A fatal accident on 25 May 2017 also shows UK D&D in a bad light. Extracts from AAIB Bulletin: 5/2018 G-CEOF EW/C2017/05/03 below. The Air Traffic response was excellent, but D&D???? The last thing they need is more checklists.
“At 1040 hrs, the pilot of G-CEOF relayed a message to Scottish Information, via a second aircraft, that he was over Lochgilphead at 1,000 ft and that he was routing to Carlisle via the Turnberry VOR. Scottish Information, in turn, relayed a message informing the pilot of G-CEOF that he would receive a Basic Service and to squawk 7401. He was also advisedthat better two-way communication could be expected as the aircraft routed south towards the Turnberry VOR. The flight details were passed to Prestwick ATC as Scottish Information anticipated transferring the aircraft to Prestwick once it was in the vicinity of Bute.”
“Approximately 20 minutes after the relay call to G-CEOF, Scottish Information had still not heard from the pilot of G-CEOF and therefore the FISO attempted to communicate with him. As there was no response from the pilot, and the FISO could see no evidence of the aircraft on his Flight Information Display, he checked with ATC at Prestwick, Glasgow, Campbeltown, Oban and Carlisle to determine if any of these units were in contact with the aircraft. As none of these units had made contact with the pilot, at 1115 hrs the FISO at Scottish Information reported his concern for the safety of the aircraft to the Airways Watch Manager and the Distress and Diversion (D&D) Cell at Swanwick.”
“Therefore, the D&D Cell will take into consideration the maximum endurance of GA aircraft before escalating the emergency phase. It is also not unusual for the D&D Cell to undertake tracing action for a GA aircraft to discover that the aircraft is parked in a hangar, or has flown to a different airfield.”“On being informed by Scottish Information at 1115 hrs of their concerns for G-CEOF, the D&D Cell assistant on duty was tasked by his controller with contacting the operator of the aircraft, who reported that the aircraft was not due to arrive at Carlisle until 1200 hrs. When the aircraft did not arrive at the expected time, the D&D Cell initiated tracing action which included contacting the same ATC units as Scottish Information. However, there was no internal record of the actions taken. After the initial tracing action had been carried out, the D&D Cell requested a radar replay from NATS which identified a target, believed to be G-CEOF, which faded from the radar at 1050 hrs when it was approximately two miles north-east of Skipness. At 1320 hrs, the D&D Cell alerted the ARCC of the incident, who verified the information by conducting their own inquiries which included contacting the same ATC units as the D&D Cell and Scottish Information. At 1356 hrs, the D&D Cell informed the ARCC of the outcome of the radar replay and the last known position of the missing aircraft. At 1401 hrs the ARCC tasked a Coastguard helicopter that was operating in the Edinburgh area with conducting a search for the aircraft in the area where it was last seen on radar. When the helicopter reached the search area at 1440 hrs, the crew received reports from a nearby vessel that wreckage had been sighted. The helicopter crew identified the wreckage near the last reported radar position of the aircraft at 1441 hrs and then two minutes later sighted a casualty in the water.”
Having read the report (though I did skip over some bits), one thing to note is that at the time of the call to D&D, the pilot’s situation was not as bad as it would have seemed to the pilot.
While they were stuck above an overcast with no idea where to go on the positive side they were in a functioning aircraft, they were in control of the aircraft, they were in clear air, they had 1.5 hours of fuel left and (unknown to the pilot) there were a number of places within range with good weather.
The situation was resolvable with the pilot’s skillset, with a bit of outside help and direction, which they had now (a little late) asked for.
Some other things worthy of note is that the Exeter controller who finally handled the aircraft was not involved in the lead up to it. They were not the controller working the other traffic at Exeter and the assistant involved in the call, wasn’t reporting to them. They simply were informed of a diversion and offered to take it on a dedicated frequency. (At least that’s my reading of the report, but it’s not 100% clear to me if they were in fact shadowing the working controller at this point).
