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

Con­firm who's in charge; and op­er­ate un­der SOP to avoid ap­pear­ing here

Su­pe­rior? Not in the cock­pit!

Air­craft Type: Piper Tom­a­hawk Date & Time: 12 May 2018 at 1215 Com­man­der’s Fly­ing Ex­pe­ri­ence: PPL, 199 hours, 57 on type Last 90 days: 15 hours Last 28 days: 8 hours

The pi­lot in the right seat of the Tom­a­hawk was not a fly­ing in­struc­tor. In the left seat was a se­nior work col­league who, while a stu­dent pi­lot, was not qual­i­fied to fly without su­per­vi­sion from an FI. Although he had re­ceived no in­struc­tion on the air­craft type it was he who made the take­off from Black­pool and flew it to Caernar­fon, with his PIC col­league mon­i­tor­ing his ac­tions and mak­ing the R/T calls.

Fol­low­ing an over­head join for Run­way 25 at Caernar­fon, the un­qual­i­fied pi­lot flew the cir­cuit, but when es­tab­lished on fi­nal ap­proach the PIC sug­gested that they were too high. The un­qual­i­fied pi­lot ac­knowl­edged, but did not sub­se­quently es­tab­lish the cor­rect ap­proach path, so shortly be­fore touch­down his col­league in­ter­vened, selected idle power and ‘fol­lowed through’ on the con­trols. He then took con­trol and ap­plied full power to go around, but did not move the flap lever from the land­ing po­si­tion. Air­field CCTV im­agery showed that the air­craft’s main­wheels made ground con­tact about one-third of the way along the run­way, then it bounced, veered left of cen­tre­line, bounced twice again, and flew over the left edge of the run­way in a nose-up, left wing-low at­ti­tude.

Re­al­is­ing that they were not gain­ing al­ti­tude and see­ing a han­gar ahead, the PIC turned the Tom­a­hawk away from the han­gar be­fore the air­craft de­scended. CCTV im­agery showed that it turned left as it de­parted the run­way and climbed to about 20ft be­fore adopt­ing a wings-level, nose-up at­ti­tude, over­fly­ing a par­al­lel taxi­way and de­scend­ing to­wards the ground, af­ter which it was hid­den from the cam­era’s view. Af­ter pass­ing through the air­field fence it crossed a pub­lic road, hit an­other fence, turned over and stopped abruptly, point­ing back to­wards the air­field.

The un­qual­i­fied pi­lot saw fuel leak­ing from the left wing and it took him twenty sec­onds to undo his seat belt and es­cape. The PIC made en­gine and elec­tric con­trols safe but was un­able to undo his seat­belt, so his com­pan­ion re­turned to as­sist him. Both had suf­fered mi­nor in­juries, but were quickly treated by paramedics from the lo­cal air am­bu­lance unit.

In hind­sight, the right-seat PIC re­alised that his de­ci­sion to al­low his com­pan­ion to fly the air­craft was prob­a­bly sub­con­sciously in­flu­enced by the fact that he was a se­nior work col­league. He was aware that he was not a qual­i­fied pi­lot, so should not have han­dled the con­trols without be­ing su­per­vised by a fly­ing in­struc­tor. Other safety lessons high­lighted by the ac­ci­dent were that a go-around should be ini­ti­ated if it looks un­likely that touch­down will be made in the first third of a run­way, and the vi­tal need to make an ap­pro­pri­ate flap se­lec­tion when go­ing around. The PIC noted that, although he was in the habit of mov­ing the flap lever dur­ing touch-and-go land­ings, his ac­tions on this oc­ca­sion were af­fected by be­ing in an un­ex­pected and stress­ful sit­u­a­tion and thus, be­cause full flap was still set, he sub­se­quently lost con­trol of the air­craft.

A clash of Ravens

Air­craft Type: (Both) Robin­son R44 Raven Date & Time: 5 May 2018 1125 Com­man­ders’ Fly­ing Ex­pe­ri­ence, 1: CPL, 913 hours, 226 on type Last 90 days: 54 hours Last 28 days: 21 hours Ex­pe­ri­ence, 2: CPL, 6,846 hours, 1,705 on type Last 90 days: 62 hours Last 28 days: 13 hours

One Robin­son R44 (’FL) had its ro­tors turn­ing, prior to de­part­ing Cumbernaul­d for a trial les­son flight when an­other R44 (’ND) re­turned from a sight­see­ing flight. Be­cause both he­li­pads at the eastern end of the air­port were oc­cu­pied, the pi­lot of the ar­riv­ing he­li­copter landed on a grass area be­hind ’FL and trans­mit­ted “se­cure on the ground com­plete”.

