Birmingham Airport near miss caused by radio mix-up
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Birmingham Airport near miss caused by radio mix-up
A radio frequency mix-up was to blame for a near miss at Birmingham Airport, according to an air accident report.
The pilot of a six-seater private aircraft lost contact with air traffic controllers and passed "over the top" of a stationary passenger plane.
The Socata TBM 850 landed safely after avoiding the Flybe-operated Q400 bound for Guernsey.
The Air Accidents Investigation Branch (AAIB) described the events of 12 January as a "serious incident".
In its report, the AAIB said the pilot of the TBM thought he had selected 118.300 megahertz (MHz) on his radio standby position, but in fact the active frequency was 118.030 MHz.
'High workload'
There was no time for the Flybe plane, carrying about 50 passengers, to taxi clear of the runway before the TBM arrived.
The report said: "The controller's only option was to keep the Q400 obstructing the runway and rely on the TBM pilot either going around or seeing and avoiding the Q400."
It added that the tower controller had not read a recent safety notice which contained advice for dealing with this type of situation, but did alert the other controllers on duty, and the supervisor, of the problem.
The AAIB made four safety recommendations and said the pilot's decision-making process had been "degraded" by a "high workload".
There was no damage to either plane.
BBC News - Birmingham Airport near miss caused by radio mix-up
The pilot of a six-seater private aircraft lost contact with air traffic controllers and passed "over the top" of a stationary passenger plane.
The Socata TBM 850 landed safely after avoiding the Flybe-operated Q400 bound for Guernsey.
The Air Accidents Investigation Branch (AAIB) described the events of 12 January as a "serious incident".
In its report, the AAIB said the pilot of the TBM thought he had selected 118.300 megahertz (MHz) on his radio standby position, but in fact the active frequency was 118.030 MHz.
'High workload'
There was no time for the Flybe plane, carrying about 50 passengers, to taxi clear of the runway before the TBM arrived.
The report said: "The controller's only option was to keep the Q400 obstructing the runway and rely on the TBM pilot either going around or seeing and avoiding the Q400."
It added that the tower controller had not read a recent safety notice which contained advice for dealing with this type of situation, but did alert the other controllers on duty, and the supervisor, of the problem.
The AAIB made four safety recommendations and said the pilot's decision-making process had been "degraded" by a "high workload".
There was no damage to either plane.
BBC News - Birmingham Airport near miss caused by radio mix-up
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The report said: "The controller's only option was to keep the Q400 obstructing the runway and rely on the TBM pilot either going around or seeing and avoiding the Q400."
Hugh, you are no doubt press. The report is here Those who read it will be clear what happened and the resulting Safety Notice highlights a discrepancy in SOPs
Safety Recommendation 2011-073
It is recommended that the Civil Aviation Authority resolve the conflicting expectations of flight crews and air traffic controllers following a loss of communications during approach.
It is recommended that the Civil Aviation Authority resolve the conflicting expectations of flight crews and air traffic controllers following a loss of communications during approach.
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Sounds reasonable, given that he was in the tower and had no obvious way to teleport himself to the TBM and take over its controls.
PS: I have not idea if the light gun in a tower is permanently rigged and instantly available.
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Yes-failure to read relevant information has a bearing on this incident.
Standard procedure surely is to go back to the frequency you came from if no reply on new frequency
Standard procedure surely is to go back to the frequency you came from if no reply on new frequency
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Thank you for the link Whopity.
Interesting report...
Overall, the report reads a lot less dramatic than the initial posts here which basically suggested that the pilot was some kind of a cowboy. Also, if the aircraft had indeed been impounded once on the ground (as had been reported here) that would seem a massive over-reaction. By who, I wonder?
Interesting pre-occupation by the AAIB with NDB approaches.
I can see they could not officially say anything else, but they really ought to know that practically every modern pilot flies NDB approaches using the GPS, either using an overlay or using the OBS mode. Thus, an NDB approach is no different from e.g. a VOR approach (which would be flown using the same method). The actual navaids are (or should be) tuned in, at least.