But the main point I’d like to make is that I think this incident could make a really useful learning opportunity if done as a “Recreation” in real time.
First of all, show things from the pilot’s point of view, from about 10 minutes before they turned around.
We’ll probably see a pilot struggling to make their destination. Probably pushing things a little bit too far (In my experience, whenever a VFR pilot decides to turnaround and divert, they usually wish that they’d done it 3 minutes earlier!) We don’t tend to turn around without trying to find a way around the bad weather and investigating alternative ways of getting to the destination.
We’d see them finally giving up on their day trip and turning around .We’d see them trying to solve their own problems then, with the growing realisation that going back where they came from was not going to solve their problem (it usually does!). We’d see them resort to climbing above….always a desperate option for a VFR pilot in difficulty. The stress levels would have been building. They probably thought that the weather below the clouds was like it was when they left, and that their problem was how to get below. Then the call to Dunkeswell where they were told the cloud was on the deck must really have sent a shockwave to them. Their problem had now escalated from “how to get below” to how to get anyway landable.
A this point they must have been under quite a lot of building stress for over an hour and when they finally did (what they should have done much earlier), what they were not comfortable at doing, asked ATC for help.
I think this part of the reconstruction would help people understand the state of mind of the pilot and why the accepted the instruction from ATC to descend into cloud, without question. They were exhausted, stressed and not a clue what the best option was. They’d now mentally delegated the task of finding the best option to D&D, and assumed that the horrible option of descending into IMC at Exeter, was the best option D&D could come up with. They probably assumed everywhere had IMC on the deck and that this was the best option that D&D could come up with.
Then the reconstruction should take a break. Then come back and we get to see the whole thing play out in real time from the D&D controller’s point of view. Again, this should be in real time. D&D were dealing with the aircraft for a total of 3.5 minutes to the point where they were handing them over to Exeter.
Then another break, before watching it from the Exeter (new) controller’s point of view, taking up their station, to agreeing to accept an aircraft on a separate frequency. This part of the story is all over in 2 minutes from initial contact.
I think to truly understand it from each side, you need to see it happening in real time. The pilots side was long and slow, and continuous ramping up of sustained pressure, while both ATC units was very rapid and probably over before either unit really got their head around what was needed and what the solution was.
Seeing it in real time from each perspective, I think would aid the understanding from all sides.
I think this part of the reconstruction would help people understand the state of mind of the pilot and why the accepted the instruction from ATC to descend into cloud, without question. They were exhausted, stressed and not a clue what the best option was. They’d now mentally delegated the task of finding the best option to D&D, and assumed that the horrible option of descending into IMC at Exeter, was the best option D&D could come up with. They probably assumed everywhere had IMC on the deck and that this was the best option that D&D could come up with.
Yes; I think there is a tendency for pilots to blame ATC. In this case ATC did a really bad job, but really it was for the pilot to make the simple decision to fly elsewhere and land in VMC. He could have just asked any of the non-busy units (even D&D) like Exeter, London Info, etc, to get him some metars.
This was two years ago. This huge time was presumably spent by AAIB to deal with the ATC issues (which would have been highly political, so needing a delicate treatment, since “AIB” reports, in all countries, normally carefully avoid criticism of “the system”). But one can get historical wx data for a given date/time, and see what the picture would have been like. It is really unusual (though I’ve had it once or twice) for the whole of the south coast to fog in fast.
The pilot was so scared of the situation ond so “out-of-the-cockpit” that he simply followed instructions to fly into IMC. He asked back “you want me to descend…?” and clearly stated that he is flying just above cloud tops. Alarm bells should have rung loudly on the side of ATC. But they did not.
However, the pilot flew a 100% working aircraft. He should have asked better for help and should have stated more clearly what he can do and what he is unable to do. It looks to me like he wasn’t able to understand this any more.
