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
Fuel starvation, avoiding obstacles, and wet conditions
‘Poor procedures or procedures not being followed, and poor tactical planning and execution by pilots are this month’s predominant themes,’ says the UK Airprox Board of the 26 incidents examined at its April meeting. Seven involved drones/uass, the remainder were aircraftto-aircraft, of which six were assessed as Category A (risk-bearing) and three were Category B, where safety was much reduced. ‘The incidents ranged from selection of transit heights that needlessly exposed aircraft to extra risk in the GA flight band of 1,000-2,000ft; flying non-standard procedures or poor compliance with procedures, and the lack of a ‘Plan B’ when things went wrong or changed,’ it says. Other topics examined included inaction either by controllers or pilots, late- or non-sightings, sub-optimal ATS selection, and insufficient or late traffic information from controllers.
‘After a busy start to the year, March was relatively quiet for aircraft-to-aircraft Airprox notifications,’ says the Board, ‘but April saw a return to historic norms, and so overall numbers of aircraft-toaircraft incidents for 2019 are still tracking the expected fiveyear average (43 actual versus 43 expected). On the other hand, drone incidents remain well above expectations (28 actual versus 15 expected)… Aircraft-to-aircraft clashes in the visual circuit seemed to be a common scenario – there were eight events where aircraft came into conflict either in the circuit, joining it or flying though.
‘The key lessons from these are the need to follow procedures, be clear to others about one’s intentions and, above all, maintain a robust lookout at all times even when conducting visual circuits in case others might lose (or have flawed) situational awareness or ineffective lookout.
Other quick-wins would be for pilots to avoid the 1,0002,000ft transit height block whenever possible, and to seek a Traffic Service if conducting simple transits.
It seems to be a feature of some helicopter operations in particular… that pilots choose to transit at about 1,000ft by default when off-task. This means they risk passing unknowingly through, or near, the circuit patterns of small strips where aircraft might be getting airborne and climbing, or encountering GA aircraft either routing to or from airfields themselves or conducting training activities such as PFLS.’
The Board’s ‘Airprox of the Month’ features the pilot of a Piper PA-28 who was turning from base to final at Southend when his radio contact was lost. Failing to hear any of the controller’s subsequent calls and fearing that he wasn’t cleared to land, he decided to orbit on final and then turn away while trying to resolve the R/T problem. Meanwhile, a Eurocopter
EC155 on an ILS approach was already quite tight on the PA-28 and, aware that the pilot wasn’t responding to radio calls, its crew suddenly saw it turn towards them on final. Although the pair came reasonably close, the helicopter’s crew had seen the Piper early on and were ready to take action if necessary, so it was felt that there was no risk of collision.
The Airprox Board judged this to have been a Category C incident, noting that it raised a number of issues worth highlighting. ‘For the PA-28 pilot, Southend’s local radio-failure procedures were that in his circumstances he should have followed his last clearance and landed as soon as possible while watching for visual signals from the tower. He had previously been given traffic information about the EC155 but probably became task-focused on his radio problem and might not have remembered it. Aviate, Navigate, Communicate remains a well-recognised mantra for prioritising activities and avoiding distractions.
‘Even if he wasn’t fully aware of the radio-fail procedures in the circuit, rather than turn back up final towards the instrument approach, the pilot would probably have been better advised to have simply gone around early onto the deadside at circuit height, or simply continued through the final approach track, departed the circuit, and then conducted a full radio-failure join. For the EC155 crew, aware that the other pilot was having problems, it might have been better to have made an early decision to go-around and take the pressure off everyone rather than carry on to see how things unfolded, only to be surprised when the PA-28 turned towards them.
‘The messages from this incident are: know your airfield’s procedures and what to do when unexpected things such as radio failures happen; expect the unexpected, always have a Plan B, and give those experiencing difficulties a wide berth not just out of consideration but also to avoid you being put in a difficult situation if they do something you don’t anticipate.’
