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 - Com­piled by Mike Jer­ram

Mustang midair, un­der­car­riage over­looked and other safety news

Mustang midair

Air­craft Type: (Both) NA P-51D Mus­tangs G-SHWN and G-BIXL Date & Time: 23 Septem­ber 2017 at 1530 Com­man­ders’ Fly­ing Ex­pe­ri­ence: 1 ATPL, 18,000 hours, 600 on type 2 ATPL, 19,000 hours, 87 on type Last 90 days: 1 9 hours 2 119 hours Last 28 days: 1 5 hours 2 37 hours

The two air­craft were part of a for­ma­tion fly­past at a Dux­ford air­show that included a B-17 Fortress that had al­ready com­pleted a fly­past with a Dou­glas DC-3 and C-47. For the next se­quence the Mus­tangs were to join the Fortress for an­other fly­past, then sep­a­rate from the bomber and give a dis­play of for­ma­tion aer­o­bat­ics. G-SHWN was to lead, with G-BIXL fol­low­ing.

The P-51D pi­lots had ar­rived at Dux­ford the day be­fore the air­show and that evening dis­cussed the for­ma­tion aer­o­bat­ics they planned to fly. It was the same se­quence they had flown to­gether at an­other show three weeks ear­lier, when the pi­lot of G-SHWN had led the dis­play, as he was to do on this oc­ca­sion. Next morn­ing they both at­tended the main pi­lots’ air­show brief­ing at Dux­ford, af­ter which the pi­lots of the C-47, B-17 and P-51DS were given an ad­di­tional for­ma­tion brief­ing by the DC-3’S pi­lot, who was to be the leader of their part of the dis­play. In ad­di­tion to the ver­bal brief­ing, he gave the pi­lots a writ­ten brief­ing.

When dis­cussing how the P-51DS would join the B-17, the lead Mustang’s pi­lot stated that, af­ter tak­ing off sep­a­rately from the other air­craft, they would ini­tially prac­tice some for­ma­tion aer­o­bat­ics away from the air­field, with the sec­ond P-51D on the right. Af­ter the DC-3 and C-47 had com­pleted their fly­past with the B-17, the Mus­tangs would join the B-17, G-SHWN would join on its right with G-BIXL on its left. The Mustang pi­lots then dis­cussed what they would do dur­ing the for­ma­tion aer­o­bat­ics. At this time, G-BIXL’S pi­lot’s fo­cus was on this part of the dis­play, as he re­garded the for­ma­tion fly­past as “bread and but­ter fly­ing”, hav­ing flown many of these be­fore, in and with var­i­ous types of air­craft.

About thirty min­utes be­fore take­off, the Mustang pi­lots met at their air­craft and dis­cussed the dis­play again. The fo­cus was again on the for­ma­tion aer­o­bat­ics, which they walked through to­gether. While the pi­lot of G-BIXL waited in the cock­pit to start, he went through the for­ma­tion se­quences in his head with his eyes closed, but did not go through the join with the B-17. Af­ter take­off, and hav­ing com­pleted the prac­tice aer­o­bat­ics with G-BIXL on his right, the pi­lot of G-SHWN be­came vis­ual with the B-17, which was fly­ing at about 500ft agl, so the Mus­tangs flew to­wards it to com­mence the join.

B-17 started a right turn back to­wards the air­field, and the P-51s passed be­low and through its 6 o’clock in a left turn, be­fore re­vers­ing the turn. Once in the right turn, G-BIXL’S pi­lot flew through the B-17’s 6 o’clock to join on its right. As he did, he looked at G-SHWN, from which he was mov­ing away, and be­lieved it was go­ing to join on the B-17’s left. Think­ing that both P-51s were now on their nom­i­nated sides of the B-17, he looked in­side the cock­pit to check his in­stru­ments. At this point he be­lieved that the airspace to the B-17’s right was only for his air­craft and he was thus clear to fly into po­si­tion for the fly­past. He briefly looked in his nine o’clock and saw noth­ing, but was not con­cerned that he could not see G-SHWN, as they were both at low level and it may not have been eas­ily vis­i­ble against the ground due to its cam­ou­flaged paint scheme. He also be­lieved the pi­lot would have been do­ing the same as him, fly­ing low and fast be­fore climb­ing into po­si­tion with the B-17.

