Air­prox re­ports

In­jured In­jun-1 Air­craft Type: Piper PA-28 Chero­kee 140 Date & Time: 11 Fe­bru­ary 2018 at 1143 Com­man­der’s Fly­ing Ex­pe­ri­ence: PPL, 55 hours, 6 on type Last 90 days: 8 hours Last 28 days: 4 hours

This was the pi­lot’s first flight since the is­sue of his PPL and since com­ple­tion of Piper PA-28 fa­mil­iari­sa­tion train­ing eight days pre­vi­ously (his stu­dent train­ing was mostly on Cessna 152s). It was also his first flight with pas­sen­gers and the first time he had flown with a rearseat oc­cu­pant. He cal­cu­lated that the air­craft’s weight would be a lit­tle less than MTOW and that its C of G would be near the mid­dle of the per­mit­ted range.

Fore­cast wind at Southend Air­port was 260/17kt, with gusts to 32kt from the same di­rec­tion ex­pected later in the day. Us­ing Rwy 23, pi­lot and in­struc­tor were sat­is­fied that the air­craft’s cross­wind limit of 17kt for take­off and land­ing would not be ex­ceeded, nor the fly­ing club’s max­i­mum wind limit of 30kt for PPL air­craft hire. How­ever, be­cause tur­bu­lent con­di­tions were ex­pected, the in­struc­tor rec­om­mended that the Chero­kee be landed us­ing two stages of flap rather than three so that there would be no need to re­tract one stage of flap in the event of a go-around. He also rec­om­mended that the ap­proach speed be in­creased by five mph to ninety, to pro­vide a mar­gin of safety if gusts were en­coun­tered.

Af­ter an un­event­ful lo­cal flight the pi­lot re­turned to land on Rwy 23 via a straight-in ap­proach from 12nm out. He later de­scribed con­di­tions as “choppy”, es­pe­cially once be­low 1,500ft aal, with the strong, gusty wind lead­ing to “a long and un­com­fort­able ap­proach”. He set two stages of flap but for­got to add a safety mar­gin to his air­speed, thus ap­proach­ing at 85mph. At two nau­ti­cal miles out he re­ceived land­ing clear­ance from ATC and was in­formed that the wind was 280/19kt.

Near­ing the run­way, the pi­lot thought he was be­low the ideal ap­proach path but con­tin­ued be­cause he felt he could still reach the dis­placed land­ing thresh­old. Prior to touch­down he sensed a sud­den gust blow­ing the air­craft to the left and it im­me­di­ately hit the run­way and bounced. He at­tempted to go around but the air­craft pitched up and, although he did not no­tice if the stall warn­ing light il­lu­mi­nated, he re­alised that there was a dan­ger of stalling. Be­fore he was able to take any cor­rec­tive ac­tion the air­craft sank quickly and struck the grass to the left of the run­way, break­ing off all three un­der­car­riage legs, then skid­ded and turned right be­fore com­ing to a halt fac­ing to­wards the run­way and rest­ing on its left wing. Pi­lot and pas­sen­gers es­caped un­aided and in­jured.

Air­field CCTV record­ings in­di­cated that the air­craft be­gan to flare but, at ap­prox­i­mately 20ft aal, it rolled left, and the rate of de­scent in­creased be­fore it con­tacted the run­way, hav­ing re­gained a wings-level at­ti­tude. It im­me­di­ately bounced and climbed in a 25-30 de­gree nose-up at­ti­tude un­til it lev­elled for three sec­onds at 40ft with a re­duced nose-up at­ti­tude, and as it de­scended to­wards the grass area south of the dis­placed run­way thresh­old its rate of de­scent in­creased and the right wing dropped.

The in­struc­tor who had com­pleted the pi­lot’s Chero­kee train­ing re­ported that the four ap­proaches and land­ings that he had per­formed with him were “good” and this re­flected the level of land­ing com­pe­tency recorded in the pi­lot’s pre­vi­ous train­ing notes. He had landed ap­par­ently with­out dif­fi­culty with a cross­wind of 12kt from the right and in gusty con­di­tions.

