Boy pilot died after tower gave suprise instruction
 

The Times Fri 13 Jul 07
Does anyone know why this go-around instuction was classed as an "unusual manoeuvre"?
And how do you feel that it is recommended that controllers should take into account the limited abilities of trainee pilots?

Here is a link to the AAIB report.http://www.aaib.dft.gov.uk/publicati...0l__g_babb.cfm

The Times has it somewhat simplified. The instruction was:

“Golf bravo bravo roger and er maintain runway centreline but go around er circuit height one thousand feet there’s fast traffic behind to land”.

followed soon by

"Er golf bravo bravo disregard that just take a left turn and fly north I’ll call you back in very shortly ”.

I can't understand why an aircraft on finals was required to go around because of following traffic. The student pilot, presumably being the lower aircraft, surely had right of way and the following traffic should have been told to go around.

Well quite.

"I can't understand why an aircraft on finals was required to go around because of following traffic. The student pilot, presumably being the lower aircraft, surely had right of way and the following traffic should have been told to go around."

At an airport with busy IFR traffic it can be hard to fit in VFR traffic between the jets. Sometimes I go for a gap with the VFR traffic then becoming No1, but on the understanding that if the IFR aircraft behind is catching up then the VFR ahead is sent around to hold north or south to wait for the next opportunity to land. This will not be done indefinitely and at some point a gap will be made for the VFR traffic but unless in emergency etc it will certainly not take priority.

I would sooner send a light aircraft around than a jet with 150 paying passengers! :ok:

Just downloaded and read the report (Thanks, lobby.)
Was a little surprised to read that the ADC had a PPL issued in'96, as, (with hindsight, of course) it is very easy to perceive how the student could become confused by the instructions issued.
However, it is also easy to perceive from the report that the ADC was in a slight pressure situation with time running out to make a plan and make it work. Likely this affected his choice of wording to the Cessna pilot.

At our place, when we have solo (pre-PPL) students, an "S" is written on the right hand box of the strip. There are instructions in the handbook specific to our unit ( sometimes known as "Local Unit Orders") that complicated and conditional clearances are to be avoided to student pilots, and a few other remarks the details of which escape me right now.

It seems to be effective.
Even without the ATCO flying training that used to occur routinely prior the end of the eighties, when cost cutting got real serious. We haven't had any flying training of ATC trainees for a number of years, now.

The local flight instructors are also very "on to it", and before students solo they are exposed to a very wide range of traffic sequencing related manoeuvers, which is necessary because of the range of commercial operations and large speed differences. I would estimate the average student here is probably the equivalent, in traffic situational awareness, to a low time PPL elsewhere, so it's a bit hard to gauge just how effective the local procedure is.

I would also recommend against more than one or maybe two pieces of info/instructions within the same transmission, (ICAO suggest a maximum of three, to regular pilots,) and a nice, slow, even delivery.

One question: WHY?

Unfortunately this accident tragically shows what can happen when a low performance light aircraft flown by a low-time pilot is sent around from finals! Safety of flight should always take priority over perceived "other priorities", such as commercial pressure; we all know it often doesn't happen.
In any event, in this case the following traffic was merely another GA aircraft joining the pattern and the pilot would presumably have had no trouble whatsoever in going around and joining the normal visual circuit.

Thanks Lobby, a very interesting read...Does this raise the question of when to allow a student to go solo?....He seemed confused by a number of instructions (including back-track). When operating in a shared circuit should he not be prepared to a good standard for instructions that would modify a standard circuit before the solo phase?

What do people think of the suggestion that students (both ATCOs and pilots) should have a call sign addition of "student"?

Errr,
When I last instucted in the US, training in go-arounds was a pre-SOLO item. In other words, a student should be able to demonstrate the ability to perform a go around safely before he could be signed off for solo. All my students did....

Yep..
"Cleared for the option" was one way my instructor could mess with my mind during pre-solo training as you didnt know what to expect, Bump'n'go, full stop or Go Around. :ooh:

vector4fun. Agree 100%. I think it's outrageous that a youngster who couldn't hold a full driving licence here in the UK should be sent solo at a busy airfield when he apparently had difficulty coping with a very common situation. I can't see that the phraseology used by ATC has any bearing on the matter; I have used "non-book" on many occasions when dealing with inexperienced pilots with great success.

