2023 June Analysis

Fatal Accident (1)

Evektor spun into terrain after take-off killing both occupants.

Airprox Reports (15)

including 3 Near Miss.

Occurrences

Engine Failures (14), most were Lycoming models, one TAE 125, one Austro, one Rotax and one Jabiru.
Fuel Exhaustion (2)
Landing Accidents (15). 
Take-off Accidents (6)  
Runway Excursions (9)
Runway Incursions (8)
Tyre Failures (3)
Maintenance Reports (5)
Tech Failures Following Maintenance (1)
Taxiing Events (8)
Taxi with tie-down weights attached (1)
Loss of Coms (4)
IFR Level Bust (20) *
Part Fell Off in Flight (2), baggage door, seat cushion.
Hatch/Door Opened in Flight (2) *
Cockpit Smoke (3)
Brake Failure (1)
EFIS/Avionics Failure (1), total, affecting left and right displays.
ATC Coordination of IFR GA Flights (7) 
Fuel Leak (1), visible from engine cowl BE200.
Airframe Icing (1), caused airframe damage to a BE200.

Airspace Infringements (142)

In 15 cases IFR traffic was affected i.e. delayed, descent stopped or vectored around the infringer.  .
The relative navigation factor is used for cases where either the believed vertical and horizontal position of the aircraft or the perceived location of the proscribed airspace was in error. This may be termed situational awareness with respect to controlled airspace boundaries.
Airspace categories affected were:
TMA Class A (20)
CTA Class D (64)
CTA Base 1500ft Class D (17) Included in figure above.
CTR Class D (21)
CTR Class D (8) Arrivals/departures from an airfield wholly or partly within a CTR
TMZ Class G (5) Incorrect squawk, frequency or not listening
RMZ Class G _
ATZ Class G (12) Including gliding sites and para drop zones
Danger Areas (5)
RA(T) (6)

Various contributory factors were:
Inadequate planning.(6).T
Weather Factors - turbulence (3)
Transponders Mode C faulty or over reading (4). S
Lack of Knowledge (1), - altimetry, T
Take Two (3). T
Misidentified surface features, lateral navigation error or misread the moving map (6).
Confusion of CAS bases (8), including moving map presentation. S
Chart obscuration (5) cases reported
Altimetry (11), failure to set 1013 climbing to IFR level or QNH when descending, QFE set beneath CAS. S
Manchester LLR .No violation of the boundaries in two cases. S
North Weald Departures/ Arrivals (6). S
Moving map failure (3).Two were due to Sky Echo traffic awareness system causing loss of map display, a common failing. S
Farnborough CTR/CTA (9) S
1,500ft base (6) S
Distractions:- Workload (3), instructing or task (1), tech problems (5), passengers (3)
Instrument scan (7).Lookout, Attitude, Instruments, particularly altimeter and VSI.  Altitude keeping errors are often caused by failing to observe these instruments frequently T.
Frequency Monitoring Code not used or pilot not listening (7) T.
Non-compliance with cleared route or not above altitude, (12)
London FIS (11). Guidance as to when this service might be useful is required. S & T.
No moving map used (1).
Glider infringements (3)
RT skills lacking (4)
Misunderstood clearance (3)
No squawk, wrong squawk or departed with transponder on SBY (7)

