Beyond belief

[jollyrog]

This was published today.

http://www.aaib.gov.uk/publications/bulletins/december_2007/piper_pa_28_140_cherokee__g_bbbk.cfm

[Superpilot]

Here's a similar accident from 10 years ago.

http://www.aaib.gov.uk/publications/bulletins/november_1997/piper_501911.cfm

Both are a vivid depiction of press-on-ititis.

[moggiee]

Not beyond belief at all - in fact all too believable (and all too common).

Look at the lamentable list of failings:

1. No serviceable nav kit.
2. Not IMC rated yet took-off into IMC!
3. Didn't check the weather before setting off from Exeter.
4. Planned to land in IMC at Blackpool, after sunset (although it's not officially night until sunset + 30 minutes).
5. Didn't carry enough fuel to get to an alternate airfield.
6. Either didn't check or didn't understand the Blackpool ATIS.
7. Apparently got no advice, or got bad advice, from someone who had nearly 1800 hours on a (lapsed) BCPL.

I know that we should not expect too much from low hours pilots and relatively inexperienced BCPL/CPL holders but this is truly dreadful. Anyone with a degree of common sense and half decent training should have been able to work out that Blackpool was unfit.

It also raises questions about the FTO that let him have the aeroplane. Whilst the arrangement was a "private" one, and responsibility for adherence to the rules and regulations rests with the aircraft commander, you do have to ask what advice was given to them by the FTO/acting CFI? You have a moral, if not legal, responsibility to attempt to persuade them not to go. They could, of course, have refused to hire the aeroplane out to them. Poor supervision, I'm afraid.

[Sky Wave]

26 years old, Very Sad.

Hopefully others will learn from this.

[jollyrog]

Not just "pressonitis" - it was the bit where he took off into a 200-300ft cloud base without an IMCR/IR that amazed me. Everything that followed just seemed to be compounded stupidity with an inevitable conclusion.

I'm a low hours PPL and I'm pretty sure that at my airfield, they just wouldn't let me do that. Someone would stop me. Earlier this year, the admin (not a pilot as far as I know) wasn't sure it was a good idea for me to go up and sent an instructor out to speak with me whilst I was prepping the aircraft. Following discussion, we agreed it was OK to fly as planned, but the point is, people were watching me, they cared and were paying attention.

In this case, his CFI seemed to arrange and encourage the flight. Not exactly an advert for that FTO.

[clearfinalsno1]

Yes, very very sad. For all PPLs the AAIB report is essential reading.

I remember the accident happening. Reported here:
http://news.bbc.co.uk/1/hi/england/lancashire/6329637.stm

[Life's a Beech]

I worked for a flying school that was not bad, but far from the most careful or strict I ever came across, especially under my first CFI. However they would never have allowed, let alone encouraged, anyone to take off in a Cherokee 140 with 4 adults on board! Full fuel just compounds the stupidity. Encouraging a basic PPL holder to fly into IMC, when it was clear that VFR flight was impossible, well it beggars belief. Even that CFI, who flew some marginal VFR himself, would not have flown VFR much less allowed a hirer to fly in the conditions (hirers were monitored until the club was happy, usually 100 hours or so. Other clubs they are always counter-signed).

Check weight, check fuel, check weather. Every flight.

[eharding]

I'm confused: is this the

a) "I've got sod-all hours, but I'm glad the flying club administrator keeps me on the ground so I can spend more time posting holier-than-thou finger pointing threads on the Proon" thread...

or the

b) "Call me Nostradamus, but 4 up on a warm day in a Cherokee 140 filled to the gills with fuel isn't a good idea" thread?

I might have misread the timbre of the postings above, but personally picking out an AAIB report and crowing over the findings doesn't strike me as a productive, or tasteful, exercise.

[kiwi chick]

What an interesting read.

I was going to say "everyone can learn something from this" but I haven't.

[TheGorrilla]

Perhaps a more constructive thread involving an analysis of the commanders descision making processes and factors influencing the flight would lead to better feedback and contributions from other posters here chaps. The "I told you so" and "I wouldn't have done that" comments are nothing short of pointless.

Not much is beyond belief in aviation. This is no exception.

[moggiee]

I might have misread the timbre of the postings above, but personally picking out an AAIB report and crowing over the findings doesn't strike me as a productive, or tasteful, exercise.
Yes you have missed the point.

The AAIB report catalogues a series of errors which were completely avoidable if the pilot in question had been better trained, better supervised by the FTO which hired out the aeroplane or if he had just applied a little common sense.

For kiwi chick - there is plenty to be learned if your mind is open, not least of all for companies which hire out aeroplanes to inexperienced pilots. The FTO at which I work, for example, retains the right to refuse to let someone use one of our aeroplanes if it's inappropriate to fly.

For The Gorilla - let's look at those decisions then.

1. The decision by an inexperienced, non-IMC rated pilot to take-off from BPL in conditions that were below VFR minima shows a failure to understand (or adhere to) the limits for VFR flight.

2. The decision by the FTO hiring out the aeroplane to the deceased pilot shows a lack of appreciation by that FTO of the potential risks to which the pilot was exposing itself. It also shows a lack of regard for their duty of care towards someone using one of their aeroplanes - a point which I feel that the AAIB report glosses over.

3. The decision to set off from Exeter without properly checking the weather demonstrates either a lack of appreciation of the potential weather risks, a lack of regard for those risks, a rather poor standard of training or a plain, old fashioned lack of airmanship (or combination of several of the above).

4. The decision to leave Exeter for an airport with marginal weather without enough fuel to get to a suitable alternate airfield shows the same failings mentioned in point 3. In fact "marginal weather" is a charitable assessment - it was actually much worse than that.

5. The failure to check weather en-route quite possibly shows a poor standard of training - I am frequently surprised by the number of CPL holders who have never been made aware of the existence of the "VOLMET" system and the same applies to an even larger percentage of PPL holders. If the weather had been checked, then there would have been an opportunity to divert en-route to somewhere like Welshpool or Liverpool.

6. Failure to appreciate that it would have been better to conduct a Precautionary Forced Landing in a field in VMC to the south than a crash in IMC near home indicates a possible failure in initial training, recurrent training or airmanship.

These comments are not intended to be "holier than thou" but to point out some pretty basic failings in training, supervision and decision making. Poor decision making in the air would not have been an issue if the correct decision had been made on the ground - don't take off.

[neilmac]

Words really fail me! Im gobsmacked! Very sad 2 people lost their lives

The old question.....why? so many clues and people that could have broken the chain of events.

NM

[eharding]

"everyone can learn something from this"


Clearly so....

[TheGorrilla]

if the pilot in question had been better trained, better supervised by the FTO which hired out the aeroplane or if he had just applied a little common sense.


The FTO where the pilot learned to fly, the outfit renting him the aeroplane (where he probably did a check ride) and the examiner who last signed his licence obviously all thought he was trained well enough. As a licence holder you are accountable for you own decisions and should not expect to be "spoon fed" or abide by the descisions of an organisation when they tell you "it's ok to go, the ops clerk says so".

[Chuck Ellsworth]

involving an analysis of the commanders descision

Is a " Commander " the same as a pilot when referring to the person flying these light single engine airplanes??

Or does the term commander require some special training?

[TheGorrilla]

Yes the commander is a pilot.... Always the case in this country, except in the air force perhaps. A pilot is trained to be a commander in order to get his/her licence as part of the ppl/cpl training as a matter of course. No special training is required in addition to the normal licence requirements Chuck.

[Chuck Ellsworth]

O.K....it just seems a bit over the top to describe a private pilot as a commander but I guess that is the way it is........:ugh:

[moggiee]

The FTO where the pilot learned to fly, the outfit renting him the aeroplane (where he probably did a check ride) and the examiner who last signed his licence obviously all thought he was trained well enough. As a licence holder you are accountable for you own decisions and should not expect to be "spoon fed" or abide by the descisions of an organisation when they tell you "it's ok to go, the ops clerk says so".
As you should know, holding a licence does not necessarily give you all the skills you need. There are a great range of abilities and experience levels amongst PPL holder (indeed holders of all licences) and to simply say that he was a licence holder who had been checked out is a gross oversimplification and misses the point. The aeroplane owner has a responsibility to ensure that the hirer is properly qualified to use the aeroplane in the manner in which he intends. We check licences, medicals and ratings before we let someone loose in one of our aeroplanes - it isn't difficult to do and would have highlighted that the pilot was insufficiently qualified for the flight he planned to undertake.

The point in question is that regardless of whether or not the pilot is accountable for his own actions, the operator of the aeroplane has the right (some would say duty) to advise the hirer that what he intends to do is illegal. His decision to take off into IMC took him outside the privileges of his ratings and thus the FTO lending hi the aeroplane were complicit, given that they would have been aware of the weather at BPL at the time of take off.

