Confidential Human Factors Incident Reporting Programme
Issue No: 40 October 1996
Organisation. In the past month CHIRP has been entered onto the Companies Register and has gained the
consent of the Charity Commissioners for the award of charitable status. Accordingly, with effect from 1
November 1996, the responsibility for the Programme will be assumed by the independent Board of Trustees
with Air Commodore Tony Nicholson as Chairman.
ATC Operations and Training Standards. Since the publication of FEEDBACK Issue 39, meetings have
been held with senior National Air Traffic Services Managers, at which the principal concerns that had been
expressed through CHIRP reports were presented. On the subject of training a visit was made to the College
of Air Traffic Control Hurn during which the views of reporters and staff were debated. There is some
evidence to suggest that the concerns expressed by reporters may be a legacy of the training policy that was in
existence some three to four years ago. One of the aims of the recent Review Group ATC Training (RGAT)
initiative was to match training more closely to the requirements of operational units. As yet, relatively few
post-RGAT graduates have entered On Job Training (OJT) at major operational units although early
indications are encouraging. Undoubtedly, this issue will continue to be monitored with some interest.
CHIRP Confidentiality and Anonymity. In the past few months I have received a number of anonymous
reports on important issues, in which the reporter has cited "leaks to the press" or "breaches of confidentiality"
as the reason for submitting an anonymous report. On the issue of press coverage of reports published in
FEEDBACK, it should be recognised that within a circulation of 20,000 copies per issue, it is likely that
information on CHIRP reports may be passed to media representatives. Hence it is accepted that any item
published in FEEDBACK may be placed in the public domain. However, it has been and remains the CHIRP
policy not to discuss specific reports with the media. It is equally important to understand that CHIRP must
retain the ability to conduct a confidential dialogue with reporters, in order to validate details of a reported
incident and if necessary to represent reporters' views on an absolutely confidential basis. Anonymous reports
are not normally acted upon as they are rarely able to be validated or analysed.
PLEASE NOTE: Recipients of FEEDBACK who do NOT hold a valid pilot/ATCO licence, including
organisations, received address slips to be completed and returned to CHIRP in the last two issues. Of the 1046
slips issued, only 535 slips have been returned. If you have NOT replied and have received a further address slip
with this issue, it is essential that you notify us of your wish to continue to receive FEEDBACK.
A Reminder on the magazine format: Inside This Issue
The following type fonts are used for: 1 Fatigue P 2
• Disidentified reports - printed with minimum
text changes 2 ATC Reports P 5
• CHIRP comments are italicised
• Verbatim Third Party Responses are printed in
3 That Sinking Feeling P 7
SWISS type 4 GPWS - True or False? P10
CHIRP, Freepost, Royal Air Force School of Aviation Medicine, Farnborough, Hampshire GU14 6BR
Tel: (24 hrs) 01252 370768 Fax: 01252 543860
FEEDBACK - Comments individual sleep patterns that, by
inference, might influence the
Fatigue Authority's approach to this problem.
What happened to the information
(1) learned from the little blue booklet
I write not to report an incident but to that I, and many of my colleagues,
contribute to your investigation into religiously filled out with exactly that
cumulative fatigue with a copy of my information.
roster, which is relevant because of The booklet was completed some two
two features, excessive flying hours to three years ago and returned to
and repetitive day to night scheduling Farnborough. We were fatigued then
Over recent months, I and my and our work pattern has since
colleagues have commonly been deteriorated, perhaps you might
rostered for 90-100 hours in each imagine how we feel now.
calendar month. Many are almost The data for the study referred to by a
continually on the brink of 100 hours number of reporters were collected by
in 28 days, and several have the Royal Air Force Institute of Aviation
accumulated well over 800 hours in Medicine (RAFIAM), under contract from
the last 12 months. What makes my CAA Safety Regulation Group between
roster period interesting is that I have September and December 1993. This
been scheduled in excess of 90 hours period was immediately prior to the
flying despite eight days leave, i.e. 90+ transfer on 1 April 1994 of all
hours in 23 days. Simple arithmetic contracted research sponsored by CAA
converts this to an annualised rate of from RAFIAM to the Defence Research
flying of over 1400 hours. It is Agency (DRA).
perfectly legal, of course, but the spirit
of CAP 371 limitations has The study involved the completion of
disappeared! sleep log questionnaires over typically a
28 day period. A total of 241 aircrew
The blocks of flying duties show a
submitted reports of which 116 were
regrettable, but now customary
from B747 three-man crews.
pattern: two night flights after one or
two day flights, allowing little chance The report on this study "Sleep Patterns of
of obtaining adequate rest before an Aircrew on Long Haul Routes" was
all-night duty. published by DRA on 25 October 1995.