Fear narrows the brain’s capability. While gliding we learned to always first leave the glider and when outside get rid of the parachute on the back. Because if you leave it in the cockpit you train this sequence. And in the case you do have to leave the cockpit in air, it did happen several times that pilots left the parachute in the cockpit.
This is why we all do checklists, why we train special situations. Because the brain may not be a reliable partner in distress.
Which leads me to the conclusion that, yes, it is ATC to blame here. They should have asked him about his capabilities. This is precisely why they are there. The very core idea of ATC is to lend us a hand when we’re unable to proceed and really need one. And from my experience (mostly in Germany) most of the times they do it in a proactive and cooperative way.
dublinpilot wrote:
Probably pushing things a little bit too far (In my experience, whenever a VFR pilot decides to turnaround and divert, they usually wish that they’d done it 3 minutes earlier!) We don’t tend to turn around without trying to find a way around the bad weather and investigating alternative ways of getting to the destination.
That view might be a bit biased, in the sense that these are the cases we hear about, leading to incident or accident. When a VFR pilot decides divert early enough, he just lands somewhere and nobody really knows about it. It’s like the trains not being on time, you don’t talk about the ones which are on time :-)
But I do understand the point, in case of accident, you often find VFR getting in too deep before it’s too late…
In my usually harsh way, yes, ATC were poor, but I regret to say this is pilot error. Tragic as it is. Personal responsibility and accountability is constantly being eroded in the new age of always someone else to blame. ATC may well have been useless, but, as is very clear here, the buck always rests with the individual.
This report might make for an interesting Zoom Lounge conversation?
The conclusion: You Are On Your Own.
I think it’s symptomatic of wider cultural issues in UK flying
How could either unit ignore an emergency? I get what dublinpilot is saying re relativity, but I’m still completely blown away by this. An utter systemic failing. To my non-legal mind, a breach of duty of care.
Reading between the lines in the report, Distress & Diversion is military and therefore not directly accountable. As RAF they may have high staff turnover, in that controllers are rotated out at the end of their posting. What kind of workload and currency do they have? Unfortunately there’s no independent information on the internet.
My anecdote: on first flying in the UK I inadvertently entered IMC, and telling Manston Radar this they replied with, “Roger, freecall enroute”. A good lesson: expect zero help to be offered, especially to an implied question. Of course, this is self reinforcing: I’m probably not going to ask next time. Pascal had the same experience 300 years before: On mourra seul. Il faut donc faire comme si on était seul.
In a similar incident in France in 2018, the controller sent a jet to guide a DR400 through the cloud layer to an airfield. They recreated the flight for Info-Pilote; cover photo below. I’ll try to find it later. It could be a different procedure, but how come there’s no procedure at all in the UK? Is VFR on top really as rare as suggested?
The cost of an AAIB investigation would pay for quite a bit of training for both civilian and military ATS. Maybe incentivise controllers to gain a PPL, or exchange schemes to get experience in other countries.
I sincerely hope systemic and cultural lessons are learnt from this.
Pig wrote:
In my usually harsh way, yes, ATC were poor, but I regret to say this is pilot error. Tragic as it is. Personal responsibility and accountability is constantly being eroded in the new age of always someone else to blame. ATC may well have been useless, but, as is very clear here, the buck always rests with the individual.
Well, yes and the pilot paid for it, but for an ATC it was less than ideal to send an unequipped a/c with an unrated pilot on a SRA IAP with MDH higher than cloud base, while pilot has apparently already communicated it to D&D – it was just not passed to EGTE. It’s a big mess and (hopefully) a wakeup call for everyone involed…
While thinking about this incident, I realised that usually no PPL student or pilot practice diversions, at least not to my knowledge.
I was thinking of an exercise – an instructor says something like “OK, this area is now under a low cloud. Let’s do a practice diversion with a full stop landing”.
Not as a thought experiment, but as a flight in an aircraft…
This report might make for an interesting Zoom Lounge conversation?
It is Tuesday 
