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)
Graham Smith
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