AAIB Report A109E accident at Vauxhall, and Inquest Verdict
Well we have turned down work today in marginal weather, could do with the monies but ones life is for more important. Have discovered over the years with regular customers they are much more interested in you being honest especially when it comes to safety. In fact have gained customers due to this attitude rather than loose them. More than happy to tell a customer where to get off, years ago I put down in a field due to weather being considerably worse than forecast. Customer complained so i gave him the keys and said help yourself. Needless to say machine stayed in field. Taxi called customer arrived safely still on time !
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Read through the AAIB report again last night.
Pitts - personally I don't see an issue with human factors that caused the aircraft to take-off that morning. It was reported 999 at EGKR and expected to remain so. In that machine, VFR on-top under Radar control, was not unsafe. The decision to abort overhead EGTR and RTB was sound, and initially executed without additional risk. The flight back was uneventful to begin with and would have remained so (EGKR approach and landing were not hampered by Wx) if the plan had not changed.
We can't - and shouldn't - exclude humans from the equation and no amount of "rule creation" or "kit solution" will do that. There is always a balance between risk and other matter and only a human will make those complex decisions. As many have noted, simply saying "pilot error" does not help prevent recurrence, and so more analysis is needed. With the benefit of hindsight we can identify decisions that now look to be unwise and so the pertinent human factor question is: why did those decisions at the time look to the pilot to be the most appropriate responses given the information held and the options realistically available?
Carrying on with the flight sequence, this is where it seems to me things began to go wrong:
1. Getting a text to say EGLW was open - relevant as it presented an option not planned & prepared for. It would add pressure to check the information and to plan approach, etc. It would also allow for distraction of thought to what subsequently would happen - quicker response time to pick-up the client once the Wx improved - and hence add to the factors weighed in making the decision whether to continue RTB or to divert. Options at this moment were to respond that cloud was too bad to get through, or to try use resources to plan / execute the divert if it is available.
2. Asking LHR Special for confirmation that EGLW was open and would accept the landing. Given location, speed, etc this put time pressure on the task of getting below cloud but the option was to orbit above cloud whilst the matter was researched and reported back.
3. Deciding to drop through a "sucker hole" to get below cloud rather than orbiting.
4. On getting below cloud, finding the base to be very low in a flight environment filled with obstacles, continuing with a "normal" approach; flying the dog-bone holding pattern. Options at that time include going straight back up and rejecting the diversion, or alternatively going into a (noisy) OGE hover over the river.
5. Possibly being distracted (radio frequency change, for example) whilst executing a more challenging manoeuver in conditions that were certainly less than ideal; option of completing one task before commencing another.
Interested to learn if others agree that the relevant chain of events starts where I put it or somewhere else. I agree that prior interaction with the client, with other clients and with management are relevant to the decision process in accepting / attempting / rejecting the diversion. Also interested to hear if others see more "decision points" in the sequence.
Based on my interpretation (valueless, as I am neither an AAIB investigator nor a lawyer), the verdict of the inquest was not accurate as it cites perceived client pressure and Wx in relation to the decision to lift from EGKR. I suggest above that there was no safety problem with that decision or with the decision to RTB. The perceived client pressure was a factor in the decision to divert to EGLW and I would have liked to see both the AAIB and the inquest to have focussed more on the human factors that led to that decision, and to subsequent decisions once the descent through the sucker hole commenced.
Pitts - personally I don't see an issue with human factors that caused the aircraft to take-off that morning. It was reported 999 at EGKR and expected to remain so. In that machine, VFR on-top under Radar control, was not unsafe. The decision to abort overhead EGTR and RTB was sound, and initially executed without additional risk. The flight back was uneventful to begin with and would have remained so (EGKR approach and landing were not hampered by Wx) if the plan had not changed.
We can't - and shouldn't - exclude humans from the equation and no amount of "rule creation" or "kit solution" will do that. There is always a balance between risk and other matter and only a human will make those complex decisions. As many have noted, simply saying "pilot error" does not help prevent recurrence, and so more analysis is needed. With the benefit of hindsight we can identify decisions that now look to be unwise and so the pertinent human factor question is: why did those decisions at the time look to the pilot to be the most appropriate responses given the information held and the options realistically available?
Carrying on with the flight sequence, this is where it seems to me things began to go wrong:
1. Getting a text to say EGLW was open - relevant as it presented an option not planned & prepared for. It would add pressure to check the information and to plan approach, etc. It would also allow for distraction of thought to what subsequently would happen - quicker response time to pick-up the client once the Wx improved - and hence add to the factors weighed in making the decision whether to continue RTB or to divert. Options at this moment were to respond that cloud was too bad to get through, or to try use resources to plan / execute the divert if it is available.
2. Asking LHR Special for confirmation that EGLW was open and would accept the landing. Given location, speed, etc this put time pressure on the task of getting below cloud but the option was to orbit above cloud whilst the matter was researched and reported back.
