Enhancing pilot skills in a dynamic environment seminar with Tim Penney, Aviation Safety Advisor

Enhancing pilot skills in a dynamic environment seminar with Tim Penney, Aviation Safety Advisor


Welcome to the 2018-2019 AvSafety Seminar series. This seminar we’ve entitled Enhancing
Pilot Skills in a Dynamic
Environment. The reason why
we’ve used the word
‘dynamic’ is because when we go flying, things rarely stay the same for very
long, things are constantly changing, and, as a result,
our human factors needs to keep up with the operation
that we’re undertaking. So today in our presentation, the information that
we’re going to give you is applicable to you
no matter what you fly. You could be flying
an RPT turboprop. You could be flying an IFR twin. You could be into sport aviation
like gliding or parachuting. It doesn’t matter what you fly, the human factors concepts
that we’re going to explore today are applicable all the way
across the board. There’s three things that
we’re going to look at in our presentation today. The first is communication. Why communication? Well, because the way we communicate
when we’re in the air has significant challenges, significant challenges
for us to overcome. And the way we communicate
in the air is often very different to the way we communicate
when we’re on the ground just chatting to people face to face. The second thing we’re going
to look at is situational awareness. Now, situational awareness by itself
is a huge, huge area of study. People go to university
for many years and study all the ins and outs
of situational awareness. First of all, what it is. And secondly, to perhaps identify
some of the red flags that you might be able to recognise
in your own flying that might be clues to the fact that you might be losing
situational awareness. And the third thing that
we’re going to look at today is a concept called
threat and error management. Threat and error management has been
around in the aviation industry now for a couple of decades, and it’s becoming more and more
important in the way we go flying. So let’s have a look
at communication. As I said at the outset,
the way we communicate in the air is often significantly different and
has a host of different challenges to the way we normally communicate
when we’re on the ground. And ATSB research bears out the fact that communication is an
important factor when we go flying. Non-towered aerodromes, which is
the focus of our presentation today, they’re a central component
of the Australian airspace system. And when we go through
the ATSB accident database, they’ve identified issues to do with communication, situational awareness and threat and error management as being contributing factors
to a whole host of different incidents and accidents
in this realm. The ATSB research also indicates that problems with communication and
situational awareness in particular do lead or do have the potential
to lead to accidents. Not only insufficient communication but also communication
that is inaccurate or even too much communication
in the circuit area where the CTAF frequency
gets certainly very busy. And that in itself
presents us with challenges to maintain the safety of flight. Let’s perhaps start with
a bit of a case study. This case study was an incident that
occurred at Port Macquarie Airport. This incident occurred about
12 years ago, back in 2007. Port Macquarie, of course,
is a regional aerodrome on the Mid North Coast of NSW. It’s a reasonably busy airport,
has a large flying school and it also has an RPT service
that comes up from Sydney. There are two runways – a sealed
runway and a small cross strip. And as you can see
from the photograph, the suburbs of Port Macquarie are now starting to encroach into
the boundaries of this airport. We have nothing against
Port Macquarie. But this example is a classic case
of where breakdowns in communication have the potential for
serious safety implications. So let’s set the scene
with regards to the four players, or the four actors, if you like,
in our scenario. Now, we’ve identified
these four aircraft in the vicinity of
Port Macquarie Airport. These aircraft aren’t exactly where they might be
depicted in the picture. But they at least give you a relative direction from the airport to help build our mental picture. So let’s start the process. The first aircraft that
we’re going to look at is a Dash 8. The Dash 8, as you know,
as many people know, is a twin turboprop
commuter aircraft. This Dash 8 was doing a regular
public transport flight. It was coming inbound from the south,
from Sydney, inbound to Port Macquarie. This Dash 8 was an IFR aircraft, and it was inbound for Runway 03, which is the sealed runway
there at Port Macquarie. The second actor
in our scenario is a Beechcraft Baron. This aircraft was
a twin-engine machine often used for personal transport. But in this instance,
it was an IFR training exercise. This aircraft was inbound
from the south-west, and they were performing
a GNSS approach onto Runway 03. The Baron and also the Dash 8,
