Beyond belief
Joined: Jun 2003
Posts: 407
Likes: 9
From: UK
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...
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...
Joined: Feb 2007
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From: Amsterdam
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?
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?
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.
Guest
Posts: n/a
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
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
Joined: Mar 2002
Posts: 2,814
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From: Euroland
a series of unfortunate decisions
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
Joined: Jun 2003
Posts: 407
Likes: 9
From: UK
I would not call intentionally departing inot IMC IFR with no instrument qualifications "unfortunate".
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.
Joined: Dec 2007
Posts: 481
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From: France
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'.
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).
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'.
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).
Last edited by frontlefthamster; 15th December 2007 at 08:44.
The Original Whirly
Joined: Feb 1999
Aviation Qualifications: CPL
Posts: 4,327
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From: Belper, Derbyshire, UK
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.
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!!!!
Joined: Jan 2007
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From: Dunno ... what day is it?
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.
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.
Joined: Aug 2002
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From: Lymington
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.
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.
Last edited by yawningdog; 16th December 2007 at 08:01.
Guest
Posts: n/a
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
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
Joined: Nov 2000
Posts: 3,443
Likes: 1
From: Cambridge, England, EU
And Fred is guilty of indecisiveness and wimpishness, but is that an offence that deserved what happened?
Last edited by Gertrude the Wombat; 15th December 2007 at 21:37.
Joined: Dec 2007
Posts: 481
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From: France
yawningdog, you wrote:
That reminds me of something...
or rather, two things...
...and they're both between my legs, and they're hairy...
Yes but the only reason those pilots died was because they set the wrong altimeter setting. Simple as that.
That reminds me of something...
or rather, two things...
...and they're both between my legs, and they're hairy...
Joined: Oct 2004
Posts: 1,199
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From: Hunched over a keyboard
Their fate was sealed when they went IMC on the return to BPL with insufficient fuel to divert.
Fly Conventional Gear
Joined: May 2007
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From: Winchester
Yes but the only reason those pilots died was because they set the wrong altimeter setting. Simple as that.
Joined: Mar 2002
Posts: 2,814
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From: Euroland
but the fact that they had reached sea level and not realised it suggests perhaps not.
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
Joined: Aug 2003
Posts: 1,218
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From: Surrey
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??
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??
Fly Conventional Gear
Joined: May 2007
Posts: 1,600
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From: Winchester
Not true.
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.
Joined: Mar 2000
Posts: 3,130
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From: U.K.
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.
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.
Fly Conventional Gear
Joined: May 2007
Posts: 1,600
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From: Winchester
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.
Joined: Aug 2002
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From: Lymington
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.
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.