Learning Lessons in a Just Culture

I recently took on the role of Safety Officer for Thames Valley Hang Gliding Club and was immediately presented with a problem. How do you measure, promote and increase flight safety? Well, I believe you can shout and scream about pre-flight checks, lookout, airmanship and SIV (Simulation d’Incident en Vol) courses all you like, but what it actually comes down to is culture.

I firmly believe that you can’t even start to promote flight safety without operating a ‘Just Culture’ where people can be free to stick their hand up and say ‘I got that wrong’ without fear of punishment, ridicule or being ostracised. The basic premise is very simple and one that children learn very quickly; if you tell someone off for telling you about something that went wrong they won’t tell you again. It also means that people should be able to make full, free and open reports in order that others can learn from their mistakes. It is much better to learn from others’ mistakes, and often a lot less painful too.

One of our members recently made a navigation mistake resulting in a number of airspace infringements. The pilot didn’t set out in the morning thinking, ‘I’m going to infringe three separate pieces of airspace today,’ which means he made an error, or mistake. It also means that the organisation, tools, presentation of information or the pilot’s attitude towards flight planning were not up to the job, and that it could happen to other people in the future. That makes it my job, that of the BHPA Flying & Safety Committee and maybe all of us to fix those problems and try to make sure it doesn’t happen again.

I would like to thank the pilot involved for submitting this highly open and honest report …

“I’ve been flying for about 17 years, mostly paragliding and some hang gliding before that. I usually fly on weekends as I’m busy with my work, and of course my family needs some of my time. My longest cross countries have been 70 - 80km. I’ve had one infringement before, a couple of years ago, where I touched restricted airspace on final glide in strong winds.

Before I go flying I usually watch the weather online, and the evening before I open NOTAM Info too to see where it is possible to fly. Sometimes I prepare and download a route, but not always. On the day in question I had loaded waypoints for a particular route, which turned out to be useless that day. I had briefly learned the airspace for the first 50km as I did not expect to fly any further. In my navigation instrument I had prepared a route I had flown previously but, discussing it with another pilot, I realised the wind was stronger and had a more westerly component than I had expected. I looked at the air map again and only set a direction to the goal area.

I launched, but quickly landed downwind. Returning to the hill, I was rushed while preparing for my second flight. I did not check my instrument and took off. At cloudbase after 6 km, I realised that my instrument wasn’t showing the proper screen. Finally I reset it and it seemed to be giving me good directions to my  goal.  I saw  two  other paragliders in front of me and pointed myself in that direction. Airspace was initially very restricted and the wind was strong; lots of pilots were funnelled through gaps in the local ATZs.

After a while I tried to zoom my screen but it didn’t respond. It showed proper data and direction but was permanently zoomed in. I followed the other paragliders, believing I had a functioning airspace warning. I only had a vague awareness of airspace on this route as I usually flew in a slightly different direction. Then I lost visual contact with the others and hesitated on where to fly. Finally I decided to follow my original direction as I didn’t realise how far off my original track I was.

I only found out that something was terribly wrong as I got lower and turned my focus from cloudbase to the ground. The features of the land were significantly different – no roads, no villages, only vast open land with little holes in the ground. I got frightened and my only intention was to get away as soon as possible. I took a thermal at about 400m and got back to cloudbase. From there I flew more towards my original goal as I felt in completely the wrong position. After half an hour or so my instrument gave me an airspace warning and I landed immediately.

Afterwards I went through my entire setup and found that the advance airspace warning was not set up. More importantly, the current piece of hardware I used was crippled.

What have I learned? How inappropriate my navigation equipment is for longer flights. How poor my preparation for the cross country (XC) was, in setting up my device and in knowing all the settings options. Finally, how tough it is to find courage to land when you don’t know where you are. UK airspace is extremely complicated, especially in combination with the potential for long XC flights.    It puts extra emphasis on the pre-flight preparation and good navigation equipment.”

Does any of this ring any bells with you? Have you – or could you – ever find yourself in a similar situation? And what can we learn from this pilot’s ordeal?

Where do you get your airspace and NOTAM information from? There are many useful tools out there, but you and you alone are responsible for knowing which permanent and temporary airspace is near your planned flight. And you should know what the limitations are of any tool that you are using before taking off.

When you’re engaged in any form of free flight you can’t go from waypoint to waypoint to get to your goal. You’re at the whim of the wind and lift and may find yourself many miles from your planned track. You can’t use a pointer to the next waypoint and assume it will keep you clear of controlled airspace. There is no substitute for knowing where you are now and where the nearest controlled airspace is!

After all, it is every XC pilot’s responsibility, and a legal requirement, to be properly briefed. Some say that this means carrying an up-to-date air chart for navigation and cross-reference purposes. Paper is still the primary source for navigation; let’s be honest, although somewhat yesterday’s technology, it never fails!

Try and put yourself in the position of this pilot. What would you do? What if the ground underneath you looked worse than the ground ahead, or worse than staying airborne? Yes, you should land as soon as practicable and safe, but please try not to judge this pilot until you’ve flown a mile in his shoes!

Nick Smith,
Thames Valley Hang Gliding Club
Safety Officer