If you lend someone an item or piece of equipment knowing that it is to be used illegally then the law regards you as an accomplice to that illegal act.

None of this is rocket science - it's just plain common sense.

[kiwi chick]

eharding....

I think you may be the only one who understood my comment. Maybe I was too subtle.

Moggiee
For kiwi chick - there is plenty to be learned if your mind is open

My mind is completely open and I never, ever stop learning. I thrive on learning.

I was trying to avoid slagging, but my point was there is nothing that I can learn from this because I would never ever be in that situation from the start.

I was gobsmacked.

[Say again s l o w l y]

Nah, it's just a nice phrase to work out who's backside to kick in the event of a problem!

Unfortunately this is an accident that was easily preventable and there are lots of things for people to learn.

The first one is use some commonsense.

It is a bit bad taste to throw rocks at someone who perished in an accident like this, but looking at the decision making processes and factors that caused this to happen are very worthwile.

My concerns aren't with the decisions made by the pilot. In my eyes he was very inexperienced and was easily lead by others which probably confused the whole go/no go decision.

The CFI should hang his head in shame really. With a forecast and conditions like that, it is criminal that he allowed a flight to go ahead, especially when the pilot was so far out of currency.

Madness and totally unnecessary.

[moggiee]

Is a " Commander " the same as a pilot when referring to the person flying these light single engine airplanes??

Or does the term commander require some special training?
It simply means "the pilot in command of the aeroplane". In this case, the pilot who was flying the aeroplane was licenced as a PPL holder, held a "Single Engine Pilot (SEP)" rating and had signed for the aeroplane - making him "commander" in the eyes of the CAA and the law.

The training and licencing system assumes that the pilot is also commander as it is a single pilot aeroplane.

[Chuck Ellsworth]

Yeh, moggiee, it just sounds weird.

[Contacttower]

Yeh, moggiee, it just sounds weird.


Well its the language the AAIB chose to use I suppose...

What they did was stupid...and the report does rather 'speak for itself' in that respect but to think what must have been going through their minds, the panic that must have set in as they realised that their chances of making a successful approach were almost nil and that they were running out of fuel....their last moments must have been terrible beyond words.

[KeyPilot]

A really shocking report. The young pilot was very foolish but was totally betrayed by several others who should have known better - one of whom also losing his life.

Does anyone know which FTO the aircraft was from?

[bjornhall]

Maybe the problem here wasn't insufficient training or supervision; perhaps the pilot had learnt too much.

Namely, that there is one set of rules you use in training and for check flights, and another, completely different set of rules you use "in the real world".

I can not imagine that there is any pilot who isn't taught during basic training that you don't fly in IMC as a non-rated pilot in a non-IFR aircraft. If the pilot considered flying under these conditions to be acceptable, then that is something he must have learnt after and outside of his PPL and ATPL training.

So maybe there isn't a lot we should learn from this accident after all ...

[englishal]

the operator of the aeroplane has the right (some would say duty) to advise the hirer that what he intends to do is illegal. His decision to take off into IMC took him outside the privileges of his ratings and thus the FTO lending hi the aeroplane were complicit, given that they would have been aware of the weather at BPL at the time of take off.
Rubbish.

There is an exam in the PPL called "Human factors and performance"....The pilot should have known about the aeronautical decision making process, and should have decided to stay on the ground....The FTO shouldn't have to spoon feed every baby pilot that walks through the door. Indeed the dispatcher may not even have known the pilots ratings......

Sorry that some people died as a result, which is very sad, but unless people learn from other's mistakes and have a bit of common sense then these sorts of accidents will continue. I think we'll see a rise in them with the end of the IMC rating....

[gasax]

This place is great at 'moral outrage' the finger pointing stuff. At the end of the day we have a very unforgiving hobby - as I tell my friends if iot all goes right it is pretty boring, if it goes wrong it very exciting, it is goes very wrong its nasty.

Callous though it may be this is evolution in action. As for the hirer or some other party being at fault? If you cann't take responsibility for your own well being and actions then you are not going to last long.

[wsmempson]

Wow!

A real cautionary tale with so many opportunities for problems, it does rather begger belief.

So, just to recap, A low hours pilot, who is arguably not current, takes off in an a/c that is over-weight and out of w/b, with no working nav equipment other than a hand-held gps, into IMC for which he is not rated. A braver man than I, and those are only the probems he had on the way out.

It does seem a bit surprising that a/ the training organisation let him go and b/ that his passengers (who were also pilots - one of whom was an ex-instructor) didn't stop him.

A genuinely tragic and avoidable accident.:confused:

[PompeyPaul]

what must have been going through their minds, the panic that must have set in as they realised that their chances of making a successful approach were almost nil and that they were running out of fuel....their last moments must have been terrible beyond words.
I agree, a very sad tail. The fact that the altimeter was set incorrectly also makes me think that panic had set in some time before the accident. I really feel for them. RIP

For the finger pointers, and "I would never do that" brigade, you should hang your heads in shame for some of your posts.

[FullyFlapped]

I've no particular desire to get myself or Proon on the receiving end of a writ, so I'll be careful what I say : but I do wonder what part money had to play in the tragic tale. I just wonder if there were any financial pressures on anyone to complete this recovery flight ...

This is also the second report I've read recently where wrong altimeter settings may well have played a part in proceedings. I don't quite understand how two pilots, actively considering very low flight, and obviously in decent verbal comms with ATC can have got that so wrong - even given that I can well imagine the increasing sense of panic which must have been setting in once they realised just how deep in the mire they were, poor souls.

Sad, sad, sad. RIP.

FF

[micromalc]

This is so sad on so many levels..my respects to the families.

[Superpilot]

A few people have touched upon how this is down to lack of training or poor awareness. If a person receives instruction and passes exams on the subject then the training cannot be blamed in anyway. Some people are completely aware of potential problems but take risks in the face of these. You might be the best taught pilot out there and completely aware of all the problems you could face but this does not make you a good pilot if you have the sort of mentality to take risks. Which is exactly what has happened in this tragic situation. This guy was being offered 4 hours in a PA28 for the cost of peanuts. This added to his determination. If you’re determined to go flying even if it’s a bad day then that is down to your own mentality, not always lack of training and poor awareness.

[A and C]

I shall say no more than this AAIB report will become required reading for my PPL students.

[BackPacker]

5. The failure to check weather en-route quite possibly shows a poor standard of training - I am frequently surprised by the number of CPL holders who have never been made aware of the existence of the "VOLMET" system and the same applies to an even larger percentage of PPL holders. If the weather had been checked, then there would have been an opportunity to divert en-route to somewhere like Welshpool or Liverpool.

I agree about checking the weather in general, but I doubt whether mentioning VOLMET is appropriate in this case. Yes, Blackpool is on VOLMET (London North 126.6) but at the low levels GA flies at, reception can be difficult at best, unless you are very close to the antenna. And even if you can get decent reception, it requires a second com box which, the way I read the report, this plane did not have, and it requires a few minutes of fairly dedicated listening to the detailed weather reports of some eight other airports before Blackpool comes up.

VOLMET has its place, but I think that place is in well-equipped (dual comms) aircraft, up high, flown by a single pilot with plenty spare mental capacity (ie. very current and in the cruise), or multi-pilot. For the rest of us, well, you can always ask for a weather report from whatever ATC unit you're talking to. Especially if you found during flight preparation, that the weather at your destination would be marginal.

[FlyingForFun]

What a tragic, senseless loss of life.

I wonder if I can throw some fuel on the fire, by suggesting that the "Commander" was maybe not as much to blame as some posters (and the AAIB) are suggesting?

The AAIB report suggests that the Commander may have thought that his "experienced passenger" was in fact an instructor. In which case, is it not likely that he thought that the "instructor" would be Commander of the flight? Especially since he was out of currency.

Now, the picture is rather different. Maybe the Commander knows that the flight is well outside of his limits, but he has an experienced instructor sat next to him. Maybe he believes that the flight is to be carried out IFR, with an instrument-rated instructor supervising him at the controls? Since he has no instrument training, he would not be expected to know what the instrument minima are, nor what equipment might be legally or practically required for an instrument flight. Certainly when teaching IMC rating or IR students I help them out with weather decisions at the start of the course (in the same way a PPL instructor helps his students out with weather decisions at the start of a PPL course), so it would be reasonable for the "student" to expect his "instructor" to check the weather and make the go/no-go decision?