G-BIXL’S pi­lot’s next rec­ol­lec­tion was that the air­craft nosed down slightly and started to shake moder­ately. He checked the en­gine in­stru­ments, which were in­di­cat­ing nor­mally, and be­lieved some­thing had de­tached from his air­craft. As the shak­ing in­creased, he turned to­wards Dux­ford, trans­mit­ted a May­day and made an un­event­ful land­ing on grass Rwy 06L.

The pi­lot of G-SHWN said that as the B-17 was in its right turn, the P-51s passed through its six o’clock in a left turn and be­low, be­fore re­vers­ing the turn. Just be­fore the right turn re­ver­sal he looked over his right shoul­der and saw G-BIXL, but this did not con­cern him as they had briefed to do a loose for­ma­tion join. G-BIXL next ap­peared de­scend­ing from above right, and its tailplane passed through his pro­pel­ler arc as he was about to move up and into po­si­tion on the B-17. He did not see G-BIXL prior to this, as he was pre­dom­i­nately con­cen­trat­ing on the B-17 that was then in his eleven o’clock. He felt a very slight knock which made him re­alise they had col­lided. Hav­ing heard G-BIXL’S pi­lot’s May­day, he fol­lowed the B-17, and once the other Mustang had landed safely, sep­a­rated from the Fortress and landed on hard Rwy 24.

Ex­am­i­na­tion con­firmed that dam­age on both air­craft had come from con­tact be­tween the pro­pel­ler blades of G-SHWN and the left hor­i­zon­tal sta­biliser of G-BIXL. The pro­pel­ler strike had been within a few cen­time­tres of the con­trol ca­bles for the el­e­va­tor trim sys­tem, but re­sulted in struc­tural dam­age only. G-SHWN’S four pro­pel­ler blades all ex­hib­ited scuff­ing to the paint, but no vis­i­ble struc­tural dam­age.

G-BIXL’S pi­lot later stated that when he draws a di­a­gram of a for­ma­tion dis­play he usu­ally an­no­tates an air­craft sym­bol with ‘ME’ to in­di­cate which air­craft is his in the for­ma­tion. On this oc­ca­sion he an­no­tated ‘P-51’ against both sym­bols rep­re­sent­ing the Mus­tangs, and was “fairly sure” that had he dif­fer­en­ti­ated be­tween the two sym­bols he would not have joined the B-17 on the right. He would

en­sure that he al­ways does so in fu­ture.

Also, he said, that had all the pi­lots walked through the dis­play on the ground, as is gen­er­ally the norm, and had he flown the whole dis­play through in his mind dur­ing his pre­flight prepa­ra­tion, he was al­most cer­tain his mis­un­der­stand­ing would have been no­ticed and cor­rected be­fore take­off. The two Mustang pi­lots had only walked through the for­ma­tion aer­o­bat­ics as the join and fly­past with the B-17 was con­sid­ered a “stan­dard piece of fly­ing” that they had flown re­cently, al­beit with a dif­fer­ent lead air­craft. He be­lieved he was likely to have suf­fered from ‘risky shift’ as a re­sult of hav­ing done sim­i­lar joins “hun­dreds of times”. (‘ Risky shift’ is a ten­dency for in­di­vid­u­als to make more dar­ing de­ci­sions when they are in groups, than when they are alone – Ed.) He stated that in fu­ture he would keep the lead air­craft vis­ual un­til it was es­tab­lished in for­ma­tion with the fly­past’s lead air­craft be­fore mov­ing to his briefed side. Had he be­lieved G-SHWN was on the in­cor­rect side he would have sought clar­ity over the R/T.

The AAIB re­port con­cludes: ‘The P-51 pi­lots had flown many for­ma­tion fly­pasts to­gether be­fore, in dif­fer­ent types of air­craft. They had also prac­tised the for­ma­tion aer­o­bat­ics part of the dis­play three weeks prior to the ac­ci­dent. The pi­lot of G-BIXL agreed and ac­knowl­edged at the brief­ing that [he] would for­mate on the left side of the B-17. How­ever, hav­ing planned and prac­tised the for­ma­tion aer­o­bat­ics in ech­e­lon right he may have had some con­fir­ma­tion bias to sup­port his be­lief that be­ing on the right of the B-17 for the fly­past was cor­rect.