The fly­ing club that op­er­ated the air­craft noted this was the pi­lot’s first flight with an air­craft close to its MTOW and with a rear seat pas­sen­ger. He would thus have had to over­come a ten­dency for the air­craft to pitch nose-up be­cause the C of G was fur­ther aft than he had pre­vi­ously ex­pe­ri­enced. The club is now con­sid­er­ing in­tro­duc­ing a re­quire­ment for newly qual­i­fied PPL hold­ers to prac­tice fly­ing an air­craft at its MTOW with an in­struc­tor be­fore fly­ing solo with pas­sen­gers.

The pi­lot thought he should have tried to gain more ex­pe­ri­ence in var­i­ous wind con­di­tions be­fore he car­ried pas­sen­gers, and be­cause he had flown a long fi­nal ap­proach in tur­bu­lent con­di­tions he had felt “un­nerved” by the time he reached the air­field. He recog­nised that he should have gone around ear­lier, and when he did at­tempt to go around he should have con­cen­trated on fly­ing the air­craft rather than try­ing to com­mu­ni­cate with ATC.

In­jured In­jun-2 Air­craft Type: Piper Chero­kee War­rior II Date & Time: 16 Novem­ber 2017 at 1141 Com­man­der’s Fly­ing Ex­pe­ri­ence: PPL, 925 hours, 755 on type Last 90 days: 6 hours Last 28 days: 3 hours

When the pi­lot de­parted Wolver­hamp­ton (Half­penny Green) Air­port he was aware that there was a cold weather front to the north­west which was mov­ing to­wards the air­field. Be­fore tak­ing off the Flight In­for­ma­tion Ser­vice Of­fi­cer in­formed him that the es­ti­mated wind was from 230/8kt. Af­ter leav­ing the cir­cuit the pi­lot en­coun­tered de­te­ri­o­rat­ing weather con­di­tions in­clud­ing low cloud, rain, re­duced vis­i­bil­ity and tur­bu­lence. He told the FISO that he was re­turn­ing to the air­field, and sub­se­quently re­joined the cir­cuit for Rwy 16, which has a land­ing dis­tance avail­able of 858m.

The pi­lot called down­wind. Af­ter ask­ing the him to re­port on fi­nal ap­proach, the FISO no­ticed the wind had veered and told the pi­lot, then on fi­nal, that there was a tail­wind es­ti­mated at 300/10kt. While trans­mit­ting this mes­sage the FISO saw the air­craft fly­ing at about 10ft aal more than half­way along the run­way. It touched down ad­ja­cent to the Precision Ap­proach Path In­di­ca­tors for Rwy 34 which are 393m from the stop-end of Rwy 16.

Ac­cord­ing to the pi­lot the air­craft seemed re­luc­tant to de­scend while on fi­nal ap­proach, but he did not re­mem­ber hear­ing the FISO in­form him of a tail­wind. Vis­i­bil­ity had re­duced be­cause of rain, but he ap­pre­ci­ated that he was still air­borne when more than half­way along the run­way. His pas­sen­ger, a for­mer flight in­struc­tor, twice sug­gested that he went around, but the pi­lot con­tin­ued be­cause he still be­lieved he had suf­fi­cient run­way avail­able to com­plete a land­ing.

Af­ter touch­ing down, the pi­lot had dif­fi­culty slow­ing the air­craft due to the wet sur­face and tail­wind so he in­creased power and at­tempted to go around. Once air­borne, he was aware of the left wing dipping, prob­a­bly be­cause he had not ap­plied suf­fi­cient right rud­der to coun­ter­act the in­creased en­gine torque, and the left wingtip then struck a bound­ary hedge. The air­craft then lost height and hit a sec­ond hedge and fence, where­upon the left wing de­tached, and it spun around and stopped abruptly. Both oc­cu­pants suf­fered mi­nor head in­juries.

A se­nior flight in­struc­tor at the air­field when the air­craft took off re­ported that the weather was de­te­ri­o­rat­ing, the sky dark­en­ing and it was driz­zling. When he heard the crash alarm, he noted that it was rain­ing and es­ti­mated from the wind­sock that the wind was from 340/15kt. The sky cleared and the rain stopped a few min­utes later. Given the po­si­tion of the wind­sock, he con­cluded that a pi­lot ap­proach­ing Rwy 16 might have found it dif­fi­cult to dis­cern that it was aligned in the re­cip­ro­cal di­rec­tion to that ex­pected.