Which now raises the question, why did the "experienced passenger" let the flight go ahead? Legally he had no responsibility to make such a decision, and if my hypothesis that the Commander thought he was an instructor is right, there is no reason to suspect that he knew this..... but, if the Commander did not have the experience to know that what he was undertaking was dangerous even for a suitably qualified pilot, then surely the passenger must have known this?????

FFF
------------------

[llanfairpg]

Nothing unusual about these accidents.

November 1972 Graham Hill at Elstree with Luton wide open.

within 35 minutes same at Birmingham with EMA wide open, CFI of the Warwickshire Aero Club killed.

Attitude is the main killer--wrong attitude produces the wrong decisions

[xraf]

Although FFF makes several very good points, and God knows we've all relied on the 'experienced guy' on occasion, unfortunately after an accident its the letter of the law not the usual practice at FTO's that counts. The younger guy here was P1 - end of story and incidentally, I suspect the 'experienced' one in this case wasn't as 'experienced' as the P1 thought.

Notwithstanding, there are clearly many and various other circumstances surrounding this extremely sad case and recrimination is now mostly pointless but I wanted to chuck in my 2p on a specific aspect which just might help someone somewhere.

The main thing I have to add is that training in the discipline of command is largely missing from PPL training. It was certainly missing from mine! However, luckily for me after about 5 minutes in the RAF system that soon changed.

I dont mind telling anyone that there are times without number I have wondered quite literally how I survived those first couple of hundred hours before that. I try not to be the 'old fart' these days but that long forgotton trait of 'Captaincy' has saved many lives when light aircraft were not hi-tech, glass screen, gps driven pretend airliners.

PPL Instructors should spend at least some time (and I know some do) talking about how once a PPL is in your pocket, you are in command, even if you have a 10,000 hour ATPL/IR TRE..TRI skygod... etc etc etc sitting alongside you, if its your P1 its your decision.... and yes sometimes its difficult to voice your opinion but a quick read of this AAIB report should hammer the point home!

Also point out to trainees that the airlines themsleves have a serious and growing problem with the 'gradient' in the cockpit especially with younger fATPLs and they include it in their courses now and the crusty old farts are having to learn it too.

Anyway, as always condolences to all involved and as someone has already said this report should be required reading for all!

Regards

Xraf:ok:

[Contacttower]

I think if the younger pilot did believe the older one to be an instructor that would explain a lot...one sometimes sees a mentality among student pilots or even qualified PPLs that 'it will be OK since I have an instructor on board' and hence mentally they relieve themselves of some of the consideration for the flight and also of any worry they may have.

I agree 'command' decision making should be underlined more and the state of play should have been made clearer before they got into the aircraft. The situation where a new PPL is flying P1 but has a more experienced pilot next to him (but not an instructor) so they can 'take over' if things get difficult is not always ideal because it can lead to confusion over 'who is in charge'.

[BackPacker]

It might even be so that the younger pilot did not consider him to be PIC at all. After all, according to the report, he had said to the CFI that he was not legally allowed to fly with passengers because of the 90-day rule. The CFI then told him that he would fly with a more experienced pilot and this may well have lead him to the conclusion that the older pilot would be PIC.

This is then reinforced through the fact that the older pilot had made the decision to fill the tanks to the brim. In a -140, with four adults on board, that's not something you do without consulting the PIC. So again this may have give the impression that the older pilot would be PIC.

[Life's a Beech]

Kiwi

Indeed, a lot to learn. As eharding (who should check some profiles before suggesting people have "sod-all hours") might consider, no-one is going to learn anything if we don't discuss the issue. A and C has clearly learnt what I think is the most important lesson - we instructors are all imperfect, and there is always value in pointing our students to other sources of learning.

Flying for Fun (and englishal, who brings up HP&L)

There is also risky shift to consider. A group of people will often take decisions that are less cautious than any one member of the group would make. Everyone thinks it is OK if no-one else has raised any objection. This whole exercise was a committee decision, that had actually been made by the time the aircraft commander had arrived.

Then we consider authority gradient (like cockpit gradient, but some decisions made outside the cockpit and considering other people than crew). This is an inexperienced pilot - about 40 hours on his PPL. He is given a decision, as a fait accompli, by more experienced pilots. He doesn't make a decision to go (or indeed not to refuel in Exeter). He simply does not question decisions already made, which should rightly have been made by him. All (f)ATPLs know the dangers of steep cockpit gradient, but have also been taught the dangers of flat, or reversed cockpit gradient, when a weak, inexperienced commander flies with assertive, experienced crew. They were not crew, but did act like they were!

The club also gave him something I constantly work with my fine ops staff to make sure my crews are not given - an unworkable plan. There was no way he could get back safely before nightfall, when his flying privileges no longer apply. The flight could not be completed in the time available before nightfall. He could fly the sectors, but did not have time to refuel. Fuelling at Exeter is reasonably swift, but with only one pump, and that on the South side (note they went to the North) would have delayed their return beyond nightfall.

[moggiee]

Rubbish.
There is an exam in the PPL called "Human factors and performance"....The pilot should have known about the aeronautical decision making process, and should have decided to stay on the ground....The FTO shouldn't have to spoon feed every baby pilot that walks through the door. Indeed the dispatcher may not even have known the pilots ratings......
In a similar vein, then, you would argue that it would be OK for a car rental firm to allow a clearly drunk driver to drive off in one of their vehicles or for an airline to allow a crew member to operate whilst known to be unlicensed.

There would be no defence in "but he knew the rules". I would argue, as a professional pilot of nearly 25 years experience both civil and military, that any self respecting FTO hiring out an aeroplane has a duty of care to itself, it's customers and the general public at large. This "duty" extends beyond the legal minimum responsibility placed upon them by the government and CAA.

There seems to be an impression here that "he passed a test and should have known the rules" is good enough - it simply is not. For example, we all should expect a pilot to improve his skills and decision making over time after passing his PPL skills test. If he does not, then he has effectively gone backwards.

Any flying organisation that believes that they should operate "down to the level of the regulations" rather than aspire to operate "up to the highest standards" is failing its members and customers. Just doing enough to satisfy the lowest level of regulation (the letter of the law) is not good enough - surely it's the spirit of the regulations that counts in the long run.

Assuming that the bloke flying your aeroplane knows what he's doing is not good enough - you have to KNOW that he knows what the rules are, and that may require some coaching. If I lend my car to someone, I want to know that he is licensed and insured - it's not good enough for me to say "well, he should know the rules" and the same applies to renting out aeroplanes.

xraf makes some good points about supervision, an aspect of flying that is sadly lacking at all too many FTOs and clubs.

EDITED to remove typographical errors.

[eharding]

As eharding (who should check some profiles before suggesting people have "sod-all hours")


Simply referring to the OPs statements and the tone of the first few postings, chum.

[Life's a Beech]

I know. One of which was mine. I have a fair number of piston hours, though I am still learning. Another of which was by another CPL holder, although no hours mentioned. how many hours do the other contributors have? Why does that make their comments any less valid. Try addressing the comment, not the commenter.

Moggiee

You make a good point about the comparison with a car. If you lend your car to someone who is not qualified to drive it and the police stop that person you will be prosecuted as well as the driver. The insurance would also be invalid, as I assume it was in this case!

[bjornhall]

Is there anything unprecedented about this accident? Is there anything about it that has not happened before?

Is there anyone on this forum who has not heard of similar accidents before?

Has anything been said in this thread that is not covered in PPL human factors training (I mean today; wouldn't know what was included 15 or 45 years ago)?

If the methods and procedures taught in PPL training had been followed, the accident would not have happened. Given that, what in those procedures should be changed as a result of this accident?

Provided "don't fly VFR in IMC" is already included in one's personal flying standards, what should one change in one's flying behavior as highlighted by this accident?

I fail to see what can be learned from this that we didn't already know.

Possible exception: To unlearn. We are supposed to fly the way we have been trained; the VFR rules are not just for show and tests but are to be applied on every flight. So unlearn anything learned after the PPL that suggests those rules and methods can be bent or discarded.

In my view, when faced with the circumstances of this accident, one should be able to say, with confidence: I would never do that!

[Say again s l o w l y]

Whilst the outcome was decided by IMC conditions the seeds of this were sown by more than just a daft decision to take off.

Personally, I think that it is CFI's and Instructors that have most to learn from this. We all know no to take off in rubbish weather conditions, but the pressures that can be put on a student or PPL by more experienced pilots are what this highlights most to me.

It has certainly made me think and even though I would never put someone under pressure someone to fly whilst out of currency or because an a/c needed moving, it still gives you pause for thought.

[wsmempson]

Agreed SAS!

Given that the only cost the pilot was paying was for the fuel, does the balance constitute payment of a sort???