The study states that no direct information
The company's standard admonition was collected on levels of alertness during
that crew members are "responsible duty periods, as it was designed to
for planning and using their rest investigate sleep problems of long haul
periods properly in order to minimise crews, but the data was used to derive
incurring fatigue" cannot disguise the estimated levels of alertness. Although
fact that this sort of rostering the report details significant levels of
promotes fatigue. In my own case, I degradation in the level of alertness at the
find that the two days off in between end of the return duty period from NE and
blocks of flying are fully used in Central USA, it concludes:
recovering to near normality, just in "On westward trips most aircrew slept
time to start the debilitating process slightly in advance of local time, especially
again. on the first night. Some sleep problems
****** persisted throughout the layover period on
(2) the west coast of America, but there was
In your response to the letters in no strong evidence of difficulties coping
FEEDBACK 39 you state that you do with trips to the east coast even during 24
not have the detailed evidence on hour layovers."
From our own review of the roster data What does become quickly apparent,
that have been supplied by a number when considering this issue, is the
of reporters, we feel that crews in almost protected status expected and
several sectors of the industry are indeed afforded to Civil traffic outside
currently operating duty periods CAS (Controlled Air Space) by Air
and/or frequencies which, although Traffic Control. While I do not
within the detailed requirements of CAP advocate any action by Military
371, may be conducive to significant aircraft that would give another
levels of fatigue if operated on a Captain cause for concern for the
continuing basis. safety of his aircraft, common sense
must be applied if Military and Civil
CHIRP has proposed to the CAA (SRG) aircraft are to operate in the same
that there is sufficient evidence to open airspace.
justify that the data previously
collected, together with the data There is no need for a Military jet to
provided recently by reporters, be practice "high speed interceptions"
re-evaluated to examine the specific against civil traffic, "coming as close
areas of concern. As an example, the as it dares". Equally, a Civil pilot
effect of continually scheduling rest sighting a Military jet in his vicinity
periods between 18 and 30 hours after should not automatically make an
flights involving multiple time zone AIRPROX report. Finally, if Civil
changes should be assessed in relation traffic chooses to leave the protective
to CAP 371 Paragraph 2.3, which shallows of CAS ventures out into the
requires consideration to be given to deep blue waters of open FIR, then it
avoid such rest periods when planning must expect to come across the
duty rosters. creatures that live there; namely
Military Fast Jet traffic.
************ However, if we all adhere to the rules
Interceptions - A Military and apply common-sense, we can all
Response get the job done safely.
As an operational Tornado Pilot, I ************
could not let the comments of the
retired ATCO, printed in the July
Maximum Duty Limits
issue of FEEDBACK, pass without Your report headed "Maximum Crew
trying to restore some balance to what Duty Limits" in FEEDBACK July 1996
is a very emotive issue; namely Civil raised an important area of
and Military traffic in open FIR. interpretation. While I remain a
While endorsing Gp Capt Gooding's supporter of your good work and your
statement that interceptions are not publication, I fully concur with the
authorised against civil air traffic, I sentiments expressed in the report
would add that actual infringements and wish to take issue with the CHIRP
are extremely rare. I use the word comments that followed.
actual advisedly. While the ATC Based around a normal, average
standard separation is indeed working week of 40 hours, an upper
5nm/1000ft, when flying VFR the limit of 55 hours a week would not
minimum separation required is seem unreasonable. I firmly believe
1000ft vertically from other aircraft. that this limit applied to a period of
Thus I am perfectly entitled to fly VFR seven consecutive days was the
1500ft directly below a civil aircraft in original intention.
open FIR, but considering that
However, by using the literal
prospect must indeed cause Civil
interpretation of a week, as only
"neck hairs to elevate".