The lateral accuracy of the final approach suggests he did indeed use the GPS (**)
Apart from his frequency selection mistake, he did not commit any crime by landing without a landing clearance.
[my bold]
The ATC assumption assumes the pilot detects the loss of comms, but that is obviously not always going to happen...
Another little gem:
(**) I have just looked up the ILS 15 for EGBB and wonder if the AAIB report page 2 (shown as page "54" in the PDF, curiously) has a mistake on it. The plate does not suggest the ILS or NDB is offset, but the AAIB diagram shows a ~ 5 degree offset. The Jepp plate shows both the ILS/NDB 15 and the runway 15 to be 148 degrees.
Interesting report...
The ANSP at Birmingham, in common with several other major UK airfields, had applied to the CAA to remove their signalling lamp approximately six to ten years before the incident. This application was supported by a study which showed that signal lamps had limited effectiveness at those airfields. The CAA acknowledged that they had given permission for the signal lamp to be removed but neither they nor the ANSP could locate a copy of the application, permission or the supporting study.
The Tower controller had logged onto the briefing system after the Safety Notice had been issued but had not seen or acknowledged it. It was subsequently determined that the Safety Notice had been removed in error and thus was not available for the controller to view or acknowledge at that time.
After it became apparent that the controller had not read the Safety Notice, the AAIB asked the unit air traffic manager to interrogate the system and provide a list of staff who also had not electronically signed as having read or printed it. The system generated a list that included this controller but also included members of staff who were not licensed controllers and were therefore not expected to have read it. It also listed controllers who for various reasons were no longer at the unit.
The pilot stated that he last flew an NDB approach four years before the incident and could not recall flying one in the TBM 850 even though he was reported to have accomplished two during his TBM course.
The lateral accuracy of the final approach suggests he did indeed use the GPS (**)
Apart from his frequency selection mistake, he did not commit any crime by landing without a landing clearance.
ICAO Doc 4444, the UK AIP and the specific instructions for Birmingham, in common with most other UK airfields, require a crew having lost communications on intermediate or final approach to continue visually or by means of an appropriate final approach aid. As the pilot of N850TV had lost communications, albeit through a frequency mis‑selection, this is the situation in which he found himself.
Following a loss of communications, ICAO Doc 4444 and the UK AIP require aircraft to continue visually and at least 17 multi-pilot public transport passenger flights have landed without clearance in the UK in the 12 months to March 2011. In those cases the runway was clear.
In summary it is likely that air traffic controllers assume that a loss of communications will probably result in a go-around while pilots are expecting that they will land if they are able.
Another little gem:
The ATIS also significantly exceeds the recommended MATS (Part 1) length
(**) I have just looked up the ILS 15 for EGBB and wonder if the AAIB report page 2 (shown as page "54" in the PDF, curiously) has a mistake on it. The plate does not suggest the ILS or NDB is offset, but the AAIB diagram shows a ~ 5 degree offset. The Jepp plate shows both the ILS/NDB 15 and the runway 15 to be 148 degrees.
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Sounds like a case of the pilot getting a bit overloaded and making a simple mistake with the frequencies. However even considering poor visibility and its position on the displaced threshold I do find it hard to understand how he simply didn't seen the Dash 8 sitting there.
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I have just looked up the ILS 15 for EGBB and wonder if the AAIB report page 2 (shown as page "54" in the PDF, curiously) has a mistake on it. The plate does not suggest the ILS or NDB is offset, but the AAIB diagram shows a ~ 5 degree offset. The Jepp plate shows both the ILS/NDB 15 and the runway 15 to be 148 degrees.
Jepps plate 11-1 is the NDB to the ILS with DME for Runway 15, thus the NDB gets you to the ILS which is the final approach aid, inbound course 149
Jepps plate 16-1 is the NDB with DME for Runway 15, thus the NDB is the final approach aid, inbound course 154
the Runway is 149.