A dreadful waste of a life and my thoughts are with the young pilot's family and with the ATC people involved.

In the military a three figure callsign is used or the word Tyro. This gives everyone the clue!

Holes in the cheese?
 

When I was a student PPL, I felt very frustrated that my instructor didn't let me go solo until I could demonstrate engine-off landings, PFLs, go-arounds, low-level and/or restricted circuits and being asked to hold. I didn't go solo until nearly 40 hours under my belt.

I felt I was being unfairly and unnecessarily held back; even spoke to the Chief Pilot about it. However, this incident and another involving a student helicopter pilot who was asked to hold have made me think that the decision was wise. In the end, it made no difference to the number of hours in which I got my licence.

There is quite a bit of pressure and competition amongst students to go solo early on as a confidence booster (which I can understand) but, given there are many things that can make a circuit "non-standard", a few more hours to cover most eventualities should be given. In my case, a bird-strike!!! :eek::ouch:

All the controllers where I learned knew I was a student and I'm sure allowances were made.

My sympathies to the boy's family and all those involved as I am sure it will haunt them. However, having read the whole report, I can see a number of things which would have caused the holes in the cheese not to line up.

Cheers

Whirls

Some info about the following aircraft type (gleaned from planeandpilotmag.com) : I think it is important to put one thing in perspective. A student on his/her second solo is likely to be working to the limit of his capacity just to get the aircraft around the circuit and safely back on the ground. Anything above the norm is likely to overload him. I watched a good friend of mine crash a JP3A on his second solo. After a self determined go around from a steep approach, he received a message from the tower along the lines of "Land and report to the tower on landing". The second landing resulted in very severe PIO and a crash from about 150 feet onto the runway. Thankfully, he survived, despite sitting on a live ejection seat which could have gone off, due to damage to the cockpit floor. He wasn't lacking in natural ability, he proved that by going on to win the course flying prize and later became a fighter pilot and a B747 captain.

I felt obliged to intervene (I called across "No - let her land, please!"; I was sitting in the tower, observing) when the RAF tower controller told my first solo UAS student to go around and change frequency to the tower alternate simply because her finals call was very quiet. He wasn't impressed at first, but after she had landed safely I explained that she was unlikely to cope with a mandated go-around and fiddling with the radio. He saw my point.

This is indeed a tragic case. Most posters appear to have read the AAIB report. But I do differ from the tone of some posts, especially Heathrow Director.
Apart from him not understanding 'backtrack', thinking he should do it on the taxiway, to me he seems to have done everything 'text book', until his failure to maintain flying speed in an entirely unexpected situation.
The radar shows he flew an excellent circuit, his responses on radio to ATC were clear and proper. On reporting 'downwind' he was told he was No.1 to land. In 1450 hours entirely private flying, to airfields of every size, including Gatwick, I have never had a 'number one to land' revoked. Of course we have all had to go around occasionally because of runway obstruction, but not for letting another aircraft to be No.1.
After reporting 'final' he was then told to go around, maintaining runway heading. I suggest that had he been left with this instruction, which he repeated correctly, there would have been no incident at all, I'm sure he was trained for this. But ATC reversed that instruction, telling him to turn North, which clearly left him in a situation, at very low level, he couldn't cope with.

My veiw is that this sad fatality was caused by the the two reversals of ATC instructions. One that he was No.1 to land, and secondly to go around on runway heading. Both of these were reversed, leaving a student in a postion for was totally unprepared.

There is no evidence from the AAIB report that the student, whatever his age, was not properly and responsibly trained and capable of a second solo.

I slightly resent the general assertion that 16 year olds shouldn't be sent solo. I myself went solo when I was 16 and on my third solo circuits session had to deal with lots of traffic spacing problems (usual GA scene on a Sunday afternoon: very busy uncontrolled airfield with everything from ultralights to twins wizzing round all at different speeds and some trying to do glide approaches :E ) involving going around at least twice, it is difficult. But it seems to me that the instructor in this case had every confidence in the boy and can't be blamed for sending him solo. From reading the report it sounded like the controller got a bit flustered and issued an odd instruction which was the main contributing factor in the accident.