applicable from a predefined day, CHIRP does not support unsafe
operators may abuse the scheme and practices.
roster duties far in excess of 55 hours
The difference in the definition of
in a seven day period. In fact, rosters
'Maximum Duty Hours' between fixed
of 90 duty hours in a seven day period
and rotary wing is as stated and is a
can be legally written using this
deliberate difference in CAP 371 policy.
interpretation. The 95 duty hours
limit in two consecutive weeks is CHIRP has represented the view of this
technically achievable in just eight reporter and others in recent
days! discussions with CAA (SRG), in that the
Having flown to the limits of CAP 371 different definitions are inconsistent.
for many years, I know such rosters We strongly support the adoption of the
would be unflyable and completely rolling limit definition for fixed wing
unsafe. Even nurses and junior operations.
doctors would think twice about As stated in the last issue, any
working such practices. evidence of significant abuse in relation
Now, if the current (mis)interpretation to the calendar definition should be
of maximum duty hours in a week can forwarded to Captain John Mimpriss
be proved to be inherently unsafe and Chief Flight Operations Inspector CAA
illogical (as I believe it can), then the (SRG). CHIRP also remains available to
only logical conclusion is to interpret assist in specific cases.
the limit in its wider sense of seven ************
Indeed, CAP 371 itself is far from
consistent in its use of words with I was most interested in the
regard to hourly limits. In the case of correspondence in your last issue re:
flying hours, 28 consecutive days are LOFT. As far as I am aware the term
used, NOT four weeks. is self explanatory, but I do not know
of any formal definition. In my
To quote the corresponding section opinion LOFT should be considered as
relating to cumulative duty hours for an integral part of CRM (Crew
helicopter pilots, (Appendix D, section Resource Management).
22.1 page 84) …
Your writer is quite correct in
"Maximum duty hours shall not suggesting that multiple emergencies
exceed 60 hours in any seven are a rare event in practice, but crews
consecutive days and 200 hours in are nonetheless required to be
any 28 consecutive days." competent with any situation that
If the intention is for helicopter pilots may arise on the line. There is
to limit their duty hours in seven therefore every need for the six month
consecutive days, why should other 'Competency Check' in which the
pilots be treated differently? simulator is used only incidentally for
'simulation' and more realistically as a
I firmly believe the true meaning and procedure trainer.
intent of CAP 371 is clear that all
weekly limits should apply to any On the flight deck, however, as in life,
consecutive seven day period. It is many situations arise where, at the
regrettable that in this instance the point of decision making, there is no
CHIRP position would appear to right or wrong answer; the decision,
support an unsafe practice, condoned having been made, has to be carried
by the CAA, and readily abused by through to its conclusion, or perhaps
commercially focused operators. modified as circumstances dictate,
and it is then that the individual will
demonstrate his/her ability to Ground Controller to contact Tower
successfully manage the resources Controller.
available in the cockpit. Subsequent
Workload quite high, busy with both
discussion and analysis, if
arrivals and departures, so did not
approached in the correct frame of
make any transmissions to the two
mind by both the instructor and the
aircraft entering the holding area.
participating crew, can be of the most
Obviously both crews felt they had the
enormous value in enhancing the
'right of way' as both had their
airmanship not only of the crew but
illuminated route into hold, so
also the instructor. To me it is quite
continued as per normal only
appalling that any such exercise, even
expecting to stop when they had a red
badly conducted, should be looked
upon as a "career stopping hoop",
perhaps your writer should reconsider Suddenly they both see each other as
his own attitude towards training conflict, slam on the brakes and query
which, at none too little expense, is who is first. I say "Normal rules
being provided to enable him to be a would say traffic on left to give way to
better pilot. that on right". "But I'm overtaking him
and have the greens" says one on left.
Having said that I must admit that in
my considerable experience as a I retreat to read the ANO (Air
training captain and simulator Navigation Order) and think about the
instructor I have encountered many latest ATC instruction and whether
training staff who either have the it's a good idea to have all the green
"trapper" mentality, or whose idea of routes on around a holding area at
LOFT is merely to use most of the same time.
