Issue 13
Transcription
Issue 13
DAEMS reporting I learnt about flying from that… Military Aviation Courses AirClues Issue 13 Spry says… Competition Air Clueless Awards Do you believe what your aircraft says? Regulation 18 Mythbusting 10 Air Clues 50 6 20 48 33 Contents Spry’s view 4 Report today for a safer tomorrow 33 Blast from the past … 5 Aberporth Danger Area Complex 36 December…fog…USAF…Wales… 6 Feedback… 40 I learnt about flying from that… 10 MAA Flight Safety Courses 42 Do you believe what your aircraft says? 16 Competition time 48 Airside Operations - Heathrow Airport 18 I learnt about writing DASORs and flying from that… 50 I learnt about flying from that… 20 Regulation 18 - Mythbusting 24 Awards31 Back to Flying Business 54 55 Erratum The views expressed within Air Clues are those of the authors concerned, and do not necessarily reflect those of the Royal Air Force, or MOD. All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form without prior permission in writing from the editor. Unless by prior arrangement, articles and photographs will not normally be returned. Write to the Editor: [email protected] ISSUE 13 contents 3 Air Clues Spry’s view It has now been some months since the RAF Safety Centre reached Full Operating Capability and I am pleased to say we have all hit the ground running (but not hard enough to merit raising a H&S Report!). There are many changes afoot which will enable a more streamlined and integrated Safety Centre here at Spry Towers, but I will give you more detail in my next issue. For now, though, I strongly recommend you have a read of our new AP8000, the RAF Safety & Environmental Management System. This supersedes the previous AP3207 and AP7002 and is intended as a ‘Safety for Dummies’; in other words, a simplistic overview of how the RAF deals with Safety, without undermining the importance it places on it. Links to AP8000 can be found on the RAF Safety Centre MOSS-page and online through the Intranet. For those of you serving overseas, do not fret, we will have the document available on disc in the not so distant future. In March, we hosted the inaugural Total Safety Governance & Command Boards, respectively chaired by DCom Ops and the Chief. These highlevel board meetings act as the coordinating body within AIR to identify common themes across all areas of Total Safety and provide strategic governance of risk, assurance, policy, process and promotion. The Command Board meeting was presided over by CAS in order to ensure the highest standards of Total Safety are being set and maintained and that we deliver a coherent and coordinated Total Safety policy. I hope you find the articles in this edition of Airclues as interesting as I did. I would ask you, in particular, to have a read of my response to the letter on page 40 regarding self medication. There has been a lot of discussion around the bazaars, especially since I issued my recent Safety Note on this topic, as directed by HM Coroner during the XX177 inquest. However, let me make one thing clear - I wasn’t writing anything new!! Self-medication, in all forms, has always been forbidden. However, as you will read in my response, I have listened to the debate and re-engaged with CAM in order to elicit sensible guidance with regard to the time required for any effects of the medication to have worn-off. The upshot is that the medics consider 24 hrs sufficient to rid your system of any of the adverse effects (and there ARE many!) of self- 4 sprys view ISSUE 13 medication. By the time you read this, I will have written to the Groups directing them that aircrew should not use over-thecounter medicines, drugs, tablets or remedies within 24 hrs of reporting for flying duties unless prescribed by a Military Aviation Medical Examiner (MAME). Put simply, if, when within 24 hrs of flying, you feel ill and can’t get to a MAME, but consider you need to ‘take something’, ie you self-med, then you are to take yourself off the flying programme - if you stop taking your self-med 24 hours before flying and you are FIT TO FLY, you don’t need to come off the fly-pro. That said, I will always stick to the overriding principle that if you are sick, you should see a MAME, and not self-medicate, because if you feel ill enough to take a remedy, then you are not fit to be in the cockpit! If you have an article you wish to be considered for publication in one of our future editions of Airclues, please don’t hesitate to get in touch. Please note that my email address has now changed, along with the rest of the team at Spry Towers. You can contact me at [email protected] or call 01494 495699. Spry Download the free Blippar App from Google Play, Blackberry App World (For the new Blackberry Z10 Series phone) or App stores and scan the page or image wherever you see the Blippar logo. Air Clues Blast from the past… Extract from Tee Emm, October 1942 Here is an extract from a letter written by a pupil at an SFTS (Service Flying Training School) to one of his officers at his ITW (Initial Training Wing). It should be explained that upon his first arrival at the ITW, this particular pupil was a bit of a tough customer. He had done some flying already and held the view that it was sheer waste of time for him to go through the ITW Course! His letter shows that his views have now been modified: “Day before yesterday, I did my first solo in the Hurricane; they are indeed a grand plane and it is little wonder that they have gained the name they have. Luckily for us they are not as hard to handle as the Master which may sound strange. They are harder to land though, because of the narrow wheel base. I got a rather big surprise when I came here, and that was the mortality rate. There are quite a few deaths here, and this fact has made me extremely careful in everything I do in the air. I have come to the conclusion that most of the accidents are caused by the things, carelessness and disobedience, known in the RAF as breach of discipline. For some reason many of the boys simply will not obey the orders that have been given to them. I can give two good examples of this: A Dutch boy was sent up to do aerobatics and was told not to do any aerobatics under 7000 feet, yet with that order in his mind, he started doing rolls at 2000 feet, got into a spin and was unable to pull himself out, thus killing himself. Another case: a boy on the more recent course went up with only two hours solo and went 70 miles to ‘shoot-up’ his home. He crashed into the house, killing himself and some others. He knew the orders about low flying, yet he deliberately disobeyed them. Of carelessness one sees accidents ranging from minor to major ones nearly every day; fortunately most of them are not very serious, and a plane is put out of use for a few days only, but some terrible accidents have happened since I’ve been here (all accidents due entirely to disobedience of orders). You may wonder why I write about all this. Well, simply to thank you for being strict when I was in the ITW. That strictness has probably kept me alive. Secondly, I know that because you know this you will be able to tell others that they may profit by others’ mistakes. I know we all used to grumble at the discipline, but I know that it was for our own safety and our good.” 5 Air Clues December… fog…USAF…Wales… By Sqn Ldr E Seymour, OC Ops Sqn, RAF Valley RAF Valley, on 11 December 13, found itself unexpectedly hosting 13 armed F15Es from the 494th Fighter Squadron, based at RAF Lakenheath. The weather at Valley was excellent: Blue (BLU), forecast BLU, whilst that over most of the rest of the UK was poor and deteriorating. As a result, RAF Valley was the diversion airfield for a number of aircraft whose crews wanted to make the most of whatever weather was available. The only other military airfield that remained unrestricted during the rest of the day was RAF Lossiemouth. ATM Force Orders state that: ‘When own weather colour state is Blue or White and forecast to remain Blue or White, there is no limit on the number of aircraft that can be accepted for 6 december…fog…USAF…wales… issue 13 weather diversion’, and: ‘When own weather colour state is Green or worse, and forecast to remain Green or worse, up to a maximum of 30 aircraft per 15 minutes (‘quarter’) period may be accepted provided that a runway precision aid is available.’ Bearing that in mind, Valley was the diversion airfield for the following: •• •• •• •• Coningsby – 8 aircraft (mixed type)/quarter Marham – 4 aircraft (GR4)/quarter Boscombe Down – 4 aircraft (mixed type)/quarter Shawbury – 2 aircraft (rotary)/quarter Air Clues •• Warton – 2 aircraft (non-Typhoon) total •• Lakenheath – 6 aircraft (F15E) total followed by 6 further pairs between 1327 and 1401. As the aircraft landed, ATC were informed that all aircraft were in fact armed with chaff and flares and 5 were armed with live guns. The aircraft were marshalled to Airfield Servicing Platforms (ASP) that had the maximum number of parking slots for armed aircraft with safe headings. At 1414, other airfields, for whose aircraft Valley was the diversion airfield, were told that Valley was at diversion capacity. Valley policy is to maintain the diversion for any aircraft that are airborne although this intent was lost in communications, as Valley was later informed that Coningsby had conducted an airborne recall of its aircraft. Fig 1. Colour states of UK areas 11 Dec 13 – the bad weather spread until only RAF Lossiemouth and RAF Valley were operational. Valley was told, having asked Lakenheath for the armament status of the aircraft, that they were unarmed. At approximately 1300, Valley ATC took a call from LATCC mil, notifying us that they would be handing over 13 F15s for ‘weather divert’. At 1310, the first F15, callsign Gremlin, came on frequency, declaring ‘pan for fuel’. At 1312, Gremlin landed, As OC Ops Sqn, I received briefs from Stn Ops and from the engineering staff who were on site at the other side of the airfield where the aircraft were parked, before driving over to assess the situation. On arrival, the aircraft were parked according to safe procedures, with the ‘live’ guns on safe headings. I was informed the guns had been pinned up by the aircrew. However, owing to the aircrew requesting immediate refuel, a bowser crew was busy refuelling the penultimate aircraft, meanwhile the MT bus to take the aircrew to the Mess was not even 100m behind one of the aircraft, and a USAF crew, with good intent, were showing some personnel around the aircraft. This was where the difference between air forces came into play: to the USAF, chaff and flares do not mean that aircraft are armed whereas to the RAF, they most definitely issue 13 december…fog…USAF…wales… 7 Air Clues do. Once on the ground, any aircraft equipped with chaff and flares requires an exclusion zone as prescribed in the aircraft safety and maintenance notes, with the exception of essential maintenance staff and aircrew planning to fly. If the specific aircraft safety and maintenance notes are unavailable, an exclusion zone of 200m around the entire aircraft is to be applied. The Maintenance of Airworthiness Process (MAP) guidance is that all foreign aircraft, including those based in the UK, are to be ‘assumed armed until it has been determined that [they are] not’. For engineering personnel, this means that no maintenance, including replenishment/refuelling, is to take place before clearance from the Principal Engineer (or equivalent) is granted. We cleared the pan of personnel, however the 200m exclusion zone included some buildings and the perimeter access road to the 24/7 Search and Rescue (SAR) services of 22 Sqn C-Flt and RAF Valley Mountain Rescue Team (MRT). Of note, the F15s are much thirstier than Hawks and we were now concerned, having filled up the F15 tanks, how many days of supply of fuel for our own aircraft we had left. The USAF crews had taken over the disused Visiting Aircraft Section (VAS) building, using the one functioning landline in order to contact their engineering staff and guarding staff back at base. I was using my mobile phone to make all other phone calls (noting weapons safety zones). The SAR Force had sent over a liaison officer and he kindly offered the SAR planning and rest facilities. RAF Valley had stood up a guard force to enforce the cordon. In the event, with the SAR force fully aware, all non-essential personnel finishing the dayshift, and the USAF aircrews guarding their aircraft until their own guard force arrived, it was deemed unnecessary for the RAF Valley guard to be used. Meanwhile, RAF Valley Ops and Spt Wings had ensured the necessary support facilities, both operational and domestic, were in place. The Lakenheath guarding and engineering teams arrived overnight and the next day we ensured there was a Stn Ops representative with the USAF crews to facilitate any requirements and to keep Ops and the rest of the airfield informed as appropriate. All F15s departed without further incident the day after they arrived - after their mandated 12-hours of crew duty rest and the appearance of a suitable weather window. We admit that we were unprepared for the number and type of aircraft; notably, ATM Force policy considers that ‘the possibility of mass diversion of large numbers of aircraft … is deemed remote.’ RAF Valley were pleased to be able to host these unexpected visitors at such short notice, without further incident and, despite the specific occurrences mentioned above, the operation went very smoothly. That said, we identified some important lessons from this that we hope other stns can benefit from. 8 december…fog…USAF…wales… issue 13 Key Lessons •• Assume all foreign aircraft are armed until it is established otherwise. •• Ensure clear communications and confirm understanding of information. •• Know the armed parking slot locations and what effect each type of armament will have on the airfield, including access routes. •• Do not replenish any visiting aircraft until given the goahead by the senior engineer on the airfield. •• Support elements should consider broadcasting unusual activity across the stn to inform all relevant parties and ensure safety considerations are given the widest possible publicity. •• Be prepared to provide a cordon for the maintenance of safe distances and inform all personnel that they should not approach the airfield. •• Provide Ops liaison personnel to any diverted detachment: worth their weight in gold. •• What is own sqns’ diversion policy? Does one fly to divert? How will the diversion airfield cope with a mass diversion of aircraft from your own airfield? •• Aircrew should ensure awareness of base weather, diversion criteria and facilities and your own aircraft’s engineering requirements. •• How much fuel will large numbers of aircraft need (not ask for)? What impact may this have on your own operations? Post Script Valley and Lakenheath were able to put into practice the lessons identified much sooner than expected. On 21 Jan 14 RAF Valley received an early call from Lakenheath as they were planning their day’s flying: could we accept a weather diversion of 20 F15Es, armed with flares? 20 F15s would have meant evacuating buildings and restricting access to a major part of the airfield, therefore we negotiated the request down to 10 F15s. Since this was not an emergency, there was time for the Ops assistant to take all the details and to check the necessary elements at RAF Valley before confirming with Lakenheath: •• Latest met forecast locally and for the UK. •• How many aircraft were we already acting as a diversion airfield for and until what time? •• Were the engineers happy to accept 10 aircraft with flares? •• Did we have enough fuel to replenish 10 F15s and maintain our own flying? •• Was OC Ops Wg (and by extension the CO) happy with the plan? We were at colour state White, forecast Green and had already agreed to act as diversion for 22 aircraft. The other answers Air Clues were in the affirmative therefore Lakenheath were informed that yes, RAF Valley could accept a total of 10 aircraft, no more than 8 per quarter. Stn Ops then refreshed their memories of the checklist, were any of the F15s to actually divert in: •• Which slots would the F15s be parked in for minimal disruption to the rest of the airfield? Confirm this with the engineers. •• Confirm that no refuelling would take place until the Chief Engineer gave permission. •• Prepare to tannoy that foreign aircraft would be landing at RAF Valley and no personnel were to approach without permission of the Chief Engineer. •• Prepare to stand up small cordon guard to enforce the flares exclusion zone. •• Prepare to provide Ops liaison personnel, MT, food and accommodation. As it happened, no diversion was made. However, it was a useful contingency exercise to reinforce the lessons learnt a month previously. It was also cheering to note that Lakenheath phoned us to discuss the plan – reinforcing the good relations we already enjoy with the USAF. Photos courtesy of Paul Heasman, RAFValley issue 13 december…fog…USAF…wales… 9 Air Clues I learnt about flying from that… Are you sure you are ok to be in the cockpit…? By Flt Lt JJ Caley, B Flt 22 Sqn, Wattisham I am a 45 year old helicopter pilot, grey, balding and yes overweight; I am indeed fond of chicken tikka madras and an occasional Domino’s Pizza. I do Search and Rescue as a job and I am a current QHI on the ‘Yellow Sea King’ based in Suffolk, Lovejoy country. I do little exercise other than swimming and lots of Scrabble when deployed to the Falklands. Every 6 months I have to do a fitness test in the form of a fast walk over a measured mile, which measures elapsed time against heart rate. It is fair to say that physical fitness has never been a favourite of mine, but I manage to do just enough in order to pass the test. Uncharacteristically one night prior to going to bed, I went to the gym at work and did 30 minutes on the treadmill, (motivation came 10 I learnt about flying from that… issue 13 from my ‘electric 80’s CD’). Due to my fitness test being 4 days later, I again went to the gym the next morning prior to taking over shift at 10 am. Once more I did a further 30 minutes of cardio vascular exercise raising my heart beat to 146 bpm. To be honest, I felt confident that I would pass the test and then give my dodgy knee a well earned rest. All SAR shifts are 24 hours and as a captain you have to be very aware of fatigue. For instance, you could legally fly up to 4 ½ hours training and then be tasked in the middle of the night to do something quite special, in rubbish weather with minimal time to plan or brief, whilst still waking up. That morning we completed a winching exercise to a wind Air Clues turbine standing nearly 400 ft from propeller tip to sea; it was completed without incident and lasted 80 minutes. The rest of the shift unfolded as normal with a light lunch, followed by an afternoon of admin, coordination with the engineers and fielding the odd phone call, normally a random request starting with the phrase ‘can you just…?’ I had planned to night fly that evening and so we were going to eat dinner around 6pm, watch a bit of news on the TV and then brief and walk for a sortie in the dark lasting approximately 2 hours and 30 minutes. The Sea King Mk 3a is an incredibly capable Search and Rescue platform, it is a very robust helicopter backed up with some safe operational flight profiles, solid radar and optical facilities. As a result of the aircraft being so capable, this means that as a crew we have to consistently practise a whole host of different skills and disciplines, in order to be ‘second to none’. The crew consists of four: Captain, Co-Pilot, Radar/Winch Operator and a Winchman (Paramedic). I think it is only fair and honest of me to mention that I have an enormous amount of respect and admiration for the people with whom I work, they are total professionals, each and everyone of them dedicated to saving life. Night flying skills on reflection are just as important, if not more than, day skills because executing a rescue at night is in my mind much more taxing in terms of raw ability and capacity. As a handling pilot, trying to hover over a moving vessel at night with one of your best mates (whom you can’t see), hanging on a wire beneath the cab, is not what you would choose to do for rest and relaxation. I’m lucky enough to have been doing this job for years and with nearly 6000 hours flying helos, I can promise you that just like golf, you have to keep at it, otherwise the possibility of ‘skill fade’ might rear its ugly head. I was particularly keen for this sortie to go ahead because primarily I had a large proportion of my compulsory training statistics to achieve with only one more shift after this one available. Two nights prior to this one, I was bitterly disappointed to abort a night sortie on take off. On transitioning from the hover into forward flight, I felt a harsh feedback force coming through the yaw pedals and the airframe shook in sympathy. I stuck the aircraft on the ground fairly sharpish and handed the aircraft back to the engineers, saddened that another opportunity to make a dent in the tally of night stats had slipped by. So all in all we needed to fly tonight and do some radar work and primarily deck winching. We took off and transited towards the North Sea coasting out in the Felixstowe area taking on board radar control from the Radar Operator and letting down to a nominal 200ft over the sea. Both of us up front had NVGs mounted on our helmets in accordance with standard operating procedures, the left hand seat co-pilot had his goggles down for look out, but I had elected to stay off goggles to simulate being in cloud at low level, whilst solely maintaining an instrument scan. Under this regime the Radar Operator is effectively ‘steering the ship’ by telling the pilot to fly certain headings, thereby allowing the aircraft to safely manoeuvre around a plot of moving and stationary targets which he can see on the Radar display in front of him. This procedure is practised all the time because the ‘all weather Sea King’ has to be capable of doing a fully coupled auto-pilot let down to an ejectee in atrocious weather. The Rad Op was working particularly hard, as that night there were several targets in the area of operation and, as always, a whole host of navigational and marker buoys, none of which can be over flown whilst under internal radar control. We successfully carried out a letdown to a large freighter, it was heading downwind and therefore far from ideal because the power required (torque in a helo) was greatly increased in order to keep a relative hover off the ship’s port quarter. The Sea King does not hover on one engine unless it’s very light and has a decent headwind component, so sitting next to this ship with few options was not an ideal place to be, let alone winching for exercise. Added to this were difficult comms, language problems with the ship’s master and smoke exhaust from the funnel, making the whole thing untenable, so we departed the scene and climbed to 200ft and resumed internal radar control. As planned, we had dinner, cooked by the co-pilot, and it was delicious. On shift we are very independent and a member of the crew always volunteers to be Keith Floyd. Perhaps foolishly I had seconds because it was so tasty and after all, it would be a shame to waste it. We then briefed and walked for the aircraft, I was conscious that I hadn’t done much night training recently and wanted to do well. I was wearing under garments and an immersion suit, (compulsory when flying over the sea at night even when the air temperature is quite mild, it can certainly make you feel hot and stuffy in the cockpit). issue 13 I learnt about flying from that… 11 We had now been airborne for approximately 50 minutes to an hour and there was no doubt about it - I felt uncomfortable. I had a full stomach, was feeling hot in the immersion suit and I definitely did not feel sharp, in fact I was feeling particularly rusty. My mind was notably preoccupied by how tight across my chest my Mk 25A large LSJ was feeling. I was sure that I was wearing the large jacket and not the regular size, but my word did it feel tight across my chest. Aligned with this discomfort was the fact that my breathing was different and I did feel short of breath. The co-pilot is a good friend of mine, a gifted individual and he is the only natural pilot I have ever flown with, to say he is a ‘sharp cookie’ is an understatement. It didn’t take him long in the sortie to notice that not all was well with me and he remarked to that fact, “mate are you sure you are feeling alright because you don’t sound like yourself?” I told him and the rest of the crew that my jacket was causing me discomfort but I felt ok to continue. I cannot deny that part of me was being task driven; besides, how would it look if the Flt QHI was short on stats? Plus, I needed the practise, so I elected to press on and 12 I learnt about flying from that… issue 13 we again let down to another ship - a huge container vessel. On completion of the let down I had asked the co-pilot to climb the aircraft from 50ft to 85ft using the hover height controller but as he correctly pointed out we weren’t in hover mode we were still in the transition down mode. I felt stupid, this was a basic error and as the QHI I shouldn’t be making such a mistake, I couldn’t be that rusty surely not, why was I making these mistakes? Once alongside the vessel we arrived at the briefing point with all the lights on and took stock for a moment. For the third time the co-pilot clearly expressed that he didn’t think I was my normal self and suggested that he took control whilst I unbutton the three fasteners on my LSJ. I did this and felt a definite release of pressure across my chest and an easier breathing pattern. I thanked the crew for their concerns but then assured them that I felt fit to carry on with the sortie or so I thought at the time!!! We stayed working with this ship for 45 minutes, it was huge and carrying lots of containers stacked on top of each other, so finding a clear winching area wasn’t easy. Air Clues We discussed the options as a crew and ended up winching to a gap between the containers of approximately 20ft. In order to get into the overhead we needed to be in a high hover of 145ft over the sea with the winchman suspended on a lot of cable. We carried out several parallel deck evolutions of this, moving the aircraft into the 3 o’clock to place the winchman in the gap and on the deck, it went well and the rearcrew swapped over and did reverse role. The sortie now seemed to be going better and I felt more content with my performance. As briefed, we said goodbye to the ship and flew to the local cliff training area at Walton on the Naze. Night situation winching offers different challenges but at least they don’t move at 15 knots. We did one winching exercise and then recovered to Wattisham with the guys in the tower providing us with a short pattern PAR. We landed on at dispersal and shutdown the rotor head but kept one engine running whilst the cable was run out and washed by the engineers. Whilst still sat alone in the cockpit I had 5 minutes to reflect on what had happened. I consider myself to have a reasonable ‘pair of hands’ but tonight’s performance overall was definitely below par, something wasn’t right and it was frustrating me. I’m normally a jovial laid back bloke but I was not feeling content within myself, I shut down the engine and signed in the aircraft. I took off my LSJ and placed it on the hook, it was the correct large size jacket the one I always wear. ‘So why did it feel so tight?’ I asked myself. We made a brew and sat down in the crewroom and debriefed the sortie thoroughly, the copilot said that my performance was uncharacteristic, almost as though I was happy to be led - food for thought. It was bedtime now but the winchman and I stayed up just a little longer discussing how I was feeling. I did not feel as though I was firing on all cylinders, tired and maybe a little vague but then I’d done a lot since that treadmill first thing this morning. The winchman is a caring soul and deep down he must have had more concern for my welfare than I had. He said to me in his London boy accent, “ Heh Jezza, if you don’t mind mate I’d like to plug you into the heart monitor and just give you the once over”. He was right, after all what harm could it do? So there I was sat in the crewroom chair, jersey off looking like the 6 million dollar man, all plugged into the Propac with an oxygen sensor hanging off my finger. Well, the camera never lies! There it was for all to see, I had a heart rate double what it should be, beating erratically and irregularly and to top it all my oxygenation was low. Put simply the winchman was an angel, he put tubes up my nose and turned on the oxygen bottle and said in a very calm way, “Mate I’m not happy with your heart, I’m taking you to A&E”. The penny had dropped, I was obviously far from well, from feeling a little under par I had now become a casualty! The Flight was now down declared OFF STATE, pilot and winchman en route hospital and there I was holding my oxygen bottle being driven to Ipswich by the Opsy in the Flt Astra - a short time ago I’d been in charge of a 9 tonne helicopter with 4 pink bodies on board. On arrival at A&E I was soon plugged into some A grade machinery where I was monitored and assessed. I could watch for myself as my heart trace created some random unsymmetrical linear artwork on the screen and constantly the audio ‘your heart is not well’ alarm was sounding in sympathy. It soon became apparent that things weren’t good, my heart rate was 120 bpm and my SPO2 was 85%; in other words, slightly hypoxic. Lying there in hospital pyjamas I felt exposed and concerned; ‘why and how could this have happened?’ After several hours in A&E I was taken to the cardiac ward where I was given some medication and I fell asleep for a couple of hours around dawn. In the morning a Dr (ex USAF) came to see me, a very calm and professional Texan and he gave me the full Cardiologist version of what was going on. My heart had gone into Atrial Fibrillation (AF), a condition that causes an irregularly and often abnormal fast heart rate. The upper chambers of the heart (atria) contract randomly and sometimes so fast that the heart muscle cannot relax properly between contractions, this reduces the heart’s efficiency and performance. His main concern was that this may cause clotting in the blood and possibly induce a stroke. This all sounded a bit serious now “I recently saw a psychiatrist, the discussion revealed to me that in my flying career I have had 9 incidents that have seriously frightened me including, an engine failure on a deck winching exercise, airmisses and having a winch cable break and come up through the rotors. All of these incidents put together have made me wonder if I want to be flying helos anymore or alternatively that I am incredibly lucky and this is what I do.” issue 13 I learnt about flying from that… 13 Air Clues and when I looked around the other patients who’d had a cocktail of bypasses, strokes and heart attacks I felt vulnerable, this wasn’t what I had in mind. I was given an injection to the abdomen and put on Warfarin to thin the blood and all the time kept on oxygen. Several hours later that day and with great relief my heart was beating with symmetry and uniformity again - thank you God, the NHS and, of course, my winchman. My pulse was normal at around 67 bpm and the oxygen level was a little low around 91%, all in all I was feeling much better and bantering with the nurses. The NHS staff were absolutely faultless and I cannot praise them enough in the care and professionalism they showed to me. I was in hospital for four days and a whole range of tests were carried out including numerous blood tests, CT scan and audio scan - the good news was that I had not suffered a heart attack. The staff cannot say why I went into AF, indeed it may be a combination of things but I remain pleased that the results of the tests were good, my heart and arteries are in good shape and my cholesterol is less than 5. I’ve never smoked and I don’t drink anymore but my lifestyle could definitely be healthier, so on discharge from the hospital I went to see the SMO and she’s been really helpful. I now go to Slimming World and the middle aged spread I had is now diminishing, I’ll never be Charles Atlas, but losing a couple of stone will help me 14 I learnt about flying from that… issue 13 the next time I have to put on No 1s. I’m currently grounded and on Beta blockers and in the mornings I regularly go swimming, enjoy going to the pool on camp and besides, you get a free bath. As a seasoned aviator, this whole account still concerns me, particularly as to why I didn’t realise that something as potentially serious as this was happening to me, whilst flying an aircraft with a winchman on the wire surrounded by 20,000 tonnes of container ship. We can all pick the bones out of this story about what I did wrong and how I could and maybe should have done things differently. More than anyone I thought I knew myself better than this but that’s the key point to this article, we often don’t. For example, I recently saw a psychiatrist, the discussion revealed to me that in my flying career I have had 9 incidents that have seriously frightened me including, an engine failure on a deck winching exercise, airmisses and having a winch cable break and come up through the rotors. All of these incidents put together have made me wonder if I want to be flying helos anymore or alternatively that I am incredibly lucky and this is what I do. There are so many factors and injects in aviation that require us to make a swift yet considered decision, balancing the needs of the aircraft and crew against the task and its Air Clues surroundings. I think it would be unwise to comment on my own CRM, you would have to ask my colleagues, but what I will say is that I believe that in Search & Rescue it is vital to create a relaxed and at ease cockpit. The question that I ask myself most about this incident is, although I had heard and processed the concerns about my well being from my trusted co-pilot, I chose to carry on thinking that I was fit enough, when hindsight clearly tells me I wasn’t. I ponder about being task-driven to achieve the sortie aims that night and what would people think about the QHI not being stats-complete. In a way, and I would imagine we as aviators have all done it to a greater or lesser degree, but how often when you’ve had a cold or a bit of a sore throat have you said I’ll be alright, besides if I go sick my mate will get the phone call, “we need you to come in and cover, Bloggs has gone sick” etc. It is a fine line indeed and different theatres will dictate a different decision. understand, give it back to the engineers, don’t do too much diagnosis yourself because your summary may be incorrect and that could have dire consequences. That night, my copilot and crew were my warning panel and I should have acted differently, handed over control and returned home. The message is clear, that even with 23 years of military flying experience I can say that we don’t know ourselves as well as we think we do. As individuals, we are probably the worst people to admit when something is wrong with ourselves. I would hope from this experience that I have learnt not to self diagnose, besides how was I to know what the symptoms for AF are? Before this, I didn’t know it existed. Thinking back to all those years to Av Med training at North Luffenham, I remember being on the ground in the chamber and the doctor sat there with us at altitude and before we took off our oxygen masks, he described how the onset of hypoxia creeps up on you and you don’t know it’s happening. This is an extreme comparison I know but the point I want to make is that where health is concerned there is no warning or caution panel that says you are not fit because of this or that reason. Just like an aircraft that has a snag which you can’t Spry Says Now that’s what I call real CRM. Talk about looking out for each other on the team! Levity aside, this is a salutary tale which we could all learn from to various degrees. I can say with some certainty that we’ve come a long way from my early days in the RAF when each squadron invariably had a gnarly old spec-aircrew pilot with a faded, slightly tootight flying suit, who took great pride in announcing himself as the “Sqn Sports Prevention Officer”. It is so heartening (no pun intended) to see a much more positive approach to health and fitness nowadays. But we cannot rest or let complacency creep in – how many of us accept the “scraped pass” on our fitness test? How many of us nod sagely when the doc says we could do with shifting a few pounds at our PME? How many of us relate to the words “I had seconds” or “physical fitness has never been a favourite of mine”? issue 13 I learnt about flying from that… 15 Air Clues docs corner Do you believe what your aircraft says? By Dr David Stevenson & Ms Vicki Cutler, RAF CAM The quotation left, which is not what the woman intended to say, reflects in part our somewhat ambivalent attitudes regarding the degree to which computers intrude into our lives. These attitudes are also reflected in our responses to computer generated warnings in aircraft. During my many years studying aviation safety and aircraft accidents, I have been particularly interested in controlled flight into terrain (CFIT) accidents. CFIT continues to happen at depressingly frequent intervals in spite of CFIT avoidance technology being installed in all but the most inexpensive aircraft. With equally depressing frequency, flight data recorders reveal that many of these aircraft have struck the ground to the sound of “PULL UP! PULL UP! TERRAIN! TERRAIN!” or some such verbiage being broadcast to the flight deck by the aircraft’s computers. Common threads which accompany many CFIT incidents include: Distraction “I have never given a name to any computer I have ever known.” – a technology correspondent’s reply on being asked if she had ever given a name to a gadget or computer she had owned. 