[tmmorris]

Certainly made me sit up and think. I've passed a copy to a friend who is a pilot but doesn't usually bother reading this sort of thing, just in case.
But I can't help agreeing with the AAIB's conclusion that, in essence, there are no recommendations they can make which would prevent this sort of thing happening - there are oodles of leaflets, regulations and guidance on this, yet people still do it.
Tim

[eharding]

I know. One of which was mine. I have a fair number of piston hours, though I am still learning. Another of which was by another CPL holder, although no hours mentioned. how many hours do the other contributors have? Why does that make their comments any less valid. Try addressing the comment, not the commenter.


Indeed. In context, I was specifically referring to the opening couple of statement professing limited experience, the reliance on the OPs FTO to keep him out of trouble, combined with a castigation of certain parties named in the report, all of which appeared a tad on the censorious side, hence my arguably boistrous reply. As I recall, your profound words of wisdom had yet to appear on the thread when I started composing it - although it does regretably appear that the inadvertant juxtaposition has loosened some form of bee into your bonnet...

None of which has much of a bearing on the matter in hand - but as has been set out in numerous postings above, the responsibility remains with the commander of the aircraft. Had a few of the factors involved not been aligned so perfectly, the occupants might have got away with one of those frightening, but surviveable, episodes which most of us have experienced along the way. Sadly, that wasn't the case.

[Whirlybird]

the pressures that can be put on a student or PPL by more experienced pilots are what this highlights most to me.

I agree. What we have here is a young pilot who was ASKED to do a flight by the CFI. A flight which needed doing. He tries to refuse, saying he's not current. The CFI tells him he'll have someone more experienced with him. He could also have implied that the accompanying passenger would be unofficially in command, even though the pilot would be officially, since he needed the hours.

At this point, I wonder how many young, inexperienced pilots would do exactly as this one did...go along with it? More than would admit to that on here now, I would say. After all, hindsight is always an exact science.

Once they were in Exeter, the accompanying passenger seems to have made all the decisions. But it's very, very difficult to fight that kind of thing. And as someone pointed out (sorry, can't remember who now), they were on a treadmill by then....refuelling would make them late back, they had to leave, picking up fuel on the way would make them late. It's hard under those conditions to say to someone who appears to have lots more experience than you: "No, I'm not going; this is wrong and illegal and I want to stay here overnight and to hell with who it upsets". Because that was really the only other option the pilot had by then!

Kiwi chick - of course you'd never end up in this situation; you're too experienced. But would any of your students? Do you make sure they are strong-minded enough to stand up against anyone, however experienced, however strong a personality, however much older than them, and never go along with a decision they think might possibly be wrong, when the more experienced pilot says it's OK? Do you make that a condition of them getting a PPL?

I can think of a couple more accidents over the years where a more experienced pilot influenced the person who had the accident in a similar way. I really don't know what we can do about this sort of thing.

This is a human factors issue. And there but for the grace of God go (or could have gone in the past) a great many of us. :(

[bjornhall]

I think that it is CFI's and Instructors that have most to learn from this

That is a good point!

For 'mere PPLs' (or even more so for us students!), I still think it as simple as "don't do that!". Of course, 'simple' does not mean 'easy'...

[englishal]

In a similar vein, then, you would argue that it would be OK for a car rental firm to allow a clearly drunk driver to drive off in one of their vehicles or for an airline to allow a crew member to operate whilst known to be unlicensed.
That is slightly different. In this example it is more akin to someone turning up at the rental desk on a dark, windy, raining night, on the day they have passed their test and renting a car quite legally. They may not be experienced enough to handle the weather conditions, but then again how is the rental clerk meant to know this, and also why should it be their job to ban them.

You could argue it is the fault of ATC.....in the USA if weather conditions are below VFR, you CANNOT depart VFR. Or you could blame the ANO...the ANO doesn't say that you need an IFR clearance outside CAS for flight in less than VFR conditions....

But rather than blame everyone else, people need to learn to accept responsibility for their actions. In this case the poor sod didn't have time to learn from his mistakes....Hopefully everyone else who has read this post and the AAIB report can.

[Say again s l o w l y]

That is very true, but any decent FTO/RF has a duty of care to it's memers, especially when they are inexperienced/out of currency or both as this poor chap was.

I have often had to step in when I've seen more experienced PPL's jokingly bullying a less experienced member who's unsure about the weather.

"Och, it's not as bad as you think" or "What are you worrying about, I've just been up." etc.etc.

I don't think these things are acceptable as it then becomes a challenge to go up in conditions someone is unhappy with. Note I'm not talking about shocking weather like the conditions in this accident, but anything someone isn't happy with, be it wind, changing weather, viz, cloudbase whatever.

It doesn't take much to push someone inexperienced into doing something they aren't happy with. Clubs and schools should try and ensure that this happens as little as possible and support less experienced and less confident pilots.

[Whirlybird]

It doesn't take much to push someone inexperienced into doing something they aren't happy with. Clubs and schools should try and ensure that this happens as little as possible and support less experienced and less confident pilots.

SAS, spot-on. :ok: I think it happens more than some people realise. There's a very macho element in a lot of flying schools/clubs. I remember when I was a very new PPL(A); it was winter and I went down to the airfield three days in a row and decided not to fly because I didn't like the crosswind. A nearly-qualified student implied that I was either a wimp or a very poor pilot, and said he'd go i
f he was allowed to. Luckily I was old enough and confident enough to shrug and say that's fine, maybe you would but I won't. But it's very hard for some people to do that, especially when they're young.

The problem in this sad case was that it was the CFI who tried to persuade the pilot to fly!!! I wonder how he's feeling now. :(

[long final]

Knowing Blackpool well and also the FTO concerned it is important to recognise that the report serves only to look at the facts and give its assumption where appropriate, on the unknown facts. It doesn’t get into the character and personalities of the people involved in the whole chain.

With that in mind I have some sympathy with the pilot. That is no excuse for the very poor airmanship all round, but the report cannot portray the pressures/influences that will have been acting on him.

LF

[Pilot-H]

This book - which I read as an early PPL (before the HP&L exam was requried) should be required reading. Unfortunately it is out of print but still available through amazon, Ebay etc.

http://www.amazon.co.uk/Pilot-Command-Martin-Cass/dp/0906393051/ref=sr_1_1?ie=UTF8&s=books&qid=1197658312&sr=8-1

[moggiee]

englishal on my car rental analogy:

That is slightly different. In this example it is more akin to someone turning up at the rental desk on a dark, windy, raining night, on the day they have passed their test and renting a car quite legally. They may not be experienced enough to handle the weather conditions, but then again how is the rental clerk meant to know this, and also why should it be their job to ban them.

Your analogy doesn't work. An inexperienced driver using a hire car in bad weather is legal, if not smart. This chap operated illegally by flying IMC when not IMC rated and the CFI at the FTO would have been aware of this (and of the fact that the pilot was out of his 90 currency and therefore was carrying passengers illegally).

He rented an aeroplane to a pilot who was breaking the law just by getting airborne - and he knew it. He was therefore an accomplice to a crime (and sadly, two deaths).

[smith]

Was the "experienced passenger" in the front right hand seat when they departed BPL in IMC? The report says that the other two passengers were picking up an Aztec from Exeter. Logic would suggest that one or both of these passengers had an IR (although not definite), and they in fact might have been in the front seat or offered instrument flying advice from the back seat on departure from Blackpool, thus giving the commander the confidence to fly into cloud on take off from Blackpool.

The AAIB report did not mention the "other two passengers'" qualifications, currency or experience, or who was sitting in the front. An investigation and interview with these two passengers may shed some light on wheather they had any influence on the commander's decision to take off into IMC.

[Saab Dastard]

The AAIB report did not mention the "other two passengers'" qualifications, currency or experience, or who was sitting in the front. An investigation and interview with these two passengers may shed some light on wheather they had any influence on the commander's decision to take off into IMC.

Well, given that the Aztec made it into Blackpool in the prevailing conditions (according to the AAIB report), one could make some assumptions about the qualifications of the pilot(s) of that aircraft.

SD

[smith]

Logic would suggest that one or both of these passengers had an IR (although not definite)

SD

I had virtually said that already.

The jist of my post being did any of these two passengers have any bearing on the decision to take off into IMC. I'm sure the AAIB have considered this but there is no mention in the report.

[DFC]

Personally I believe that there was not so much "supervision" in regard to this flight but more a case of direction.

It is rather (un)fortunate depending on point of view that the only person who could explain much of the thinking behing the flight was the CFI who I believe has tried to distance themselves "defacto" from the whole situation.