Competency Check emergencies, but Pilots and controllers be warned -
to let the pilot land somewhere else! I don't get too locked into the office and
would submit that LOFT should keep a good look out!
always exercise the "little grey cells",
should concentrate on developing ************
CRM capabilities, and should What you heard is not what I
incorporate all the
paperwork/planning that is an
integral part of line operations. I The aircraft made a somewhat garbled
certainly see no reason why the actual initial report on frequency at FL370.
'flight' time should exceed 1-1½ hours Controller mistakenly replied
per pilot. "Maintain FL330" to which the aircraft
responded "Roger to maintain 330"
Whilst correctly performed emergency
again a little garbled. As the A/C
drills certainly have their place,
passed FL360 in descent the
expecting to find decisions made by
controller queried the descent. A/C
reference to the Company SOP
replied "Descending as instructed to
qualifies the pilot for the Pavlov school
330" … "but you weren't cleared … "
"You cleared us for descent…" etc etc.
It appears that North American areas
ATC Reports when given "maintain" at a different
level read it as "descend to and
Right of Way? maintain". The danger is obvious.
A busy airport, weather fine, aircraft This is not an isolated event.
following the green taxiway lighting
system towards the holding area for ************
the departing runway, instructed by
North Sea Congestion Eastbound Airways traffic routes
through the FIR to join the Eastbound
Whilst working a helicopter operating
Airway 30nm NE of XXXX.
from Platform AAA, I noticed
conflicting fast moving traffic come There is Northbound Airways traffic at
into radar cover from the east at FL60 which I am working. An
similar level to the helicopter. Danger Eastbound Airways departure is filed
area DXXX was notified 'Active' (5000 XXXX to join the Eastbound Airway at
to 55000ft) but these unknowns were FL90. The departing traffic is cleared
between 2000 and 3000ft. Due to the to climb to FL50, and climb when
extreme range it was necessary to instructed by radar to FL90.
relay my messages on this conflicting The QNH is 975mb thus the lowest
traffic through another helicopter. Flight Level in CAS is FL55 but FL45
Several contacts that I presumed to be outside.
military aircraft were observed The departing traffic leaves CAS and
operating beneath DXXX in areas shortly after reports (apologetically)
where commercial helicopters levelling at FL51 as he was using
routinely fly to platforms. What is the altitude until above 4000'. So, OK, I
use of declaring a danger area active if had 900' (and 4nm), but what if the
the traffic using it operates beneath? conflicting traffic had been at FL50 in
I feel there is an inevitability about the FIR, the departing traffic cleared
this practice which does not bear to FL40 and he had done the same
thinking about, when challenged the thing ?
response is always "It's Class G Now who is to blame, the pilot?
airspace - See & Avoid". Possibly, but the situation is
Finally MOR's receive a similar confusing, particularly early in a
response - "why file this report?" flight. Am I to blame? Certainly I am
aware of the low atmospheric pressure
It is not necessarily the case that
and its effect on Flight Levels but to
military aircraft operating in the vicinity
what level should I have cleared the
of a Danger Area have unrestricted
departing aircraft, 4000ft? This has
clearance to operate in that Area. been done previously and it resulted
These aircraft must therefore transit in a GPWS alert which was the
either under, or around, the protected subject of an MOR.
There is a simple answer to minimise
The problem of maintaining safe these kinds of incidents and that is to
separation between commercial have the same TA over the whole of
helicopter operations and high speed the UK (or Europe) to cope with most,
military aircraft in areas outside if not all of the terrain separation
Controlled Airspace remains one of the problems.
most important issues for those
charged with the management of UK The higher Transition Altitudes (TA) in
Airspace. Terminal Control Areas are normally
required to segregate outbound traffic
************ flows from the lowest terminal holding
Transition Altitudes level for inbound traffic. In other
Control Zones/Areas the TA is
The Transition Altitude (TA) in XXXX determined by local operational
Class 'D' airspace has recently been requirements.
raised to 4000', outside this airspace
it remains 3000'. The Class 'D' Within the UK FIR the TA of 3000ft
airspace is quite small. Departing AMSL conforms with ICAO PANS-Ops.