‘The two P-51s col­lided due to a com­bi­na­tion of hu­man fac­tors. The pi­lot of G-BIXL did not an­no­tate his di­a­gram of the dis­play se­quence to show which was his air­craft. This re­moved one of the pos­si­ble means of con­firm­ing which side he had been briefed to join the B-17. There ap­pear to have been omis­sions, pos­si­bly re­sult­ing from a de­gree of com­pla­cency, dur­ing the brief­ings and sub­se­quent walk through, where the join and fly­past with the B-17 were not con­sid­ered. Best prac­tice would have been for the pi­lot of G-BIXL to have re­mained vis­ual with G-SHWN un­til it was in the final for­ma­tion po­si­tion. It was only prov­i­dence that pre­vented this ac­ci­dent from re­sult­ing in a cat­a­strophic out­come.’

As a re­sult of this ac­ci­dent the CAA has made the fol­low­ing ad­di­tion to Ap­pen­dix C of Edition 15 of CAP 403 Fly­ing Dis­plays and Spe­cial Events: Safety and Ad­min­is­tra­tive Re­quire­ments and Guid­ance that was pub­lished in March 2018: ‘Use­ful guid­ance for dis­play pi­lots – Brief­ings and walk throughs. It is es­sen­tial that in ad­di­tion to the Fly­ing Dis­play Di­rec­tor’s writ­ten and ver­bal brief­ings that all dis­play items con­sist­ing of for­ma­tions are thor­oughly briefed. It is vi­tal that ev­ery mem­ber of the for­ma­tion has a clear pic­ture of the ob­jec­tives of the for­ma­tion as a whole and of their in­di­vid­ual po­si­tion­ing and re­spon­si­bil­i­ties within it. Walk throughs are an in­te­gral part of this brief­ing process and it is strongly rec­om­mended that they are adopted as a stan­dard part of all for­ma­tion brief­ings [AAIB’S em­pha­sis]. Walk throughs are not ex­clu­sive to for­ma­tion briefs and can also be of ben­e­fit to the solo dis­play pi­lot.’

Fallen Star

Air­craft Type: Di­a­mond DA 42M Twin Star Date & Time: 6 April 2018 at 0743 Com­man­der’s Fly­ing Ex­pe­ri­ence: CPL, 9,000 hours, 4,000 on type Last 90 days: 100 hours Last 28 days: 27 hours As part of a dual flight in prepa­ra­tion for a mul­ti­engine class rat­ing test the stu­dent pi­lot re­joined the Bournemout­h cir­cuit and made an ap­proach with flaps con­fig­ured nor­mally. He had dif­fi­culty main­tain­ing the run­way cen­tre­line and cor­rect

speed, due to what he de­scribed as “chal­leng­ing” conditions in tur­bu­lence and an es­ti­mated 14kt cross­wind, but a sat­is­fac­tory touch-and-go land­ing was made and the air­craft repo­si­tioned down­wind for flap­less land­ing.

While down­wind, the stu­dent com­pleted the preland­ing check­list, which in­cludes con­fir­ma­tion that the park­ing brake is se­lected ‘Off’. He then com­menced the ‘Final De­scent’ check­list and be­lieves he said “gear down” be­fore re­duc­ing power and start­ing to turn onto base leg. How­ever, the in­struc­tor re­called that the stu­dent placed one hand on the un­der­car­riage con­trol lever and was about to turn onto the base leg, when it be­came ap­par­ent that nei­ther of them could see a pre­ced­ing air­craft. Be­cause of this the in­struc­tor asked the stu­dent to con­tinue down­wind but, af­ter a short time, they spot­ted the air­craft ahead and as they turned onto base leg, the in­struc­tor no­ticed that the park­ing brake was on and pointed this out, but the stu­dent said that he thought the park­ing brake lever was off. They then dis­cussed the fact that the aft po­si­tions of the two ad­ja­cent heat­ing con­trols are la­belled ‘Off’, whereas the park­ing brake lever func­tions in the op­po­site sense – its aft po­si­tion is la­belled ‘Lock’ and the check­lists re­fer to this as ‘On’. Con­se­quently, the stu­dent re­leased the park­ing brake, but the in­struc­tor re­mained dis­tracted for sev­eral sec­onds, con­tem­plat­ing why the park­ing brake lever had been er­ro­neously set.