Given the clearly desperate circumstances, ATC could (since the Radar was U/S duie clutter) have provided more in the way of guidance using the VDF.......either a QGH or a Spiral descent in the VDF overhead. Shame that the only available approach aid went largly unused!!!!

One must also wonder what use was made of the Mixture control enroute and what if any pre-flight fuel planning was made. The aircraft seems to have arrived just south of Blackpool with suficient fuel to divert especially if one straightens out the radar trace towards Leeds and adds in the time available from the fuel remaining in the tanks post mortem.

Unfortunately, in my experience this is not just an example of what not to do it is an example seen on a daily basis at many UK airfields which goes unchallenged because as many here are at pains to point out "it's not for us to interfere" and the only difference here is that there was a fatal accident causing a report to be written.

Pitty we would not have more of those kind of flights ending in similar circumnstances and then we may through it seems the only way possible erradicate this too common a method of operation through extinction of the perpetrators.

Funny that many people who say there is nothing wrong with making DIY approaches, flying VFR into IMC, operating below IMC minima etc etc still stand up and make statements here other than simply saying that they have done the same but got away with it so far.

Can we have a UK aviation version of the Darwin Awards?

Regards,

DFC

[FREDAcheck]

I find this thread rather frightening. No criticism meant of anyone posting here. Rather that after reading the AAIB report and comments here, to see how a series of unfortunate decisions, each one probably seeming reasonable at the time, led to tragedy.

I can well remember times, especially when I was a new PPL, of suspending judgement when an instructor or someone more experienced implied it was OK. And how easy it is to let events take decisions for you: there’s no time to refuel so we won’t.

I won’t boast that I’ve never made bad decisions, nor even that I’ve never made a series of them. All I can boast is that I’m still here.

Humans like to distance themselves from mistakes. They were silly to do that, I’m not silly, so I couldn’t do that. But history (and a lot of research) shows that anyone can be lulled into making poor decisions without realising it. I shall try to think of this incident every time I make flying planning decisions about weather, personal minima, fuel, alternates, daylight left...

[BackPacker]

Can anyone direct me with a link to the relavant part of the AIP or LASORS as to where the min requirements for VFR day and night are?

For instance,
1) I don't think I need a working landing light for day?
2) Can I fly with one U/S fuel guage at night?

That's stuff that you probably will not find in the AIP or LASORS but in the POH.

Just because I have nothing better to do I checked the PA28-161 Cadet POH. Apparently a working landing light is not require for any type of flight (...???), but nav and strobes are required for night VFR and IFR. The fuel quantity indication system is required for any type of operation.

[Sir George Cayley]

I've been around flying clubs long enough to know some of the things that go on. And persuading a young eager beaver to go fetch has happened many a time. To me included, and it was Exeter by coincidence.

I feel very strongly that the actions of those around the deceased, in encouraging and creating perhaps a false sense of security were reprehensible.

I would be quite happy to say this to their faces ( I have strong ideas who they are) and invite anyone to pm me with names. I'll not do it in public nor report the outcome.

I do from time to time meet the CAA's Head of ARE and I'll ask him for his view as to whether any action should be taken. Endangerment comes to mind.

There but for the Grace of God etc.

Sir George Cayley

[DFC]

a series of unfortunate decisions

I would not call intentionally departing inot IMC IFR with no instrument qualifications "unfortunate".

I would not call failing to ensure suficient fuel for the proposed flight ws carried as unfortunate.

Remember that even if the weather had been CAVOK, the aircraft did not have enough fuel for destination and 45 minutes holding plus contingency. Never mind alternate course of action.

The ironic thing in all of this is that while the pilots were happy to fly illegally in respect of VFR, as well as IFR, the one thing that really sealed their fate was a reluctance to delay the flight by taking on fuel becuase they would have to fly at night.

Imaging the aircraft arriving overhead Balckpool with the same weather, at the end of Daytime but with 2 hours fuel remaining. A night VMC flight to Leeds would have been possible...........but would probably have highlighted an illegal operation.

How much was influenced by a requirement to keep knowledge of this operation at a local level in Blackpool?

Regards,

DFC

[FREDAcheck]

I would not call intentionally departing inot IMC IFR with no instrument qualifications "unfortunate".
I quite agree DFC. One might add that they took off in conditions that would make an immediate return to Blackpool near impossible. The cloudbase was below minima for all but an ILS approach, and the plane had no ILS. I would regard that as imprudent.

My point was that I was trying not to distance myself from questionable planning decisions. I've been flying for years, but I fly less than 50 hours a year, which means I'm in the danger zone where I'm certainly not immune from poor decision making. I take this as a salutary lesson for ME.

[frontlefthamster]

Sir George,

I suspect that you'll find the Ian would love to 'do' the bloke concerned, but there's no chance of a case being made. There is considerable, ahem, 'previous'. :uhoh:

Regarding unserviceability, I'm astonished that so few people have got to grip with the formal fact that any defect not covered by an MEL or CDL renders an aircraft unairworthy. The PA28 doesn't have an MEL, so everything on it must be working for flight. (Some operators, such as C****r, have 'negotiated' pseudo-MELs with the Authority for aircraft such as the PA28, though this is a work-around rather than a solution to the problem). ;)

[Whirlybird]

I find this thread rather frightening. No criticism meant of anyone posting here. Rather that after reading the AAIB report and comments here, to see how a series of unfortunate decisions, each one probably seeming reasonable at the time, led to tragedy.

That's my feeling too.

May I set out a possible scenario. Note that I don't know what happened, or know anyone involved. I'm only saying it MIGHT have been like this...

CFI (on phone): Fred, would you like to fly to Exeter today?

Fred: I can't; I'm way out of currency. Besides, I don't like the look of the weather.

CFI: Well, you'd have Tom with you. He used to be an instructor, and he's got loads of experience. And the two passengers you're taking, who really need to pick up an aircraft in Exeter, at least one of them has an IMC rating. So you'll be fine. Tom will be in charge really, but you need to log the hours, don't you? So I'm willing to help you out, as I have before. And I really need you to do this.

Fred: Is that all legal?

CFI: Don't worry about it; I'm saying it's OK.

Fred: Wellllll...OK then.

CFI: Good man!

Later....

Passenger: Weather doesn't look so good, does it? Tell you what, shall I sit in the front so we can fly on top? I've got an IMC.

Fred: Is that legal?

Passenger: Not really...but it's safer, isn't it?

Tom: Sounds good to me.

Fred: Wellll...OK then.

After the flight to Exeter....

Tom: Jeez, it's getting late. And we're the wrong side of the airfield to get fuel. Let's head back and pick up fuel on the way if we need to.

Fred: Have you checked the weather at Blackpool?

Tom: Don't you worry, kiddo. It's probably no worse than when we left.

Fred: But...if the weather gets any worse... And we don't have any reserves of fuel, only just enough. And the chap with the IMC isn't with us. And I learned...

Tom: Now look, mate, I've been flying for years, OK? No-one worries about that reserves of fuel stuff. It's like being 1000 feet above the ground and always talking on the radio and all that other good old exam stuff; it's not relevant in the real world. You know that the instructors fly till they're almost out of fuel, don't you? And I told you, if it looks like we need to, we'll stop for fuel. I can fly in this, I've been flying for years and I've managed in a lot worse; so don't you worry.

Fred: I...I...don't like it.

Tom: Well, what's the alternative? We get fuel here, and we'll be late, and flying back at night AND in not perfect weather. Or we stay here overnight, and they need the plane tomorrow at Blackpool, and I've got no money or cards with me and I have to work tomorrow. If you decide not to fly back - unnecessarily in my expert opinion - it'll really upset a lot of people. And I doubt if the CFI will help you hourbuild any more after that. And why? Because you with your 105 hours think you know enough to decide to abandon a flight, when someone with a lot more experience thinks it's OK. And look, everyone else is flying today. Bit arrogant, aren't you?

Fred (unhappily): Wellll...OK.

And off they go....

And Fred is guilty of indecisiveness and wimpishness, but is that an offence that deserved what happened?

PLEASE NOTE AGAIN THAT THIS IS ONLY A HYPOTHETICAL SCENARIO!!!!

[Life's a Beech]

eharding

Sorry, I should have noted the close timing, and thought of the possibility! I understand from a mutual acquaintance that you are a pilot we could all learn a lot from.

Whirls

It contains some very interesting thoughts though, over and above the obvious human performance comment.

Like the fact that we not only teach but are also an example, and often students learn from our own attitude, as much as what we try to teach them. I have known instructors who did fly until almost out of fuel (admittedly only in the immediate area of the field, within 15 minutes of several alternates), even on one occasion flying two more circuits with a fuel-warning light on! What if another pilot forgot his gear, and fouled the runway?