I am advised that the UK policy is to Separation standards are necessarily a
seek a progressive standardisation of compromise between traffic flow rates
TA's. and absolute wake avoidance.
Research in the United States has
This type of incident is frequently the
shown that in calm atmospheric
cause of level violations. Pilots should
conditions, vortices developed by some
be reminded that since 1994, the UK
large aircraft, usually when flying in
procedures on setting altimeters were
high lift configurations, may continue to
simplified as follows:
exist with significant velocities at
"Within Controlled Airspace...... ranges up to 10 miles.
When cleared for climb to a Flight
Level, vertical position will be *****************************************
expressed in terms of Flight Level,
unless intermediate altitude Flight Deck Reports
reports have been specifically CHIRP Comment
requested by Air Traffic Control."
(UK AIP RAC 2-2 Para.5.1.4) Accidents are rarely the result of single
causes, but often are caused by a
************ number of different but related
influences, which act in combination to
Although not within the strict definition form a chain of events that can lead to
of a Human Factors issue, the following an inevitable conclusion. The detail in
incident report has been included in the following report has been published
order to maintain an awareness of this with the approval of the author and the
important issue. operator.
Wake Separation That Sinking Feeling
While working as a Radar Controller Good VMC en route base from the ***
in a busy Terminal Area I was handed rig in the cruise 2000ft. Acting as
an outbound B767 by an Approach PNF (Pilot Not Flying).
Controller climbing about eight miles
behind a descending wide-body which Hydraulic System Warning lights
was positioning downwind. About 30 appear in sequence, indicating an
seconds later the B767 crew reported imminent total loss of the Left
a shock which they first thought to be hydraulic system. *** PF (Pilot Flying)
a major airframe problem. After was hands-on and suggested the YYY
checking the aircraft and controls platform as a suitable diversion. I
they concluded that it was an agreed.
externally produced shock of very I attempted to establish R/T contact
violent magnitude. They reached their with YYY without success, also failed
destination without further incident to re-establish contact with *** rig.
as far as I am aware. Still no answer from YYY. Meanwhile
The only possible explanation I can I continued to monitor the Hydraulic
find for a shock like that, was the Pressure. Both systems in the 'green'
wide-body running eight miles ahead. and *** was happily flying AP out. I
This is well above normal separation did not declare an emergency as we
minima but I am forced to assume were flying in VMC and there were no
that the arriving aircraft was signs of fire, I knew I would raise the
decelerating and deploying all manner YYY somehow as there was lots of
of spoi1ing devices which (on what traffic around. Finally I called
was a still day) produced very another aircraft and asked him to
disturbed air. raise the YYY on marine frequency.
Back in the cockpit the Left and The engineers arrived, replaced the
Auxiliary Hydraulic Pressure went to union, replaced the hydraulic pump
zero. It all went just like the and told us that as well as the union
simulator. Very reassuring. having failed there was also damage to
the hydraulic pack indicating there
I picked up the Emergency Checklist
had been an overpressure. *** and I
and using the thumb index managed
were concerned that the amount of
to open it at "Double
overpressure that blew a solid union
Transformer/Rectifier Failure". Re-
apart could also have done other
selected and started reading, as one
does at the top left of page "R/H .. "
etc. Finally I found "Complete loss of FLASH BACK - Back to the first start
L/H pressure" and carried out the up of the day, as *** turned the first
checks by the book. Down to "Land booster pump on we both heard/felt a
as soon as possible" at this point there clunk which we knew was not a
was a line across the page so I put the booster pump!
checklist down. It was a lot easier to
Back to YYY rig. The engineers had
pump the gear down in the aircraft
fixed it, so I supervised the deck crew
than the simulator. I turned off the
in manhandling the aircraft back to
auxiliary pump as required although
the centre of the helideck. I saw *** in
it was not on the checklist.
P2 seat and asked him to move to the
By this time we are on finals for YYY, P1 seat so he could operate the toe
we had spoken to them, the deck crew brakes. He did this by shuffling his
are on their way up and it's time for body across the cockpit as the deck
me to give my final excuses for the crew were milling around the cockpit
possible wobbly landing to the doors.
passengers. It was a superb landing!