they were both IFR aircraft, so the chances are that
they knew of each other’s existence. They would have been given traffic
on each other by Melbourne Centre, and they certainly would have
been chatting to each other on the Port Macquarie CTAF frequency. Let’s have a look at
the third aircraft in our scenario. The third aircraft in our scenario
was a Cessna 152. They were also using Runway 03, and they were departing to the north
on a navigation exercise. So now we come to the final actor
in our scenario. The final piece of the puzzle
was an RA-Aus Foxbat aircraft, and they were taxiing
for circuits on Runway 21. Now, that’s the first, perhaps, little chink in the armour
that we can see here. We have three aircraft that have
nominated and are using Runway 03, but unfortunately
our fourth aircraft, for reasons which we’ll discuss
later in the presentation, has decided to use Runway 21. So let’s keep building the scenario and building that mental picture
as we go. The Cessna 152 broadcast
its departure call as it leaves Runway 03, but unfortunately
is over-transmitted by the Foxbat. Over-transmission,
which essentially means that there are two radio calls in at once
from different stations, has a potential to be an instant
breakdown in situational awareness and presents enormous problems
for communication. Calls can’t be understood, calls can’t be deciphered
or heard properly when there’s two stations
over-transmitting each other. Instant loss of
situational awareness. Upon hearing this over-transmission,
the Dash 8 pilots, what they do is they jump on the CTAF frequency
and they ask for a repeat of both of these broadcasts
from the pilots, but in actual fact, it’s only the Cessna 152 that repeats its broadcast. There’s no repeat broadcast
from the Foxbat. The Dash 8 is overflying
for Runway 03, but, lo and behold, sees the Foxbat actually rolling for take-off
head-to-head on Runway 21. As you can see, this has
enormous safety implications. The first thing that the Dash 8 does is jump on the CTAF frequency and advise the Beechcraft Baron that they are head-to-head with
an aircraft taking off towards them. The Baron upon hearing this
does a very wise thing and exits stage left and conducts
a go-around from short final. It resolves this conflict
by getting out of the immediate area. But we still have the situation whereby we have a Dash 8
in the vicinity of the circuit for 03 with, unfortunately,
a Foxbat coming straight at them. The scenario develops even further, and we find that the Foxbat
actually takes off on Runway 21. As you can see, a very dangerous, or the potential for an air proximity
event is rapidly occurring. So what the Dash 8 has to do
is modify their circuit entry to maintain separation
with the Foxbat. Please be aware that Dash 8 aircraft
and larger turboprop aircraft, the larger aircraft
and faster aircraft, they usually give
their first inbound call at about 30 miles from the airport as they come down through
about 10,000 feet. They’re moving down the slope
at about 4 miles a minute, so they’ll be in the circuit area
in about 7 minutes or so from about 30 miles. The workload in the cockpit
of the Dash 8 is usually quite high, and the visibility outside
the cockpit is often quite poor. So the last thing they want
to be doing, if at all possible, is doing manoeuvring in the circuit, which involves often
significant angles of bank, changes of power,
changes of configuration. So at the last minute,
as you can see from our diagram, the Dash 8 has to modify
its circuit entry to maintain separation
with the Foxbat. But as you’ll see from the next slide
that I’m going to put up, things don’t resolve themselves
immediately. What happens is that
further in the circuit the Dash 8 has to do a go-around when the Foxbat cuts in front
of that Dash 8 on short final. This is not a good state of events. Now, this Dash 8 might have anywhere
between 50 and 70 people onboard, and we’re flying around and overhead
the suburbs of Port Macquarie. Not a good state of affairs. The go-around, actually,
by the Dash 8, when the Foxbat pilot was interviewed
after this event, was in fact the very first time that
that Foxbat pilot became aware that there was any other aircraft
in the circuit. Now, certainly we’re not here to lay blame or to pass judgement
on the Foxbat pilot because here but for the grace of God
go you and I. We’ve all made mistakes
in these types of environments. But as you can see from the scenario
that we’ve described, breakdowns in communication can have serious ramifications
in the air safety space. So what happened then? The Foxbat then made
probably a good decision and actually departed the circuit to troubleshoot what they thought
was a radio problem. This was a good decision
by the Foxbat pilot because it got the Foxbat
away from other aircraft. Many pilots have had to troubleshoot
issues when they’re in the air. These issues might be
problems with electrics, problems with the flap,
engine problems. Two pieces of advice
that I often provide when I run this seminar to pilots if they do have a problem
