Fatal Accidents (0)

Airprox Reports (5) plus TCAS RA (2)

Occurrence Reports (79)

Engine Failures (10), including rough running, return to land and double ECU failure.  Lycoming (3), Continental (2), TAE125 diesel (2), Austro diesel (3).  It would seem that with an ECU fail warning the actual fault, such as a sensor, may not be displayed and may affect both ECU’s.
Landing Accidents (2)
Take-off Accidents (3) of which 2 were helicopters plus one fixed wing rejected take-off with overrun into a field. 
Take-off without Clearance (-)
Runway Excursions (7)
Runway Incursions (2)
Wrong Airport (1), wrong runway (2).
Tyre Failures (1)
Landing Gear (1), a glider landed with the wheel retracted.
Maintenance Reports (9)
Taxiing Events (8) including ground handling.
Loss of Coms (4)
IFR Level Bust (7), including late setting of 1013 in climb or QNH in descent.
IFR Departure Turn (3), turned in the wrong direction.
VFR Level Bust (3), exceeding not above altitude.
Prop spinner detached (1)
Blocked Pitot (1), not the cover.
Smoke, Fumes (2) or CO Warning (7). Four CO warnings were in PA 38 Tomahawk aircraft, 3 of which were in the same aircraft.
Alternator Failure (3), one of which led to complete electrical system failure.
ATC Coordination of IFR GA Flights (-)
Fuel Leak in Flight (1),
Incorrect Fuel Type (2)
Bird Strike (4)

Airspace Infringements (51)

T indicates areas where training could be improved effectively.  S suggests that systemic improvements could be implemented. 

Airspace categories affected were:

Airspace Category Class  No  Remarks 
 IFR traffic affected  General  4 Delayed, descent stopped or vectored around the infringing aircraft 
 TMA A 11  
 CTA D  0  
 CTA Base 1500 FT D 7  
 CTR D 8  
 CTR D  3 To/from an aerodrome wholly within a CTR
 TMZ G 0  
 RMZ G 1  
 ATZ G 4  Including gliding and para dropping sites
 Danger Areas/ RA G 0  
 RA(T) G 0  
 MAN LLR D 2  Avoiding weather; squawk code late

Various contributory factors were:
Inadequate planning (1).T
Weather Factors, including turbulence (10)
Transponders Mode C faulty or over reading (2).S
Lack of Knowledge (2); RMZ, altimetry. T
Take Two (1). T
Misidentified surface features, lateral navigation error or misread the moving map (2).
Relative navigation (5)
Confusion of CAS bases (2), including moving map presentation. S
Chart obscuration or presentation (-) when reported or indicated.
Altimetry (9), S
Climbed too soon (1)
Descended too late (2)
North Weald Departures/ Arrivals (3). S
Moving map failure or not used (1). S
Farnborough CTR/CTA (4) S
Distractions: - Workload (3), instructing or task (3), tech problems (5), passengers (1).
Instrument scan inadequate (1).T.
Frequency Monitoring Code not used or pilot not listening (1) T.
London FIS (-).
Avoiding VFR traffic (2)
Glider infringements (-)
Misunderstood clearance (1)
Instructor on board (7) cases reported, student solo (1).

Engine Failure at Night

A Robin 2160 suffered partial engine failure (about 1,500 RPM) on a night training flight about 10nm north of Blackpool; a fuel issue is suspected.  The aircraft could not quite make it back to the airport and landed safely on the beach with no apparent damage.  The brief occurrence report suggests superb airmanship with cool decision making; it must have been so tempting to try for the airport.

Door Unlatched

A PA28 pilot climbed well above the intended level off altitude due to distraction; the cabin door was not latched closed.  This happens occasionally; the door can appear to be latched when it is not.  It is however nothing more than a mild nuisance that slightly increases cockpit noise and ventilation.  Aircraft handling is not affected and occupants will not fall out!  The priority as always is to aviate, navigate (both laterally and vertically), continue with the planned departure whilst ignoring the door and finally communicate if the intended flight is changed, e.g. if a return to land is decided on.  The POH gives a procedure for closing it which involves reducing speed to 89 KIAS or less, closing the air vents and opening the side window.  This procedure is not a priority, may not be successful and will involve considerable distraction from accurate flying.  I would suggest it only be attempted in an area where altitude and heading deviations with reduced lookout are acceptable.  On short flights it is probably better to ignore the unlatched door and avoid unusual manoeuvres.

Low Pressure and Altimetry

Many of November’s high incidence of altimetry events included IFR level busts as well as infringements.  A common SOP for IFR flying is to set 1013 when cleared to climb to a flight level and set QNH when cleared to descend to an altitude, as detailed in the AIP.  With a QNH of 970 Hpa, and it has on occasions been considerably less than that, there is a difference of 1,290ft compared with standard so a CAS base of FL65 becomes more significant for flights intending to operate beneath it.  One reporter set a QNH of 1002 in error when the nearest ATIS actually gave 1022.  As usual two reporters had QFE set when flying beneath controlled airspace.   Systemic and training modifications could resolve many of these errors.

Graham Smith