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G-BXBU CAP10B - appalling performance by ATC, D&D, and everybody else

@Peter while I agree pilot error was a factor, I try and be more charitable and it would be helpful if these accident reports look into the training background of the pilot. We could do a poll, but am pretty sure very few pilots have had any actual formal training in precautionary off airport landings. With the current fashion for STOL and off airport in the USA, perhaps this skill set will be resurrected.

Oxford (EGTK), United Kingdom

I agree what I am proposing is not trained in the PPL, but I would expect (maybe incorrectly) somebody flying a CAP10 to know how to fly it at 300ft while occassionally checking the compass. No radio calls to make… radio is hard work if you are new. Chances are nobody would even find out, because you will be out of there as soon as the cloud lifts.

One cannot train for everything and one cannot teach common sense.

In my PPL – 2000-2001 – there were precautionary landings, but in CAVOK conditions, and it was immediately obvious that had I ever done one, somebody would have got a huge bill. Minimum 3k (for the salvage) and that assumes nothing was broken.

Administrator
Shoreham EGKA, United Kingdom

UdoR wrote:

It’s a very figurative example of the swiss cheese model.

As much as I dislike this swiss cheese ting “principle”, this particular swiss cheese was 1% cheese and 99% hole This was an example of lack of cheese IMO. Everyone should know and remember that ATC is a bunch of gamers. Seriously, it’s among gamers they find the best candidates for the job: Taking decisions in a multitasking, multi-object environment in front of a screen. What they do, they are probably very good at. But would you bet your life they will take VFR pilots out of this kind of trouble when it actually occurs? I would not.

There was a Lancair with a take off accident here at ENVA some months back. The aircraft was totaled, but the pilot was (by a miracle) almost unscratched. The investigators gave the ATC the grade F, because they failed to recognize the severity of the accident and did none of the things they were supposed to do. And this was an accident they had first row seats for. They couldn’t have done anything to prevent it or anything like that, but just failed to comprehend that a real accident had occurred. They only thing they were occupied with was to remove the wreck ASAP to get the runway in operation. A wreckage shall not be removed before investigators have been there.

I think I see the same tendency in this accident. The focus is on getting the traffic going – exclusively, because that is what they know how to do. When the shit hits the fan, there is no cheese there. Just a big black hole. Screaming MAYDAY load and clear many times could perhaps improve the situation. It certainly does not help to be modest with a PAN PAN.

The elephant is the circulation
ENVA ENOP ENMO, Norway

Peter wrote:

I agree what I am proposing is not trained in the PPL, but I would expect (maybe incorrectly) somebody flying a CAP10 to know how to fly it at 300ft while occassionally checking the compass. No radio calls to make… radio is hard work if you are new. Chances are nobody would even find out, because you will be out of there as soon as the cloud lifts.

One cannot train for everything and one cannot teach common sense.

Peter, he had over 1000hrs, AFAIR.

What surprises me was how did he go 300ft? Was that in VMC and just low fog preventing him to go down? Or was he in IMC and he realised the cloud base is too low?
And another questions is – has he lost control while going down to EGTE runway or has he managed successfully to get of clouds and the decided to divert back home and entered IMC/lost control?

It’s a weird one…

EGTR

LeSving wrote:

The investigators gave the ATC the grade F,

You mean an investigation criticised ATC? Not that I’m surprised, but…

ESKC (Uppsala/Sundbro), Sweden

Ibra wrote:

he was hopeless after failed freestyle attempt and likely did not have any brain power left neither for radio or decision making

I also suspect that this was the case – he was mentally in very bad shape. We also don’t know what was happening with his passenger. We were not in the cockpit so can only guess.

This is the first time I’ve read about controllers requesting a pilot that is flagging an emergency due to being stuck on top of clouds to simply descend into those clouds. Clearly a serious gap in understanding of the situation they were handling.

I think ATC needs more training to deal with this kind of situation. If a pilot gets to the point of squawking 7700 they are in desperate need of help. Based on this and other accident reports I’ve read, there seems to be a big gap in the training of some controllers. Things like requesting a pilot with total engine failure to maintain an altitude or even worse, descend and maintain a specific altitude. ATC need to be trained to remind the pilot to fly the aircraft, keep the wings level, trim for best glide, steer towards the best suitable landing site, switch tanks, boost pump on, and attempt restart. Typical memory items for any pilot, and ATC can assist when the pilot’s mental engine has also stopped.

Fly more.
LSGY, Switzerland

My house is at 100’ above the sea. 300’ cloudbase usually has insufficient visibility for someone flying directly towards the coast at 80 knots and 200’ above the sea to avoid hitting something.

Maoraigh
EGPE, United Kingdom

Clearly a serious gap in understanding of the situation they were handling

In the UK, ATCOs used to need a PPL but that ended many decades ago.

We might think that no way should an ATCO send somebody who obviously sounds like he is not instrument rated into IMC, but actually I doubt that their training explicitly covers this. I’ve been watching ATCOs on forums for over 20 years, and we’ve had lots here on EuroGA, and the vast majority of them have no interest in anything to do with flying, or planes. Only illegality, rule breaking, enforcement, infringements, and of course any criticism of ATC. Obviously this is only a sample of those who are on forums, and doesn’t apply to those (tiny %) who actually fly GA.

It’s easy to assume something is obvious but one can be wrong. Many years ago a renter here started up, towbar in place, a 2cm chunk out of the prop, chucked the towbar into some tall grass, went for a flight, was never seen again. Sounds incredible but think about it: prop strikes are not taught in the PPL (in fact zero is taught about the many precautions needed for taxiing at a lot of airfields) and if you are cutting grass and hit a brick, you just chuck the bits of the brick somewhere and carry on, so long as the crankshaft on the mower is not so badly bent that the whole thing shakes. Why should a plane be any different?

The UK also has the ambiguity that IFR is allowed in G (historically most of Europe didn’t) and there is the IMCR which so many people have that ATC can’t really make assumptions about whether a pilot is instrument capable. Well, in this case he obviously wasn’t…

Very good point about the passenger. A huge amount of pressure can be applied on a pilot that way.

My house is at 100’ above the sea. 300’ cloudbase usually has insufficient visibility for someone flying directly towards the coast at 80 knots and 200’ above the sea to avoid hitting something.

Sure; could be. But also there are various spots on that beach which run all the way down to the sea.

Administrator
Shoreham EGKA, United Kingdom

Are D&D “normal” ATC, funded by fees, and busy with traffic tasks? Or an emergency service, like rescue helicopters? What other work did they have when they passed this aircraft to Exeter? Did they prioritize “Practice Pan” calls?

Maoraigh
EGPE, United Kingdom

Maoraigh wrote:

Are D&D “normal” ATC, funded by fees, and busy with traffic tasks? Or an emergency service, like rescue helicopters? What other work did they have when they passed this aircraft to Exeter? Did they prioritize “Practice Pan” calls?

I think they are ordinary military ATC, but could be wrong.

EGTR
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