16 do you believe what your aircraft says? issue 13 Spatial disorientation Giving more credence to the body’s sensory inputs rather than flight instruments and/or verbal warnings (not listening to your aircraft when it is trying to help you). This combination of factors led directly to the fatal crash of Afriqiyah Airways Airbus A330 Flight 771 during its approach to Tripoli Airport in May 2010. The accident is well summarized in the AeroSafety World, July 2013 cover story regarding the accident, which is available on line at http:// flightsafety.org/aerosafety-world-magazine/july-2013/ fatal-hesitation. Spatial disorientation, in the form of the somatogravic illusion, had a primary role in causing the Air Clues down control inputs. As the aircraft entered a descent under full power, it accelerated even more, accentuating the nose up illusion. My dear reader, consider this very carefully. You are flying near to the ground and accelerating. You have the gut-wrenchingly powerful sensation that the nose of your aircraft is pitching up, and I am telling you to pull back on the controls? In this instance, yes. The Flight 771 A330 was clearly telling the accident aircrew to pull back on the controls. As the situation progressed, both the aural warning system and the aircraft’s flight instruments would all have indicated that the aircraft was descending, yet the crew relied on their erroneous sensations of pitch up, leading to pitch down control inputs and the deaths of 103 people. Why did the crew not listen to their aircraft, which was trying very hard to tell them what was happening? Why did they not act on the aural warnings? Several human factors may have played a part, such as distrust of technology and perhaps past experience with false positive computer generated warnings. accident. The article discusses the somatogravic illusion in some depth, so I will not dwell on the physiology involved. This illusion occurs when an aircraft accelerates or decelerates; the change in aircraft velocity results in an inaccurate sensation of pitch up or pitch down respectively. Now for reality rather than theory: Flight 771 was approaching Tripoli at night, with the co-pilot flying on instruments. They were well below the minimum descent altitude on the approach, which required visual contact with the runway prior to receiving a landing clearance. The pilot indicated to ATC that the runway was in sight, which was impossible from their position at the time. The co-pilot looked up, and could not see the runway. Apparently due to this distracting contradiction and uncertainty regarding where they were, the co-pilot request a go-around. The aircraft then broadcasted “TOO LOW – TERRAIN” at which point the captain commanded a go-around. Seconds after applying go-around power, retracting flaps and landing gear and establishing a climb, the co-pilot applied nose down input into his side stick controller and the aircraft began to descend. “DON’T SINK”, “TOO LOW TERRAIN” and “PULL UP” warnings sounded. The captain took control of the aircraft, and - (Can you anticipate what’s coming?) - applied further nose down control inputs, flying the aircraft into the ground. Analysis The co-pilot was distracted and confused by the captain’s indication that he had the runway in sight, when he did not. As the aircraft accelerated away from the ground, the crew felt as if the aircraft was pitching up more than it actually was (the somatogravic illusion), and applied nose The most important factor is that the accident aircrew relied on an interpretation of reality based on their physiological sensations rather than on interpretation of their instruments. Spatial Disorientation 101 tells us that we cannot rely on our physiologic motion and position sensors in flight, and we are taught always to rely on our instruments. The crew of Afriqiyah Airlines disregarded these teachings with fatal consequences. •• Believe your instruments rather than your body. •• Illusions may be very powerful, and require huge effort to overcome. •• While powerful, they may also be very subtle, and take one unawares. •• Any distraction close to the ground should sound alarm bells in your mind regarding terrain avoidance. “When things start happening, you have to pay attention to paying attention.” Spry Says As ever, some very wise words from the ‘doc’ that provide a timely reminder of the hazards posed by disorientation and distraction. If in doubt, admit your problem, get on instruments and report the incident so others can learn from your experience. issue 13 do you believe what your aircraft says? 17 Air Clues Airside Operations – Heathrow Airport By Simon Newbold, Airside Training Manager, Heathrow The objective of an Airside Operations Team is to provide a safe and efficient working airfield for all users at all times, in all weather conditions and in all operating circumstances. This involves providing resources and infrastructure, and establishing and monitoring safe operating procedures with constant liaison amongst all operating companies. It is important to remember that airside safety extends not only to aircraft but also to the personnel, vehicles and other equipment that work and operate on the airfield. The team ensures compliance with international and national regulations for operating an international airport. This means upholding the requirements of having a licence to operate, a complex and detailed list of items. All of this happens when working with up to 1,400 live aircraft movements, 200 towed aircraft movements, 4000 vehicles moving around 50miles of airside road and three vehicle tunnels within one of the busiest and capacity-constrained airports in the world. Every day we need to ensure that the airlines, aircraft and nearly 200,000 passengers arrive and depart safely and on time, every time. The Airside Operations team carry out a huge range of tasks all to ensure optimum safety and efficiency. The majority of these tasks are common with any other airport, but here at Heathrow it’s all about the capacity constraint and the sheer volume. 18 AIRSIDE OPERATIONS - HEATHROW AIRPORT issue 13 It’s a responsible job, with little margin for error, and requires skills of awareness, technical understanding coupled with a proactive attitude and, of course, a great interest in aircraft and how they operate. The training can take up to a year, but once signed off, the team works four shifts on a 365 – 24/7 basis covering days and nights. Even when the aircraft are not flying during the night period, the airport is still busy with works parties carrying out essential maintenance and construction that cannot take place whilst aircraft are using the runways or taxiways. There is so much to do every night just to prepare for that first departure or arrival. During the day, as well as all the planned tasks, the team prepare for what’s ahead. This is largely dependent on the weather and so a forecaster from the Met Office is based within the control tower to ensure we have the most up to date and accurate information. Strong winds, fog, thunderstorms, snow and ice can all hugely affect the operation, not just on the ground but in the air, for departures and arrivals. During extreme adverse weather and working closely with the Met Office, Air Traffic Control and the airlines, the operations staff will make decisions with regard to reducing or Air Clues moving the schedule of flights just to ensure that the airport continues to operate. Once this is agreed, there is then a base plan to work to, yet an unknown such as an emergency, incident or world disaster can then have a huge impact on it. The operational managers then need to be flexible and use a combination of experience and support of stakeholders to return everything back to normal as safely and as quickly as possible. Operational effectiveness is a key term that is used to describe the product airside. As well as the unknowns of the weather and emergencies there are a huge range of tasks that include so much more than the popular image of someone waving ping pong bats at an aircraft. Firstly, the task described above is known as marshalling – this is the manual guidance of an aeroplane. In reality automated electronic parking aids guide the pilots to the correct stopping position by the terminal. It’s only when these systems fail or there is an obstruction, that a marshaller is deployed. This affects only 2% of all arrivals, but is still required to ensure the flow of the airport is maintained. Safety inspections are a licencing requirement and are a critical task to ensure the Air Traffic controllers know that all areas are safe and fully serviceable for aircraft. This extends to all parking stands, road systems and footpaths –to ensure that no one and nothing is put at risk. The inspections include checking the surfaces, building infrastructure, airfield lights, of which there are 20,000 on the runways and taxiways alone, and ensuring the airports operating and driving rules are being upheld. To ensure safe working on the apron, “policing” is a very important task of the unit. Audit checks of aircraft turnarounds, attendance at all vehicle incidents, monitoring speed and patrolling helps ensure the free flow of traffic and that all staff are behaving and operating in a responsible manner. Another licencing requirement is to provide a dedicated bird management team. A bird striking a plane has been identified as one of the top risks, therefore a team patrol the airfield on a 24 hour basis, to deter birds from visiting Heathrow. Grass management, bird-proofing of structures, minimising or protecting water bodies, providing a presence out on the airfield are all tasks that can prevent the airport appearing on a bird’s holiday or residential wish list. The open space and food sources at an airport are very attractive to birds! Inevitably birds will fly here, despite the team’s efforts, and our tactics will change from deterrence to dispersal. This must be carried out in a controlled manner and will sometimes simply involve monitoring numbers and behaviours. Active dispersal can include the playing of distress calls, simple arm waving, sounding of a horn, or the use of pistols firing blank shells or two stage fire crackers. The whole subject of “birds” has a double edge in terms of safety – one for the airfield, but just as importantly, one for the staff and the use of handguns, and driving close to the runways, requires regular specialist training and concentration. Heathrow airport has been dubbed one of the world’s largest building sites. At any one time there are over 100 different projects taking place from the construction of the new Terminal 2, to the maintenance of lighting systems to even resurfacing of the runways. All of these works must be carefully managed so that the operation can continue safely and that the contractors are protected. This is carried out by the use of a permit system, the formal adherence to operational rules. Once again this is regularly patrolled to ensure safety. All of the works are managed by the department and are given a high priority. Working on the airfield at Heathrow is an exciting, dynamic and vibrant job. Every day can be different and no two days are ever the same. The Airside Team are passionate about their patch and their roles in such a way that many of them stay for their entire working career. Being at the leading edge of the safe running of one of the world’s busiest airports really is exciting, enjoyable and rewarding. Spry Says And you thought you worked at a busy airfield?! I can tell you that some of my colleagues and I were invited to spend a day last year with the Heathrow airside operations safety team, to witness first-hand its efforts to maintain a safe working environment. The sheer level of activity which is needed to support 1400 aircraft movements a day (yes a day!) and 200,000 passengers is a dizzying spectacle. Despite the intensity of this effort, the work of the airside safety team ensures that there are relatively few safety-related occurrences. Reputationally the airport and the airlines stand to be seriously damaged by any serious safety incidents, and therefore invest a lot of time and effort into ensuring that their regulation, processes, procedures, training, reporting and safety assurance are all carried out to the highest standards, and rigorously enforced. I’m pleased to say that our world is generally less frenetic, but strict adherence to good practice and the principles listed above is no less important. Moreover, there is no place for complacency in the operating environment, whether you have one movement a day or 1400! issue 13 AIRSIDE OPERATIONS - HEATHROW AIRPORT 19 Air Clues I learnt about flying from that… By Flt Lt P Farmer, RAF Odiham In October 2013 I was the captain of the medical evacuation Chinook in Afghanistan, on my seventh deployment on Op HERRICK. During six previous tours I had the dubious pleasure of being subjected to Surface to Air Missiles, AAA fire, HMG, Small Arms and Mortar rounds. On numerous occasions I had led formations on second attempts into ‘hot’ landing sites (following aborted first attempts due to enemy fire) in order to extract ISAF troops. I (as is the case for many Chinook crews) had previously landed on many medevac landing sites under either enemy fire or the threat of enemy fire. I make this point to provide an insight to what I and the majority of Chinook crews have learnt from, and experienced, in Afghanistan since 2006. That said, as the campaign draws to a close the level of acceptable risk has changed; what had previously been considered the norm is no longer acceptable under today’s scrutiny of risk versus reward. 