Whatever we teach about fuel reserves, we must also follow. My rule of thumb, as instructor and now line trainer, was to plan to land with an absolute minimum of an hour's cruise fuel (this again at a field with at least one nearby alternate any time our field is open). I have only broken that twice, once inadvertently and to my shame and annoyance, and once in very carefully considered situation for a very short ferry flight. Even though I had fuel for 3 IFR alternates, including the airfield I had just departed so knew was good, plus more than 30 minutes' reserves, it was a close decision.

[yawningdog]

Yes but the only reason those pilots died was because they set the wrong altimeter setting. Simple as that.
The whole human performance factors argument highlights contributing issues, but I wouldn't be surprised if that passenger had a personal culture of flying close to the limit.
If the altimeter setting was correct they probably would have found a way of surviving, and put it all down to an exciting days flying later on in the pub. After all, the passenger was psychologically the pilot in command in this particular flight, and they were playing by his rules.

[Sir George Cayley]

Keeping it local.

Yes, and I wonder when 'BK was next due to fly? 09.00 the next day?

I think the picture painted by Whirly just about fits, and has been played out many times before (and sadly maybe again in the future) somewhere across the UK.

I recall flying in Spain a few years ago where one had to have your wx brief signed by an official before ATC would give you taxi. Bit draconian in my view at the time but it did force you to plan very carefully.

Not suggesting for a moment the introduction of this system into the UK but it will be interesting to see what EASA's rules of the air look like.

Sir George Cayley

[Gertrude the Wombat]

And Fred is guilty of indecisiveness and wimpishness, but is that an offence that deserved what happened?
Well, that depends what "deserve" means in your personal moral code, doesn't it. But in real life that's what happens, and I'm not religious, so my answer is "yes" I'm afraid. And I'd say the same if it happened to me.

[frontlefthamster]

yawningdog, you wrote:

Yes but the only reason those pilots died was because they set the wrong altimeter setting. Simple as that. :rolleyes:

That reminds me of something...









or rather, two things...







...and they're both between my legs, and they're hairy... :cool:

[moggiee]

Yes but the only reason those pilots died was because they set the wrong altimeter setting. Simple as that.
No - that is the final link in the chain that led to their deaths. Even if they had set the correct QNH they still had insufficient fuel to get to airfield with decent weather and with a cloudbase below 100' then they almost certainly would have crashed before managing to find somewhere to put down.

Their fate was sealed when they went IMC on the return to BPL with insufficient fuel to divert.

[Contacttower]

Yes but the only reason those pilots died was because they set the wrong altimeter setting. Simple as that.


Yes well the line between dying and surviving with just a bad experience is often very thin in aviation (and plenty of other activities for that matter). Could they have managed to land had they not miss set the altimeter? Perhaps...but the fact that they had reached sea level and not realised it suggests perhaps not.

[DFC]

but the fact that they had reached sea level and not realised it suggests perhaps not.

Not true.

Have you ever crossed the channel and noticed that the sea and sky blended into one and there are simply no references.

Imaging descending in a visibility of 100 to 200m grey cloud towards a grey featureless flat water surface that simply merges with the cloud and fog.

There would be absolutely nothing to visually warn them of the approaching surface.

However, at night, while in this case I doubt it would have made a landing at Blackpool possible, remember that the effect of the runway and approach lights has the effect of improving the RVR values compared to daytime.........thus very slightly improving the chances of seeing the runway on an approach say using the VDF.

Regards,

DFC

[mm_flynn]

Many posts ago someone mentioned the culture and attitude of the organisation (or one of the individuals). This has got to be the root cause of this crash (one can hardly call it an accident).

5 pilots, 1 of whom is a CFI all decided it was a good idea to take a woefully ill-equipped aircraft up, over weight, without an IR/IMC rated/current pilot, in weather that would cause even an ILS equipped crew to consider they had a reasonable possibility of being unable to recover to Blackpool and then planned to arrive back at dusk/night in forecast worse weather with no fuel.

The fact all 5 went along with the plan suggest in my mind this broad disregard for the rules must be a common feature around the organisation. I have a lot of sympathy for the young lad and believe his view of the world was likely to be similar to Whirlybird's suggested, BUT the other 4??? and particularly the CFI??

[Contacttower]

Not true.

Well I'm not sure...it is very difficult to tell sea and sky sometimes (and I know I have a sea plane rating) but the pilots had decided to descend over the sea, which perhaps suggests that they thought the could tell roughly how far they were from the surface. As well as that I imagine they would have been constantly looking back towards the coast to see if they could see anything yet. The fact that they got down to sea level and probably still couldn't visually identify the coast suggests that they were never going to and probably therefore doomed to crash altimeter miss set or not. I suppose had they had a true indication of altitude they may have been prepared for a water landing and therefore would have been able to get out alive...but who knows?

The altimeter is a bit of a red herring though with regard to this accident, the important point was the bad the decision to fly in the first place.

[Say again s l o w l y]

All accidents have a chain, the altimeter setting is just one link in that.

There is more in learning from these reports in just reading the end and saying "I wouldn't do that" and then ignoring the rest of it.

There is a hell of a lot more to this accident/crash than just the poor decision to fly into IMC conditions and looking at the human factors involved is vital to the learning process.

I'm really glad to see the debate on this, because that means people are thinking about it and that is the entire point of these reports. Each of us will take something different from it and all will be better for it.

This is a dangerous activity that we all love to do and it can go wrong very quickly. These reports are a vital aid to flight safety and I can't imagine how many lives have been saved by debates like these.

[Contacttower]

There is a hell of a lot more to this accident/crash than just the poor decision to fly into IMC conditions and looking at the human factors involved is vital to the learning process.



Certainly, what worrys me about this accident so much is the relationship between the low hours PPL and the more experienced guys around him. Perhaps another low hours PPL reads PPRuNe and is up to speed with the latest AAIB reports...but more likely he is not and is liable to fall victim to another CFI who has a 'oh it'll be OK just this time' sort of attitude.

[yawningdog]

The altimeter is a bit of a red herring though with regard to this accident, the important point was the bad the decision to fly in the first place.

I don't agree. Regardless as to whether the circumstances of this flight were well advised or not, the fact is that the end of this scenario could have occurred during a well planned flight as an emergency. For instance if the flight was en route to a VFR destination over the top of poor IFR, but encountered a legitimate problem such as illness, rough running engine, fuel leak etc. A descent to minimum level should have been survivable.

The pilot, with 1,778 hours, felt confident that he could descend through cloud safely, but he made a crucial mistake with the altimeter setting. If he hadn't made this mistake, he probably would still be flying today and would have put the whole flight down to "experience".

I can bet that loads of incidents like this (except the crash) take place all the time, but we never hear about them because they are hidden in memories. In some cases I wouldn't be surprised if some pilots are proud of their close shaves as successes.

Of course this is a great lesson in poor airmanship, but to descend through cloud without checking the QNH is in my opinion the crucial error.

[Contacttower]

yawningdog maybe you are right, I just think that they probably would have crashed anyway. OK they might not have died (because they would have been warned that they were about to crash by the altimeter reading zero) but certainly the report made it clear that the AAIB believes that by the time they had reached the Blackpool area their chances of making a successful landing on a runway were almost nil.


From the report:

The cloud ceiling was between 100 ft and
200 ft aal and daylight was fading, conditions that would
have made it nearly impossible for a pilot, flying an
aircraft without serviceable navigation equipment and
without instrument flying training and experience, to
locate and land at the airport. There were few options
open to the pilot. He was unable to make a safe approach
and landing at Blackpool, the aircraft did not have
enough fuel to fly to an alternate airport and the onset
of darkness would have made it unlikely that a suitable
field could be found for a precautionary landing beyond
the area covered by cloud.

[airborne_artist]

Their fate was not sealed on leaving Exeter, as after leaving Exeter they must have passed/been within range of airfields that were open and with better conditions than Blackpool.

Knowing they were not flush with fuel, at 45 mins from Blackpool, for example, they could have a) checked Blackpool's actuals (by phone if needed), re-checked their fuel state and decided to divert, as they would have known they did not have enough fuel to attempt Blackpool and then divert.

Basic en-route checks of fuel, distance to run and actuals at the destination would have given them loads of options.

[llanfairpg]

Correct AA and its not beyond belief as the original poster writes, it will happen time and time again--break the rules, pay the consequences!

[llanfairpg]

A38

I am afraid ERROR CHAIN goes over the heads of a lot on here, to them an accident occurs at point of impact. It is a shame really because the chain is so much more interesting than the end result and provides more lessons to be learnt.