Once into wind on the helideck it was
It was reassuring as we landed to see
time for a one minute ground run.
the standby boat all prepared, fast
The nose wheel was off centre and we
rescue boat and scramble nets
used external power. I did the walk
round while *** did the cockpit
We shutdown, off-loaded the checks. Then I got in, checked with
passengers, phoned base and climbed *** that he had done the checks and I
up to see where all the oil was leaking did a visual look round the cockpit.
from. I found a little disc of metal that Whilst I did the control check I
had been blown (fractured) out of a noticed that the external power was
union. I contacted engineering to off, so we got it turned on. When it
advise the details of the failure and was, there was a solid "clunk" and we
organised the deck crew to manhandle delayed the start for a few moments
the aircraft to the edge of the deck. whilst we discussed it. Remember we
had just had a hydraulic failure in
*** and I were quite pleased with
flight plus a "clunk" before start at
ourselves, we decided that we were
base. As there was nothing
both more than happy with the way
apparently wrong we decided to
we had handled the situation. I had
continue with the ground run.
even managed to work the GPS to get
us to YYY (not that we needed it!) Yes we are in the kneeling position -
so what? I had done a start in this
While we waited for the cavalry (a
position before (someone had
helicopter full of engineers) we cleaned
inadvertently lowered one down
up all the oil, had lunch and promised
overnight and I started it for them).
the OIM we would be off his deck in a
On type conversion we had taxied and
shut the aircraft down kneeling and
been told that it could be treated as I started #1 up to flight idle, all
normal. Technical training was that temperatures and pressures OK.
all the logic circuits still recognise the Nothing abnormal. Started #2. Just
'ground' condition whilst kneeling so I as I was advancing to the flight idle
am happy to start with AMBER - gate the aircraft started to move
GREEN - AMBER indications. forward and down. My only thought
was to let it sink under control so it
FLASH BACK - Back in February, I
stayed upright and to stop the rotors
was P1 in the SIM, the P2 is doing P1
as quickly as possible. There was a
under instruction. I'm PF he is PNF,
lot of grinding, grating and crunching
dealing with an undercarriage fault.
noises as it went down but no panic!
Out of the corner of my eye I notice
that he keeps screwing it up by After we had shutdown and *** had
pumping the gear down with it left the cockpit, I noticed that the
selected DOWN, I did not allow myself emergency undercarriage handle had
to be to distracted whilst as PF but been returned to the NORMAL
three times said "Put the gear up, position. My first thought was that
read the checklist and start again!" this was the sole reason for the
Now I know that the circumstances undercarriage retracting. *** had
were different but the impression left pushed it down as he had shuffled his
on my mind was that it was normal to body across the cockpit!
select UP to pump the gear down. (It
So what had gone wrong? In the
is foreign, after all!).
subsequent investigation, the FDR
As I pressed the starter button the showed the undercarriage logic
external power dropped off line and as reverted to the IN FLIGHT mode before
usual all the warning lights dimmed. I I shutdown on the initial landing and
did notice that the AMBER - GREEN - the rest you know but…
AMBER undercarriage lights were
*** and I were in a confident mood, we
either so dim I could not see them, or
were pleased with the way we handled
the hydraulic failure and the resultant
Eyes now returned to the hydraulic sorting things out… were we too
pressure increasing. We ran at flight hasty? Over confident? I was quite
idle for about one minute with all happy to start in the kneeling position
indications normal except no - the Guru of the type had told me it
undercarriage position indications, was okay. I was perhaps overconfident
but also no abnormal gear warnings. having done it before - a little bravado
The aircraft was stable in the kneeling perhaps!
I was happy with the position of the
We shutdown with no problem, got undercarriage selector and emergency
out and had a chat with engineers handle after I had done the checks - it
about everything that had happened. was okay on the LOFT exercise and in
Everything "on top" was okay so it was accordance with the checks!
decided to go for a 10 minute ground
We were both very concerned about
run. We intended to lift into the hover
what had caused the hydraulic
to return the gear to the normal
failure, even though it had been fixed.
position during this run.
Were we distracted?
*** got in whilst I did another walk
I am more than happy to allow the P2
round. The aircraft was in the same
to do the cockpit checks - he after all
configuration as during the previous
trusts me to do the walk round - it
ground run so I felt happy to start it
was for a ground run after all. Were
we both complacent?