20 I LEARNT ABOUT FLYING FROM THAT issue 13 During this particular sortie my crew and I did our absolute best to save a Cat A (very seriously injured) casualty’s life in the face of enemy fire and some difficult aircraft issues. Every ‘risk’ was calculated and, with the information available at the time, worth taking to save a life. If presented with the same information as was available at the time, I would make the same decisions again. However, with the benefit of hindsight and the other pieces of the jigsaw that were not available to me whilst airborne, I would have done things very differently. The following is an account of what happened: Shortly after 0700 we received notification to launch on a medevac mission. The crew ran for the aircraft and started in good order. Halfway through the start, the co-pilot alerted me to the fact that an element of the aircraft protection Air Clues During this particular sortie my crew and I did our absolute best to save a Cat A (very seriously injured) casualty’s life in the face of enemy fire and some difficult aircraft issues. Every ‘risk’ was calculated and, with the information available at the time, worth taking to save a life. system was not functioning correctly. Multiple ‘aircrew resets’ from both myself and the co-pilot failed to resolve the issue. I quickly sought engineering advice, who reported that the fault could not be rectified with the aircraft running. Owing to the briefed severity of the casualty (CAT A with head and facial injuries caused by an IED blast), I informed the crew that we did not have time to swap to the spare aircraft and would have to make the short trip with a degraded aircraft protection capability at low level. This had previously been common practice in such circumstances. During the 150kts, 50ft transit to the pick up, one of the radios failed, not an ideal situation with multiple ATC, ROZ clearances, comms checks and medical information to be passed in a very short period. Approximately 2 minutes from the HLS the aircraft sustained small arms hits. The crewman and I confirmed this to the rest of the crew. My immediate action was to check that the crew were uninjured, thankfully this was the case. Next I checked that the aircraft was flying correctly and had the crew check all of the systems. This showed no apparent issues. Happy that the single round that was heard had not affected the flying characteristics of the aircraft, I instructed the crew to check the passengers. Again this check had a positive outcome. My next thought was to inform the Apache escort that we had taken small arms fire. I elected not to call a contact because we were no longer under effective fire. Once safely on the HLS I instructed the crewmen to check the outside of the aircraft, he informed me that there was a leak from the number 2 engine but that no other damage was obvious. The crewman advised me that the leak was minor and a check of the engine Ts and Ps confirmed this to be the case as both remained normal. Pressure and density altitude were calculated and the performance figures consulted. These showed the aircraft to be safe single engine above 32kts. Sadly, there was no option to top up the engine oil as the ‘risbridger’ was not part of the aircraft role. With a perceived requirement to get a critically ill patient to hospital as quickly as possible, I briefed the crew of my intention to load the casualty, check the engine before lifting to a high hover, then check the engine once more before transitioning. The transition from a high hover gave a flyaway option to clear the Forward Operating Base and achieve safe single engine as soon as possible or reject the transition should a problem with the engine occur. I ensured that the crew were briefed on the engine shutdown drill, should it be required. I transitioned as briefed and departed to Bastion at height with the previously defective aircraft protection system now serviceable. The aircraft was flown gently throughout the transit with a keen eye kept on the engine instruments. During the transit, JAG Ops ordered me to fly the casualty to another airfield that would have increased the distance flown with a damaged aircraft; I explained the circumstances and informed them that the aircraft would be landing at Bastion. JAG Ops then ordered me to transfer the casualty to a US military CSAR asset for onward transportation to the aforementioned airfield. I passed this message to the Doctor who informed me that the casualty needed to be taken to Bastion. In the same conversation, I asked how stable the casualty was and explained my intention to land on the issue 13 I LEARNT ABOUT FLYING FROM THAT 21 Air Clues helicopter landing strip and have an ambulance meet us there, rather than at the hospital. The Doctor was content with this course of action. The aircraft was landed from a precautionary running landing and the engine shut down immediately so as to prevent engine damage caused by a lack of oil. I can report that the casualty survived his injuries and is alive and well - a job well done? What about the last pieces of the jigsaw…? Further engineering investigation showed that the engine oil leak was not caused as a result of the enemy fire but was a complete coincidence. The engineers did however discover that a further round had damaged a control run in the aft pylon and the aft vertical shaft. Subsequent considered engineering advice was that, had the control run or aft vertical shaft failed, the aircraft would not have been flyable, this would have inevitably lead to the loss of the aircraft and all 12 on board. This is a danger faced and accepted by all operational crews, especially those with a medical evacuation role operating in Afghanistan. Further medical investigation showed that the casualty was in fact stable on our arrival at the HLS and could have remained there for 24 hours. These final two pieces of the jigsaw change things markedly. With the casualty no longer a CAT A and in no desperate need of hospital treatment there was no need to risk the aircraft or crew by flying a damaged helicopter back to Bastion. It is absolutely not the place of aircrew to question the medical expertise or judgement of the doctors and medics who classify patients and, in previous tours of HERRICK, I have never felt the need to do this. But the fact remains that on this occasion a damaged aircraft was flown further than was required on the incorrect premise that the patient was in a critical condition, and, had he not been delivered to hospital ASAP, he might have died. Clarification of the imperative to deliver the casualty to hospital may have provided the crew with the final, vitally important piece of the jigsaw. Hindsight is a wonderful thing. Had we been in possession of all of the facts the answer is obvious; shutdown and call for a spare. Spry Says This article not only reminds us of the very real threat crews face on operations but the difficult decisions they are forced to make in dangerous and dynamic situations. It is critical that all parties understand the risks involved and Deliberate Operations utilizing rotary wing is an area where land/air integration has led the way. Full integration of the troops and crews at all stages of the planning has allowed the development of a plan which exposes all sides to the minimum risk possible while still achieving the military aims. Quick response to medical shouts should be no different and this article will be shared with Army publications to shed some light on the thought processes that will happen in situations like this. 22 I LEARNT ABOUT FLYING FROM THAT issue 13 Air Clues issue 13 I LEARNT ABOUT FLYING FROM THAT 23 Air Clues Regulation 18 Mythbusting By Wg Cdr N Severs (MAA Legal Advisor) & Col M Smith (Hd Mil AAIB) Most of you will have heard of “Regulation 18”.1 Over the course of the last couple of years, DG MAA has convened a number of Service Inquiries (SIs) which the MilAAIB have assisted in. It is clear to all of us that Regulation 18 has a serious perception problem. The aim of this article is to tackle some urban myths surrounding Regulation 18, explaining what it is for and, perhaps more importantly, what it is not for. It is worth nothing that Regulation 18 not only applies to aircrew, but also ground crew. This article is obviously based on MAA experience and ways of working in relation to the examples and procedures described, but the legal principles hold good for ground enquiries also. 1 “Reg 18” refers to Regulation number 18 of JSP 832 (Guide to Service Inquiries) which is copied verbatim at the end of this article. Imagine your mate is involved in an SI. Is this how the conversation would go?: 1 2 What’s up? I’ve been Reg 18d by the service inquiry 3 It means I’ve been placed under Regulation 18. Sounds serious, but you didn’t answer the question, what is it? What’s that mean? Does that sound familiar? This is a very common perception, as inaccurate as it may be. 24 REGULATION 18 MYTHBUSTING issue 13 I’m not entirely sure. It’s complicated. The SI panel explained it – some guff about my protection – but what they’re really saying I reckon is that they think the accident was all my fault, and they’re out to get me. Air Clues What we are aiming for are more conversations like this: 1 2 What’s up? 3 It means I’ve been placed under Regulation 18. I’ve been Reg 18d by the service inquiry panel. It does sound serious, but that’s because it’s in legal speak. It’s part of the Armed Forces Act, so it’s law, and it’s Regulation number 18 at the back of the JSP, hence the name; but it’s about protecting individuals not prosecuting them. Sounds serious, but you didn’t answer the question, what is it? What’s that mean? Really? 4 5 Yes, part of the report talks about me, albeit I am not named, and the SI president is of the view that my character or reputation could be impugned. Now that sounds painful. 6 Alright, no more legal speak. Basically, if the SI president thinks that someone reading the report might question my character or professional reputation, because of what it says, then he has to afford me Regulation 18 protection. “Afford” is bordering legal speak, but I’ll let that one go. What sort or protection? I get to see whatever evidence the panel has that relates to me or my actions, hear what they intend to draw from it, add any context or additional information that they might have missed, and make formal comment. And what do they do with that? issue 13 REGULATION 18 MYTHBUSTING 25 Air Clues 7 8 Respond, formally, and reconsider where they see fit. What’s the boss think? Some bits, yes. Why wouldn’t they? Not all though, I guess. I’ll have my say, but at the end of the day it’s the SI president’s call. 26 REGULATION 18 MYTHBUSTING issue 13 What about disciplinary action? Is he happy for you to continue flying? 11 I don’t reckon so. If the SI had found evidence that I had committed an offence, it has to report it to the chain of command, so I would know about that by now. As for admin action, the boss has been advised to wait until the report is complete before he considers it, which makes sense. The SI is a no-blame safety investigation, so any disciplinary or admin action against me would have to compile its own evidence. Yes, as long as I feel fit to fly. He doesn’t know the full detail of why I’ve been given the protection but he knows that DG MAA has to tell him if the inquiry has found evidence that might call into question my ability to hold safety critical responsibilities. He knows about it, the SI president has to inform him, but only from a “duty of care” perspective, the accident was unsettling enough, and this adds to the stress factor. Will they? 10 9 12 Bordering on legal speak again, mate, last warning. So when’s the report out then? Not for a while. I’ll pretty much know what it’s going to say about me though, and I’ll get told when the report is going to be published. Once the report is complete, I will be formally told that Reg 18 has finished. So all’s well then? Maybe, but the report might highlight things that I could or should have done better. That doesn’t make it your fault though, nor is this all about you. Air Clues 13 Agreed. It’s no-blame safety investigation designed to prevent a recurrence of the circumstances that led to this accident, or any accident for that matter. The facts might make uncomfortable reading but you’re right – it isn’t all about me now that SIs look at everything, the whole system in fact; there’re lots of areas that the SI will cover and I will probably be just one of a number on Reg 18. Well our two friends might not like legal speak, but this is a legal process so we can’t really avoid it! Let’s unpick the conversation: “It’s part of the Armed Forces Act” The power to make regulations governing SIs derives from section 343 of the Armed Forces Act 2006, and the regulations themselves are contained in the Armed Forces (Service Inquiry) Regulations 2008 which is a piece of secondary legislation. You can find the regulations and more policy on how SIs are conducted in JSP 832 (Guide to Service Inquiries). “The SI president is of the view that my character or reputation could be impugned” The threshold for this is very low, and Regulation 18 is triggered if the character/ professional reputation may be affected by the findings of the panel. “May” is very subjective and it’s up to the president to decide if it has been met. If you think of the criminal standard of proof used in disciplinary offences (beyond reasonable doubt) as being at the top of your head, the civil standard of proof used in administrative action (on the balance of probabilities) being around your waist, the threshold for triggering Regulation 18 (“may be affected”) would be barely at ankle height! Therefore, it does not necessarily mean that an individual has done something wrong warranting disciplinary or admin action. An individual who is subject to Regulation 18 is called a “potentially affected person” (PAP). “What sort of protection?” The regulations permit the PAP access to the evidence in a number of ways. The “traditional” Regulation 18 scenario envisages witness X saying something adverse about witness Y, and witness Y being invited (under Regulation 18) to listen if the panel decide to re-interview witness X and cross-examine him/her. However, in my experience, it is increasingly rare for this scenario – straightforward adverse comment made by one witness about another – to arise. The move towards investigating human factors and wider systemic/organisational factors (as recommended by Charles Haddon-Cave QC in the Nimrod Review) has meant that often it is only where the investigation is nearing completion and the totality of the evidence is being analysed that the need for Regulation 18 is firmly established. It is the comparing and contrasting of various witness statements against other documentary evidence (such as regulations and orders), and other evidence gleaned from a wide variety of sources which informs the panel’s findings. Therefore, the need for Regulation 18 may only become apparent after all the witnesses have been spoken to. In such cases, the PAP will be given access to all the evidence which has triggered the Regulation 18, and to any pertinent draft findings. “And what do they do with that?” Once the panel receive the PAP’s formal response, they will consider it carefully and make appropriate amendments to their findings. That is not to say that all the PAP’s comments will be incorporated – it’s the president’s call. However, the PAP’s response in toto will become evidence in its own right and will be placed on record with the SI evidence pack. “What does the boss think?” Although it’s not a specific requirement of the regulations, the president will inform the PAP’s chain of command about Regulation 18 being engaged. Being involved in an accident, especially a fatal one, will be a pretty stressful experience and your chain of command have a duty of care towards you, which includes looking after your welfare. For all the panel know, the PAP may be having huge domestic difficulties, with the accident and Regulation 18 just adding to the stress. By informing them about the Regulation 18, your chain of command will be better placed to keep an eye on you. “Is he happy for you to continue flying?” The mere fact that Regulation 18 has been engaged does not mean that the individual can no longer do their job, or is not fit to fly. If DG MAA considers that the actions of an individual present an ongoing risk to air safety, he will inform the chain of command of this fact quite independently of any Regulation 18 action. The chain of command, and the PAP’s peers, must retain a sense of proportion; ensuring that they keep an eye on the welfare of the individual, but guarding against jumping to any erroneous conclusions that the PAP has become a danger to themselves and others simply because of Regulation 18. Remember the threshold for Regulation 18 is deliberately low, so its initiation does not “prove” anything. issue13 REGULATION 18 MYTHBUSTING 27 Air Clues “What about disciplinary action?” The 2008 Regulations prevent, by law, information given to a SI from being used against someone in disciplinary proceedings. For example, a witness statement given to the SI cannot be handed to the police and used to sustain a charge under the Armed Forces Act 2006. However, if the panel do come across information which it believes could point towards an offence having been committed they will have to consider very carefully whether to report this to an individual’s CO. We are all striving towards a just culture in aviation, and we recognise it is neither beneficial nor appropriate to report (for disciplinary purposes) each and every misdemeanour. However, if the panel believe the actions of an individual have “crossed the red line”, they are to report it to the CO. Once the CO becomes aware of a potential offence, he must (in accordance with the Armed Forces Act) investigate it. Whether he tasks the police or not is a matter for him, not the SI or the MAA. If the police become involved, they must gather their own evidence iaw their strict legal procedures. The decision on whether to charge an individual with an offence is a matter for the CO; the MAA has no powers of discipline. The CO will take his own independent legal advice on this – it’s standard chain of command business. Once the chain of command has received a copy of the SI report, it may decide to initiate administrative action for, say, professional failings. There is nothing in law to prevent the chain of command from basing its decision to raise a QR1027 report (RAF admin action, or other single service equivalent) upon the content of the SI but it must then gather its own evidence and follow the process set down in QR 1027 (or equivalent). Again, remember that the threshold for Regulation 18 is very low and is way below the standard of proof required in disciplinary (beyond reasonable doubt) or administrative (balance of probabilities) proceedings, so the mere fact that Regulation 18 is in place does not necessarily mean that disciplinary/administrative action is warranted, nor should Regulation 18 be seen as an automatic pre-cursor to such action. “So when’s the report out then?”In a non-fatal accident, the SI will be published on the MOD internet pretty soon after completion, having been suitably redacted for the public domain. The chain of command will see it slightly in advance of that, to enable the immediate progression of any recommendations made. With a fatal accident, there may be a Coroner’s inquest or Fatal Accident Inquiry (in Scotland), and MOD policy is to wait until those processes are complete before publishing in the public domain (although NoK will receive a copy prior to the inquest/FAI and the chain of command will have a copy to enable recommendations to be progressed). “It’s a no blame safety investigation” One of the areas we must work very hard on is ensuring that the report does not explicitly attribute blame, as we are required to by the Regulations. Whilst we can and do ensure that there is no 28 REGULATION 18 MYTHBUSTING issue 13 explicit blame attributed, it can be difficult to avoid the inference of blame especially where the SI finds that human factors played a significant part; quite often the facts will speak for themselves and an element of culpability may be inferred. In such cases, the individual would be made a PAP and given access to the report in accordance with Regulation 18. I stress again that initiating Regulation 18 in this situation does not mean that action by the chain of command is automatically justified; the fact that the panel believed the PAP could/should have done things a bit better does not necessarily amount to a professional failing warranting further action. So, next time you hear about Regulation 18, remember: •• It is a legal requirement for the panel; •• It is a legal entitlement for the individual; •• It is not a precursor to disciplinary or administrative action. The SI process needs YOUR help to ensure that it is kept in perspective, noting that: •• It does not mean that the individual has done something wrong; •• It does not mean that disciplinary or administrative action is needed; •• It does not mean that the individual is not fit to fly or perform their job. If individuals who are PAPs, their peers and the chain of command at all levels understand the drivers and requirements for Regulation 18, and ensure that their response is proportionate and supportive, we may start to chip away at the perception and misconception that surrounds it. Regulation 18 from JSP 832 Persons entitled to attend 1.Subject to paragraph (2), a potentially affected person shall be entitled to be present at the proceedings of a service inquiry panel. 