The Coventry Incident - the ONLY thread?
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Just curious but on what grounds do you make that statement? I never worked at Coventry but I did spend a year at Kidlington where that sort of situation arose many times every day.
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While there may be 'nothing new', a number of things struck me.
The challenges of mixing fast and small aircraft are clear, however, it is achievable with a high level of safety as demonstrated everyday in many airports throughout the world (particularly in the US). Sadly in this case, too many links in the accident chain lined up.
- There is no mention of anything like
- 'if both aircraft had been transponder equipped the Short Term Conflict Warning would have altered the controllers to the collision risk', which would suggest this does not exist with regard to ATM displays
- 'If G-BOLZ had a Mode-C or better transponder then G-EYES's TCAS would have prevented the collision'. Sadly even if both aircraft were Mode-S equipped, due to the lack of airborne traffic detection in either aircraft, it appears transponders would not have helped in this particular accident chain.
- 'if both aircraft had been transponder equipped the Short Term Conflict Warning would have altered the controllers to the collision risk', which would suggest this does not exist with regard to ATM displays
- The clear misunderstanding between pilot and controller about what flight rules G-EYES was operating under, and what protection the flight rule choice might or might not provide.
- More generally, there may be a view among some pilots that being IFR means one has a higher priority and does not need to look for traffic in VMC (something I see implied in some posts)
- The lack of clarity if a Tower or Approach Controller, is actually 'controlling' VFR aircraft. Until reading the report, if I was instructed to 'continue through the localiser and establish right base', I would not have considered the possibility someone else sequenced behind me on the ILS would be about to T-Bone me
- The practical impossibility of seeing smaller aircraft (even the PA-28) in anything like adequate time at 160knots (let alone the maximum 250 knots that is allowed down low)
The challenges of mixing fast and small aircraft are clear, however, it is achievable with a high level of safety as demonstrated everyday in many airports throughout the world (particularly in the US). Sadly in this case, too many links in the accident chain lined up.
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Just a thought
This idea may be a result of me learning to fly doing oval circuits on an RAF airfield, but the trace shows the circuit traffic a long way from the runway. That's such a big circuit that they are outside the ATZ.
I'm not suggesting it is causal, but I am wondering if it is normal for you guys to fly such big wide & long circuits. I can normally manage to pfl from 800feet (QFE) on the downwind leg, but I don't see that working from a couple of miles away.
I can see how the ADC might have initially expected them both to be on the Runway before the calibrator got close.
I'm not suggesting it is causal, but I am wondering if it is normal for you guys to fly such big wide & long circuits. I can normally manage to pfl from 800feet (QFE) on the downwind leg, but I don't see that working from a couple of miles away.
I can see how the ADC might have initially expected them both to be on the Runway before the calibrator got close.
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As a retired ATCO, I recognise elements of those awful sequence of events, fortunately without the fatal consequences. The holes in the swiss cheese lining up. You take away just one item and the incident/accident does not happen. You just have to hope that while you may be very good at what you do 99.99 % of the time the moment you do have a lapse, and you cant go through a long aviation carreer without having one, the other links in the chain are working as they should.
Obviously, you cannot plan for every eventuality, but procedures and management must be robust enough to provide an adequate safety net and regulatury authurities should be prepared to bare their teeth where they consider all is not what it should be. Sorry if this may sound a bit emotive but "been there, almost done that"
My thoughts are with all concerned, especially those who lost their lives and the bereaved.
Obviously, you cannot plan for every eventuality, but procedures and management must be robust enough to provide an adequate safety net and regulatury authurities should be prepared to bare their teeth where they consider all is not what it should be. Sorry if this may sound a bit emotive but "been there, almost done that"
My thoughts are with all concerned, especially those who lost their lives and the bereaved.
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I'm not sure that there is any problem with mixing the types of traffic in question. Years ago, Farnborough would often have very slow aircraft and very fast jets in the circuit together. At Kidlington there would be many Cherokees in the circuit togerth with fast twins joining off instrument approaches.
I have never criticised a fellow controller because I always assume that whatever decision one reached had a good reason. What immediately made me sit up was the decision to instruct the smaller aircraft to go through the ILS and re-position on the right side, but we don't know if there was other traffic behind in the circuit. I assume that the pictures of the radar shown in the AAIB report were from the display in the Tower, hence visible to the Aerodrome Controller, so he should have had a good idea of the relative positions of the two aircraft and of the closing speeds.
Why did he decide to tell the smaller aircraft to go through the final approach rather than a) instruct it to orbit or b) to extend downwind? He must have a reason but we shall never know..
AAIB reports always list in some detail the qualifications and experience of pilots involved, but rarely those of the controllers. In this particular case, it merely says he held an ATC Licence - no information on ratings or validations. Was he a validated radar controller at the unit? If he was, and given the snaps shots in Figs 1, 2 and 3, I am sure that he would have taken different action. I truly feel for him.
Sure it would be extremely useful if all GA aircraft had transponders.... but you know the attitude of many of the clockwork mouse brigade. Hell, many of them don't want radios!