Mike,

I agree the "reversal in instructions" were a CONTRIBUTORY factor but certainly not the CAUSE as you put it. We're not apportioning blame here, just trying to understand factors which learnt by the rest of us will hopefully make us better controllers/instructors/pilots. I think it is a valid point that a student pilot operating in a potentially busy/mixed ac type circuit,should be able to react to the unexpected before going solo.

I agree with the last sentiment; this is why ATCOs were in previous years given some pilot training - so that they understood the pilot's perspective a little easier. The military also made it mandatory for student pilots to visit the tower at least once every month whilst undergoing basic flying training.

At the end of the day, we are all (by all I mean pilots, ATC, all other support services)hopefully here trying to make flying go on as safely and as expeditiously as possible.

I am appalled yet again, that some individuals are coming the old
"Well if you ask me" and "Of course I would never do that" routine.
AAIB have looked into all aspects and have published their findings accordingly. Why do certain controllers and PPLs for that matter consider it necessary to state their opinions and by so doing, indirectly seek to apportion blame. Sometimes it is far better to keep ones own counsel. I believe this to be one of those occasions
:(

Magp1e,
I think its semantics between 'cause ' and 'contributory'. Nearly all fatals have a chain which if any link had been broken, people would now be alive.
I this case, the ultimate 'cause' was that flying speed was not maintained.
But I posted my reply because Heathrow Director, an obviously highly experienced ATCO, stated that the the student could not cope with a common situation.
This means that it 'common' to tell an a/c that it is 'number one to land', and then reverse it. It is 'common' to tell an a/c reporting final anything other the 'cleared to land' or 'go around'.
In my opinion, and experience, HD is just plain wrong. In all my 37 years of flying I have never had either of these. It almost makes me angry that a student had to deal with this.
My thoughts on the early reports and rumours last year were that this may be a case of a young chap pushed too early. Now, reading the AAIB report, my view is that he was as good as any for solo, and, as I said, the circuit was 'text book', and the aircraft was found by AAIB configured correctly for final approach.

State their opinions? Yes, because the original thread starter asked for them. Indirectly apportioning blame? No, indirectly learning from the opinions and experiences of others.

I would normally agree in circumstances where the AAIB has not been published - speculation does nothing for anyone. However, the AAIB report has been published and read, pretty much, by all those who have posted.

By recounting ones own experiences, we can all learn and maybe further accidents like this can be prevented. A number of questions are posed; links in a chain, holes in the cheese.

I'm sorry if you were personally affected by this accident, really I am but we should all ensure that something like this does not happen again i.e. should ATCOs be informed of the student status of a pilot, should students be sent solo after 15 hours, should a larger, faster aircraft take priority over a small one ....

Cheers

Whirls

MikeJ

Well, in my opinion and my very little l experience I think your talking utter tosh!!

During my last cycle I had to send 2 GA lights around in 2 days because of their speed control on finals. It is almost a daily occurance at my unit when GA traffic is operating, for instructions to be changed purely because GA is of a lower priority than Commercial traffic. It is often commented that we control & seperate VFR in Class D as we've had so many incidents of lights just treating it as an uncontrolled environment.

I work at an airfield where you don't send your students solo if they don't understand a Controlled ATC environment e.g. Wake Vortex seperation, orbiting start, mid-point, end, traffic at 10miles keep your base tight, traffic at 5 is catching you up, break off the approach return to base report reaching (or go around, I say again go around, early right turn to the north)....

''Makes you angry that a student has to deal with this.....'' I'd sooner they learnt it now and have the experience stored in their memory banks for next time, than add to the amount of utter GA clowns there are out there who can't even read back a Clearance to Land!!!

I am in no means attributing blame to the unfortunate chap or ATC. Just kinda think that maybe a little more experience in these unusual circumstances, would stand all those that operate in a controlled environment a better appreciation of what can/could happen to them and what they should do.

Rant over..... awaiting incoming

ICAO - 'controlled airspace is for the protection of IFR traffic' - don't see the mention of VFR in there.............as a controller for 25 years, makes me think we tend to bend over backwards for the VFR's in airspace not designed for VFR's!! My 2 cents worth anyway.

A bit of thread drift but it needs comment.

CAS is there to protect IFR flights.........by enabling VFR flights to be separated from them or by providing a known traffic environment where ATC can give them traffic info on relevant VFR flights (OK, this bit doesn't work so well in class E but I guess nothing is perfect!). It doesn't mean that VFR is not permitted, simply that VFR - by definition - gets 'less' service from ATC.