2.A potentially affected person’s entitlement under paragraph (1) shall be subject to such conditions and exclusions as the president, after consulting the convening authority, may reasonably impose from time to time. Such exclusions may a.include an exclusion from being present at such part of the proceedings of the panel as the president may specify; and b.be imposed before or at any time during the proceedings of the panel. 3.Where under paragraph (1) a potentially affected person is entitled to be present at any part of the proceedings of the panel. Air Clues a.he may be represented at that part by a legal representative or, with the consent of the president, he may be represented by a person other than a legal representative; b.he may give evidence, question witnesses or produce any witness to give evidence, in each case as to any other matter as to which, in the opinion of the president, the potentially affected person may be affected in relation to his character or professional reputation by the findings of the panel; c.where he is represented, his representative may question witnesses and may, with the permission of the president, address the panel; and d.the president shall provide him with a copy of any part of the record of the proceedings of the panel, if the president considers it appropriate to do so. Spry Says All too frequently, at venues such as the Flying Supervisors’ Course, I hear the same questions arising about Reg 18 and I hope that this simple article puts these common concerns into perspective. Reg 18 shouldn’t instil a paranoia that “this is a witch-hunt”, and “they’re out to get you” - the default reaction should be that Reg 18 is giving you extra input into the Service Inquiry so that you get sight of what is being investigated and can comment accordingly. As with all culture-shifts, removing any perceived stigma about Reg 18 will take time, but this excellent article should help speed up that process. 4. In this regulation “potentially affected person” means a person who in the opinion of the president may be affected in relation to his character or professional reputation by the findings of the panel. issue 13 REGULATION 18 MYTHBUSTING 29 Air Clues Real people, helping real people. Every day. Imagine losing your leg. Imagine losing your sight. Now imagine, on top of that, losing your job. That happens. And when it does, we’re there to relieve some of the financial hardship that follows. Supporting fallen heroes is not our day job; we volunteer to make life easier for the people who serve our country. Can you volunteer too? See our website for more info: www.soldieringon.org. www.soldieringon.org Air Clues Awards 2012 LG Groves Memorial Awards The LG Groves Memorial Award Ceremony was recently held at the Royal Navy Historic Flight, RNAS Yeovilton. The LG Groves Memorial Awards were established in 1946 by Major Keith Groves and Mrs Groves in memory of their son, the late Sergeant (Meteorological Air Observer) Louis Grimble Groves RAFVR, who lost his life on a meteorological sortie in September 1945. The Awards are open to personnel from the Meteorological Office, Royal Navy, Army and Royal Air Force and their civilian support staff. Following a fruitful trawl for nominations in Spring 2013, the selection committee had the difficult job of selecting winners from a highly competitive field, itself an indication of the importance that the Met Office and each Service place on Air Safety. In the end there were winners from the Met Office, Army and Royal Air Force which, when combined with the location of the award ceremony, ensured that each Service was signified in some way to the representatives of the Groves family who attended the awards in the atmospheric setting of the Royal Navy Historic Flight hangar. LG Groves Memorial Awards Information The aims of the scheme are: 1.To encourage the study of the problems of the safety of aircraft and flying personnel. 2.To stimulate research in the science of meteorology to aviation. 3.To recognize good work by personnel engaged in meteorological observer duties, or other duties relating to meteorology and in operational meteorology. There are 4 categories of Award: •• Air Safety Prize. For the most important contribution made during the previous year towards improving the safety of personnel or aircraft in flight, or enhancing the survival of aircrew. •• Ground Safety Award. For the most important contribution made during the previous year towards improving the safety of personnel, aircraft or equipment on the ground, either at a flying station or at an associated unit elsewhere. LG Groves Memorial Prize for Ground Safety, for the most important contribution made during the previous year towards improving the safety of personnel, aircraft or equipment on the ground, either at a flying station or at an associated unit, was awarded to 47 Air Despatch Squadron, Royal Logistic Corps. 47 Air Despatch Squadron moved to RAF Brize Norton in 2011 and undertook significant work to integrate with their new parent station’s Air Safety organization and develop a positive safety culture. •• Meteorology Prize. For important contributions to the science of meteorology, the application of meteorology to aviation or operational meteorology either by practical work or by the publication of scientific papers. •• Meteorological Observation Award. For outstanding work in the field of meteorological observation, particularly where flying duties or service at sea are involved. The prizes/awards range from £500 - £1000, with an award ceremony in September. Nominations should be sent to the email addresses detailed below: Air Safety Prize & Ground Safety Award: Submit to Sqn Ldr Doug Fowler [email protected] Meteorology Prize & Meteorology Observation Award: Submit to Miss Pip Gilbert [email protected] Further information can be found in GAI 1047. Please note that the deadline for this years nominations was 1 March 2014 however please keep this information in mind for future nominations. LG Groves Memorial Prize for Meteorology, for important contributions to the science of meteorology, was awarded to Professor Adam A. Scaife for his research into the North Atlantic Oscillation. The North Atlantic Oscillation dominates the winter climate over Europe, the eastern USA and Canada; Professor Scaife’s work has lead to major breakthroughs and key insights into the future climate of the UK and Europe. (Photo - Professor John Mitchell, Principle Research Fellow, pictured with the Met Office winners) issue 13 AWARDS 31 Air Clues LG Groves Memorial Award for Air Safety, for the most important contribution made during the previous year towards improving the safety of personnel or aircraft in flight, or enhancing the survival of aircrew, was awarded to Warrant Officer Peter Woodward. Warrant Officer Woodward was the Parachute Jump Instructor SME within the RAF Brize Norton Duty Holder Support Cell and was tireless in his work to ensure that military parachuting is as safe as possible and the risks allied to military parachuting are understood, managed and mitigated as far as possible. (Photo - Warrant Officer Peter Woodward pictured with Air Commodore David Lee, Air Officer Air Mobility) LG Groves Memorial Award for Meteorological Observation, for outstanding work in the field of meteorological observation, particularly where flying duties or service at sea are involved, was awarded to Doctor Pete Francis for his important contributions in the field of exploiting satellite imagery for weather forecasting and hazard monitoring. Among the many products he has developed, he led an effort in 2010, following the eruption of Eyjafjallajokull in Iceland, to derive quantitative data from satellite imagery to support the advice issued to the London Volcanic Ash Advisory Centre. More Flight Safety Awards… SAC(T) Aistrop On the morning of Monday the 9th September 2013 SAC(T) Aistrop was tasked with supporting the flying programme and was on the Southern HAS site when he noticed that a Typhoon aircraft had its nose wheel bay door pushed against the nose landing gear leg. On approaching the aircraft he noticed that a small bolt shaft was protruding from the underside. On closer inspection the bolt was observed to be caught in the hinge line of a closed circuit breaker panel bay. SAC(T) Aistrop, immediately realising the seriousness of his discovery, informed the Rectification Controller who removed the aircraft from the flying programme and instigated a full investigation. SAC(T) Aistrop’s attention to the detail is always exemplary, but on this morning his actions far exceeded what would normally have been expected and these actions prevented a serious Flight Safety hazard from developing. For his diligence, attention to detail and subsequent actions, SAC(T) Aistrop is awarded this AOC No1 Gp Safety Commendation. 32 AWARDS issue13 Mr Powell Mr Powell was the Aircraft Handler responsible for supervising the start on a Squirrel helicopter at Shawbury on 03 Jul 13. This was one of many starts he supervised that day. This sortie was a ‘starts and stops’ sortie for a CFS(H) student QHI with a staff QHI supervising. When the aircraft was started for the second time, Mr Powell was cleared under the disk to complete a routine leak check when he noticed that the lower main servo mount nut was loose. He immediately sought an engineer’s advice and the aircraft was shut down. The lower main servo mount on the Squirrel is located on the side of the main gearbox and with the panels closed for start is very difficult to see. Mr Powell’s meticulous attention to detail to spot something out of place was incredible. The Flight Safety implications of servo jack becoming detached in flight are extremely serious as it would have resulted in the loss of the aircraft and crew. Through his diligence and conscientiousness Mr Powell prevented a potentially catastrophic accident and was presented with a Flight Safety award. Air Clues Report today for a safer tomorrow By Sqn Ldr Tony McLoughlin, SO2 AEMS, RAF Safety Centre DAEMS reporting The Defence Aviation Error Management System (DAEMS) - what does it actually mean to you? It is not merely an IT system, but, rather, a combination of policies, processes and tools for reporting and analysing errors and near misses in Defence aviation. The actual tool it uses is the existing Aviation Safety Information Management System (ASIMS), which is a computer-based reporting system, database and analysis tool. The more Air Safety information that is stored in ASIMS, the more effective the system is, so it is essential that everybody reports any aviation related event, issue or occurrence – this is known as a “Reporting Culture”. Everybody who experiences an accident, incident or near-miss must therefore ensure that they report it and, if it is related to Air Safety, capture it on ASIMS; there are 2 ways of doing this: **Raise a hand-written Aviation Error Management System (AEMS) form, which is probably the only method available to you if you don’t have easy access to ASIMS. or **Raise a Defence Aviation System Occurrence Report (DASOR) directly into ASIMS. Occasionally, the individual might not be sure if the incident is aviation related; in these circumstances, submit an AEMS anyway, as it will be passed to trained specialists who can determine whether it is Air Safety-related or would be more appropriately dealt with under the headings of Health & Safety or Quality Assurance. In these last two cases, they will pass the report to the appropriate departments to deal with using their own systems. issue 13 REPORT TODAY FOR A SAFER TOMORROW 33 Air Clues Determine root cause We need to find out why accidents, incidents and near-misses happen, so we can prevent their re-occurrence. Having reported the event, there may be a requirement to conduct an investigation to determine the root cause. If required, these investigations will be conducted by staff specifically trained not only to determine the root cause, but also to identify any contributory factors and make effective recommendations to prevent reoccurrence. Just Culture The primary aim of reporting and investigating these events is to learn from them and prevent them reoccurring; this will only happen if our people are freely willing to submit their reports, and fully appreciate that, by doing so, they are contributing to improving safety. To create this Reporting Culture all personnel need to be certain that the process focuses on understanding behaviour and the drivers behind people or organisations operating in ways which could compromise Air Safety. In addition, we are also a Just Culture, ie we recognise that humans make mistakes – this should not be misinterpreted as a “No-Blame” culture. The RAF’s Just Culture policy is explained in AP 8000, as is the FAIR (an abbreviation of Flowchart Analysis of Investigation Results) tool, which is copied below. The investigators will look at Human Factors, including how the behaviour of people or organisations which led to the issue or occurrence, was influenced. However, it must be emphasised that we will never tolerate reckless conduct and when proven, appropriate action will be taken, as depicted below. Regional Air Safety Teams The RAF Safety Centre has 3 regional teams of full-time investigators which are there to support units and/or Unit SEMSCOs within their region. As well as providing support for investigations they support Occurrence Review Groups (ORG ) and provide advice on policy and how to get the most out of your EMS. FAIR (Flowchart Analysis of Investigation Results) System START Was there a conscious and unjustifiable disregard for risk? Was there malicious intent? Yes Yes Sabotage or attempted sabotage No No Recklessness Were rules intentionally broken? Could the task have been done in accordance with the rules Yes Yes Was the action to the benefit of the organisation No No Was a correct plan of action selected? Yes No Error Rule-breaking for personal gain No Was the situation outside normal practice? Mistake 34 REPORT TODAY FOR A SAFER TOMORROW issue 13 Yes Exceptional rule-breaking Yes Rule-breaking for organisational gain Air Clues Spry Says Aviation is complex and people will make errors and mistakes. In many cases the ‘system’ sets you up to fail, for reasons such as poor procedures, time pressures and lack of equipment. Reporting these issues makes management aware and puts ownership of the risk back at the right level. The RAF Just Culture policy ensures that people who make errors are treated fairly and that the circumstances and pressures are understood. This should encourage all of us to report both our errors and the everyday issues that make doing our job safely more difficult. Ultimately, AEMS is generating a genuine culture change within the RAF, so, whatever the concern, report it and let’s make that change. Northern Regional Team RAF Leeming REMSCO Flt Sgt Rob McCormack (Des) - 95851 TBD Flt Sgt Gordon Cooke - 95851 7230 RAF Lossiemouth Flt Lt Mick Letch - 95161 7608 Chf Tech Steve Valentine - 95161 8820 Midland Regional Team RAF Cranwell REMSCO WO Martyn Bayley - 95751 6859 Flt Lt Graham Bruce - 95751 6989 Flt Lt Mick Lismore - 95751 6679 Flt Sgt Jules Harrison - 95237 7087 Flt Sgt Ralph Winstanley - 95751 6863 Chf Tech Si Birkwood - 95751 6680 Chf Tech Hugh Shaw - 95751 6679 Southern Regional Team RAF Halton REMSCO WO Steve Coleman - 95237 7091 Flt Lt John Wright - 95327 6583 Flt Sgt Steve Bevan - 95237 7127 Chf Tech Dave Edwards - 95237 7087 Sgt Michael Fletcher - 95237 7047 RAF Safety Centre Regional Error Management teams Unintended Action Unintended Consequence Intended Action Unintended Consequence Situational rule-breaking Intended Action Intended Consequence Rule breaking for personal gain Exceptional rule-breaking Error Mistake Rule breaking for organisational gain Recklessness Increasing Assess No Culpability Sabotage Culpability The tests applied to determine level of capability: 1.Substitution Test: Would another ordinary person with the same competence, education, training and experience behave in the same way under the same circumstances (time, goal demands, organisational context? 