Notes to the above

Bar Codes and QR Codes are recognisable by computers but human beings cannot remember, recognise or reproduce them because their patterns are so complex.  For the same reason, the complex patterns of our CTA airspace are a major contributor to the high infringement rate above.
IFR level busts (20).  An unusually high number this month; many involve passing through the cleared level by 300 – 500ft then returning to it.  It may be that some of these types did not have an altitude capture facility, or they did but it wasn’t armed.  Related to this, reports suggest that some of the aircraft climbing to a flight level had not set 1013 or had not set QNH when descending to an altitude.  The SOP of some operators is to set 1013 when cleared to a FL in climb and QNH when cleared for descent to an altitude.  This works well in Europe where transition altitudes are usually quite low, in North America it may be more usual to change setting passing 18,000ft.
Altimetry (11).  This unusually high figure includes some in the above category but also highlights a not uncommon error, that of setting an incorrect figure perhaps due to number transposition e.g. QNH transmitted 1032 but pilot sets 1023.  This can affect IFR flights especially those making an RNAV/LPV approach as well as VFR operations.  One guide to the latter is to note the QNH when checking the weather before flight and actually find it interesting!  If the QNH is likely to be 1032 or 985, you have a fair idea already what the weather is going to be like.  When you get the QNH from the ATIS or taxi clearance, check whether it is close to what you thought it would be, rather than just digits you must set on the altimeter. 
One reporter had set the destination QFE early while flying beneath controlled airspace and suggests he should have set the Regional Pressure Setting which would again be wrong.  When flying beneath controlled airspace defined by an altitude the QNH of the nearest or controlling airfield should be used.  Personally I find it regrettable that many airfields situated beneath CAS do not concur and continue to use QFE.  The RPS should not be used to determine altitude when beneath CAS, though AIP ENR 1.7 says it should be used to determine terrain clearance.  This is not much help to aircraft with only one altimeter. 
Chart Obscuration.  Two reports include Melton Mowbray as an en route visual fix or waypoint.  It happens that this point is partly obscured by excessively thick boundary lines, along with many other features elsewhere.  Neither report mentions this as a factor so they are not included in the above analysis.
Door unlatched in flight.  One of these led to a runway excursion on landing probably due to distraction and preoccupation with the unlatched door.  Numerous accidents have resulted from this unnecessary concern.  The POH’s for aircraft with a typical side opening door such as Piper and Cessna SEP’s state that handling characteristics are not significantly affected; it will not open much – an inch or so.  The increased air noise may be a nuisance, but nothing more, so ignore it, fly the departure normally and as planned.  If time and airspace permit you could try the POH procedure for closing it which will involve reducing speed, opening it more and closing it.  That’s a major distraction for a single pilot and flying accuracy will suffer.  I would suggest in most cases it is better to leave it, consider returning to land or on short flights continue to destination. It is not a dangerous situation and handling is not affected.  There is the possibility that exhaust fumes could be drawn into the cabin although I have not heard of this happening and in winter the increased ventilation may be uncomfortable.  In aircraft with canopies check the POH, the dangerous ones are side doors that hinge upwards, such as the aft door on a DA40, but that is equipped with a door warning light.  As always, aviate (fly the aircraft properly), navigate (follow your planned departure at the correct altitude) and communicate (perhaps your intention to return and land).
Engine Instruments.  After starting the engine, we check the oil pressure has risen correctly.  When we have taxied to the run-up area near the holding point we check the engine instruments again, mainly to see that the oil temperature has moved off the stop and the oil pressure is in the green.  As we do the power check we confirm the oil temp and particularly the oil pressure are in the green.  As part of the power check we throttle back to idle to check the idle RPM and that the oil pressure remains above minimum.  Then we do the before take-off check which again calls for checking the oil pressure and temperature.  Having found all these checks satisfactory, including four checks of engine instruments, we are ready for departure.
There is one thing we haven’t normally checked: does the engine produce full power?  We’ll soon find out as full throttle is applied, therefore I like a student to call ‘Full power checks’.  That involves knowing what RPM is expected and it could be that more than a few pilots don’t know, because the checklist doesn’t give the answer and even the POH doesn’t make it very clear.  This check must be no more than a very brief glance at the RPM needle or display.  The instructor’s view of the RPM gauge may be obstructed by the student’s arm but an instructor would probably know from the noise level and acceleration that the aircraft is going to fly or, unusually, that it doesn’t feel like full power. Possible causes: the student hasn’t applied full power or the carb heat is hot.
The student was carrying out their first take-off.  After applying full power the instructor looked down to check the engine instruments.  Upon looking up the instructor saw that the student had veered left, which on a first take-off is almost guaranteed.  It was then too late to avoid the runway edge and they hit a runway light, breaking it, and the instructor rejected the take-off.  This was from a large, major airport runway.  After the airport had picked up the broken pieces of light and re-opened the runway, the aircraft took-off again uneventfully.  Runway lights are pretty solid affairs, so we have to hope that during this time the aircraft was inspected for damage because it could well have come off worst from the encounter.  The instructor blamed himself for giving an inadequate briefing on the subject of directional control during take-off. 
That maybe, but the real problem was looking down at the engine instruments.   During take-off, total concentration is required to control the aircraft; that is far more important than checking engine instruments yet again. When driving at speed along a winding road, it would be unwise to look down at the fuel gauge or engine temperature, this might cause a serious accident.  If the oil pressure was fine as it evidently was, it proves little because it could fall to zero two seconds later; conceivable but very unlikely. If you’re not looking where you are going, a serious accident is highly probable.  I have heard other pilots call engine instruments check during a take-off roll and would advise against it.  A full power call is enough; airspeed rising involves a smaller change of focus.
I can think of one accident and three other occasions when an engine did run out of oil and lose oil pressure.  All were in the en route phase of flight, two of these involved SEP aircraft and two were large jets. In all cases a check two minutes earlier, which almost certainly was made, would have shown oil pressure normal.
Graham Smith

(Please note that the commentary provided is the view of the author and may not necessarily reflect the views of the Council)