Their fate was not sealed on leaving Exeter, as after leaving Exeter they must have passed/been within range of airfields that were open and with better conditions than Blackpool.

Sadly, in aviation, the fate of some is sealed the day they sign their licences

[Say again s l o w l y]

I wish more examiners knew that. With the standards of some people I've seen being passed, I fear you may be right.

[yawningdog]

I am afraid ERROR CHAIN goes over the heads of a lot on here.

Llanfairpg, careful how you make judgements on posters you know nothing about. It discredits not only your comments, but also the whole nature of open forum discussion.

If it is my comment to which you are referring, that the altimeter setting was the crucial cause of the crash, then perhaps you do not understand my point. My point is that many pilots will continue to push the limits and lower their safety margins with every surviving flight, regarding survival as success. I am not referring to the previous events that led to the situation. That's obvious and has been repeatedly discussed.

Although you may talk about "error chains", the perceived value of an error will differ from one pilot to another. Perhaps to the passenger in this case, there were no errors, except for the final incorrect QNH setting.

[llanfairpg]

Yawindog, careful how you make judgements on posters you know nothing about. It discredits not only your comments, but also the whole nature of open forum discussion.

[Whirlybird]

To summarise...

1. They could have refused to go in the first place in that weather.
2. They could have checked the weather at Exeter and decided to stay there overnight.
3. They could have re-fuelled at Exeter.
4. They could have refuelled at a number of airfields on the way back.
5. They could have checked the weather back at Blackpool by a number of means, and diverted.
6. They could have checked that all instruments were set correctly.

But by the time they got to Blackpool, it was too late.

A cautionary tale...

I remember, some years ago, I was on a flying holiday in the Highlands. We were at Oban, and wanted to fly to Plockton, then Inverness, then back. It was an extremely hot day, Plockton is a short strip, so we didn't want to go in there with more than half fuel. Half fuel would be enough to get us to Plockton and on to Inverness, where we could refuel for the return journey. Looks OK, doesn't it?

BUT...the TAFs were giving a 30% probability of fog coming in to Inverness. If we couldn't make Inverness, there would be nowhere else to refuel, and nowhere else to divert to on the way back to Oban. Even options for a precautionary landing up there are severely limited.

We mulled it over, and realised we couldn't take the risk - we took full fuel, had a look at Plockton from the air, and went to Inverness. And of course, it was beautiful weather all day.

But if we'd gone, and the weather had closed in, and we'd run out of fuel...there would have been a discussion like this one. :{ Yet it would have been so easy to just go - it looked OK, if you didn't factor in all the 'what-ifs'.

I realise it's not an exact parallel; the main point I'm making is that it's very easy to be wise on the ground after the event. :(

[llanfairpg]

We mulled it over, and realised we couldn't take the risk

For those not blessed with your aptitude, experience and sense there is 'authorisation' (Caenarfon)

[kiwi chick]

Well, that begs the whole question, doesn't it?

Is the Flight Training Organisation not closed down now? Quite rightly so if you ask me. :=

[VFE]

That accident report makes for very saddening and sobering reading for anyone connected with general aviation. A reminder that lack of understanding of our licence privilages could result in death. OUR death.

It is tricky not to come across as smug when posting on these sort of accidents - the chain of appalling errors all so glaringly obvious with hindsight etc,... but I must say this:

One thing that will always bug me is people placing Air Law at the bottom of priorities when working their way through the ground exams. How many times do you hear people slate it's importance in the scheme of the PPL course? A hurdle to be skipped as quickly as possible before the first solo, then the book to be tossed aside with glee. How foolish some can be....

With a future career planned in commercial aviation this poor young gentleman obviously wasn't aware of some basic laws regarding the privilages of his licence. That was one mistake but by far his worst mistake was having misplaced trust in the other prats surrounding him that fateful day. :(

Many, I suspect, would have fallen into the same trap this unfortunate young flyer did. Misled by older, so called 'experienced' flyers whom he would no doubt have trusted having started his flying at that particular FTO years earlier. Words almost fail me when reading about this 'de-facto' CFI - if he thought it safe for ANY of those guys to take off into a 200ft cloud base he deserves to be struck off. But he obviously knew his air law! How very poignant.

RIP fellow aviators. :(

VFE.

[llanfairpg]

Good comment

[Gertrude the Wombat]

One thing that will always bug me is people placing Air Law at the bottom of priorities when working their way through the ground exams. How many times do you hear people slate it's importance in the scheme of the PPL course? A hurdle to be skipped as quickly as possible before the first solo, then the book to be tossed aside with glee. How foolish some can be....

Thing is, there's stuff in Air Law that's mindless bureaucracy (what colour paper various notices are printed on, the date of such-and-such a convention, garbage like that), and stuff that will save your life. As a new student it may not be totally obvious which bits are which.

[VFE]

Very true Gertrude, and in the past I too will have been guilty of placing the general importance of the whole topic in the 'learn and burn' category. Indeed, at the level the established commander of G-BK was at it can be hard determining the wheat from the chaff, as those who've trodden the same career path as the one he was embarking on will attest - the ATPL exams are the worst offenders for dross content. If the JAA were testing more relevant things within Air Law then perhaps the seemingly harmless attitude displayed towards it by some would change however, as we know, it's only through experience and error that most of us will learn, sadly in the case of some, all too late...

The more I think about this crash the more I become angry. On the face of things, judging by the implications of the AAIB report, it seems someone at Blackpool ought to be facing more hardship than just a mere wrestle with their conscience over this truly soul destroying chain of events. One can only hope that if this is the case, the law empowers due punishment. Whilst being mindful of the general gist of this thread and whilst not wishing to sway it towards unsavoury corners, 'De-facto' would suggest someone assigned the title of CFI but without legal recognition, correct? The authorties must decide where blame lies for that particular state of affairs... might not be as obvious as most here think!

Looking for a positive from a negative here - it is great to see the number of people who've read this report, have offered up their own opinions, and chewed over a few possible future scenarios for themselves. If one life has been saved from the existance of this thread then PPRuNe has justified every nausiating, self righteous, and at times truly galling posting since it's inception! ;)

Stay safe.

VFE.

[llanfairpg]

Thing is, there's stuff in Air Law that's mindless bureaucracy (what colour paper various notices are printed on, the date of such-and-such a convention, garbage like that), and stuff that will save your life.

Or maybe you have never understood the purpose of an examination

[Land Dafter]

I know a lot of the people involved in this accident.

The AAIB report suggests that the Commander may have thought that his "experienced passenger" was in fact an instructor. In which case, is it not likely that he thought that the "instructor" would be Commander of the flight? Especially since he was out of currency.

He DID believe the "experienced passenger" was an instructor, because that is what the "de facto CFI" had told him

I agree. What we have here is a young pilot who was ASKED to do a flight by the CFI. A flight which needed doing. He tries to refuse, saying he's not current. The CFI tells him he'll have someone more experienced with him. He could also have implied that the accompanying passenger would be unofficially in command, even though the pilot would be officially, since he needed the hours.

He was absolutely certain that the chap in RHS was not only an instructor but therefore in command.
So in the event, NOBODY was actually pilot in command of this flight.

Was the "experienced passenger" in the front right hand seat when they departed BPL in IMC?
Yes
The report says that the other two passengers were picking up an Aztec from Exeter. Logic would suggest that one or both of these passengers had an IR (although not definite), and they in fact might have been in the front seat or offered instrument flying advice from the back seat on departure from Blackpool, thus giving the commander the confidence to fly into cloud on take off from Blackpool.

The aztec pilot has an ATPL

Given the clearly desperate circumstances, ATC could (since the Radar was U/S duie clutter) have provided more in the way of guidance using the VDF.......either a QGH or a Spiral descent in the VDF overhead. Shame that the only available approach aid went largly unused!!!!

In what way? there is no QGH procedure at Blackpool and the hand held GPS unit they had would have been way more accurate than any VDF kit.
It still doesn't enable them to find an airfield buried below a 100' overcast with poor visibility to boot.

The mis set QNH merely determined the location of the accident, not the actualilty of it.
The accident was pretty much inevitable once they crossed the Mersey (Liverpool was about 450 metres sky obscured), the only choice they had left was where.
IMHO the ATCO concerned (good friend of mine) saved a few land based lives by persuading them to go out over the sea rather than crash on land with the attendant press reports of plummetting near schools/hospitals etc and committing mass puppicide.

I don't think anyone has a troubled conscience over this, as so many of those who WERE responsible simply do not have a conscience!

[drambuster]

There was a reference earlier in this thread to Volmet as a useful inflight resource for getting a general update on the weather. I couldn't agree more.