3. Deciding to drop through a "sucker hole" to get below cloud rather than orbiting.
4. On getting below cloud, finding the base to be very low in a flight environment filled with obstacles, continuing with a "normal" approach; flying the dog-bone holding pattern. Options at that time include going straight back up and rejecting the diversion, or alternatively going into a (noisy) OGE hover over the river.
5. Possibly being distracted (radio frequency change, for example) whilst executing a more challenging manoeuver in conditions that were certainly less than ideal; option of completing one task before commencing another.
Interested to learn if others agree that the relevant chain of events starts where I put it or somewhere else. I agree that prior interaction with the client, with other clients and with management are relevant to the decision process in accepting / attempting / rejecting the diversion. Also interested to hear if others see more "decision points" in the sequence.
Based on my interpretation (valueless, as I am neither an AAIB investigator nor a lawyer), the verdict of the inquest was not accurate as it cites perceived client pressure and Wx in relation to the decision to lift from EGKR. I suggest above that there was no safety problem with that decision or with the decision to RTB. The perceived client pressure was a factor in the decision to divert to EGLW and I would have liked to see both the AAIB and the inquest to have focussed more on the human factors that led to that decision, and to subsequent decisions once the descent through the sucker hole commenced.
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the pertinent human factor question is: why did those decisions at the time look to the pilot to be the most appropriate responses given the information held and the options realistically available?
If Pete had been making the decision about going to Battersea on the ground he would have taken a lot more factors into account. He might have thought, the client is in Elstree and the weather is clear back at Redhill and towards our ultimate destination in the North of England. It will take the client 90mins or so to get to Battersea from Elstree by car at this time of the morning. In 90 mins by car from Elstree he could be at Redhill or Luton or Cranfield, the latter two of which have precision instrument procedures. Even if he still wants to go to Battersea, flying to Redhill and waiting is cheaper than parking at Battersea. After discussion on the phone about which of these options suits the client best, he could have finished his tea, had a bacon sandwich, and leisurely initiated his new plan.
So the trick is to give yourself time and options, neither of which are available in the air in highly congested airspace in bad weather.
Last edited by puntosaurus; 15th Dec 2015 at 11:03.
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Getting a text to say EGLW was open - relevant as it presented an option not planned
I have said this before on here and I will say it again untill the cows come home, Battersea was not open.
I recieved a call from the DATCO, Requesting if we would open and accept a diversion from SVFR/Thames Radar, To which I gave autherisation.
It was upon this autherisation that the DATCO tried to contact the Pilot, alas with no response!
I recieved a call from the DATCO, Requesting if we would open and accept a diversion from SVFR/Thames Radar, To which I gave autherisation.
It was upon this autherisation that the DATCO tried to contact the Pilot, alas with no response!
I have said this before on here and I will say it again untill the cows come home, Battersea was not open.
I recieved a call from the DATCO, Requesting if we would open and accept a diversion from SVFR/Thames Radar, To which I gave autherisation.
It was upon this autherisation that the DATCO tried to contact the Pilot, alas with no response!
I recieved a call from the DATCO, Requesting if we would open and accept a diversion from SVFR/Thames Radar, To which I gave autherisation.
It was upon this autherisation that the DATCO tried to contact the Pilot, alas with no response!
Can you please explain to us why you didn't share this information with either the AAIB or the subsequent Inquest?
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CD and B73: is that the right question? I think that strikes to "why did X send a text to the pilot saying Battersea was open when in fact it was not open?".
From the point of view of the pilot, it seems that he received a text saying Battersea was open. Even if that was factually incorrect, he pilot did not know that and he proceeded to act upon that information by asking Thames Radar about the option of diverting, and dropped down below the cloud-base to hold below in anticipation of being accepted into Battersea.
Puntosaurus: Thanks - I think this is a valuable point for me to take on board. It is a different matter to plan for diversions whilst on the ground compared to an environment of congested airspace / bad weather / client pressure. Though circumstances may make that scenario unavoidable, I need to be conscious of the need to take steps to reduce my workload and risk if I am to divert resource (my attention) to assessing / planning the diversion. I can make that part of my rehearsed response to in-flight "surprise".
From the point of view of the pilot, it seems that he received a text saying Battersea was open. Even if that was factually incorrect, he pilot did not know that and he proceeded to act upon that information by asking Thames Radar about the option of diverting, and dropped down below the cloud-base to hold below in anticipation of being accepted into Battersea.
Puntosaurus: Thanks - I think this is a valuable point for me to take on board. It is a different matter to plan for diversions whilst on the ground compared to an environment of congested airspace / bad weather / client pressure. Though circumstances may make that scenario unavoidable, I need to be conscious of the need to take steps to reduce my workload and risk if I am to divert resource (my attention) to assessing / planning the diversion. I can make that part of my rehearsed response to in-flight "surprise".
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John R81;
We see Battersea is open/closed as pilots. In similar conditions to the day Pete Barnes crashed (but a couple of years before) I had a passenger tell me that he had spoken to Battersea and they were open, and why was I refusing to fly? In my case Battersea was open, the problem was the LHR/LCY weather meant we would not have been able to legally get into the zone. Trying to tell a pushy passenger that yes, Battersea was open, just as reception had told him, but that the weather passed to me by Battersea ATC precluded landing there seemed utterly beyond the grasp of such an intelligent man.