The air­craft was es­tab­lished on short final, but off­set from the cen­tre­line, be­fore the in­struc­tor switched his at­ten­tion away from the is­sue of the lever po­si­tions. He con­sid­ered in­sti­gat­ing a go-around but de­cided to coach the stu­dent back to­wards the cen­tre­line. While he did this, the stu­dent made large power changes, try­ing to con­trol the air­speed, which was in­creas­ing. Fully oc­cu­pied mon­i­tor­ing the stu­dent’s ac­tions, the in­struc­tor over­looked a re­quired check that the air­craft was sta­ble and in a land­ing con­fig­u­ra­tion at 100ft aal. As they passed over the run­way thresh­old the stu­dent grad­u­ally re­duced power and the air­craft made a gen­tle touch­down on the run­way, and it then be­came ap­par­ent that the un­der­car­riage was up and that the pro­pel­lers were strik­ing the sur­face as the air­craft slid to a halt. It had suf­fered dam­age to its pro­pel­lers, en­gine gear­boxes, lower en­gine cowl­ings and un­der­side pan­els.

Fol­low­ing the ac­ci­dent, the in­struc­tor stated that both he and the stu­dent over­looked check­ing the un­der­car­riage in­di­ca­tions for three rea­sons: they were dis­tracted by look­ing for the traf­fic ahead in the cir­cuit, there was some con­fu­sion due to the mis-se­lec­tion of the park­ing brake, and they con­tin­ued an un­sta­ble ap­proach. The stu­dent re­flected that he might have been dis­tracted, ei­ther by the other traf­fic or by the park­ing brake po­si­tion, and that it is pos­si­ble he did not move the un­der­car­riage lever. Ear­lier in the flight, and on pre­vi­ous flights, he had been asked to re­spond to sim­u­lated emer­gen­cies us­ing ‘touch drills’ only – touch­ing the rel­e­vant levers or switches but not ac­ti­vat­ing them – and it was pos­si­ble, be­cause of his high work­load, that he in­ad­ver­tently touched the land­ing gear lever but did not move it.

The air­craft op­er­a­tor stip­u­lates an ‘Ap­proach Gate’ at 400ft aal when on a vis­ual ap­proach and, at this point, the stu­dent should have called “400 sta­ble” or “400 not sta­ble, go-around”. One of the pa­ram­e­ters which has to be checked be­fore call­ing “400 sta­ble” is that the un­der­car­riage is down, with three green indicators lit. Nei­ther crewmem­ber re­called this be­ing said and the stu­dent sus­pected that he ei­ther for­got it, be­cause he was work­ing hard to man­age the ap­proach, or that he made it with­out ac­tu­ally look­ing at the po­si­tion of the un­der­car­riage lever.

The air­craft op­er­a­tor’s ini­tial re­port sug­gested that the park­ing brake may have been se­lected ‘On’ in­stead of the un­der­car­riage lever be­ing set to ‘Down’. When this was no­ticed, it led to dis­trac­tion and some con­fu­sion, partly due to the dif­fer­ent di­rec­tions in which the park­ing brake lever and the ad­ja­cent heat­ing con­trols operate. This dis­trac­tion pre­vented the in­struc­tor from ef­fec­tively mon­i­tor­ing the stu­dent, who was work­ing at high ca­pac­ity dur­ing the ap­proach. The op­er­a­tor plans to re­view the op­er­at­ing pa­ram­e­ters and the ad­e­quacy of the au­ral warn­ing sys­tem, and to con­sider in­cor­po­rat­ing the la­belled po­si­tions for the park­ing brake lever in the air­craft check­lists. It also rec­om­mends that crews be re­minded of the ne­ces­sity for car­ry­ing out en­tire check­lists cor­rectly and with­out in­ter­rup­tion, of the prime im­por­tance of mon­i­tor­ing stu­dents’ ac­tions, es­pe­cially at crucial stages of flight and that a go-around is of­ten the best and safest course of ac­tion if an ap­proach be­comes un­sta­ble or is rushed.

He­li­copter Safety Sem­i­nar

The CAA and Bri­tish He­li­copter As­so­ci­a­tion are hold­ing a He­li­copter Safety Sem­i­nar at Avi­a­tion House, Gatwick Air­port on 6 Septem­ber. It will run from 1000-1600, with a light lunch pro­vided. The sem­i­nar will in­clude a brief­ing on the Safety Re­view of On­shore CAT (in­clud­ing emer­gency ser­vices), NCC and SPO op­er­a­tions which the CAA has im­ple­mented. ‘Ap­pli­ca­tions to at­tend are wel­come from all work ar­eas of the op­er­a­tions listed and early book­ing is ad­vised as we an­tic­i­pate that this will be a well subscribed event,’ ad­vises the Author­ity. Ap­pli­ca­tions should be made to: ali­[email protected]

Low-res im­age of the DA42M af­ter its wheels-up land­ing. The air­craft op­er­a­tor plans to re­view op­er­at­ing pro­ce­dures and check­lists

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