The AAIB com­ments: ‘The CAA’S Sky­way Code (CAP 1535) re­minds pi­lots that they are re­quired to con­sider the me­te­o­ro­log­i­cal sit­u­a­tion be­fore com­menc­ing a flight. A sec­tion ti­tled ‘Pre-flight Prepa­ra­tion’ in­forms pi­lots that the Met Of­fice is the main source of avi­a­tion weather in­for­ma­tion in the UK, and the doc­u­ment pro­vides de­tailed guid­ance to help them in­ter­pret charts and codes. It stresses that pi­lots should have a good work­ing knowl­edge of the con­di­tions as­so­ci­ated with com­mon weather fea­tures such as warm and cold fronts. CAA Safety Sense Leaflet SSL 1e Good

Air­man­ship ad­dresses many as­pects of gen­eral avi­a­tion flight and tells pi­lots to: ‘Get an avi­a­tion weather fore­cast, heed what it says and make a care­fully rea­soned go/no-go de­ci­sion’ and ‘Go-around if not solidly on in the first third of the run­way, or the first quar­ter if the sur­face is wet grass.’’

CHIRP ad­dresses GA pi­lot train­ing is­sues

CHIRP has briefed the CAA on a num­ber of pi­lot train­ing is­sues. ‘While some of the themes re­flect pi­lot in­ex­pe­ri­ence, it is pos­si­ble that oth­ers re­flect gaps in knowl­edge that could and should be cov­ered in ground school or dur­ing air­borne train­ing,’ it says. Themes iden­ti­fied in­cluded:

• In­ad­e­quate flight plan­ning with a lack of con­tin­gency op­tions for weather and/or airspace. Pi­lots not read­ing/ as­sim­i­lat­ing NOTAM in­for­ma­tion

• Lack of un­der­stand­ing about hu­man fac­tors – phys­i­o­log­i­cal and psy­cho­log­i­cal. Pi­lots seem un­aware of the IMSAFE mnemonic for as­sess­ing their fit­ness to fly

• In­ci­dents while join­ing and fly­ing in vis­ual cir­cuits reg­u­larly fea­ture in CHIRP re­ports with some ex­am­ples of pi­lots ap­pear­ing to have lit­tle aware­ness of what is go­ing on around them. Also an un­will­ing­ness to go around from un­safe ap­proaches

• Con­tribut­ing to the prob­lems in the vis­ual cir­cuit, but also ev­i­dent en route, use of r/t is some­times poor. Some pi­lots do not ap­pear to lis­ten out ad­e­quately in or­der to build up their sit­u­a­tional aware­ness; in­cor­rect phrase­ol­ogy is com­mon and clear­ances are not read back in full

• Mis­un­der­stand­ings about the pro­vi­sions and dif­fer­ences be­tween a Ba­sic and a Traf­fic Ser­vice are com­mon. Sim­i­larly the dif­fer­ences be­tween an air­field Flight In­for­ma­tion Ser­vice and an Air/ground Ser­vice, the lat­ter com­pounded by some A/G Op­er­a­tors ex­ceed­ing the terms of their Cer­tifi­cate of Com­pe­tence

• Many GA pi­lots fly with GPS, ipads and other tech­nol­ogy that can di­vert their at­ten­tion from look­out into the cock­pit. En route there is ev­i­dence of poor task man­age­ment be­tween the elec­tronic aids, speak­ing to ATC, and ba­sic nav­i­ga­tion

• Fuel aware­ness often seems poor. Pi­lots do not dip their fuel tanks and over-rely on in­ac­cu­rate gauges. Some re­ports con­cern pi­lots run­ning out of fuel com­pletely. Per­haps pi­lots learn to fly on air­craft types where the gauge can be re­lied upon be­fore switch­ing to types where the gauge is a guide only

• Pi­lots do not ap­pear suf­fi­ciently de­fen­sive in terms of route­ing over suit­able ar­eas for forced land­ings and in terms of be­ing un­will­ing to give way to other air­craft when they per­ceive they have pri­or­ity

• We be­lieve pi­lots are not rou­tinely taught how to look for haz­ards in the over­shoot when they are se­lect­ing suit­able fields for PFLS.

‘A re­cent re­port about a Fly­ing In­struc­tor (Re­stricted) su­per­vis­ing solo stu­dents high­lighted a lack of in­for­ma­tion about the na­ture of su­per­vi­sion for re­stricted in­struc­tors,’ CHIRP notes. ‘There is no for­mal def­i­ni­tion of the level or means by which the su­per­vis­ing in­struc­tor pro­vides that su­per­vi­sion.