I accept my plates may be out of date so a 1 degree change to 148 may exist now.
every modern pilot flies NDB approaches using the GPS, either using an overlay or using the OBS mode
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Do you think he would have even noticed a light signal if he didnt even notice a large aircraft on the runway starter strip?
The facts in the report are that he was a low total time and low on type pilot.
He flew for several hours from Italy with three sectors to pick up other businessman as a sole pilot.
The workload on such a mission even on the ground with the sectors would have been high!
Add to that that he was also dealing with his business associate PAX and probably thinking ahead to his business meetings and in all it doesnt make a good mix for NOT making a mistake.
The confusion over the radios, probably seeing the runway between the numbers clear and the overiding desire to land probably lulled him into doing something which he would now kick himself for.
Sadly it was in an N reg with FAA licences and and will probably be heralded as an example of JAA V FAA while such errors are made in every realm of aviation and licence even multi crew.
In future he would be best to have a sit in in the right seat who can take some of the workload on a multi sector flight like that!
Contact Tower
He could have thought that ATC had realised that he had lost his radio and were holding the aircraft clear of lining up on the numbers waiting for him to land and clear?
Crazy maybe but overloaded pilots do get crazy ideas.
Pace
The facts in the report are that he was a low total time and low on type pilot.
He flew for several hours from Italy with three sectors to pick up other businessman as a sole pilot.
The workload on such a mission even on the ground with the sectors would have been high!
Add to that that he was also dealing with his business associate PAX and probably thinking ahead to his business meetings and in all it doesnt make a good mix for NOT making a mistake.
The confusion over the radios, probably seeing the runway between the numbers clear and the overiding desire to land probably lulled him into doing something which he would now kick himself for.
Sadly it was in an N reg with FAA licences and and will probably be heralded as an example of JAA V FAA while such errors are made in every realm of aviation and licence even multi crew.
In future he would be best to have a sit in in the right seat who can take some of the workload on a multi sector flight like that!
Contact Tower
He could have thought that ATC had realised that he had lost his radio and were holding the aircraft clear of lining up on the numbers waiting for him to land and clear?
Crazy maybe but overloaded pilots do get crazy ideas.
Pace
Last edited by Pace; 13th Oct 2011 at 10:58.
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Sounds like a case of the pilot getting a bit overloaded and making a simple mistake with the frequencies. However even considering poor visibility and its position on the displaced threshold I do find it hard to understand how he simply didn't seen the Dash 8 sitting there.
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The NDB ILS DME is not the same as an NDB DME, an easy mistake to make with the way plates are named... for Brum
Jepps plate 11-1 is the NDB to the ILS with DME for Runway 15, thus the NDB gets you to the ILS which is the final approach aid, inbound course 149
Jepps plate 16-1 is the NDB with DME for Runway 15, thus the NDB is the final approach aid, inbound course 154
Jepps plate 11-1 is the NDB to the ILS with DME for Runway 15, thus the NDB gets you to the ILS which is the final approach aid, inbound course 149
Jepps plate 16-1 is the NDB with DME for Runway 15, thus the NDB is the final approach aid, inbound course 154
Sadly it was in an N reg with FAA licences and and will probably be heralded as an example of JAA V FAA while such errors are made in every realm of aviation and licence even multi crew.
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It also seems that because of his high workload and letting the aircraft get ahead of him (note the speed mentioned at 1.6 DME in the report!) he gave himself a lot less time than he otherwise would have to consider his options.
Well quite; yet to have this happen on final approach but several times enroute I've had to go back to the previous, either because I've heard it wrong or been given it wrong. As the report mentions though the fact that the radio on this aircraft had failed before may have lead him to assume in the confusion of the moment that it had done so again...
As for changing to 7600 I agree it is a bit fiddly on the G1000.
Standard procedure surely is to go back to the frequency you came from if no reply on new frequency
As for changing to 7600 I agree it is a bit fiddly on the G1000.