2.Routine test: Does this happen often to 1. the individual 2. the organisation? Proportionality Test: If culpability is evident, the proportionality test is applied to determine the safety value of administrative disciplinary action. Manage Managed by improving performance influencing factors: person, task, situation and environment. In some cases, dependant on the outcome of the above tests, administrative disciplinary action may be necessary. Likelihood that administrative or disciplinary measures will be appropriate. The improvement of performance influencing factors should remain a consideration. issue 13 REPORT TODAY FOR A SAFER TOMORROW 35 Air Clues Aberporth Danger Area Complex EGD201 and EGD202 Things go whizz and bang in here!D202 By Mr J Beckett, Air Traffic Control Officer, MOD Aberporth Range MOD Aberporth is a busy, fully instrumented, weapons test and evaluation range. The Range’s Danger Area Complexes (EGD201 A-E and EGD202 A-C) are established over some 6,500km2 of Cardigan Bay from sea level to unlimited height and overland from the western edge of the Sennybridge Range (EGD203) westwards to the west coast of Wales. These areas are no doubt familiar to most aviators as they are published and feature on all airspace charts. The Range has been in existence since 1939 and it is currently operated by QinetiQ on behalf of UK MOD under what is known as the Long Term Partnering Agreement (LTPA). 36 ABERPORTH DANGER AREA COMPLEX issue 13 The purpose of the LTPA is to deliver defence test, evaluation and training support services to ensure air launched weapon systems, associated sub-systems and UAVs are safe and fit for purpose. More information can be found on the LTPA website (www.ltpa.co.uk). National Air Traffic Services (NATS) Ltd. is contracted to QinetiQ for the provision of all Air Traffic Control Services within these Danger Areas and ATSOCAS (Air Traffic Services Outside Controlled AirSpace) in the adjacent class G airspace. Aberporth Air Traffic Control (ATC) provides a Danger Area Activity Information Service (DAAIS) and Danger Area Crossing Air Clues Use of Airspace”. This changed the way in which the danger area activity was promulgated. Before it was notified as permanently active, nowadays activity is subject to daily NOTAM action and disseminated accordingly to all airspace users. Generally it is open 0900-1600 local time Mon-Fri, but checking your NOTAMs is still vitally important as these hours do change depending on the trials being carried out. Danger area activity is sometimes termed in several different ways, at Aberporth we use the standard terms of “Active” and “Not Active”. Active means that the danger area is currently up and running, with ATS personnel available for a DACS, DAAIS or ATSOCAS. Not Active means that the airspace is available and ATS, DAAIS or DACS may be available. Infringements These are still one of our biggest safety concerns and preventing them remains at the forefront of the Range Operators’ priorities. Infringements do have a significant impact on our operations and we continue to try to reduce the number, year on year. Within the last 12 months, the Range has reported 16 infringements; this figure does not include the potential infringements that we prevented using the techniques described below. Photograph © Geoffrey Lee, Plane Focus ltd Service (DACS) coupled with an ATSOCAS when open. Air Traffic Controllers are therefore licenced by both the MAA (Military Aviation Authority) and the CAA (Civil Aviation Authority). Working closely with other ATC radar service units, NATS Aberporth provide ATC services to Civil and Military Aircraft, and, within the Range, a bespoke service to multiple aircraft, various types of UAVs and even surface vessels. This bespoke service enables the Range to operate air-to-air, air-to-surface, surface-to-air and surface-to-surface weapons testing and evaluation in a safe and highly controlled environment. NATS can also provide other non-Range airspace users with ATSOCAS over most of Wales, outside any Controlled Airspace. Recently (late 2012), D201 Complex and its little brother (D202 complex) became involved with the now familiar phase of, “Flexible Unfortunately, we can’t reduce this number alone, we do need airspace users to work with us to be mindful of the potential impact that infringements may have and to consider different ways of operating their aircraft close to the danger area boundaries. So how do we prevent infringements? Range Air Traffic Controllers actively monitor the Range boundaries during NOTAM’d periods of activity and by using proactive and defensive controlling techniques; they try to prevent infringements before they ever become actual reportable events. We also actively promote the danger areas in the wider aviation community, through safety evenings and seminars around the local flying clubs and aerodromes, whose operations are adjacent to, or within, our operating areas. During these visits we actively pass on information to occasional airspace users, who find the information adds to their flying knowledge. For pilots who operate within our operational area, we would expect them to be aware of the danger area complexes though comprehensive flight briefing, being aware of their exact position at all times and requesting an ATSOCAS service from an appropriate radar unit. However, this isn’t always the case, as historic data shows that even with GPS systems, 37 Air Clues navigation software, and provision of radar ATSOCAS available, pilots (both Military and Civil) are unfortunately still infringing the danger areas. The team at Aberporth are always keen to promote the ATSOCAS that they can provide around the danger area complexes boundaries and encourage any pilot to call for a service, even if it is just to let Aberporth know that they are operating in the area. We would encourage all pilots to routinely call, as the whole of Wales can be very busy with military low level traffic and we can advise if any traffic is near their intended flight path. When planning a route close to our danger area boundaries, please don’t hesitate to call ahead to discuss with ATC your plans. The number for Aberporth is listed below. What happens when an aircraft infringes an active danger area? Mandatory reporting action is carried out for all danger area infringements and these events are thoroughly investigated. Any recommendations will be acted upon in a timely manner. In the event that an infringement does occur during a live firing trial, Aberporth range controller immediately carry out stringent safety “Stop Actions”, to ensure that the trial is made safe. The trial team have to reset the trial in order to achieve its objectives. This could involve vectoring the fighter and target or it could involve aborting the trial because of aircraft fuel constraints. This impacts both financially and operationally on trials which are critical to the UK MOD. Crossing the Danger Area Can you cross an active danger area? The danger area can be crossed when there is no trial activity or when specific non-firing trial activity is taking place. Depending on the nature of the Range activity, it may be possible to allow aircraft to cross or enter the danger areas. Each aircraft will be advised when the request to enter or cross is made. The crossing aircraft will have to be positively identified and provided with an Air Traffic Service before a crossing clearance will be issued. This clearance may also be requested from another Air Traffic Control Radar Unit (ATCRU) e.g. RAF Valley or London Military. Outside any trial activity the DA may well still be classed as “Active”, this means that the danger area is open but trials are not taking place. A Range Air Controller will always be present 38 ABERPORTH DANGER AREA COMPLEX issue 13 whenever any part of the Ranges is notified as active and can provide a DACS, DAAIS or ATSOCAS. Summing up We hope you have found this short article interesting and that it has enhanced your knowledge of our operations within D201/202, along with the impact that any infringement has on it, has increased. We do hope that the next time you’re flying over Wales; you take into consideration the services available from the Range Air Traffic Controllers at Aberporth. We will be happy to hear from you. Contact details when planning a trip: “Aberporth Radar” ATSOCAS Frequency VHF 119.65 MHz or UHF 338.925 MHz Aberporth Range Air Control 01239 813219 www.nats.co.uk | www.aberporth.qinetiq.com | General enquiries: [email protected] Air Clues Spry Says This article provides some useful information with regard to air operations in and around D201/202. Previously strictly off limits, the area is no longer a permanent no-go area, however, all aviators are reminded to make use of the comprehensive radar service that is provided by Aberporth ATC and they are encouraged to use the range airspace when it is available. issue 13 ABERPORTH DANGER AREA COMPLEX 39 Air Clues Feedback… tell us what you think about Air Clues New Message To: Air-Flt Safety Wg Cdr Spry CC: Subject: Stuffy nose My dear Wg Cdr Spry, I recently found myself on the receiving end of a mild cold, thoughtfully brought home to me by my three year old daughter via her play group. Now, I was only slightly snotty and bunged and could clear my ears without difficulty. I had to fly, for several reasons, and considered buying some decongestants from the local chemist. Remembering the article on self-medication in the Summer 2012 issue of Airclues and having just read your recent Air Safety Matters, I thought better of it. My question is, why are we so concerned about these widely used medications? It seems as if everyone but aviators takes cold medicines. Yours truly, Flt Lt Stuffy Nostril 40 FEEDBACK issue 13 Air Clues New Message To: Airclues Reader CC: Subject: RE: Stuffy nose Let me repeat the response from our medical experts when asked about taking over-thecounter medications: Firstly, what is causing you to ask whether you should take these meds? If you are ill enough to want “something to help”, you are ill enough to consult your aviation medicine trained doctor prior to flying. This is for two reasons - to discuss the flight safety aspects of the illness, as well as any possible medical treatment for it. Over-the-counter medications are considered “verboten” to aircrew primarily due to two types of side effects - commonly expected and idiosyncratic. The first are those listed on the labels and are self-explanatory; the more worrisome are idiosyncratic – they are rare and completely unpredictable. Whereas thousands of people may take ColdCure “X” safely, a few people will have unusual, and potentially severe, side effects. This could be you, and it could happen either when you take the first dose or when you take subsequent doses, even after having taken it successfully on previous occasions. These are the reasons why the rules on self-medication have been around so long. Let me stress that my recent Air Safety Matters wasn’t saying anything new – self-medication has always been discouraged. The trouble is, when a Coroner at an inquest into a fatal accident questions our rules, as happened recently, we have got to be clear – unless we can be specific about the timescales for taking self-medication, then the ban on them must be interpreted as total. Such clarity was recently asked of us by HM Coroner as these timescales were not clear, hence my Air Safety Matters. However, I have gone back to CAM and discussed this topic further. They are content that ‘not within 24 hrs of reporting for flying duties’ is a realistic time-limit for the taking of over-the-counter medications; the medics consider that any potentially adverse side-effects will be out of your system after 24 hours. That is why by the time you read this, I will have issued guidance to the Groups which directs that aircrew should not use over-the-counter medicines, drugs tablets or remedies within 24 hours of reporting for flying duties, unless prescribed by a MAME. I have been reliably informed that this advice will be seen in MAA Regs by this summer. So those of you who feel the need for an aspirin on a Saturday morning after Friday night’s Happy Hour won’t need to see the doc if you’re not at work until Monday! Similarly, if you’re crippled with “man-flu”, you can take B**chams or Lem-S*p, but if you do so within 24 hrs of reporting for flying, then you need to take yourself off the fly-pro (then again, wasn’t that always “best-practise”? – ie “Colds and flying don’t mix”). However, if you know that you’re not reporting for flying for over 24 hrs, crack on and dose yourself up! That said, my stance also remains aligned with the current regulations, in that self-medication is simply a very bad idea on several accounts. It is an issue which has been raised in many recent Service Inquiries. If you are ill, visit your friendly doctor in the Station Medical Centre and discuss the situation, even if the illness seems relatively minor. The risk of side effects adversely affecting safety of flight is real and significant. There may be more things going on medically than you appreciate, which the good doctor might discover before he discusses medications. However, if you feel compelled to self-medicate and are within 24 hrs of reporting for flying duties, do NOT do so if you wish to remain on the fly-pro, unless the medications have been cleared by a MAME. Spry issue 13 feedback 41 Air Clues Military Aviation Authority (MAA) Air Safety Courses Air Safety training assists in mitigation of Risk of Life. It increases safety awareness and supports the establishment and maintanance of an Air Safety culture. The following courses are held at the Centre of Air Safety Trg, Defence Academy of the UK, Shrivenham. If you wish to apply for a course, email [email protected] Further in formation can be found at http://defenceintranet.diif.r.mil.uk/Organisations/Orgs/HOCS/Organisations/Orgs/MAA/Pages/MAACentreofAirSafety Training.aspx or http://www.maa.mod.uk/training/index.htm Training Contacts: For courses based at Shrivenham contact the MAA Centre of Air Safety Training (CoAST) email: [email protected] For courses based at Cranwell contact Human Factors Admin on +44 (0)1400 268190 International Defence Training on +44 (0) 1296 656 162 Duty Holders Air Safety Course - DHASC Course Aim Duration The DHASC aims to improve Defence Air Safety by ensuring that DHs are fully conversant with their role and responsibilities in the safe management of Defence aviation. 2 days Validity: 5 years further details in RA1440 at http://www. maa.mod.uk/regulation/index.htm Outline of Syllabus Course dates The course is aimed at Operational Duty Holders (ODHs) and Delivery Duty Holders (DDHs) but will be of value to Senior Duty Holders (SDHs), Senior Operators (SOs) and Chief Air Engineers (CAEs). Personnel filling other senior engineering or operational posts may apply. Related regulatory documents can be found on the MAA intranet site. •• •• •• •• 42 MILITARY AVIATION AUTHORITY AIR SAFETY COURSES issue 13 10: 1-2 May 14 11: 3-4 Jul 14 12: 22-23 Sep 14 13: 3-4 Dec 14 For more information please call +44 (0) 1793 314183 Air Clues Flying Supervisors’ Course - FSC Course Aim Duration To prepare flying unit executives for their forthcoming flying supervisory roles. 3.5 days Validity: 5 years further details in RA1440 at http://www. maa.mod.uk/regulation/index.htm Outline of Syllabus The course is aimed at Sqn Cdrs and Flt Cdrs of OF3 rank and above who are appointed to flying posts. Applications are also welcomed from senior engineering and air traffic control officers. Suitably experienced junior officers may also apply although justification from their commanding officer will be necessary. Contractors and overseas applicants are to apply through International Defence Training. Course dates •• •• •• •• •• •• 373: 19-22 May 14 375: 14-17 Jul 14 376: 15-18 Sep 14 377: 13-16 Oct 14 378: 17-20 Nov 14 379: 01-04 Dec 14 For more information please call +44 (0) 1793 314183 Flying Authorisers’ Course - FLAC Course Aim To prepare Junior Officer (JO) and SNCO aircrew for their duties as flying authorisers and junior supervisors. Outline of Syllabus Validity: 5 years further details in RA1440 at http://www. maa.mod.uk/regulation/index.htm Course dates Contractors and overseas applicants are to apply through International Defence Training. •• •• •• •• •• •• Duration For more information please call +44 (0) 1793 314183 This course is only for JO and SNCO aircrew who have been selected to become flying authorisers. 