Hard landings (8).
Damage to nose-wheel and/or propeller.
Burst tyre on landing (3).
Runway excursions (5).
Engine failures (9). Not all involved complete failure, some immediately followed maintenance action. In one case, the right engine of a light twin with Austro engines emitted black smoke with vibration; both symptoms reduced at a low power setting of 30%. The next day the same symptoms recurred on the right engine, whilst returning to base the left engine also emitted black smoke with vibration. No cockpit indications observed in either case.
Engine fire on start (3).
Brake Fire (1). after landing.
Trailing smoke after departure or in cockpit (3).
Ground Maintenance Reports (5).
Prop and wing de-ice both failed while in icing conditions (1).
Loss of pitch control (1), roll control (1).
Collision with mid-air object damaging canopy and injuring the pilot who bailed out.
Airprox reports (4)
Runway incursions (2). In one the pilot of a turbo prop twin was unfamiliar with the particular aircraft, the checklist, the airfield and was somewhat pre-occupied with the extended checks required post maintenance.
Runway excursions (5).
Landed at wrong airfield (1).
Complete electrical failure (3)
Avionics or radio failure (4).
Flaps failed in an extended position (2)
Airspace Infringements (70)
There are numerous
contributory factors, in some events more than one apply.
After departure from a busy London area GA airfield the pilot did not fly the correctly calculated heading towards a town on his route but aimed for another town, ignoring the heading which was some 90° in error, becoming lost and confused. (Training).
Climbed too soon after flight beneath CAS (3). Systemic improvements are possible including chart depictions, airspace standardisation and simplification.
Situational awareness of the base (5). This involves comparison of aircraft position with the location of the different CAS bases. (As above).
Misread chart (5). In two cases highly experienced pilots conducting air tests did not see the base of CAS on moving maps. In another case north of Luton there are confusing depictions of the rapidly changing bases. (As above).
Foreign aircraft (only 1 identified from reports).Our airspace must be navigable by all.
Using London FIS (1).
Flying at the base of CAS (2). (Pilot training).
Frequency congestion (3). All Farnborough LARS West. (Steps can be taken to reduce radio congestion, the most obvious being to use the frequency monitoring code when possible. (Training).
Pilot not listening out on appropriate frequency (4). (Pilot training).
Complex clearance via VRP’s (2). ATC appreciation that unplanned VRP’s can be hard to locate on the chart, moving map and visually.
Manchester LLR (3). None had exceeded the boundaries of the LLR but were not squawking correctly. (Procedure).
Not monitoring altitude frequently (3). (Pilot training: lookout, attitude, instruments).
Altimetry (2). Both involved use of QFE. (Procedure, use of QFE at airfields beneath CAS, or indeed anywhere other than military aerodromes is questionable).
Redhill joining traffic (4). For airfields inside, underneath or close to CAS, it may be necessary to limit circuit traffic to enable safe circuit joining. Pilot training points: do not extend the circuit, do not exceed circuit height, go-around at circuit height if too close to traffic ahead.
Distraction (11) This is the most common contributory factor. In March 22, the following distractions could be identified:
- Headset mic jack. Identifying and correcting comms failure may take minutes. Headsets and sockets are a common cause.
- Setting frequency or squawk with a small multi-function switch, (It is for consideration whether such equipment should be permitted).
- Reprogramming devices which ideally should be set up before departure to minimise such activity in flight.
- Visually avoiding circuit traffic. (2)
- Trying to set up conspicuity display.
- Autopilot in GPS mode not intended heading mode.
- Avoiding cloud while climbing.
- Giving instruction to student (2) (Instructor training).
- Concern for passenger (Pilot training).
- Fuel leak and smell of fuel after maintenance, confirmed after landing.
- Air test considerations (3).In one case there was discussion with the engineer about maintenance manual provisions; this document is not intended to be used in the air.
Several infringements occur each month on instructional flights. Instructors and students alike should come to an understanding at an early stage that speech in flight needs to be limited. The instructor cannot explain things verbally in the air, questions and explanations must happen on the ground. That needs flying schools to adjust by making sure there is time to do this. During circuit training, most students will follow a touch and go landing with a question such as “What did I do wrong there?” The climb after take-off is a critical stage of flight requiring complete concentration and is no time to be discussing what happened a minute or two ago.
Passengers sometimes make very useful observations like “Traffic over there” or “There’s oil coming out of the right engine” and should not be ignored. If they don’t feel well, are sick or even die, there’s nothing the pilot can do about it except to fly the aircraft safely and return to land in a correct and normal way when possible. The pilot should not turn to make eye contact nor keep asking if they are all right because if pilot and aircraft are OK, it follows that the passengers will be too. It is not a reasonable excuse for infringing. (Naturally, if there is another passenger on board who is able to assist, pilots would ask them to do so while they concentrated on flying the aircraft thereby mitigating the risk)