‘We pe­ri­od­i­cally re­ceive re­ports about solo stu­dents be­ing sent on qual­i­fy­ing cross-coun­try flights with barely suf­fi­cient time be­fore des­ti­na­tion air­fields close or, in win­ter, day­light fades into twi­light.

‘On the pos­i­tive side, many pi­lots write to CHIRP about er­rors or mis­judge­ments they have made with a gen­uine de­sire to help oth­ers avoid sim­i­lar prob­lems.

‘Sadly ‘turn back’ ac­ci­dents fol­low­ing at­tempts to re­gain the air­field con­tinue to haunt us, de­spite it be­ing a fea­ture of fly­ing since the start of the last cen­tury. It’s the old­est killer in the book. Events last year trag­i­cally saw at least four such ac­ci­dents cul­mi­nat­ing in death or life-chang­ing in­juries, largely as a re­sult of par­tial en­gine fail­ures… A ten-year sur­vey of ac­ci­dents in Aus­tralia showed that there were nine fa­tal­i­ties with par­tial en­gine fail­ures and none with to­tal en­gine fail­ures. An anal­y­sis of the cer­tainty of ac­ci­dent against re­main­ing power out­put has in­di­cated that if a pi­lot had be­tween 25-75% power, the like­li­hood of los­ing con­trol and a fa­tal ac­ci­dent was high. Pi­lots were tempted to turn back or have a go at a low-level cir­cuit and ended up stalling/ spin­ning at low level, which is in­vari­ably fa­tal.

‘While in­struc­tors reg­u­larly teach ‘fan stop’ ex­er­cises, there is lit­tle or no em­pha­sis on deal­ing with a par­tial or pro­gres­sive loss of power. It is often harder to de­tect, and can leave a pi­lot with too many de­ci­sions to make. Per­haps greater aware­ness by the in­struc­tor com­mu­nity to this in­sid­i­ous killer may mean we can re­duce the ca­su­alty rate in the com­ing year.’

Air­prox re­ports

At its April 2018 meet­ing the Air­prox Board as­sessed 25 in­ci­dents of which nine­teen were air­craft-to-air­craft, of which nine were as­sessed as hav­ing a def­i­nite risk of col­li­sion (two Cat A ‘where prov­i­dence played a ma­jor part’, and seven Cat B ‘where safety was much re­duced due to serendipity, mis­judge­ment, in­ac­tion, or late sight­ing’).

Notes the Board: ‘The dom­i­nant themes were poor/ in­com­plete plan­ning by pi­lots

who should have been able to avoid the re­sult­ing sit­u­a­tion by ap­ply­ing more thought to their route­ing or ac­tions (eleven in­ci­dents); poor/in­com­plete sit­u­a­tional aware­ness (also eleven), prob­a­bly re­sult­ing from the for­mer lack of plan­ning in some cases; nine in­volv­ing late- or non-sight­ings; pi­lots not fully fol­low­ing pro­ce­dures in six in­ci­dents; in four events there was poor in­te­gra­tion by pi­lots and/or con­trollers; and three where pi­lots could have asked for a bet­ter Air Traf­fic /Ser­vice (i.e. a Traf­fic Ser­vice) in busy airspace.’

The Board made three Ga-re­lated rec­om­men­da­tions dur­ing the meet­ing: ‘1: Lee-onSo­lent to in­clude in­for­ma­tion in their AIP en­try to high­light the pos­si­bil­ity of glider traf­fic cross­ing the cen­tre­line and the ex­is­tence of a glider land­ing strip on the north-western side of the main run­way as a re­sult of a glider cross­ing in front of a DA40 on fi­nals; 2: The Avon Hang Glid­ing & Paraglid­ing Club and SPTA Ops to re­fresh their LOA to cover us­age of the Brat­ton launch site and how that in­for­ma­tion is con­veyed af­ter a [Royal Navy BAE] Hawk pi­lot flew through a num­ber of paraglid­ers that he didn’t know were there’ (the re­port of this in­ci­dent fea­tured in the na­tional press−ed); and 3: HQ Air Com­mand re­view the ra­dio pro­ce­dures for CGS op­er­a­tions from Sy­er­ston af­ter a tug/ glider com­bi­na­tion climb­ing to 6,000ft en­coun­tered a Piper Tom­a­hawk or­bit­ing at 3,000ft that was talk­ing to East Mid­lands.’