Parked on the north­ern of the two he­li­pads was a Robin­son R22 that had re­cently flown. Shortly af­ter the sight­see­ing R44 ’ND had landed, the R22’s oc­cu­pants walked in front of ’FL to­wards the he­li­copter op­er­a­tor’s build­ings. The pi­lot of ’FL then ob­tained the lat­est air­field in­for­ma­tion and, a minute af­ter the last trans­mis­sion from the ar­riv­ing R44 ’ND, ra­dioed “Lift­ing from the eastern he­li­pad to Al­pha”. ’FL’S pi­lot’s view was re­stricted for­wards and right of the parked R22 and by a sta­tion­ary Cessna that was in front of him, fac­ing away with its pro­pel­ler turn­ing. There was a sec­ond light air­craft parked left of the Cessna and he did not wish to dis­turb these with his he­li­copter’s down­wash. He knew that, when he had boarded his he­li­copter, the area to the rear was clear, and he had no rec­ol­lec­tion of hear­ing any ra­dio trans­mis­sions from the ar­riv­ing R44, so was not aware of its po­si­tion and not ex­pect­ing an­other he­li­copter to be parked there. Af­ter lift­ing to the hover he de­cided to move rear­wards and then taxi be­hind the parked R22. He did not turn his R44 to check that the area to his rear was clear be­fore re­vers­ing be­cause of the prox­im­ity of the R22, and be­cause he did not want to turn his he­li­copter’s tail left to­wards the build­ings, where some spec­ta­tors had gath­ered. CCTV record­ings showed that the R44 lifted be­fore mov­ing slowly rear­wards and slightly right, with its skids about six feet above the

ground. The ro­tor blades of the just-ar­rived R44 were still turn­ing slowly and one of them struck the en­gine hous­ing of the hov­er­ing he­li­copter on the left side below its tail­boom.

The de­part­ing R44’s pi­lot heard a bang and his he­li­copter pitched nose-up and right, so he made a for­ward cyclic con­trol in­put to re­turn to­wards the he­li­pad and low­ered the col­lec­tive lever. He then re­alised that the he­li­copter was pitch­ing nose-down so he moved the cyclic stick aft, the tail struck the ground and the R44 bounced for­ward off its skids to­wards the parked R22. De­spite the R44’s pi­lot quickly mak­ing a left cyclic stick in­put its ro­tor blades struck the ground and it vi­brated vi­o­lently be­fore land­ing heav­ily in a noseup at­ti­tude near the R22, with its tail rest­ing on the ground. The he­li­copter op­er­a­tor’s staff helped the un­in­jured oc­cu­pants to es­cape.

The pi­lot of ’ND had turned off his ra­dio and re­moved his head­set while the ro­tor blades slowed. Af­ter writ­ing post-flight notes he looked up and saw the de­part­ing he­li­copter mov­ing to­wards him. He tried to turn his ra­dio on and re­place his head­set so that he could warn the other pi­lot, but be­fore he could do so the blade strike oc­curred. His three pas­sen­gers were un­in­jured and when the ro­tor blades stopped turn­ing they all dis­em­barked nor­mally.

CCTV record­ings of the col­li­sion showed that the de­part­ing R44 pitched rapidly to ap­prox­i­mately 45º nose­down, but ini­tially main­tained its height above the ground while mov­ing away from the other and to­wards the he­li­pad. As it ap­proached the pad it de­scended and the nose pitched up, its tail struck the grass and the rear of both skids hit the con­crete, caus­ing it to bounce about two feet from the ground into a nose-down at­ti­tude, while the tail turned anti-clock­wise to­wards the parked R22. It then struck the ground heav­ily, ori­en­tated at 90º to the pad, with the left skid hit­ting first and the he­li­copter then rolling onto its right skid and pitch­ing nose-up un­til its tail struck the ground. The R44 now bounced a sec­ond time, its tail turned quickly clock­wise and it rolled left un­til the main ro­tor blades struck the con­crete pad and it fi­nally hit the ground be­tween the two land­ing pads with its tail on the grass close to the R22. Its ro­tor blades stopped turn­ing 33 sec­onds later.