For details of this and other incidents examined by the Board visit: airproxboard.org.uk
A key issue
From the Aviation and Maritime Confidential Incident Reporting programme’s excellent quarterly CHIRP journal (see related story below) this tale of how a seemingly insignificant factor could have had a serious outcome.
“On a VFR flight from Kidlington to Guernsey, I had just entered the Channel Islands Control Zone in the cruise at 5,000ft when the aircraft hit a patch of turbulence, throwing me against my straps. Immediately there was a major reduction in engine power, which didn’t respond to opening the throttle. I turned on the booster pump and changed fuel tanks, with no improvement. At this point I put out a Mayday and turned towards Alderney as my nearest airfield. I was unable to maintain height and quickly realised that, with a strong south-westerly wind, I was not going to reach Alderney and was facing a ditching in the Channel.
“I returned to seeking possible causes and, having selected alternate air, I reached across to check the magnetos. At this point I realised that the switch was turned to right mag only (or slightly beyond). Reselecting ‘Both’ restored normal engine output and I was able to cancel my Mayday and continue safely.
“Analysing how the magneto selection had come about I realised that, in the turbulence, my knee must have connected with the other two keys on the ignition key ring and forced the ignition key round−not something I have ever seen before or would have thought possible. It was probably only possible because the key ring itself was a chunky and a fairly firm fit on the keys. Lessons learned: Methodical situation analysis in extremis works. Keep the ignition key separate from other keys!”
CHIRP comments: ‘The incident was an unusual one, but served to demonstrate that Murphy’s Law is alive and well: if something is possible, no matter how unlikely it may be, eventually it will happen to someone. The reporter had remained calm, analysed the situation logically using a careful and systematic check with nothing assumed or skipped. His prompt action in declaring a Mayday and turning towards land is to be commended (a Mayday can always be cancelled or downgraded if the situation improves). Well done!
‘His point about keys and key rings is a good one. There can be a lot of leverage generated when a force is applied to other keys on a ring. Both objects and limbs can be thrown around in turbulence [so] when you’re getting comfy before a flight and checking control movements, perhaps that’s a good time to check that your key is as secure and protected as it can be.’
CHIRP’S new CEO
CHIRP has a new Chief Executive Officer. Ken Fairbank flew Harriers and Hawks in the RAF before starting a career in civil aviation flying Boeings and Airbuses on which he qualified as Line Training Captain, Type Rating Instructor and Authorised Type Rating Examiner. He was Chief Training Captain with a major UK airline, with responsibility for the training and operating standards of the company’s pilots on its fleet of Boeings, and subsequently took on the role of Training Manager for another UK airline.
‘I have been involved with flight safety in various ways for many years,’ he writes, ‘including nearly thirteen at the AAIB, part of which I spent as an advisor to the General Aviation Advisory Board. Further back, I served on the secretariat of the UK Airprox Board and (even further back) as a Flight Safety Officer in the RAF. Above all, I’ve been flying for forty years and suppose I must have seen and learned a lot in that time, although it doesn’t always show or feel like it! Now, working with our highly experienced Advisory Board members, I want to ensure that CHIRP remains a relevant and worthwhile programme for all.
‘I want to ensure that FEEDBACK continues to ‘do what it says on the tin’ and remains informative and educational for its many readers. Our Advisory Board members bring all their knowledge and experience to the table when discussing your reports but your input is the most important−after all, you were there! So when you sit down to write a CHIRP report, I urge you to share not only what happened or what was wrong, but why you think it happened, how it affected you and others, what you did to mitigate the risks−and why you’re still here to tell the tale! Those of you who, like me, grew up on ‘I Learned About Flying From That’ articles (especially those published in Pilot, we trust!−ed) will know what I’m getting at. And we’re all still learning.”
CHIRP can be contacted at: Centaur House, Ancells Business Park, Ancells Road, Fleet GU51 2UJ. Tel: 01252 378947. Email: [email protected] co.uk web: chirp.co.uk
CHIRP CEO Ken Fairbank