I have never criticised a fellow controller because I always assume that whatever decision one reached had a good reason. What immediately made me sit up was the decision to instruct the smaller aircraft to go through the ILS and re-position on the right side, but we don't know if there was other traffic behind in the circuit. I assume that the pictures of the radar shown in the AAIB report were from the display in the Tower, hence visible to the Aerodrome Controller, so he should have had a good idea of the relative positions of the two aircraft and of the closing speeds.
Why did he decide to tell the smaller aircraft to go through the final approach rather than a) instruct it to orbit or b) to extend downwind? He must have a reason but we shall never know..
AAIB reports always list in some detail the qualifications and experience of pilots involved, but rarely those of the controllers. In this particular case, it merely says he held an ATC Licence - no information on ratings or validations. Was he a validated radar controller at the unit? If he was, and given the snaps shots in Figs 1, 2 and 3, I am sure that he would have taken different action. I truly feel for him.
Sure it would be extremely useful if all GA aircraft had transponders.... but you know the attitude of many of the clockwork mouse brigade. Hell, many of them don't want radios!
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HD, Yes I fly a clockwork aircraft and also more sophisticated general aviation aircraft. I can tell you that having a radio is not the be all and end all. Many times I have been flying under radio control from one of the flight information centre's and have had another aircraft go wizzing past that I was not advised of causing me to take avoiding action. Also when I used to fly at a certain airfield in southern england where none of us used a radio or transponder. We never had any mid air collisions until we had mandatory radio, then we had a collision which killed 4 people. The answer
is always - look out of the cockpit and look before you turn.
is always - look out of the cockpit and look before you turn.
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Why did he decide to tell the smaller aircraft to go through the final approach rather than a) instruct it to orbit or b) to extend downwind? He must have a reason but we shall never know..
I don't blame the controller in this instance, he was just one of a chain of events. The fact was both aircraft were VFR and in VMC, but even had they not been, "see and avoid" still applies to IFR traffic in VMC, especially OCAS where no seperation between VFR and IFR is provided.
Perhaps landing lights on the Cessna would have helped?
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<<Many times I have been flying under radio control from one of the flight information centre's>>
If you mean from, for example, the London FIS, it is not a "control" service nor can they provide you with effective traffic information as significant numbers of pilots do not participate.
If you mean from, for example, the London FIS, it is not a "control" service nor can they provide you with effective traffic information as significant numbers of pilots do not participate.
I think this incident highlights the dangers of large non-standard visual circuits. Both aircraft in the visual circuit were outside the ATZ on the base leg. The second aircraft was told to position behind the PA28 with the inevitable result of extending a large circuit even further. It is not uncommon to see Coventry based aircraft with trainee pilots who have less than ICAO level 4 English flying Bomber circuits at nearby airfields. A pilot on an ILS is not expecting to encounter circuit traffic on a 3 mile final, lookout would be directed towards the base leg at about 1 mile. We have to educate pilots to fly correct circuit patterns and not extend downwind. If a student can't fly a proper circuit they should not be flying solo. If they can't speak English they shouldn't be flying at all.
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I agree, but how can one tuck in behind previous traffic, without flying a "big" circuit?
One also sometimes flies a big circuit when the traffic before you is not visible, which is quite often the case.
One also sometimes flies a big circuit when the traffic before you is not visible, which is quite often the case.
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This 'bomber circuit' discussion rolls on and on, but no-one ever gets to the point: complainers! It is people living in villages and sometimes individual houses who cause the big circuit mentality.
We must presume that many of these people have lived in their property since a time before the airfield was built. However, there must be a proportion who have moved in since 1945 taking advantage of a discount in the price of their home due to aircraft noise and now hope to leverage a cash advantage by restricting flying.
These people cause airfield operators to require ludicrous operating proceedures that often extend to the edge of the ATZ. And then, because of difficulties for pilots identifying which complaining village is which, the circuits just grow. Recently, following downwind traffic far from the airfield, I enquired of ATC if the aircraft ahead was departing the circuit. "I'm still in the ATZ" came back a strangled response from an instructor, as though that was justification for flying so wide.
Most of these wide circuits are outside gliding range. What's needed, next time there's an off - airfield forced landing due to this, is for the pilot to hold the complainer (and it's often one ringleader) personally responsible.
Just a thought.
We must presume that many of these people have lived in their property since a time before the airfield was built. However, there must be a proportion who have moved in since 1945 taking advantage of a discount in the price of their home due to aircraft noise and now hope to leverage a cash advantage by restricting flying.
These people cause airfield operators to require ludicrous operating proceedures that often extend to the edge of the ATZ. And then, because of difficulties for pilots identifying which complaining village is which, the circuits just grow. Recently, following downwind traffic far from the airfield, I enquired of ATC if the aircraft ahead was departing the circuit. "I'm still in the ATZ" came back a strangled response from an instructor, as though that was justification for flying so wide.
Most of these wide circuits are outside gliding range. What's needed, next time there's an off - airfield forced landing due to this, is for the pilot to hold the complainer (and it's often one ringleader) personally responsible.
Just a thought.
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An inquest into the deaths in this accident is taking place this week.
