Engine Failures (14). Few reports
give details of the failure cause.
Serious
Accident, canopy not fastened, turn back attempted.
ASI
Failure on Take-off (1), caused by an insect.
Landing
Accidents (11), excluding runway excursions
Hand
Swinging a Prop (2). In
one case the aircraft left the airfield and crossed a public road.
Runway
Excursions (12)
Runway
Incursions (8)
Hitting
Obstruction on Short Final (5) of which two were gliders.
Level
Busts under IFR (5)
VHF
Com Failure (6). Even a headset failure can take time to rectify.
Alternator
Failure (2).
Maintenance
Reports (4).
Airprox
Reports (21) plus 2 near miss reports
Infringements (138)
Common contributory factors were:
- Misread chart including electronic displays (5)
- Take 2, i.e. avoiding CAS by at least 2nm and 200ft (8)
- Climbing too soon after flight beneath CAS (8)
- Distraction (15). Passenger (2), instructional tasks (2), avoiding other VFR traffic (4), technical (2).
- Complex Boundaries of CAS, (6) could be identified, in reality this figure is probably much higher.
- Transponder mode C confirmed to be over reading (5).If a similar number under read, TCAS avoidance could be compromised.
- Lateral Navigation error (3) reported
- Resetting GPS in flight using Direct TO (1)
- Instrument scan of altitude too infrequent (4)
- Hired aircraft had inoperative directional gyro, magnetic compass affected by turbulence (1).
- GPS warning missed (5) reports, actual figure probably much higher. Aural warnings are unlikely to be heard without blue tooth headsets.
- Repetitive warning requiring repeated cancel action led to missed warnings.
- GPS failure due to tablet overheat causing distraction (3).
- Excess circuit traffic at airfields inside or close to a CTR. I have been asked whether it is possible to fly a circuit within a 2nm ATZ. The answer is yes, it’s quite easy but as the traffic level increases it will not always be possible. Considering just two aircraft, A departs to fly circuits. Aircraft B is ready to depart behind to fly circuits. B can legally and safely depart with much less horizontal separation than would be safe on final approach to land. Aircraft B will then have to fly a larger circuit than A. If meanwhile a jet is cleared for a straight in final approach, A and B will have to fly even larger circuits.
- London FIS (5). This may not be a useful service if flying near controlled airspace, they do not have radar, cannot issue instructions and will only know of other traffic that has called them. They can obtain joining clearances for IFR traffic, do know the activity status of danger areas and can activate filed flight plans. They cannot instruct pilots to change frequency to another ATSU, Jersey zone often reports VFR infringements for this reason. Foreign pilots in particular may not be aware of these limitations.
- Altimetry (4). Three aircraft infringed after departing with QFE set. The fourth was IFR and did not set 1013 at the cleared flight level.
- Unfamiliar with aircraft and/or avionics (3).
- ATC coordination of GA flights on an IFR flight plan (4).
- Planning (3). While a lack of planning was evident in three cases, equally interesting are infringements that occurred to pilots who had spent many hours or even days planning a simple VFR flight but still suffered an infringement. See complex airspace boundaries above.
- Workload (4). Identified in 4 cases but probably many more. Particular contributors are pilot initiated frequency and squawk changes, congested frequencies, manual flight in turbulence (autopilots without yaw dampers are sometimes worse than manual flying) and no handovers from one ATSU to another. The workload required of a VFR pilot is far higher than IFR flights when almost every frequency and squawk change is instructed by ATC. If that was not the case, IFR flight would not be as safe as it is. Therefore errors by single pilots flying manually in turbulence are inevitable.
- Manchester LLR (7), most due squawk or frequency rather than position or altitude.
- Not Using FMC which may have prevented infringement (3)
- Thermal turbulence during the hot dry summer is mentioned frequently.
- Glider infringements (6).
- ATZ/Gliding site infringements (4).
One report states that the MSA over the Isle of Wight is 1,300ft; it is worth noting that is not an MSA but a Maximum Elevation Figure, i.e. the top of the highest obstacle in that grid section.
Conclusions
Very few infringing aircraft did not have
a moving map display, but the rate of infringement has not decreased. Without moving maps we could however
assume that the rate would be higher.
No single action
will drastically reduce the rate of infringement; all contributory factors
need to be addressed.
Infringement
hotspots would seem to be Farnborough ATZ/CTR, Stansted TMZ – Stapleford,
often involving North Weald and Manchester LLR.