when they’re airborne – many of us have had this – is to perhaps think about
doing two things if we do have a problem in the air. The first thing is to get away
from other aircraft. And the second thing
is to get away from the ground. The last thing
we want to be doing is trying to troubleshoot
an issue with our aircraft while we’re
mixing it in the circuit in close proximity to other aircraft. So the Foxbat pilot
went away from the airport, tried to troubleshoot their problem. So what happened? The pilot couldn’t determine
the problem with their radio while they were airborne, but upon landing back again
at Port Macquarie and shutting down, another pilot found that
the entire issue had a causal factor, which was basically that the pilot had neglected
to turn the volume up on their radio. It’s quite telling, isn’t it, that something as small
as forgetting to turn the volume up can have potentially serious
ramifications for aviation safety. And it was only due to the fact
that communication was hindered because volume wasn’t turned up. Again, no-one’s immune to this. I’m sure many of us have been flying where we’ve either
had the volume turned up or we’ve been on
the wrong frequency. But what this does show us is that if we have a breakdown
in communication or the ability to communicate over
the radio is somewhat hindered, the ramifications for safety
further down the track can potentially be massive. The pilot was aware that
Port Macquarie had what we call an Aerodrome Frequency
Response Unit, or an AFRU. Essentially, this is
a small piece of kit that confirms to the pilot in command that their radio
is on the correct frequency. If there’s been no communication on
that CTAF in the last five minutes, the pilot will hear back in
their headset an automatic voice, in this instance,
saying, “Port Macquarie CTAF”. It provides the pilot
with confirmation that their radio is on the right frequency
and the volume is appropriate. If there’s been no transmission
on the CTAF within the last five minutes, they’ll just get a short tone
in their headset. Now, in discussions with the Foxbat
pilot subsequent to this event, it turned out that the Foxbat pilot
as they were taxiing saw or noticed a helicopter depart
about five minutes before, so it could reasonably be concluded that the Foxbat pilot
came to the decision that that helicopter was
the only other aircraft that they had to worry about. Of course that doesn’t preclude
pilots from looking out and using alerted see and avoid,
but we’ll discuss some of that later. The Foxbat pilot’s
intention, therefore, was to gain all
their traffic information just from radio calls
from other aircraft. We take away the radio call or the ability to make a radio call
with the volume turned down, and all of a sudden we’re essentially
flying in a deaf environment where we can’t hear what’s going on. All the other aircraft have, however. They were quite successfully using
the Port Macquarie CTAF frequency to arrange their own
mutual separation. And that’s what
the CTAF frequency is for. We’ve spoken about communication
in the aviation environment. It begs the question, doesn’t it –
how do we as human beings communicate
in the non-aviation environment? Now, there’s been many studies
at universities around the world in the human factors
associated with communication. What studies do show is that the vast majority of the way
we communicate as people is in the non-verbal space
rather than the verbal space. In fact, some studies show up to 93%
of our communication as humans occurs in a non-verbal way. First of all, there’s
the acoustic way we communicate, not only just with our voice but even the tone of our voice or even using
expression in our voice. Things like the appropriate use of pauses, OK, or even sounds. Another big way we communicate is by optical or visual means. In the aviation safety advisor role, we see thousands of pilots all over Australia every year in hundreds of seminars, and one of the biggest ways
we can communicate, or the audience communicates to us, is through, essentially,
body language. We can tell a lot about how people
are feeling or what their mood is just by body language. How they hold their arms,
how they hold their face, even things like facial expressions. Even things like the clothes
that people are wearing. I was at an airport once, I remember two pilots getting out
of an aircraft at the fuel bowser. These pilots had wrinkled shirts on,
food stains. Their shirts were untucked,
their shoes weren’t polished. These pilots looked disgusting. I therefore came, rightly or wrongly,
to the conclusion that these pilots were unsafe. Because I’ve also seen
pilots at airports that have had nice uniforms
that have been ironed, their shoes are polished,
they’re wearing a tie. Instantly I come to the conclusion
that these pilots are somehow safe. That might be a wrong or a right
conclusion, I’m not sure. But that’s how people do communicate,
even by the clothes we wear. If I go out into an outback cattle
