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

Fuel star­va­tion, avoid­ing ob­sta­cles, and wet con­di­tions

Lat­est Air­proxes

‘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: air­prox­

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 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] web:

CHIRP CEO Ken Fair­bank

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