The airspace is designed for airspace users NOT for VFR or IFR or SVFR or ATC.

Vector801 wrote:

"In my opinion, and experience, HD is just plain wrong." and...

"I work at an airfield where you don't send your students solo if they don't understand a Controlled ATC environment .."

Not sure I wrote that was "plain wrong", because you seem to have agreed with my sentiments! I worked for some time at Kidlington Airport, where there would often be a dozen+ in the circuit plus IFR let-downs going on. It was very, very, frequently necessary to instruct training pilots to fly go-arounds and various other manouevres but they were properly trained to operate in a busy ATC environment before going solo and we didn't get too much busted metal or students.

Actually it was Mike J accusing you of being plain wrong - Vector was agreeing with you.

Mods - bring back the "quote" function please!

As a complete thread drift, quotes are still available as I showed in my post quoting ICAO Annex 11.

You have to type [quote=person's name] quoted text followed by [/quote

The last bit has to end in a closing square bracket - I can't do it otherwise the whole thing would show up as a quote!

Secondly, copy the text you want to quote (highlight, right click, copy), paste into reply. Then highlighting the text in the reply, click the quote button above.

Agree here with Chilli, I also mistook the quote as original.

Cheers

Whirls

I agree with Vector and HD on this. There are so many different ways in which an ATCO will do something – 20 controllers will handle a complex busy situation probably 20 different ways and they have to keep changing their plan since the traffic situation is constantly changing. Standard phraseology cannot be used for every situation, particularly on Aerodrome Control, therefore controllers will slightly modify their words as necessary.

However I do think that far too few pilots understand the way ATC goes on. At my unit as part of the Unit Training Plan a new controller has to spend some time with the flying schools in order to get a some knowledge of how they operate/what they like/don't like etc. We hardly ever get student pilots visiting radar or the tower to see it from our side.

Mike,

Didn't seem like semantics...I agree Swiss cheese was ripe with ATC instructions, lack of experience, air traffic situation....

Leuvan (spelling?)

See post 20....we're not trying to apportion blame. I'd like to think that we are a group of professionals trying to learn lessons from a tragic incident, I have certainly learnt from this event to be a lot more cautious than I already am when dealing with inexperienced pilots

Hey guys,

yeah, sorry for the quote thingy..... Was quoting MikeJ not HD.


Also totally agree with perusal & a bit off topic.

As you've all probably guessed I work at Cardiff. With the massive changes in Airspace last year we actively created pilot/atc forums with the local GA community to try to help them understand what will be required of them, what we may do to them etc...etc...

We never ever get visitors from the GA community asking to visit the unit for famil, only work experience people and the usual bods from within the airport. I've even taken it upon myself to get some of the locally based BMI crews to come and have a butchers so they can ask some of their obvious questions concearns with atc.

I remember when leaving the college last year, BA Week was so beneficial with the fam flights. Until recently fam flights at Cardiff counted towards TRUCE and were extremely encouraged.

On the flip side, its such a shame the flight training has been reduced so much for ATCO's.

Thought I might add this little extract from the MATS pt. 1 that all controllers work from. This may clarify for some of you, who has priority over who.

Category Type of Flight

A Aircraft in emergency (e.g. engine fault, fuel shortage, seriously ill passenger). Aircraft which have declared a 'Police Emergency'. Ambulance/Medical aircraft when the safety of life is involved.

B Flights operating for search and rescue or other humanitarian reasons. Post accident flight checks. Other flights, including Open Skies Flights, authorised by the CAA.

C Royal flights, Flights carrying visiting Heads of Statewhich have been notified by NOTAM/Temporary Supplement.

D Flights notified by the CAA carrying Heads of Government or very senior government ministers.

E Flight check aircraft engaged on, or in transit to, time or weather critical calibration flights. Other flights authorised by the CAA.

NORMAL FLIGHTS
i) Flights which have filed a flight plan in the normal way and conforming with
normal routing procedures.
ii) Initial instrument flight tests conducted by the CAA Flight Examining Unit.
(RTF callsign EXAM)

Z Training, non-standard and other flights.