Un­der the head­ing ‘It’s good to talk… and it can help if you’re on the same wave­length’ the Board asks, ‘How do you select the right Air Traf­fic Ser­vice in busy airspace?’ re­fer­ring to an in­ci­dent in which a Chip­munk and Cessna 172 on dif­fer­ent fre­quen­cies came very close to each other near Lu­ton.

The Chip­munk’s pi­lot was in a straight-and-level cruise and look­ing at a ground fea­ture to his left. Af­ter about fif­teen sec­onds he looked ahead and saw the Cessna 172 fly­ing slightly lower in the op­po­site di­rec­tion. He made a hard pull-up and the C172 passed be­low with­out ap­pear­ing to take any avoid­ing ac­tion. The pi­lot as­sessed the risk of col­li­sion as “high” and said he had not been closer to an­other air­craft, apart from in for­ma­tion, in forty years of pro­fes­sional fly­ing.

The in­struc­tor aboard the C172 be­ing flown by a stu­dent said that their air­craft was in a straight-and-level cruise when he no­ticed an ap­proach­ing air­craft at 1 o’clock. He could see that it was go­ing to pass to the right and above and that there was no risk of col­li­sion, but he was not com­fort­able with its prox­im­ity so he took con­trol, low­ered the nose, re­duced alti­tude by 200ft and turned slightly left. As the other air­craft passed by he no­ticed that its pi­lot turned to his left. He pointed out the air­craft to his stu­dent and they later dis­cussed the im­por­tance of the con­stant ‘Look­out, At­ti­tude, In­stru­ments’ work­flow. The in­struc­tor said that at the time of the ma­noeu­vre the other air­craft was far enough away that he could not ob­serve any de­tail, such as colour, type or reg­is­tra­tion, but could only see a dark­ish, sin­gle-en­gine, low-wing air­craft. Be­cause it was at a dis­tance, the ver­ti­cal sep­a­ra­tion was in­creased and there was no risk of col­li­sion, he did not deem it to be a re­portable Air­prox, so didn’t re­port it to Farn­bor­ough North.

‘In fact,’ says the Board, ‘we de­ter­mined that the C172 had not seen the Chip­munk but a dif­fer­ent air­craft fur­ther away just prior to (this) in­ci­dent. The C172 was un­der only a Ba­sic Ser­vice with Farn­bor­ough LARS, while the Chip­munk was on Lu­ton’s Lis­ten­ing Squawk fre­quency. If they had been on the same fre­quency there was a chance they might have been aware of each other and, even bet­ter, if they had used a Traf­fic Ser­vice they would have re­ceived spe­cific in­for­ma­tion.

‘This raises the old co­nun­drum of whether Farn­bor­ough LARS could have given a ser­vice if they were busy, the very time that you re­ally want one. The C172 pi­lot may not have asked for a Traf­fic Ser­vice be­cause he was in­struct­ing, or might have thought that he wouldn’t be likely to get a ser­vice – but if you don’t ask, you def­i­nitely won’t.

‘The Chip­munk pi­lot’s de­ci­sion to “lis­ten out” with Lu­ton meant there was lit­tle pos­si­bil­ity of him ob­tain­ing Traf­fic In­for­ma­tion while do­ing so be­cause it’s only in­tended as a means of warn­ing about nearby airspace that he might be about to in­fringe, not about other air­craft he might be in con­flict with.

‘The Board ac­knowl­edges there were many fac­tors in man­ag­ing each sor­tie, and there was a bal­ance to be made be­tween us­ing Fre­quency Mon­i­tor­ing Codes and LARS. Nev­er­the­less, in con­di­tions of less than ideal vis­i­bil­ity, or for sor­ties in­volv­ing a high work­load or ac­tiv­i­ties which might de­tract from an ef­fec­tive look­out (such as an air test or aer­o­bat­ics), it is well worth re­quest­ing a Traf­fic Ser­vice if pos­si­ble.’ air­prox­board.org.uk

A timely go-around might have given space for weather con­sid­er­a­tion

Low hours, near MTOW and gusts took a toll

Air­prox: us­ing dif­fer­ent fre­quen­cies

Newspapers in English

Newspapers from UK

© PressReader. All rights reserved.