When the undercarriage indicator GPWS - True or False?
lights went out during the first start
I have buttoned my lip for some
had they just dimmed with the
sixteen years and as a management
external power dropping? By the time
pilot I have always toed the party line,
I knew they were out we were at
but now feel the time has come to
flight/idle with everything OK.
speak out, if only to see if others
The second start was only a repeat of within the industry may share my
the first. Nothing had changed, so reservations.
there was no need to do all the nine
Put simply, the GPWS (Ground
yards The rest is history.
Proximity Warning System) as fitted to
Now over to the reader - at what stage aircraft I have flown has given literally
would you have a smelt a rat and hundreds of warnings (false, nuisance
been alerted to the fact that and genuine) mostly at a critical
something was amiss? That is a phase of the flight i.e. during the
question I cannot answer for you, as latter part of the descent or on the
we obviously were not. With approach.
hindsight, the first stage should have
On subsequent investigation not one
been the BEFORE START checks. I
of them has provided any useful
should have been more conscious that
information. They have all, by
being in the kneeling position needed
definition, caused an intentional
extra thought. Before the second start
distraction to the peace and calm of
I knew the undercarriage indicator
the flight deck at a time of high
lights were out and accepted that the
concentration. On at least one
aircraft logic circuits would not allow
occasion false warnings have led to
the gear to come up……… Oh and the
multiple go-arounds in good VMC.
big "clunk" before the first start………
Mode 2A nuisance advisories are such
(l now believe it was the nose wheel
that radar descents have to be
declined in certain areas, or in one
Two principal technical issues provided case speed reduced to approximately
the enabling factors that led to this 150 knots on the downwind leg of a
unfortunate occurrence. First, the radar circuit while still some 20 miles
Emergency Procedure in the Checklist plus from touchdown.
did not include the action to select
Although I am entirely in favour of any
NORMAL gear DOWN after pumping, as
system which helps to prevent CFIT
is required and is stated elsewhere in
(Controlled Flight into Terrain)
the Checklist. Secondly, the gear logic
incidents (what about GPWS for single
circuits reverted to FLIGHT mode, and
pilot IFR operations?) and I know
thus removed the 'on ground'
there are some improvements in the
protection. Interestingly, the technical later versions of GPWS, the whole
reason for the logic reversion has not issue seems to need a complete
been clearly established by the overhaul. I should like to see the
manufacturer. following points carefully considered
The important point is that, in spite of when mandating the use of GPWS,
the technical deficiencies, the accident with software developed which is
could still have been averted, but as in relevant to the type of operations
many other accidents the indications of planned:
impending disaster were overlooked. 1. Aircraft handling and performance
Would you have been wiser? characteristics.
2. Other advisory/warning systems prudent, the Captain elected to take
built into the aircraft (with MEL the company fuel figure.
At this time of night considerable
3. A GPWS airfield categorisation (with traffic departs from the Far East for
software selectable by the crew prior Europe at the same time, using
to descent). similar aircraft and converges over
Northern India. There is little radar
4. IMC/VMC switching, available to
coverage and poor/non-existent
communication between FIR's (Flight
5. Commander's authority over Information Regions). Separation is 15
GPWS. or 20 minutes between aircraft on the
It is sobering to reflect that accidents same track at the same level and it is
resulting from CFIT remain one of the not unusual to be assigned a flight
most significant single cause of fatal level considerably lower than
accidents in the air transport industry. optimum. This flight was no
A recent study of CFIT accidents states exception and after a long period at
FL260, FL310 was obtained with little
that in eight accidents, which occurred
hope of FL350 as a Far Eastern
between 1988 and 1994, there was no
carrier was immediately above us at
crew reaction to a GPWS warning.
FL350, also operating into a UK
Moreover, false GPWS warnings have
destination. Our routing was
been, and continue to be, a major
standard to Europe via the CIS. The
source of criticism and one which tends
fuel situation at this point was not
to degrade confidence in the adequacy
looking good to make London and the
of the system.