Cumbernaul­d Air­port’s op­er­a­tor had agreed that the he­li­copter op­er­a­tor would pro­vide its own Res­cue & Fire­Fight­ing Ser­vice (RFFS) for all as­so­ci­ated he­li­copter op­er­a­tions and the op­er­a­tor’s own RFFS ve­hi­cle was avail­able, parked out­side the han­gar a few me­tres from the ac­ci­dent site. But the only trained RFFS per­son­nel avail­able were the pi­lots from the R22 and the just-ar­rived R44. An­other em­ployee who was the first to reach the ac­ci­dent site saw no ev­i­dence of leak­ing fuel when he helped the pas­sen­gers to es­cape, and when the R22’s pi­lot reached the scene he con­cluded that there was no fire risk, so the RFFS ve­hi­cle was not de­ployed. The air­port’s A/G ra­dio op­er­a­tor, who had ac­ti­vated the crash alarm, was also trained for RFFS du­ties. Not see­ing the he­li­copter op­er­a­tor’s RFFS ve­hi­cle de­ploy he passed his ra­dio task to some­body else and drove the air­port’s own RFFS ve­hi­cle to the ac­ci­dent site. He ar­rived within two min­utes of the ac­ci­dent, and found the R44’s oc­cu­pants un­in­jured and that its op­er­a­tor did not be­lieve there was a fire risk, so lo­cal emer­gency ser­vices were not alerted.

The he­li­copter’s op­er­a­tor con­ducted an in­ter­nal in­ves­ti­ga­tion which con­cluded that the ac­ci­dent could have been avoided if the pi­lot of the de­part­ing R44 had turned its tail and made a ‘look­out turn’ to visu­ally check the area be­hind, which it con­sid­ers to be a stan­dard pro­ce­dure. The R44’s pi­lot said that he had felt con­strained from mov­ing the tail of his he­li­copter by the pres­ence of spec­ta­tors, but CCTV record­ings showed no­body on the road­way or grass area im­me­di­ately to the left of the R44, and its op­er­a­tor be­lieves that its tail could have been moved left, leav­ing a five-me­tre safety mar­gin from any peo­ple or ob­struc­tions. As a re­sult of the ac­ci­dent, the he­li­copter op­er­a­tor has taken the fol­low­ing safety ac­tions:

The north­ern he­li­pad has been ex­tended east­wards by 12m, so a parked he­li­copter is fur­ther from the apron, leav­ing space for other he­li­copters to move be­tween a parked he­li­copter and the apron

The pre­pared grass area east of the he­li­pads has been ex­tended, to en­sure that he­li­copters parked there can re­main well clear of the pads

A mir­ror has been placed at the corner of the han­gar, to

as­sist pi­lots us­ing ei­ther he­li­pad see any ac­tiv­ity to their rear

The he­li­copter op­er­a­tor no longer per­mits he­li­copters to re­verse from the he­li­pads

The he­li­copter op­er­a­tor’s safety team is due to re­view the pro­ce­dure for turn­ing off avion­ics while an R44 is be­ing shut down

Changes have been made to RFFS pro­ce­dures to re­quire two ap­pro­pri­ately-trained em­ploy­ees to be avail­able on the ground at all times of he­li­copter ac­tiv­ity, and that fire­fight­ing equipped can read­ily be ac­cessed by them.

The AAIB com­mented: ‘The col­li­sion be­tween the two he­li­copters oc­curred be­cause the pi­lot (of ’FL) was not aware of (’ND’S) po­si­tion. How­ever, the dam­age to (the for­mer) did not ap­pear to im­me­di­ately af­fect the op­er­a­tion of its en­gine or fly­ing con­trols. [Its pi­lot] stated that he re­called his he­li­copter pitch­ing nose-up and he made a for­ward cyclic in­put in re­sponse, but CCTV showed that af­ter hit­ting [’ND] his he­li­copter pitched nose­down. An ex­ces­sive nose-down at­ti­tude en­sued, close to the ground, be­fore re­cov­ery ac­tion ap­pears to have been ini­ti­ated and the nose be­gan to pitch up. How­ever, the he­li­copter was now de­scend­ing to­wards the he­li­pad and, as the nose pitched up, the tail struck the ground and ini­ti­ated the im­pact se­quence. It is likely that the pi­lot was star­tled by the un­ex­pected col­li­sion with the other he­li­copter. The “star­tle ef­fect” is likely to have im­paired his abil­ity to com­pre­hend the sit­u­a­tion and also his psy­chomo­tor skills, lead­ing to his loss of con­trol.’

Air­proxes… and how to avoid them

the Board. ‘On the one hand the PA-28 pi­lot was re­quired to con­form with the traf­fic al­ready in the vis­ual cir­cuit, one of which was the Chero­kee Six, but on the other hand the Chero­kee Six’s pi­lot was re­quired to give way to traf­fic ‘in the fi­nal stages of an ap­proach to land’, which in­cluded the PA-28 head­ing straight-in.’