Again, not wanting to labour on about the point. If your instructor deems you experienced and competent enough to send you solo, you qualify for category Z. Ok, at Cardiff for your first solo we'll put on a local standby & give you perhaps a little more attention. Other than that we're not gonna bloody control and fly the plane for you. Everything else above you cat wise comes first and foremost and if that means you orbit for 45 minutes on base then thats what you'll do.

I'm sure others that frequent this forum who also work at busy COM/GA airfields will testify, students don't get sent solo until they are completely famil with most eventualities that a busy airfield can throw at them.

Sending someone solo who can fly an aeroplane is one thing, sending them solo when not prepared for said scenarios is utterly irresponsible and downright dangerous.

Once again..... Rant Over.

That's inevitable. Every so often I get asked to do something that I've never been asked to do before, and it throws me. That doesn't mean the request shouldn't be made, but it's worth bearing in mind that the further from standard behaviour something is the more likely it is to cause confusion and error.

A go-around is a fairly well rehearsed manoeuvre even for a solo student, and the need to apply climb power is obvious. But the instruction to make a turn off final may have confused (particularly about the level he was supposed to fly at) enough to leave the student in a quite unfamiliar power/pitch/configuration/flightpath combination.

Standard procedures are never going to cover every case. But if we can find standard procedures that work, we should use them.

Most eventualities, yes. However, I did my first solo in 1971 and been flying for a living since 1977. I've sent quite a number of students on their first solos too. I've never been asked to go around from finals for one behind, although I have been asked to expedite or reduce to minimum speed! I've never been asked to deviate from finals at 90 degrees, either.

Agreed. The following aircraft could have been directed to slow to minimum safe speed during it's ILS approach.

Agree with the slowing down, but probably worth clarifying here that, although IFR, it was actually carrying out a visual approach, not an ILS and was joining right base.

What concerns me most about this tragic accident is the utter failure of the Aerodrome controller and the Approach controler to successfully integrate visual joining traffic with circuit traffic. And regardless of whether the Piper was IFR, he does not appear to have been carrying out an instrument approach but a visual join.

The Cessna pilot was told he was number one. So why didn't the aerodrome controller tell approach to instruct the Piper that he was number two to a Cessna on finals. It is then the responsibility of the Piper pilot to separate either by adjusting his position or by going around.

Furthermore, what was the concern from the controllers that the Piper if instructed to go around would have done so beneath the Cessna which the controller considered dangerous? When the Cessna called finals the Piper was still almost three times as far from the threshold so what approach was he carrying out that would place him lower? Unfortunately there is no record in the AIB report of whether the Piper was cleared for a straight in Approach, and if so when this was agreed, nor of any co-ordination between Aerodrome and Approach about it.

Can anyone tell me what independent standards checks are carried out on civil ATCOs at aerodromes like the one featured in the report?

The AIB has reported on the circumctances and made safety recommendations, has/is any further action being taken?

ShyTorque

Ok, Scenario for you....

Your asked to Go Around on short finals because the following has caught you up, for example a light, medium or heavy jet. There is no chance of a successful touch & go or full stop to vacate, possibly using a Land After.

Please answer the following if you'd be so kind....

As a pilot what would you expect the controller to do?
As a controller what would you do?

If the controller sent you around, do you really think with all your years of experience he's gonna let you climb straight ahead with a Jet less than 2 miles behind doin 2 miles a minute??? What if the Jet go's around short final due nasty turbulance (which is common at Cardiff), Possible Bird Strike?? Just imagine the traffic information and how mmm ?distracting? it would be for the Jet Crew in a scenario like that. The Jet already has possibly a better picture than you in front through Traffic Info passed earlier. The lighty is almost blind and would of course be made to make an avoiding turn.... Oh thats right, you'd like to continue climbing straight ahead.... mmm.... clean up the aircraft, get it set for a nice 15 degree angle turn for x wind at say 800' agl... all standard flying, except this ain't a standard situation is it. All this happeneing whilst the crew of the jet are hitting max power (if they have it), go around checks, stabalizing the a/c..... then bang!!! they've ran into the back of you because you've never had to initate an early turn after a go-around??? All TRM thinking, just because your a lighty doesn't mean your not part of the team, even if your not conscious of it!!

One thing that always stuck with me through training is, treat every approach as a possible go around e.g. ''Fail to Prepare, Prepare to Fail,''

Is it me, or is anyone else here truly shocked and somewhat puzzled at some of the responses being posted here!!