Captain was becoming most agitated
Some readers will be aware of the to get FL350. Some time later, the
development of Enhanced GPWS to Far Eastern carrier at FL350 seemed
overcome the limitations of to have 'disappeared' on a divergent
existing equipment. However, routing. After much negotiation partly
current standards of equipment on VHF and partly on HF with 'XXX'
will remain in service for many ATC, the Captain negotiated climb
years. clearance to FL350 but by now we
were quite close to the FIR boundary.
************ I expressed some doubts as to the
A Question of Pressure? longevity of this climb clearance, as
we would be bound to meet up with
Long haul sector Far East-UK. Senior the Far Eastern carrier again to cross
Captain, but previous experience the CIS. I also turned on the Landing
mainly in the short haul lights for the climb. This action was
environment. immediately countermanded by the
The fuel plan from the company was Captain quoting a recent notice from
extremely lean using optimum management about the cost of light
cruising levels throughout with no bulbs and the recommendation that
holding and short range London they should not be used above 10,000
diversion, even though Prob 40 (40% feet. This notice also covered the use
Probability) fog forecast at destination. of the Logo lights.
The fuel plan did contain the standard As we crossed the FIR and reached
five percent contingency but reduced FL350, the TCAS (Traffic Collision
by using a European alternate en- Avoidance System) Alert went off and a
route. Despite a discussion as to target also at FL350 closing rapidly at
whether a little extra fuel would be 90 degrees to our track was noticed.
Out of the window with Landing and
Logo lights ablaze could clearly be We boarded our passengers so that we
seen our Far Eastern carrier at eight could de-ice when the airfield was re-
miles closing. The controller opened, but we heard comments from
seemingly had no knowledge of the the runway-clearing crews on the
other aircraft at all and was very radio that it was taking longer than
agitated to receive his position report expected as the snow was falling and
at the same level and his ETA at the lying as they were clearing it.
next reporting point one minute later
When the airport re-opened some 40
than our estimated time. The other
minutes later 'XXX' called for start
aircraft's route had been unusual but
almost immediately. As he was
as predicted had rejoined our own
parked the other side of an aircraft on
an adjacent stand, we could not see
Due to the unexpected arrival of the the aircraft directly but we were
other aircraft, he was forced down to impressed with his timing of his
9600m and we were allowed to de-icing. He then pushed-back,
continue at 10600m (FL348) thereby taxied out and took-off, still in falling
saving my Captain a refuelling stop snow.
and our flight continued to a Cat 3
We were at the back of the queue for
Autoland in 250m RVR (Runway
de-icing and, by the time we had been
Visual Range) at destination. As far as
de-iced and called for start, the
I know, our Far Eastern colleague
airport had closed again for snow-
Subsequently I did not get much rest
Due to the ensuing weather delays we
in-flight, going over the
were unable to complete our schedule
aforementioned events in my mind
and during the nightstop discussed
many, many times and the large
the events of the day with another
number of Human Factors
crew similarly placed. The crew had
contributing to this incident and what
been parked on the next stand to
could have happened if we had met a
'XXX' and surprised us by saying that
few seconds later at the FIR
he had not got his de-icing time right -
Boundary, or if TCAS had been having
he hadn't de-iced! They said that the
one of its bad days?
crew had simply looked out of the
This incident also caused me to reflect flight deck window, closed the
on the company's notice regarding windows, and called for start!
Landing and Logo lights, which are
I subsequently spoke to ground
often the last line of defence in 'dodgy'
engineers at the airport, who stated
ATC areas. Strobes are OK but it is
how difficult the de-icing had been
often difficult to see exactly where the
that night, especially as aircraft had
aircraft to which the strobes belong is
accumulated large amounts of snow
and where it is going!
on the tail that had slid down from the
fin. They confirmed that 'XXX' had
been de-iced, but much earlier in the
Winter Approaches! day before the first closure.
En route to our destination, we were The additional frustrations that result
advised that the airport was closed from the delays associated with winter
due to recent snow, but fortunately it operations are well known, and yet
re-opened before we commenced our these, in combination with commercial
approach. We landed at about and other pressures, can and do lead
1630hrs in falling snow and about 15- crews to make injudicious decisions,
20 minutes later the airport closed sometimes with tragic results. If in
doubt play it safe. Remember, no one
will thank you if you get it wrong.