Light Aircraft crash at Blackbushe.
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An excellent summary of the facts by the AAIB.
However, the mystery is why, with everything going wrong around him including a microlight on the downwind leg, did a 11,000 hour pilot continue on an approach which was bound to end badly?
However, the mystery is why, with everything going wrong around him including a microlight on the downwind leg, did a 11,000 hour pilot continue on an approach which was bound to end badly?
de minimus non curat lex
Threat and Error..............
No doubt the shrinks will analyse the data, and tell us just what it is that makes an experienced pilot continue the approaching and landing, knowing that the outcome is looking worse by the second.
It is easy to sit in ones armchair and pontificate as to how this can possibly occur. Easy in the cold light of day.
Unfortunately it is unlikely to be the last accident of this type to occur.
Juniorbird men need to read this report and apply the threat and error management theory to it.
A lot to be learnt from it.
It is easy to sit in ones armchair and pontificate as to how this can possibly occur. Easy in the cold light of day.
Unfortunately it is unlikely to be the last accident of this type to occur.
Juniorbird men need to read this report and apply the threat and error management theory to it.
A lot to be learnt from it.
On the Swiss "flightforum" (Flightforum.ch) the user "FalconJockey", an airline pilot, has written on Aug 1, 2015, at 12:03:
"Bin gerade in Milano Malpense. Das Flugzeug ist hier gestartet und das FBO hat mir berichtet, dass der Pilot gestresst gewesen sei, alles musste schnell, schnell gehen. Die Passagiere, der Bin Ladin Familie zugehörig, wollten ohne Verzögerung los."
Translation:
"At the moment I'm in Milano Malpensa. The airplane was starting from here, and the FBO told me, that its pilot had been stressed / under pressure. Everything had to go really quickly. The passengers, members of the Bin Ladin family, did want to leave without delay / as soon as possible."
Link:
31.07.2015 | Phenom 300 | HZ-IBN | EGLK | Absturz auf Parkplatz - Vorfälle/Unfälle - ILS Flightforum
Stephan
"Bin gerade in Milano Malpense. Das Flugzeug ist hier gestartet und das FBO hat mir berichtet, dass der Pilot gestresst gewesen sei, alles musste schnell, schnell gehen. Die Passagiere, der Bin Ladin Familie zugehörig, wollten ohne Verzögerung los."
Translation:
"At the moment I'm in Milano Malpensa. The airplane was starting from here, and the FBO told me, that its pilot had been stressed / under pressure. Everything had to go really quickly. The passengers, members of the Bin Ladin family, did want to leave without delay / as soon as possible."
Link:
31.07.2015 | Phenom 300 | HZ-IBN | EGLK | Absturz auf Parkplatz - Vorfälle/Unfälle - ILS Flightforum
Stephan
If it helps with the "did-they-attempt-a-go-around" debate (though I suspect it won't), a closer look at the data we captured shows that the final 3 position plots were approximately 65m, 680m and 850m beyond the 25 threshold, separated by gaps of 8 seconds and 3 seconds respectively.
The transmissions imply that the aircraft was airborne at each of those 3 points (our antenna can't normally detect aircraft 7nm away on the Blackbushe runway), but clearly that's not enough data to construct a deceleration profile, nor to deduce where the Phenom may have touched down and/or become airborne again.
The transmissions imply that the aircraft was airborne at each of those 3 points (our antenna can't normally detect aircraft 7nm away on the Blackbushe runway), but clearly that's not enough data to construct a deceleration profile, nor to deduce where the Phenom may have touched down and/or become airborne again.
So what, please, have a microlight and a biz jet to do in a circuit at the same time??
It is of course also an AFIS environment, so the guys in the tower can't impose deconfliction.
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Likely multiple frequency changes in a tight bit of uncontrolled airspace while integrating in to a non-ATC pattern with the likes of microlights buzzing around sends chills down my spine - particularly if flying a jet. As does the idea the CAA are considering permitting instrument approaches at aerodromes without ATC in the future...but that's a different story altogether.
Had there not been an accident at the end of it, I would be interested to see what the airprox board would have made of the join v a microlight apparently relatively close by in the circuit.
Had there not been an accident at the end of it, I would be interested to see what the airprox board would have made of the join v a microlight apparently relatively close by in the circuit.
Last edited by EbonyGrove; 6th Aug 2015 at 19:16. Reason: further thoughts.
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I doubt that there are many pilots out there who have not pulled off a reasonable landing from a bad approach for whatever level of their experience. The more you get away with, the more you are likely to attempt.
How many times had this experienced pilot achieved this; how many times had he ignored TAWS and visual warnings (6 of the former in this case) because 'he knew better' and no-one had been any the wiser and nothing bad had happened?
He was on his own, with (as far as we know) nobody next to him to interject to break the confirmation bias. I don't believe that multi-crew will always prevent poor decision making or teamwork (look at the AAIB report on the BA A320 engine cowling incident for evidence of that), but I can't help thinking that if there had been public-transport stabilised approach limitations in place and another human voice suggesting that this was not going to work, the outcome might have been different.
1200ft AGL, 3000fpm ROD and 150KIAS at 1.2nm from the threshold, irrespective of the LDA, would give even this turboprop pilot an inkling that going around for another try was a good idea!
How many times had this experienced pilot achieved this; how many times had he ignored TAWS and visual warnings (6 of the former in this case) because 'he knew better' and no-one had been any the wiser and nothing bad had happened?
He was on his own, with (as far as we know) nobody next to him to interject to break the confirmation bias. I don't believe that multi-crew will always prevent poor decision making or teamwork (look at the AAIB report on the BA A320 engine cowling incident for evidence of that), but I can't help thinking that if there had been public-transport stabilised approach limitations in place and another human voice suggesting that this was not going to work, the outcome might have been different.
1200ft AGL, 3000fpm ROD and 150KIAS at 1.2nm from the threshold, irrespective of the LDA, would give even this turboprop pilot an inkling that going around for another try was a good idea!
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The Airprox Board would probably have assessed the actual risk of collision with the microlight (not definable from the info in the AAIB report) and put the cause as something like: "The Phenom pilot did not integrate himself properly into the aerodrome traffic pattern and flew into conflict with the microlight".
The clues were there already..
The clues were there already..
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Pressing on to 1200' at 1.1nm and Vref +38KIAS, in a civilian transport jet, in good weather. The only thing to learn here is not to be a ct!
@ATC: you don't need an Mode S for a TA/RA, regular XPDR is enough.
I wasn't there, but if the "microlight" was one of the C42 (Ikarus) based on the field with Clearprop, they regularly paint on FR24 so must be appropriately equipped.
If ever there was an accident that should have never happened, surely this is it.
If ever there was an accident that should have never happened, surely this is it.
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Biz jet owners & clients can be very difficult people to deal with. Who knows what time pressures he may have been under on this flight & what history there was between him & the people down the back.
Could be nothing. Could be everything.
Could be nothing. Could be everything.
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Hmmm, there by the grace of God. I'm sure there are other SP people out there who can recognise the scenario. Long day, a bit behind the drag, into the circuit with rather to many Joules - no problem, can get that sorted downwind. Bitching Betty/Moaning Minnie starts chipping away about traffic which you can't see, the RA cuts in and then 'changes' it's mind. Before you know it you're on final, not configured, too fast, to high ,T'rian Tammy now joining the cacophony and your punter doesn't do delay.
Absolutely no 'excuse' for landing in the wrong touchdown zone but........
Absolutely no 'excuse' for landing in the wrong touchdown zone but........