station to talk to mustering pilots, I’m not going to wear a suit and tie. I’m going to wear
something appropriate. We communicate a lot even
just with the clothes that we wear. The other way we also communicate
is in a tactile sense – putting your arm around someone, or putting a hand on the shoulder. Again, it’s a non-verbal way of
communicating to other individuals. And finally, we can communicate with what the scientists call
the olfactory sense, which is things like
smells or odours. And people think, often,
when I mention this, “Really? Is that true?” But think about the global perfume
and aftershave industry. It’s worth billions of dollars. Why? Because that’s a way
people can communicate. So there’s heaps and heaps
of different ways that we can communicate
in a non-verbal sense. How does this relate to aviation? Well, when we’re in the cockpit,
we don’t get the value, or we don’t get the benefit
of non-verbal communication. All we are is a voice on the end
of a CTAF frequency, for example, appearing through someone’s headset. Now, potentially, that can be as little as 10% of the way
that humans communicate. So when we go flying,
we are in an environment that is very, very challenging
for effective communication, and that’s why our communication
has to be spot-on and we have to continually work at it
to be effective. Because effective communication
gives us the greatest chance of staying alive out there when we go
flying around the CTAF environment. So, communication
in the aviation environment. Here’s an old adage that
people have been saying for ages, but we’ve slightly modified it. Sticks and stones may break my bones,
but words… ..words have the potential
to kill me. How is that the case? Words that are perhaps
indecipherable, words that are too many, words that are insufficient,
or even the wrong words. And Airservices Australia
in the AIP, they’re very hot on what we call
standard phraseology. Standard phraseology is a vital part
of our communication because when we talk on the radio to either air traffic control
or to other aircraft, the other party has to know
that we know, and therefore this standard
communication is so important. I listen to, in my job, radio
frequencies all over Australia, and I can tell you
it is often quite rare to hear a stock standard
AIP radio call. Often we hear mishmashes of all different types of calls
all mixed in together. Student pilots and especially
foreign student pilots who come to Australia
to learn to fly, whose English might be somewhat
at a less of a standard than a native Australian-born
English speaker, these pilots sit in the classroom
and they go through their AIP. And when they learn
the standard format of phrases, when they go flying, that’s what
they expect to actually hear. Australians, as a rule, we do have
behaviours on the radio that do have problems for communication
in the aviation environment. Often Australian pilots
we speak too quickly, we often use a lot of slang, and many times
when we communicate on the radio, we start talking
maybe half a second before that press-to-talk button goes down so we can often clip the start
of our transmissions. So we have to just every now
and then maybe do a readjust and have a think about how we
ourselves communicate on the radio. And finally, when we communicate
on the radio, think about what we are about to say
before we hit the button. The press-to-talk, or the PTT
button, is a press-to-talk button. It’s actually not
a press-to-think button. Have an idea of
what we’re about to say, who we are going to
address that call to. Is it a specific broadcast, or is it a call to
a specific individual? Think about our standard phraseology. And when we are
in the CTAF environment, one of the things that
we need to consider is that before we make the radio call, is the radio call
that we’re about to make likely to increase
people’s situational awareness, or is it likely to actually impact or decrease
people’s situational awareness? The radio is a very,
very powerful tool. And by thinking about
what we’re about to say and using standard phraseology, we will go a long way
to helping the safety of flight, especially in the non-towered
aerodrome environment. There are barriers
to effective communication. Communicating in
the airborne environment has enormous challenges
set before it. Let’s have a look at what
some of these challenges might be. The first thing is
the physical conditions. Now, I know there aren’t many open cockpit aircraft
flying around the country, but a lot of aircraft
have noisy cockpits. Many of us, perhaps, haven’t had our headsets serviced in years, or even our radios looked at. So think about the quality
of our transmission. High workload environments. If we are in
a high workload environment taxiing at a complex aerodrome, in the middle of
our take-off sequence, if we’re manoeuvring
around the circuit or in our landing phase, these are high workload environments. And as a consequence, this can represent a challenge
to effective communication if we are just so busy doing
other things at the same time. Fatigue.