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Read the report now, interesting reading. What strikes me is this:
I once flew into Malaga when the tower controllers there tested their lamps (and informed everyone on frequency about it). Both red and green were most definitely visible from about 5 miles out. Would perhaps not have made a difference in this case, but why withdraw the lamps from several airports (according to the report) ?
The trial concluded that, while a white lamp could
be seen at a range of about 1 nm, a red or green filter
would make the lamp impossible to detect
be seen at a range of about 1 nm, a red or green filter
would make the lamp impossible to detect
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IMHO, on a typical large airport there are so many lights around the place that one little light in the tower is not going to be noticed. Few pilots are going to be watching the tower anyway when on final approach, and at many airports there is more than one apparent tower (with the extra ones being disused, etc).
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I think all the talk about the approach is largely irrelevant other than MAYBE adding a little more loading to a single pilot who had flown from Italy making two pickups enroute with all the extra workload that would have entailed.
One big point not covered is the advisability of allowing an aircraft to enter a point where another aircraft could pass closely overhead.
An aircraft ready to go before another on approach should be lined up from an ajoining taxiway directly onto the runway and onto the numbers! The aircraft should have been instructed to line up not held some way back on a starter extension.
Had the aircraft been sitting on the numbers there would be NO room for confusion which there obviously was in this situation.
Pace
One big point not covered is the advisability of allowing an aircraft to enter a point where another aircraft could pass closely overhead.
An aircraft ready to go before another on approach should be lined up from an ajoining taxiway directly onto the runway and onto the numbers! The aircraft should have been instructed to line up not held some way back on a starter extension.
Had the aircraft been sitting on the numbers there would be NO room for confusion which there obviously was in this situation.
Pace
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Pace at Brum the Q was holding where you would normally start your roll from. Its a displaced threshold due to terrain clearance on approach.
15 can be a bit of a sod as well if they keep you high especially from the north.
And it can be pretty bumpy below 1000ft.
As for the tower its way down the other end with a none restricted GA apron right infront of it which is pretty well lit. I would have though with reduced viz and looking where you were landing you wouldn't see the tower. It would appear to be a hangar structure off on the right next to an apron.
As for not seeing the Q. Well I have similar when they have a light bit of concrete leading into black tarmac. You can't see the aircraft on it even if its CAVOK and you know its sitting there. The aircraft lights are low intensity and the runway lights on 15 are the high intensity CAT II lights.
And this whole business of swapping from the planned approach onto the ILS to an NDB is always fraught with potential for cockup. As a commercial crew you wouldn't be condemned for asking for delaying tactics so you could re-brief.
Lets face it he was just aviating
He had his finger tips on the elevator navigating.
And communicating was just a bit to much.
In someways this out come of landing over the top might be the most safe for all concerned. Because looking at the flight profile I suspect a go-around might have ended with an even worse situation developing.
15 can be a bit of a sod as well if they keep you high especially from the north.
And it can be pretty bumpy below 1000ft.
As for the tower its way down the other end with a none restricted GA apron right infront of it which is pretty well lit. I would have though with reduced viz and looking where you were landing you wouldn't see the tower. It would appear to be a hangar structure off on the right next to an apron.
As for not seeing the Q. Well I have similar when they have a light bit of concrete leading into black tarmac. You can't see the aircraft on it even if its CAVOK and you know its sitting there. The aircraft lights are low intensity and the runway lights on 15 are the high intensity CAT II lights.
And this whole business of swapping from the planned approach onto the ILS to an NDB is always fraught with potential for cockup. As a commercial crew you wouldn't be condemned for asking for delaying tactics so you could re-brief.
Lets face it he was just aviating
He had his finger tips on the elevator navigating.
And communicating was just a bit to much.
In someways this out come of landing over the top might be the most safe for all concerned. Because looking at the flight profile I suspect a go-around might have ended with an even worse situation developing.
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Few pilots are going to be watching the tower anyway when on final approach, and at many airports there is more than one apparent tower (with the extra ones being disused, etc).