If Pete's passenger had spoken to Battersea, I suspect he would have spoken to reception NOT ATC. Yes Battersea was either open, or about to open following all the checks, and certainly was open for passengers to sit and drink coffeee in the lounge while their pilots waited for the weather to clear enough for them to get in, that did not constitute a confirmation that the weather was suitable. Its a question of semantics, to Cave Dweller (who really does know his stuff) Battersea was closed to air traffic, 60 metres away in reception to the guys and gals who look after the pax and take all the bookings and phone calls from customers etc Battersea was definately open.
The passenger sends a text saying Battersea open from his limited level of knowledge, the meaning to the pilot is different. A box 2 call to Battersea could possibly have sorted the confusion, but we will never know.
SND
We see Battersea is open/closed as pilots. In similar conditions to the day Pete Barnes crashed (but a couple of years before) I had a passenger tell me that he had spoken to Battersea and they were open, and why was I refusing to fly? In my case Battersea was open, the problem was the LHR/LCY weather meant we would not have been able to legally get into the zone. Trying to tell a pushy passenger that yes, Battersea was open, just as reception had told him, but that the weather passed to me by Battersea ATC precluded landing there seemed utterly beyond the grasp of such an intelligent man.
If Pete's passenger had spoken to Battersea, I suspect he would have spoken to reception NOT ATC. Yes Battersea was either open, or about to open following all the checks, and certainly was open for passengers to sit and drink coffeee in the lounge while their pilots waited for the weather to clear enough for them to get in, that did not constitute a confirmation that the weather was suitable. Its a question of semantics, to Cave Dweller (who really does know his stuff) Battersea was closed to air traffic, 60 metres away in reception to the guys and gals who look after the pax and take all the bookings and phone calls from customers etc Battersea was definately open.
The passenger sends a text saying Battersea open from his limited level of knowledge, the meaning to the pilot is different. A box 2 call to Battersea could possibly have sorted the confusion, but we will never know.
SND
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John R81 has made a lot of sense on this topic, and Puntosaurus' point on why did PB not divert to say Luton is a good one, given a northern destination. Would be quite interesting to know what the EGGW METAR around the accident time was - anyone know? May well have been fogged in too though I guess. Of course not just cost but the faff of a big airport is often another reason to try to avoid them.
Something that seems missing from (what we know about) the accident flight was what contingency plans were discussed between client and pilot/operator, given the high chance that a landing at the Elstree pick up point would not be possible. Where was the client based? Was Elstree the best place to plan for the pick up? Could Redhill have been considered an option where departure would have been possible in far poorer weather than a landing? Was Luton considered as an alternate? Stansted? Wx info was probably not available at Cranfield early enough. These human factors aspects are important and can greatly add to the risks.
Frankly I doubt PB was really pressured into flying - surely he was too experienced and confident for that. But he would have simply wanted to get the job done and not let his client down, so pushed himself too far.
Pressure, whether from clients, operators or from we pilots ourselves, to get a task done is a risk factor. But it is an inevitable part of flying (and a lot of other things) and to an extent healthy, to encourage us to look at ways of achieving (albeit safely) a flight when conditions are more challenging.
I think something that does come out of this accident is the importance of considering very carefully the alternative options, in advance when on the ground, should the weather compromise or prevent the flight. And these options should be discussed with and ideally agreed by the client, and perhaps even conveyed in writing, by text or email. That might help reduce excess pilot pressure and make clients consider alternatives more carefully and make plans for such eventualities. Obviously I'm sure much of this all happens with good operators anyway, though it appears not have done here and had it occurred, the accident would probably have been avoided.
Something that seems missing from (what we know about) the accident flight was what contingency plans were discussed between client and pilot/operator, given the high chance that a landing at the Elstree pick up point would not be possible. Where was the client based? Was Elstree the best place to plan for the pick up? Could Redhill have been considered an option where departure would have been possible in far poorer weather than a landing? Was Luton considered as an alternate? Stansted? Wx info was probably not available at Cranfield early enough. These human factors aspects are important and can greatly add to the risks.
Frankly I doubt PB was really pressured into flying - surely he was too experienced and confident for that. But he would have simply wanted to get the job done and not let his client down, so pushed himself too far.
Pressure, whether from clients, operators or from we pilots ourselves, to get a task done is a risk factor. But it is an inevitable part of flying (and a lot of other things) and to an extent healthy, to encourage us to look at ways of achieving (albeit safely) a flight when conditions are more challenging.
I think something that does come out of this accident is the importance of considering very carefully the alternative options, in advance when on the ground, should the weather compromise or prevent the flight. And these options should be discussed with and ideally agreed by the client, and perhaps even conveyed in writing, by text or email. That might help reduce excess pilot pressure and make clients consider alternatives more carefully and make plans for such eventualities. Obviously I'm sure much of this all happens with good operators anyway, though it appears not have done here and had it occurred, the accident would probably have been avoided.