Fatigue’s an interesting one. If we are tired,
if we are so fatigued, often we exhibit behaviours that can be potentially hazardous. And one of those is the inability
to communicate properly. What do I mean by this?
Well, let’s look at an analogy. You might have worked a 60-hour week. You come home on a Friday night
and you’re absolutely tired. All you want to do is pour yourself
a drink and just sit on the couch and maybe watch
Friday night football. If you are so tired,
if someone walks in the room and wants an in-depth
conversation with you, are you in the mood
to actually engage? Most likely not. Fatigue is one of those insidious
things that can creep up on us, and it affects us
in many different ways and it affects individuals
differently. But one of the common things
we’re seeing with fatigue is that it does impact adversely on our ability to be
effective communicators. Interruption and distraction. Probably out of all of these factors,
this is probably the main one. There are lots of potential
interruptions and distractions in the aviation environment. It might be air traffic control. It might be passengers. It might be other things
that we’re doing in the cockpit. Interruption and distraction
has a huge impact on our ability to communicate. Stress. If we’re flying and we are
in a stressful environment, we might be dealing with
unfamiliar airspace, we might be flying
an unfamiliar aircraft, or we could potentially
be dealing with an emergency. In a stressful situation, we tend
to shut down all the periphery and just concentrate on what
we’re dealing with at that time. Again, that has ramifications
for our ability to communicate. And, finally, culture. English language, accents, flying in the vicinity with people who English is not
their first language, even using colloquialisms or local land features
in our communication. We should always, always,
always think about what our intended audience is. They might not know
where Joe’s Farm is, for example. We need to use information that
everyone has an understanding of. So what are some of the hints
and techniques that we can use to improve our technique
on the radio? Here are some that
I’d like to present to you just to, perhaps, have a think about. The first is, “Is the volume correctly turned up, “and am I on the right frequency?” It might seem simple, but I’m sure many of us
have been flying when we’ve been
on the wrong frequency, or we’ve been flying
with the volume turned down. Volume being turned down
is often a trap for instructors where they need to perhaps
reduce the distraction of the radio while they’re teaching a sequence, and sometimes forget
to turn the volume back up to normal levels afterwards. The second thing is, “Think about what information
that I’m about to transmit.” Is it to a specific party, or is it a general broadcast? Is it likely to increase
people’s situational awareness, or will it run the risk of reducing
people’s situational awareness? Especially when there might be a lot
of aircraft in the circuit area. And listen out before transmitting to prevent over-transmitting or blocking other calls. A classic case of this is when
we’re making our inbound call. For example, don’t get to
a 10 mile from the airport, and then flick across and start
transmitting straightaway. Maybe flick across about
30 seconds beforehand, have a bit of a listen out
to find out what the story is, build your situational awareness, then wait for an appropriate break
in the transmission, and then make your own. Non-ambiguous language. This goes back to our earlier
discussion on standard phraseology because the other party needs to know
exactly what’s required. So if at all possible, try and avoid using things like slang
or local land features. Try and keep it, as much as possible,
a broader transmission with commonly known features when
describing, perhaps, where you are. And the final one.