The following is the report from The Bucks Free Press online regarding the inquest so far:
The following is the report from The Bucks Free Press online regarding the inquest so far:
9:38am Friday 12th October 2012 in News
AN ERROR by air traffic controllers could have led to a mid-air crash which killed five people, including a pilot from Marlow, an inquest was told this week.
James Beagley, 34, was among those who died near Coventry Airport in August 2008.
Mr Beagley, was a passenger in a Cessna 402 aircraft which collided with a small solo-piloted plane.
His family have been fighting for answers ever since and an inquest finally started on Monday in Leamington, Warwickshire.
Seventy year-old Leamington resident Brian Normington, who was at the controls of a kit-built Rand KR-2, was killed in the crash, along with four people in Mr Beagley's aircraft.
During the hearing, a jury heard how lone pilot Mr Normington's kit-built one-seater Rand KR-2 was 'notoriously difficult' to see because of its small size.
Geraint Herbert, senior inspector of the Air Accidents Investigation Branch outlined possible reasons for the crash, including 'ambiguous' information handed to the Cessna pilots by air traffic control.
Wrong details had also been put in by air traffic control when the crew had informed them of their training intentions the previous night, the inquest heard.
The Cessna was taking part in an exercise to show pilots how to land in bad weather. It involved approaching the runway at high speed before pulling up at 50ft and flying away.
When air traffic control realised the planes were on a collision course, Mr Normington was told to alter his course.
But the planes crashed just seconds after the Cessna had been told about Mr Normington's change of course.
Other factors included the Cessna not seeing the other plane or having enough time to avoid a collision.
His report pointed out Mr Normington's plane could have been in a blindspot from the cockpit of the Cessna 402, which had been involved in routine training for aerial survey firm Reconnaissance Ventures Ltd (RVL).
Statements from the families of the victims have been read to the court, including from Alan Beagley, who spoke of the devastation his son's death had caused.
The retired helicopter pilot, said: "His death has been a huge loss, not only to myself and the family, but to many people who knew him."
The inquest, for which a jury will return a verdict, is expected to be concluded by Monday and continues today.
AN ERROR by air traffic controllers could have led to a mid-air crash which killed five people, including a pilot from Marlow, an inquest was told this week.
James Beagley, 34, was among those who died near Coventry Airport in August 2008.
Mr Beagley, was a passenger in a Cessna 402 aircraft which collided with a small solo-piloted plane.
His family have been fighting for answers ever since and an inquest finally started on Monday in Leamington, Warwickshire.
Seventy year-old Leamington resident Brian Normington, who was at the controls of a kit-built Rand KR-2, was killed in the crash, along with four people in Mr Beagley's aircraft.
During the hearing, a jury heard how lone pilot Mr Normington's kit-built one-seater Rand KR-2 was 'notoriously difficult' to see because of its small size.
Geraint Herbert, senior inspector of the Air Accidents Investigation Branch outlined possible reasons for the crash, including 'ambiguous' information handed to the Cessna pilots by air traffic control.
Wrong details had also been put in by air traffic control when the crew had informed them of their training intentions the previous night, the inquest heard.
The Cessna was taking part in an exercise to show pilots how to land in bad weather. It involved approaching the runway at high speed before pulling up at 50ft and flying away.
When air traffic control realised the planes were on a collision course, Mr Normington was told to alter his course.
But the planes crashed just seconds after the Cessna had been told about Mr Normington's change of course.
Other factors included the Cessna not seeing the other plane or having enough time to avoid a collision.
His report pointed out Mr Normington's plane could have been in a blindspot from the cockpit of the Cessna 402, which had been involved in routine training for aerial survey firm Reconnaissance Ventures Ltd (RVL).
Statements from the families of the victims have been read to the court, including from Alan Beagley, who spoke of the devastation his son's death had caused.
The retired helicopter pilot, said: "His death has been a huge loss, not only to myself and the family, but to many people who knew him."
The inquest, for which a jury will return a verdict, is expected to be concluded by Monday and continues today.
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The Cessna was taking part in an exercise to show pilots how to land in bad weather. It involved approaching the runway at high speed before pulling up at 50ft and flying away.
D.O.
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narrative verdict
The inquest has produced a "narrative" verdict on the Coventry mid-air. Not quite sure what that means.
Narrative verdict in air crash inquest | Local News | News | 107.1 Rugby FM
better link:
Air crash inquest verdict: errors led to five deaths - Local - Leamington Courier
Narrative verdict in air crash inquest | Local News | News | 107.1 Rugby FM
better link:
Air crash inquest verdict: errors led to five deaths - Local - Leamington Courier
Last edited by Dawdler; 16th Oct 2012 at 13:37. Reason: adding second link
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From Wikipedia:
A narrative verdict is a verdict available to coroners
in England and Wales following an inquest.
In such a verdict the circumstances of a death are recorded without attributing the cause to a named individual. Narrative verdicts were introduced in 2004.
in England and Wales following an inquest.
In such a verdict the circumstances of a death are recorded without attributing the cause to a named individual. Narrative verdicts were introduced in 2004.