Both Volmet and ATIS frequencies can be downloaded at:

www.smartcockpit.com/swissknife

You will see a link to each on this very useful aviation resource site (thanks to Captain Ludo Andre and Martin Kukura). The frequency charts print out in PDF onto A4 size, and if laminated they then make a handy addition to the cockpit !

[Fake Sealion]

An excellent observation and I fully concur - despite its shortcomings, this forum has one very very important function. It permits aviators to discuss events and LEARN something positive from them. This accident serves to illustrate how vital the pilots code of "don't assume - CHECK!!!" can be. It always has and will continue to save lives.
The AAIB report should be read and FULLY UNDERSTOOD by every pilot ...........and those who "authorise" them.

When something "seems" wrong.......it probably is!

FS

[Land Dafter]

BTW, AFAIK Blackpool is not on the VOLMET. It was replaced by Humberside several years ago although various publications still list it as being on London North.

That doesn't stop any pilot (or "experienced passenger") from asking whomever they happen to be tuned into at the time to phone ahead and get the very latest METAR.

[drambuster]

LD, you are correct. The Volmet info from Smart Cockpit (see above) lists the airports for each of the three UK Volmets . . .and there is no Blackpool !

[VFE]

If the young pilot of G-BK was under the impression the guy in the right hand seat was an authorised instructor then he must surely have been under the impression his flight was a dual checkout, henceforth a legal flight? In which case culpability lies with whom?

Can of worms springs to mind..... Flying Lawyer anyone?

One thing is for certain, based on what we know so far - that young pilot deserves to have some official pardon in my book. The system he trusted obviously failed him and this whole sorry saga is a bloody insult to everyone involved with flight training. It truly disgusts me.

VFE.

[QDMQDMQDM]

There was a reference earlier in this thread to Volmet as a useful inflight resource for getting a general update on the weather. I couldn't agree more.

Much better is hitting the refresh button on the preloaded metoffice METARs website page on your Blackberry or other Internet-enabled mobile device. Works a treat up to about 3K feet, I find. I always load it before I set off on a long cross-country. Doubt that it would have made a difference in the tunnel-vision scenario we have here, however.

[moonym20]

just want to stick my thoughts on this.

the report made for some very sombre reading, its truly sad to see the very desperate situation this poor lad let himself into

I hope a copy of this report will be made available at every FTO for students to read, it is a real eye opener

Hopefully students who genuinely have a passion for flying and want to work towards ATPL or CPL level will sit back a take note. Its great to be offered those kinds of flights but just remember that the guy sat in the right seat is not your get out clause no matter how well qualified he or she is. another lesion i hope some budding hour builders will learn is to look at the proposed flight a lot more closely and don’t box yourself in, just because all the other pilots (or non-pilots) are up for the trip doesn't mean you have go for it... if there's doubt there’s no doubt

all i can say is that this report has opened my eyes a little wider

[llanfairpg]

Reading this accident report reminds me of what it actually means to be the 'commander' of an aircraft. You do actually have to take command! You do not have to have started out as the commander but there may be nothing to stop you taking command.

It reminds me of an incident I had many years ago when doing a ferry flight from Manchester to Shobdon at night. I was a very inexperienced PPL without a night rating with an experienced instructor as P1. As I thought this guy could walk on water I completely followed his instruction, leaving all the planning to him, I was merely handling the controls. He had drawn a line on the map that’s all (that became apparent when we got airborne.)

As we progressed with the flight it became noticeable to me that there were no lights below us at all, as I knew the Welsh hills/mountains were off to the right and I became a little worried but no problem said the instructor, Shobdon will come up on the nose. I was still worried and tuned in the Shobdon NDB, which showed the airfield to be left of our position, but the instructor said we were out of range of the NDB so it was unreliable. We carried on and I started to become very frightened mainly because there were no lights anywhere, it was just pitch black. I was convinced we were to the west of Shobdon in the hills at 2000 ft!!!!. I tuned in the Honiley VOR and Droitwich NDB, Droitwich indicated that we were on the correct bearing and must be either east or west of the field, the Shobdon NDB showed us clearly to the west of the airfield but he would not have it saying that the ident was not clear enough so it must be unreliable. At that point I took control of the aircraft by saying well I am sorry but I am turning to the east and following the NDB. After around 10 minutes we came to Shobdon and landed. From the point of where I said, I am turning towards the NDB no other comment was made nor was the incident ever discussed again after landing.

After landing I looked at the map, we had been at 2000ft in an area with a spot height of 2166 ft.

I learned a lot from that incident, in particular about human factors. The instructor was a very over confident mouthy individual who loved putting other people down, a bully with a strong forceful character but what I detected in that small cockpit that night was a man that was completely different, quiet, under confident, frightened, who did not really know where he was but did not have enough about him to say or do anything. It was if he was swimming in glue, he was waiting for the event to happen rather than controlling events. I was very under confident and very inexperienced and I acted out of character because I was frightened, very frightened but just making one command decision most likely saved both of our lives.

[Supersport]

Indeed, P1 or Pilot in Command means exactly that. You are responsible for the safe operation of the aircraft and likewise the safety of yourself and your passengers. I'm in no doubt however that the 'PIC' in this incident was somehow influenced by the more experienced pilot in the RHS, the CFI / Duty Instructor and others.

Just wanted to throw in my 2p as I completed my flight training at the FTO related to this incident and I am very familiar with most of the characters involved. I feel that this is one of those incidents where a long chain of events / bad decisions led to this tragic outcome. There is a lot of finger pointing in this thread, the conclusions drawn maybe right or wrong, I am of the opinion that some blame lies with everyone involved in the incident (ultimately 'in the eyes of the law' responsibility lies with the PIC). One of which has been omitted from the AAIB report completely and which I feel deserves a mention in this thread:

From the report:
At 1700hrs, the controller asked for the altitude of the aircraft. On recieving the reply "2,000 feet", advised that, although there was no radar 'paint', the DF (radio direction finder) showed the aircraft to be north-east of the airfield. The accompanying pilot then asked the controller what he suggest they do.

There was actually a response from the controller, to the accompanying pilot's question, I won't go into detail about what was actually said but I can tell you the response was "less than helpful". Now, before I continue I want to express that I in no way wish to 'slag off' the work that ATC do or 'tell tales'. Without them, life as pilot would be made very difficult indeed and I fully appreciate and admire the work they do. It certainly isn't a job or responsibility I would like to take on. But, as I am sure most of you are aware, sometimes ATC can be less than helpful for any number of reasons, they are after all, only human like the rest of us.

In my opinion the 'less than helpful' reply the accompanying pilot got from ATC would have only added to the already extreme level of stress that was already being experienced in that aeroplane. Although, the comment itself was not really misplaced for several reasons, it was definately unnecessary considering the circumstances at the time of the incident.

Basically, what I'm trying to say is everyone makes mistakes, whether it be the people on the ground or the people in the air, not one of us is perfect nor infallible. Everyone needs to take more care, concern and responsibility over everything, especially over their own attitudes and actions, everything has a cause and an effect. An incident like this makes you realise how important the often criticised and trivialised subjects of Air Law and Human Performance actually are.

[bookworm]

There was actually a response from the controller, to the accompanying pilot's question, I won't go into detail about what was actually said but I can tell you the response was "less than helpful". Now, before I continue I want to express that I in no way wish to 'slag off' the work that ATC do or 'tell tales'.

But that's exactly what you're doing by making a vague accusation without offering any specifics.

I find it very difficult to understand what response the controller could have given at the time that would have been helpful. What would you suggest in the circumstances? Prayer?

[Supersport]

Nope, that is not what I am doing, and it isn't a 'vague accusation'. By ommitting the specifics I am attmpting not to cause cetain thing hitting a certain fan. I am positive that the specifics would spark a very negative reaction.

My comment regarding slagging off and telling tales was to do with ATC in General as a whole unit, not any particular individual, sorry I thought that was obvious. Surely if I had wanted to 'slag' someone or an organisation off, I'd have just come right out and posted exactly what was said and exactly who said it, wouldn't I?

Not being a religious man, no, I wouldn't of suggested a prayer, I find that comment from you pretty distasteful to be honest. I am well aware that there wasn't much / or nothing that ATC could do to 'save the day'. But there is a time and a place for everything.

[long final]

It would be good to get a look at the ATC transcript. I didnt hear the alledged comment, but know the person concerned and know that too many people I know and respect have told the same story. It would at least clear the ATC'ers name locally if we could read exactly what was said - and if he did say it? At best very very unprofessional.

I understand SS's reluctance to state what rumour has it was said.

LF

[VFE]

Hey guys, can I just draw your attention to this thread....

http://www.pprune.org/forums/showthread.php?t=308123

Thanks.

VFE.