284: 22-24 Apr 14 285: 24-26 Jun 14 286: 22-24 Jul 14 287: 02-04 Sep 14 288: 21-23 Oct 14 289: 25-27 Nov 14 3 days Flight Safety Officers’ Course - FSOC Duration Course Aim 4.5 days Validity: 5 years further details in RA1440 at http://www. maa.mod.uk/regulation/index.htm To prepare individuals to carry out the duties of the Stn and Unit Flight Safety Officer. Outline of Syllabus Applicants should be appointed to Flight Safety related posts. Contractors and overseas applicants are to apply through International Defence Training. Course dates •• •• •• •• •• 241: 12-16 May 14 243: 07-11 Jul 14 244: 08-12 Sep 14 245: 06-10 Oct 14 289: 25-27 Nov 14 For more information please call +44 (0) 1793 314183 issue 13 MILITARY AVIATION AUTHORITY AIR SAFETY COURSES 43 Air Clues Post-Crash Management Incident Officers’ Course - PCMIOC Course Aim Course dates To train military personnel and MOD civilian or contracted personnel who have been designated to fulfil the role of Post Crash Management Incident Officer (PCMIO) in the UK. •• •• •• •• •• Outline of Syllabus The PCMIOC is not pre-employment training for Theatre personnel, although the core skills covered will provide a solid base for PCM duties overseas. The course also provides essential information for those who will be exercising command and control of PCMIOs. Personnel not designated to fulfil PCMIO duties are to provide additional justification (on the application form), for their attendance on this course. 114: 08-09 May 14 115: 05-06 Jun 14 116: 01-02 Jul 14 117: 05-06 Aug 14 118: 23-24 Sep 14 For more information please call +44 (0)1793 314178 Non UK PCM Personnel who are required to fulfil PCMIO duties outside of UK, not at a PJOB, should contact MAA-MAAIB-PCM@ mod.uk for a briefing. Contractors and overseas applicants are to apply through International Defence Training. Duration 1.5 days Propulsion Integrity Course – PIC Course Aim The Propulsion Integrity Course (PIC) provides Officers, SNCOs and MOD civilians from the PTs engine EAs community with a more in-depth understanding of the principles of gas-turbine aero-engine regulation and lifing aspects of propulsion integrity. Outline of Syllabus Lectures are provided during the course by representatives from the MAA, DE&S, DSAE and Rolls-Royce plc. Topics covered include life management plans, critical and non-critical components, materials and failure mechanisms, damage under complex loading, lifing statistics, fatigue testing and service samples, health and usage monitoring, exchange rate calculation, safety and risk management, and future policy. 44 MILITARY AVIATION AUTHORITY AIR SAFETY COURSES issue 13 Duration 3 days For course dates please check the MAA website or contact +44 (0)3067 984325 Air Clues Aircraft Structural Integrity Course - ASIC Course Aim Entry Requirements To provide a synopsis of the latest available information on aircraft structural integrity (SI) matters. This course is primarily suited to military officers, Senior Non Commissioned Officers and civil servants, serving as Project Engineers, airframe/structures engineers or fleet managers. Officers, SNCOs and civilians posted to the following appointments are eligible to attend the course. DE&S PT Project Engineers, Fleet Managers and Engineers in airframe/ structures posts who have responsibility for structural integrity or aircraft engineering. RN, Army and RAF Air Staff at Command or Group Headquarters. Station, Unit and Squadron Engineering appointments. Staff in Flight Safety Appointments. Appointees involved with fatigue budgeting, processing and analysis. Appropriate staff from within the Defence Support Group (DSG). DSTL and QinetiQ staff with airworthiness responsibilities. Invited Design Authority representatives. Up to 70 students will be selected from nominations submitted to the course sponsor. Outline of Syllabus Structural issues, such as fatigue and ageing aircraft, are now the limiting factors that determine the life of many aircraft and major aero engine components. Other factors such as corrosion, also have a significant impact on aircraft structural integrity. The understanding of fatigue has improved over recent years, as have techniques used in structural testing, inspection and monitoring. The ASIC is designed to update Officers and civil servants on the latest developments relating to structural integrity issues and to highlight the importance of effective structural integrity management. The course material is delivered by specialists from the UK MOD, QinetiQ and industry and addresses the following subjects: An Introduction to Structural Integrity; Theory of Fatigue; Structural Airworthiness Requirements for Fatigue Design; Generic Helicopter HUMS; A Design Authority Perspective on Helicopter Fatigue and Qualification; Helicopter Structural Integrity; Corrosion and Corrosion Protection; Composite Materials. In-Service Fatigue Management; Ageing Aircraft and Sampling Programmes; Non-Destructive Testing for UK Military Aerosystems and Equipment; Aircraft Repair. Places may also be available on this course to officers from overseas military forces who meet the criteria above. Where English is not the first language, students must pass written and spoken English language tests and achieve a minimum score of 5.5 in each part of the International English Language Test System (IELTS) before being accepted for training. Duration 2.5 days Course dates 118: 23-24 Sep 14 For course dates please check the MAA website or contact +44 (0)3067 984325 Effective Error Management – EEM Course Aim The overall aim of this course is to enable delegates to engage and manage the Error Management System in their Area of Responsibility on a day to day basis focusing on the handling of reports, coordination and guidance of investigators, Review Groups, Communications, proactive error management and continuation training. Applicability The course is aimed at Error Management System Coordinators, Local Error Management System Coordinators, Flight Safety-responsible persons and any appointed to roles ‘championing’ the Error Management System. Prerequisite Human Factors and Error Management Foundation Training Duration 1 day Course dates •• •• •• •• •• •• •• •• 16 Sep 14 23 Apr 14 •• 30 Sep 14 7 May 14 •• 14 Oct 14 20 May 14 •• 4 Nov 14 10 Jun 14 •• 18 Nov 14 24 Jun 14 •• 2 Dec 14 1 July 14 •• 7 Jan 15 3 Sep 14 •• •• •• •• 20 Jan 15 3 Feb 15 3 Mar 15 17 Mar 15 For more information please contact +44(0) 3067 984325 or [email protected] issue 13 MILITARY AVIATION AUTHORITY AIR SAFETY COURSES 45 Air Clues Occurrence Investigator – OI Course Aim Course dates The overall aim and objective of this course is to enable delegates to carry out an effective occurrence safety investigation, by conducting effective information gathering via interview, data gathering, and photographic methods and presenting recommendations to reduce the likelihood of reoccurrence, in order to contribute to increased safety, quality and operational efficiency levels. •• •• •• •• •• •• •• •• •• •• •• •• •• •• •• •• •• Applicability The course is aimed at all nominated personnel (Mixed ranks and trades). Prerequisite Human Factors and Error Management Foundation Training Duration 1-3 Apr 14 29 Apr-1 May 14 3-5 Jun 14 17-19 Jun 14 8-10 Jul 14 9-11 Sep 14 23-25 Sep 14 7-9 Oct 14 21-23 Oct 14 11-13 Nov 14 25-27 Nov 14 9-11 Dec 14 13-15 Jan 15 27-29 Jan 15 10-12 Feb 15 24-26 Feb 15 10-12 Mar 15 3 days For more information please contact +44 (0)3067 984325 or [email protected] Occurrence Review Group – ORG Course Aim Course dates The overall aim and objective of this course is to enable delegates to engage meaningfully with an Error Management System process and to discuss and determine risk with regards to Occurrence Safety Investigations and trend analysis output, and practically apply a consistent rigour in the potential determination of culpability in order to contribute to increased safety, quality and operational effectiveness. It should also focus on the important internal assurance role of the ORG. •• •• •• •• •• •• •• •• •• •• •• •• •• •• •• •• •• •• Applicability The course is aimed at all nominated personnel (Mixed ranks and trades). Prerequisite Human Factors and Error Management Foundation Training Duration 1 day For more information please contact +44 (0)3067 984325 or [email protected] 46 MILITARY AVIATION AUTHORITY AIR SAFETY COURSES issue 13 24 April 14 7 May 14 21 May 14 11 Jun 14 25 Jun 14 2 Jul 14 4 Sep 14 17 Sep 14 1 Oct 14 15 Oct 14 5 Nov 14 19 Nov 14 3 Dec 14 8 Jan 15 21 Jan 15 4 Feb 15 4 Mar 15 18 Mar 15 Air Clues Defence Human Factors Facilitator and Instructor Course - HFFIC (RAF Cranwell) Course Aim Duration To increase an individual’s HF knowledge to enable them to achieve Level 3 of the HF Competency Framework (HFCF) and thus become competent HF Instructors and Facilitators. The course assumes that all students are experienced workplace HF practitioners. 4.5 days Outline of Syllabus this course is aimed at: a. Those people filling or posted to instructional appointments within Phase 1, 2 and 3 training establishments. b. Those people delivering HF Continuation training. Course dates Courses Apr-Jul Fully Booked 13/14:08-12 Sep 14 Limited Space available 14/14: 29 Sep-03 Oct 14 Limited Space available 15/14: 13-17 Oct 14 Space available 16/14: 03-07 Nov 14 Space available 17/14: 01-05 Dec 14 Space available 18/14: 15-19 Dec 14 Space available For more information please contact +44 (0)1400 268190 Defence Human Factors Examiners Course - HFEC (RAF Cranwell) Course Aim To train ab-initio HF Examiners in the process of HF Facilitator assessment and support and to increase HF knowledge to Level 4 of the HFCF. Outline of Syllabus This course is aimed at individuals filling posts within their DDH or Unit HQ. It is essential that all applicants are experienced workplace HF practitioners and facilitators. In line with current policy all students will have to complete the Defence Instructor Assessment and Development (DIAD) course. This can be done after attending their HFEC although they will be required to provide details of the DIAD course they are due to attend. Duration 3 days Course dates 2/14: 13-15 May 14 Spaces available 3/14: 16-18 Sep 14 Spaces available 4/14: 18-20 Nov 14 Spaces available For more information please contact +44 (0)1400 268190 issue 13 MILITARY AVIATION AUTHORITY AIR SAFETY COURSES 47 Air Clues Competition time Win… The competition this time is to send me your funny and amusing stories or jokes (anonymously if you wish) for inclusion in the Airclueless section of the magazine. The best story will receive a certificate, courtesy of CAE at RAF Benson which will allow for you and 3 guests to have a tour of their simulator facility. The deadline for entries is Friday 30th May 2014. Congratulations to last editions winner… Percy Entries can either be mailed to: Plt Off Prune RAF Flight Safety HQ Air Command Lancaster Block RAF High Wycombe Bucks HP14 4UE SE N D The winner of one of our Haynes RAF Typhoon Owners Workshop Manuals was Flt Lt JJ Caley from B Flt, 22 Sqn. You can read JJ’s article on page 10 of this edition. Please keep your I learnt about articles coming in, as usual we will endeavour to publish everything we receive. 48 COMPETITION TIME issue 13 Or emailed to: Air-SafetyCtre-WgCdrSpry@ mod.uk Air Clues Wing Commander S H P Spry DFC AFC DFM RAF Wing Commander S H P Spry DSO DFC AFC DFM RAF was the youngest son of a Brigadier from a Guards regiment. Born during the First World War (1916 is the best estimate from records) he enjoyed a privileged background (Norland nanny, clockwork train set, and 2 oranges in his stocking at Christmas) and attending public school. Unlike his brothers who all joined their father’s who was deemed to be responsible for an regiment, Spry rebelled. He has no desire to wear incident or accident. Operations and engineering puttees, spurs and a stripe down his trouser leg but personnel as well as aircrew would live in fear of instead yearned to be a fighter pilot in the RAF. a Wing Commander Spry comment, criticism or He would often gaze into the Summer skies and devastating summary of an accident or incident. watch the fighter pilots practice their up-diddly-up- These comments quickly attracted criticism ups and decided that this would be the life for him. from some quarters. In November 1957, a Wing He refused to accept his allocated place to study Commander serving in the Air Ministry wrote the classics at Oxbridge, choosing instead to feed the following: his craving for aviation matters by joining the Royal Air Force in 1934. After flying training he quickly achieved his Will Wing Commander Spry never come down off that high horse of his? After more than a year of reading his pompous, ‘holier-than-thou’ comments ambition to be a fighter pilot and was posted to I am so exasperated that I must ask if he has ever fly the Hawker Fury at Tangmere. As his expertise been an ordinary human sort of pilot himself. Did developed so did his fame and his successes the Wing Commander never have an accident, or during the Second World War won him the DSO, at least has he never been able to say “There but for were followed by “and further remarks of mine DFC and DFM. He gained a reputation for superior the grace of God go I”? It seems not. He discusses would probably be censored by the Editor!” On this airmanship and was never shot down. them with such ominous severity that it would 10th anniversary in post, it was noted that he hoped seem a criminal act to be involved in a mishap. “to continue being rude, dogmatic and pedantic fighters and despite his aircraft being severely Accidents, surely, are accidents. Everyone tries to for a further 10 years – as he doesn’t care whom damaged, on one occasion beyond all recognition, avoid them, and they occur despite what people try he upsets as long as the Flight Safety statistics he would always manage to land the aircraft on to do. The most effective way to real Flight Safety continue to improve.” British soil and walk away from the wreckage. is to encourage the type of effort by which it is By the 1970’s the “I learnt About Flying from The post-war years saw Spry involved with the achieved. Let us forget about recrimination for a that ...” articles had really taken off and were clearly test flying of aircraft and he gained an enormous change and hand out a few pats on the back. well received by the readers of Airclues. In June On many occasions he was attacked by enemy number of aircraft types in his log book. In June Wing Commander Spry, shaken but not stirred 1976 Spry made one of many such pleas for this 1956 after 20 years of flying, Spry joined the staff at by these comments, sought to reply. Whilst he sort of article and frequently, for the next 25 years, the Air Ministry. admitted that he had a far from spotless record he these articles were the most read in Airclues. His reputation for sound common sense, his argued that this was not a requirement to make “Sprys Column” was also a familiar feature in the vast experience in aeronautical matters and his Flight Safety comment. He stated that it was not magazine. A couple of Flight Safety themes would forthright observations on the matters he was well the individual cases of error that were of interest be the focus of each issue: FOD, refuelling errors, qualified to speak about made him a natural choice but the fact that incidents and accidents illustrated meteorological phenomena and tyre bursts to become the leading commentator on Flight common errors. being examples. Safety matters in the RAF. Names were always omitted from articles as Moving on to recent times, Spry has given they were unimportant; however it was important his personal assurance that he is taking a great notice and was to the effect that if the Air Ministry to publicise the ignorance, carelessness, or laziness interest in the adherence to the Just Culture model wanted some mahogany bound fighter pilot to do of personnel who made the mistakes that led to an throughout the RAF. Whilst he has observed the their equivocating for them they could dammed aircraft accident. Harsh words but perhaps significant leaps forward we have made since he well look somewhere else. not surprising as the RAF had well over 200 aircraft entered the service, he still believes that there is accidents in 1956. Indiscipline and non-adherence still some way to go in order to fully engender assurances that he would be free to express his own to procedures were often identified as the cause. this mindset. Spry is a solid advocate of the open opinions, derived from his wealth of experience and And so unperturbed by the criticism and with and honest reporting system which allows him to expert judgement, without fear or favour. And he the aim of publicising incidents so that others could identify unsuitable equipment, clumsy regulation, has continued to do just that, shunning all offers learn from them, Spry continued his work. unworkable processes and undue pressures which His very first comment was regarding his posting Thankfully he was persuaded with the of retirement. Many of Spry’s early comments in Airclues Ten years later, Spry’s comments were slightly more restrained. An occasional “well done” or even allows for others to avoid the same traps. Spry now endures as the Editor of Airclues, reflected the blame culture prevalent a congratulatory comment was sometimes seen in campaigning to ensure safety is paramount throughout the RAF at the time and would make print. However, Spry’s exasperation was still evident across the RAF. He works well into the small hours, most readers’ eyes water today. “This airman, on occasions when he perceived that personnel penning his missives to ensure that the lessons by his incompetence ...”; “I am getting fed up to were making “stupid mistakes”. learnt over the many preceding decades are not the back teeth with this loose article business” would be common expletives for the scapegoat On one occasion, following a Jet Provost undercarriage overstress, one or two mild remarks forgotten but are reinforced still in today’s capable and agile Air Force. issue 13 WG CDR SPRY BIOGRAPHY 49 Air Clues I learnt about writing DASORs and flying from that... A few months ago I made a couple of mistakes: one flying related and the other, more notably, was not writing a DASOR about it. However, Winston Churchill once said ‘All men make mistakes, but only wise men learn from their mistakes.’