And this is also a big one too. If you are in the receipt
of a transmission that is often spoken very quickly, or there are terms
in that transmission that you don’t understand, please don’t be hesitant
to ask for a repeat from either the pilot
that made the transmission or the air traffic control unit. When dealing with air traffic
control, if they give you, for example, an instruction
that you can’t comply with – it might be due to things like
weather or aircraft equipment or any other host of factors – don’t try and fudge your way through. If you can’t comply with
an instruction from ATC, say that you can’t comply, and then ATC will be duty-bound
to provide you with an alternative. Sure, it might mean that you might have to wait
outside controlled airspace, or you might be vectored
somewhere else, or there might be a few increased
track miles or a slight delay, but please don’t try
and fudge your way through if you can’t comply with
an ATC instruction. Please tell them and they will be duty-bound
to provide you with an alternative. So, going back to our scenario that we launched our seminar series
with today. The pilot of the Foxbat assumed that the lack of radio calls, therefore, meant a lack of other traffic because the pilot of the Foxbat did see that helicopter depart about five minutes prior to making their own taxi call. And it shouldn’t have precluded
the pilot of the Foxbat from at least visually acquiring
the Dash 8 and the Baron. Most likely, the Dash 8 and the Baron would have been all lit up
like a Christmas tree with their strobes
and landing lights on. So not only is communication in
the non-towered airport environment a vital part of our safety, but so is a disciplined
look-out as well, using the good old mark one eyeball. So, why didn’t, perhaps, the Foxbat see the other traffic
in the circuit area? There could be a host of reasons. First of all,
visual scanning technique. Was the pilot just
looking out into space, or was the pilot actually taking
the time and the discipline to do a judicious look-out across
the visual scanning horizon? Keep our eyes moving. We’re in a dynamic environment,
remember – things rarely stay the same. When we undertaking a look-out
in a CTAF environment, it’s very, very important to keep that visual scanning
technique up to scratch. It’s not my role here to teach
you how to visually scan. That’s something that you can do
with your instructor. But a visual scanning technique
when we’re flying around or even on the manoeuvring area
of an airport is vital. Secondly, environmental conditions can be a problem with
achieving a good look-out. Not only things like cloud, but also things like smoke or haze
or pollution or rain. Even flying with a dirty windscreen
can be difficult, OK? Try landing into the setting sun, landing towards the west late in the
afternoon with a dirty windscreen – very, very difficult to maintain
an effective look-out that way. Task overload. We are in a busy environment dealing with the aircraft, dealing with other traffic, dealing with issues that come up
when we go flying. It’s very, very difficult
to maintain a good look-out. It’s important that we learn
that skill as we go flying to not only manage those aspects
of our flight, but to do so without it compromising our ability to keep our eyes
outside the cockpit. Aircraft structure. Many aircraft, for example, have window pillars
and other bits and pieces. We have bits and pieces sitting on the coaming of the aircraft,
on the instrument panel, that might block, physically block
our ability to look out. Therefore, we don’t just look out
by moving our eyes. Oftentimes we have to look out by
craning our head and moving our head. It is important that
we use all of these things to maintain a good look-out. There’s a term here called
“empty field myopia”. Empty field myopia is essentially what our eye does when
there’s nothing much to look at. If there’s nothing much
for our eye to focus on… We might be flying through cloud
or on a dark night, we might be flying through haze
or an inversion, or we might be flying
over a large body of water. There might not be a lot
for our eye to focus on. If that’s the case, the human eye will often have
a resting focal length somewhere between 3 and 5 feet
outside the cockpit window. That’s where the eye will rest
if we just let it sit there. Hence, a way of beating
this empty field myopia is to keep our eyes moving
and to also keep our head moving. And finally, the blind spot. What is the blind spot? All this is is just a physiological
limitation of our eye – it’s where our optic nerve
hits the back of the retina. At that point in each of our eyes,
there are no photoreceptors, there are no rods and cones
to provide us with vision. So if we aren’t moving our eye,
we can have a blind spot, literally, outside the cockpit
where we could potentially have another aircraft sitting there
and we might not even know it. It’s just a physiological limitation