The Board agreed that, rou­tinely, those join­ing straightin should only do so if they can in­te­grate ef­fec­tively with those al­ready in the vis­ual cir­cuit, and cau­tions pi­lots about as­sum­ing pri­or­ity sim­ply be­cause they have called a straight-in ap­proach. ‘Equally, if in the cir­cuit and an­other pi­lot does join straight-in then it may be that they’ve done so for good rea­son, so dis­cre­tion may be the bet­ter part of val­our−give them room and, if nec­es­sary, go around early and talk about it later over tea!’

Dur­ing its Septem­ber meet­ing the Board as­sessed 31 in­ci­dents: 18 air­craft-to-air­craft, with six hav­ing a def­i­nite risk of col­li­sion (two Cat­e­gory A, four Cat­e­gory B). ‘The num­ber of air­craft-toair­craft re­ports so far this year sits just above the ex­pected five-year cu­mu­la­tive av­er­age at 146 but, at 112 in­ci­dents, drone/suas re­ports have now al­ready reached 2017’s lev­els with just over a quar­ter of the year still to go,’ the Board notes. ‘This month’s in­ci­dents were mostly Ga-bi­ased, re­flect­ing the fact that we are now pro­cess­ing Air­prox from the sum­mer months when GA fly­ing in­creases. The two dom­i­nant themes were sub-op­ti­mal plan­ning and in­te­gra­tion with other air­craft (nine), and seven oc­cur­rences of late- or non-sight­ings.

‘For the for­mer, poor vis­ual cir­cuit plan­ning and ex­e­cu­tion pre­dom­i­nated, with pi­lots ei­ther not think­ing ahead, not prop­erly plan­ning their in­te­gra­tion, or not fol­low­ing cir­cuit pro­ce­dures. For the lat­ter, an in­crease in late- and non-sight­ings is typ­i­cal in the sum­mer months as airs­pace be­comes busier and em­pha­sises the need for pi­lots to pri­ori­tise a ro­bust and ef­fec­tive look­out over in-cock­pit tasks (the 80:20 rule−with eighty per cent of the time look­ing out of the cock­pit).

‘There were three in­ci­dents where in­ac­tion re­sulted in air­craft need­lessly com­ing close to each other. One was a fail­ure to give way, while in the other two, pi­lots as­sumed the other had seen them and would give way, which, given the eye’s per­for­mance lim­i­ta­tions, is an in­ap­pro­pri­ate as­sump­tion. ATS non-avail­abil­ity or sub-op­ti­mal ap­pli­ca­tion also fea­tured in three other in­ci­dents, with con­troller work­load be­ing cited as con­trib­u­tory in two.’

The UKAB’S lat­est 2018 per­for­mance graphs re­veal­ing the weak­est and strong­est safety bar­ri­ers to Air­prox cite 69 in­ci­dents from which, it says, ‘some in­ter­est­ing per­spec­tives can be drawn’:

See-and-avoid was ei­ther in­ef­fec­tive or only par­tially ef­fec­tive in 54% of in­ci­dents

Col­li­sion warn­ing sys­tems were ei­ther ab­sent or in­ef­fec­tive (mostly due to in­com­pat­i­bil­ity) in 66% of in­ci­dents

Pi­lot sit­u­a­tional aware­ness and sub­se­quent ac­tion re­gard­ing the other air­craft was ei­ther in­ef­fec­tive or only par­tially ef­fec­tive in 75% of in­ci­dents

When present and used, ATC sit­u­a­tional aware­ness and ac­tion was ef­fec­tive in about 62% of in­volved in­ci­dents: it was not present in 28%, and not used (mostly due to an in­ap­pro­pri­ate ser­vice be­ing re­quested) in 30%.

‘The stand-out item is the use, or not, of col­li­sion warn­ing sys­tems,’ the Board con­cludes. ‘In­creas­ingly af­ford­able sys­tems are now avail­able, and for about the price of a cou­ple of tanks of fuel some hugely valu­able sit­u­a­tional aware­ness can be gained from them about other air­craft in the area. While they’re not in­fal­li­ble and can only func­tion if suit­ably com­pat­i­ble sys­tems (i.e. sec­ondary sur­veil­lance radar) are de­tected, they might just make the dif­fer­ence when all other bar­ri­ers are not per­form­ing well.’ Air­prox re­ports can be read in full at:

The re­sult of an un­qual­i­fied stu­dent pi­lot fly­ing and a full flap go-around

The de­part­ing R44 landed heav­ily nose up with its tail on the ground

PA-28 and Chero­kee Six con­flict di­a­gram – who had the pri­or­ity?

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