…so let’s learn from mine. It was a dark night in the Helmand Valley. As a pair of Chinooks, we had been shot at by some heavy machine gun fire before inserting troops into a wadi close to the Green Zone. The landing itself was a challenging one that included very few references. It was one of those in which, after you land and the dust finally clears, you discover a ditch only feet away from the aircraft; a little more to starboard and we probably would have lost some of our undercarriage. No one on the crew saw the ditch and it certainly didn’t show up on any imagery! (Maybe that was worthy of a DASOR itself?) Post the drop off, we flew to a Forward Operating Base (FOB) to lay-up and wait for the exfil. En-route to the FOB, I chose to engage the barometric altitude hold function, but I made a mistake by forgetting to disengage it as we approached 200ft on finals. This wasn’t an issue during the approach, hover positioning or landing, as I was manually overriding the hold by my normal application of the collective lever. We landed on the refuel spot and I cleared the rear crewman to unstrap his harness and leave the aircraft to connect the refuel hose. However, the static pressure must have changed causing the altimeter to drop. To counteract this, the hold function raised the collective lever to climb the aircraft back to the set datum. At that precise moment, my hand was off the lever. The lever rose automatically thus applying power to the engines and as a result the aircraft lifted itself off the ground. I immediately and positively took control, established a low hover, and made sure all of the crew were still on board and ok. I then landed the helicopter, realised the mistake and promptly disengaged the hold. It turned out that my rear crewman was standing on the ramp hinge and, as the aircraft lifted, he was forced onto a 50 I LEARNT ABOUT WRITING DASORS AND FLYING FROM THAT issue 13 Air Clues knee causing a large scratch on his leg, although afterward he told me that he’d suffered worse playing rugby… Now, is this whole incident worthy of a DASOR? Of course it is, but I didn’t submit one. Having returned to base we subsequently debriefed all of the evening’s events thoroughly which included the above incident. The question was then asked, “Should we submit a DASOR?” Various comments came out in the de-brief such as, ‘people are already aware of the issue’, ‘nothing will likely come of it’, not really worthy of a DASOR’, ‘we’ve all been reminded of it, so let’s leave it at that’… unfortunately, we (or to be exact, I) decided not to. But why? I’ll come to my conclusions later, but first I’d like to focus on the after issue 13 I LEARNT ABOUT WRITING DASORS AND FLYING FROM THAT 51 Air Clues effects of not submitting the DASOR, and what I’ve subsequently discovered. Six weeks later while I was boarding my flight home from Bastion, I was taken out of the departure lounge to take a phone call from my Boss in the UK. Of course the first thing that went through my mind was: “oh no (or words not fit for publication in Airclues), we’ve lost an aircraft”. Fortunately we hadn’t. He strangely asked about an alleged incident in theatre where a crewman had fallen from an aircraft at 40 feet! To cut a long story short, someone had overheard a story about our incident and had submitted a false account directly into our 2* HQ during an Air Safety meeting! Needless to say this did not look good as phrases like ‘cover-up’ were being thrown around. Even though we believed the incident to be minor, the subsequent rumours, Chinese whispers and inaccurate reporting all unfortunately resulted in an OSI to determine that facts which wasted everybody’s valuable time. If only I’d submitted a DASOR… Of course a DASOR should have been submitted to both remind Chinook crews of the issue and to increase our awareness of the phenomenon. It would have also served to prevent any inaccurate reporting of the event. However, whilst the OSI was being conducted I was surprised by the number of aircrew (from various aircraft types and some people senior to me) who said they had experienced their fair share of incidents and had not submitted a report. “I’ve probably had worse happen to me in LFA1 with the ‘stabs’ out!” said one person. I was also surprised at the number of experienced aircrew - on different aircraft types - who said they have, or probably would have, done the same in my situation. Really? A few weeks later, as the OSI was drawing to a close, we were on exercise in the US. During one particular night sortie I witnessed an Airprox with a V-22 whilst I was a passenger in the back of the Chinook. During the subsequent debrief, the incident was discussed in detail, but then the inevitable question came: “should we submit a DASOR?” Listening to the conversion I heard comments such as, ‘nothing will likely come of it’, ‘we could upset our relationship with the host nation’ etc, at which point I interrupted the debrief. I emphasised that, irrespective of any potential impacts, a DASOR has to be submitted to remind others of the issues of flying in foreign airspace at low level, and to add more weight for us to have a form of TCAS; not to mention the issues that could arise if rumors and incorrect reporting should leak out…in summary, “Don’t make the same mistake I did!” A month later we were working with the Royal Navy conducting night formation with their Lynx Mk 8s. It was a very dark night over the sea with no discernible horizon, and the formation references on the Lynx were difficult to observe due to the intensity of their IR lights. It transpired that the Lynx crew had no cockpit control over these IR lights: the lights are battered powered, turned on externally during the pre-flight walk around, and the intensity is directly related to the battery life! However, the Lynx crews were aware of the issue and use their Brightstar IR lamp to illuminate the lead aircraft. We subsequently tried it and were pleasantly surprised at the effect of this simple technique. I started talking about submitting a DASOR regarding the whole issue and guess what I heard from the Royal Navy? ‘There’s no point, nothing will likely come of it’, ‘the PT don’t have any money’; ‘everything is focused toward Wildcat now’... That made me even more determined to submit a DASOR! I’ve since been told that the OEU are going to come and discuss the Brightstar procedure….is that the ‘system’ actually working? So why did I not submit a DASOR, and why have I heard all of these comments since? Well I believe it’s due to 2 reasons: 1.Perceived Pressure. Did I mention that I had only just taken over command as the Sqn OC at the time of our incident? Did I really want the perceived pressure from the DH chain, and the embarrassment of a basic mistake by the Sqn OC made public with people laughing at me in crewrooms? My other crew had also recently been the subject of an OSI for an undercarriage incident and maybe we subconsciously didn’t want the extra focus on the Sqn. As we came down on the side of not submitting a DASOR, there must have been members of my crews who knew it was the wrong decision. So why didn’t they speak up? Was there a perceived pressure that ‘it’s the Boss and he must be right’, or ‘I don’t want to speak up in front of the Boss’? I sincerely hope not, but I’ve learnt that the best intentions of commanders can easily be perceived in a different way. The simple lesson here to all the JOs and NCA is that if it feels wrong, it generally is. Learn to trust your instincts and have the moral courage to stand up for what is right. I’d like to think I’ve done this all my life, but unfortunately I made a mistake on this occasion. 2.‘DASOR Fatigue’. Are all of us in Military aviation suffering from ‘DASOR Fatigue’? We tend to see our inboxes clogged up with numerous DASORs, some of which add little or no value to our actions on the front line. Do we really care that a piece of removed soundproofing wasn’t recorded in the F700? I would imagine most of you delete a lot of the emails from the MAA whilst cursing them for wasting your time. Are there some of you who don’t even log in to ASIMS because you’re pressed for time? We’ve approached the MAA and asked if they could include the DASOR content paragraph in the email they distribute to make the process more user friendly. This would hopefully allow you to absorb the issue and most of the information in 30secs rather than taking extra time logging into ASIMS, unless of course you need extra detail on the occurrence. 52 I LEARNT ABOUT WRITING DASORS AND FLYING FROM THAT issue 13 Air Clues We also don’t tend to receive any feedback on the DASORs we submit. Does this lead to an attitude of ‘what’s the point?’, or a cynical belief that ‘nothing will happen’. Surely a more robust feedback system would benefit those on the front line to show that their efforts in writing a DASOR - coupled with all of the additional pressures modern service life and flying provide - are actually worth it? Overall, I believe the best way to learn is through experience. It’s even better if you can learn through other people’s experiences, so I hope you gained something from this article. In summary, if you, or anyone on the crew, or anyone in the supervisory chain has asked the infamous question, ‘Should we submit a DASOR’?’, Then the answer of course is YES! have perhaps cleared away some of the doubt by others about the finer details of the incident, as well as informing future capability development. However, whatever our role on units, we will all encounter a time when we may have done something differently when looking back – the real test is perhaps how we respond when we face up to that realization. As such, I’m hugely grateful to the author for sharing his experience with us and for demonstrating such a positive approach to sharing and learning. Force Commander’s comments I’m grateful to the author for this fascinating insight into some of our most demanding work. It is certainly easy to understand how, when faced with significant operational risks at the cutting edge of our helicopter activity, a lesser event that resulted in no significant injuries or damage can seem relatively mundane. With hindsight, of course, we can all see how a DASOR would have been helpful and would Spry Says Hear, hear! What a thought-provoking article and my thanks to the author for being so open and honest. As I mentioned earlier in the Reg 18 Article, we have got to dispel any paranoia that the admission of our errors will reflect badly upon us - we all make mistakes! But we have to learn from them. Let’s look again at three of the basic elements of a Safety Culture Learning Culture: We must learn from errors and mistakes in order to avoid their repetition - and remember, we’re not talking here about the catastrophic lessons that Service Inquiries identify from major accidents, ie the ‘tip’ of Heinrich’s iceberg; rather, we’re talking about the hundreds of little things, as exemplified in this article, that are lurking under the waterline. Reporting Culture: We have to avoid the hesitation and uncertainty about whether or not to submit a DASOR; if you’re in any doubt about whether you think your DASOR might be worthwhile, then there should be no doubt REPORT! Who’s to know how much analytical, collective benefit, months or years down the line, could be achieved from all the snippets that are submitted? Just Culture: Possibly most importantly, however, we have to inculcate an atmosphere of trust and fairness - if you admit a genuine error, you shouldn’t be punished severely (9 times out of 10, the inevitable red face should suffice!) and the fear of an unfair, disproportionate punishment should not be the factor that stops you from submitting the report. I appreciate we are all busy, but this shouldn’t prevent us submitting DASORs; likewise, ‘being busy’ shouldn’t stop those reading the reports from providing feedback to those submitting them, be that only to express appreciation for their time spent writing them. issue 13 I LEARNT ABOUT WRITING DASORS AND FLYING FROM THAT 53 Air Clues Back to Flying Business Royal Air Force Wittering is an active airfield once more. At 10.40 am on Monday 14th April 2014, three Grob Tutor aircraft landed at Wittering, marking a new phase in the life of the famous RAF station. The historic airfield has seen no significant aircraft activity since the retirement of the Harrier in Dec 2010. Now, with the resumption of air traffic services and re-activation of the Military Air Traffic Zone, RAF Wittering has become a flying station once more. The reopening of the airfield comes as part of a relocation plan for several University Air Squadrons and elements of the Central Flying School. Fittingly, the first aircraft to touch down was piloted by Squadron Leader Christopher Kane, the Commanding Officer of Cambridge University Air Squadron (UAS), currently based at RAF Wyton just outside Huntingdon. Wing Commander James Lapsley, Officer Commanding RAF Wittering Operations Wing, said; “Today has been the culmination of months of virtually non-stop work to get us ready for flying. My team has been superb, and it’s an outstanding achievement. Our priority has been a safe air environment and that’s what they’ve delivered. The Tutors have a safe base to operate from, and we’re a flying station again.” 54 back to flying business ISSUE 13 The Tutor, a two-seat piston engine aircraft used for basic flying training, will be a regular feature in the skies above RAF Wittering from now on, as trainee pilots are put through their paces. The airfield will initially act as a relief landing ground for RAFC Cranwell and Wyton-based Tutors, but RAF Wittering will see a gradual increase in flying activity over the coming year and, by mid 2015, it will be the home of five Tutor squadrons: Cambridge UAS; University of London Air Squadron; East Midlands UAS; 115 (Reserve) Squadron; and No. 5 Air Experience Flight. Though currently operating under Visual Flight Rules only, it is anticipated that surveillance radar will be available by the end of November 14. RAF Wittering Air Traffic Control will not provide a Lower Airspace Radar Service but Ground Controlled Approaches will be available once the radar is back on line. In the mean time, Wittering is able to accept Practice Diversions with a limited Crash Category of 1A. Wing Commander Lapsley said; “The sound of aircraft is really the beating heart of an RAF base; so to have aeroplanes back is fantastic. It’s the beginning of a new and very positive chapter for RAF Wittering.” RAF Wittering hours of operation are from 0830 to 1700L, Mon to Fri and to date airfield information and frequencies are available on the AIDU website. Air Clues Erratum It has been said that I have been around for quite a while and the question has been asked regarding my immortality. I can assure you all that I am a mere mortal, and like yourselves I can make the occasional mistake when compiling my editions of Air Clues. To this end I will happily publish errata correcting and errors, such as: before “ ay “Day y befor bef effoor yesterday, efo y s rday, a I did did my y first f rs ssolo in i the Hurricane; Hurrica urr a ; they h y ar are indeed i deed a gra grand d pplane a ea and d iit is little iitt e wonder d derr that ha a they h y ha have a e gai ga gained ed d the h name a they ame h y ha have. have e Luckily ucki u y fforr us they h y are hey ar nott hard d tto ha handle d e as the Master aster which hich may sound s u d Dear Wg Cdr Spry , strange. strange stra ge They are harder to t land though, g , because of the narrow wheel base. base I got a rather big ig g surprse pprs rss when I came heree a and tthat h was as the m mortality rta ity rate rate. t T Th There are quite a fe few deaths here, here and this a his fa fact has made a me extremely careful in everything ything y yt t thing I do iin the h air. air I ha have ccom come o to the cconclusion c usi that m most st off th tthe h accidents accide ts are caused by the things things, g carelessness el el and d disodis bedience, know n in the RAF as breach of d dis discipline. s For some Wg Cdr Spr RAF Fligh y t Safety HQ Air C ommand Lancaste rB RAF High lock Wycomb e Bucks HP14 4U E Whilst re ading Air Clues Issu “Erratum e 12 of 2 s”. You sh 013, I o uld be aw (Concise are that th noted the page e OED, 8 th E ntitled e plural o dition). f erratum is errata Regards, George Wg Cdr G e orge List on Spry Say s Not at all , and tha nk you fo as accusa r your em tory. ail. It ce rtainly did n’t come across I have dir ected Pe rc y to refresh mind the h use of ‘Err atum’ in th is knowledge of la tin. I hop is edition e you do as we on n’t ly have o ne correc tion. issue 13 ERRATUM 55 R AF AEMS Aviation | Error | Management | System Report Today for a Safer Tomorrow I observed a hazard I spent a few minutes writing my concern on one of those AEMS forms You I posted the form to my LEMSCo Feedback I let the reporter know that their concerns are being looked at further I received an AEMS Form through the internal mail LEMSCo Feedback I instigated some corrective local-level mitigations I passed the AEMS Form on to the SEMSCo I received an RAF AEMS form from the LEMSCo. The issue was air safety related so I raised a DASOR on ASIMS SEMSCo You Due to the air safety implications, the Stn Cdr instigated an Occurrence Safety Investigation (OSI) The investigation provided the justification for funding to fix the issue I observed change LEMSCo = Local Error Management System Coordinator SEMSCo = Station Error Management System Coordinator Produced by Air Media Centre, HQ Air Command. 0984_13LAL © UK MOD Crown Copyright, 2013