of the eye. So, what I’m going to do now
is show you a quick video. This video, I understand, was a training flight
over southern England, and it gives you an indication as to
how easy it is to miss other aircraft and the importance of maintaining
a good look-out. So, we’re flying along
in southern England, and have a look at this video – see if you can see
that other aircraft. Very, very difficult to see. Very, very difficult to see. But when we zoom in, you can see that
that other aircraft was in fact a business jet almost at the same
level, blending into the cloud. So let’s play that video once again. This time, see if you can see
the business jet approaching from the top left-hand side
of the screen. Flying along, and you see the
aircraft appear out of the top left. Very, very difficult to see. Lots of distractions, potentially,
in that cockpit. It looked to me like it was
an instructional flight. But we can certainly be surprised
when we go flying around, especially the busy airspace around capital cities
and busy CTAF airports. So, alerted see and avoid which essentially is the correct use of our radio combined with a disciplined look-out. If we use not only our eyesight
but also our radio appropriately, we have, according to ATSB research, something like an 800% better chance
of spotting other traffic than if we were just
using our eyesight alone. We mandate VHF radio carriage around the vicinity of
CTAF environments in Australia. I don’t want to harp too much
on the regulation, but it’s a good idea
just to, perhaps, review this. CAR 166E talks about mandatory VHF radio carriage. We mandate the carriage of VHF radio when we are at or in the vicinity of any certified, registered
or military aerodrome in Australia, or any other aerodrome that we may
designate from time to time. That might be something like a fly-in
or something similar like that. That’s where we mandate the carriage
of VHF radio in Australia. We talk a lot about, “What do we mean
by ‘in the vicinity’?” There are really three pillars
to this ‘in the vicinity’ concept. The first is we are in airspace that
is other than controlled airspace. So essentially, we’re talking
about Class G uncontrolled airspace. In the vicinity also means within 10 nautical miles
of the aerodrome reference point. Now, that doesn’t automatically mean that we flick across to the CTAF
frequency when we get to 10 miles. If you’re flying a fast aircraft, or if you’re flying into
a destination that you know there’s a good chance
the circuit might be busy, there’s certainly nothing
stopping you flicking across
to that CTAF frequency at 15 miles or even 20 miles. The Dash 8 that we saw
in our scenario earlier most likely flicked across to
the Port Macquarie CTAF at 30 miles. What this does, especially
if you fly a fast aircraft or you’re going into
a busy environment, is it provides you with time
to build that mental picture. So you don’t always have to wait
till bang-on 10 miles before you go across to the CTAF. Now, the third pillar which describes
“in the vicinity” – one concept that often causes some
confusion and debate among pilots – is when we are at a height above
the aerodrome reference point that either conflicts or has the potential to conflict
with other traffic. Now, it’s not up to us in CASA
to tell you what that height is. That’s essentially the decision made
by the pilot in command, and that can vary
depending on circumstances. You might fly across the top
of a non-towered airport at 2,000 feet
at 3:00 in the morning – the chances are that
you won’t be at a height that might conflict
with other traffic. But to fly across the top
of that airport at 2,000 feet on a busy Saturday afternoon, again, that’s a whole
new different ballgame. Be aware also when we’re talking about the height
above a non-towered airport that CTAF airports in Australia, they
are no longer cylinders of airspace. There’s no defined top to them. Back in…many, many years before, we had things like MBZs and things
like that which had a defined top, but not anymore. The height above the aerodrome that you might have the potential
to conflict with operations, that’s a decision
for the pilot in command and the pilot in command only. Please also be aware that there
is no silver bullet of regulation that will guarantee 100% risk-free
aviation all the time. The CTAF environment
is a very dynamic environment. What we have done is we’ve put out,
for example, certain recommended radio calls that will give you the best chance
of separating yourself. One last thing before
we look at those radio calls that I just want to mention. Please also be aware that Airservices Australia do not monitor
CTAF frequencies. Airservices Australia
also do not monitor 126.7. So the appropriate frequency
selection is very important. When you are beyond the vicinity
of a non-towered airport, it’s important to be maintaining
a listening watch on the appropriate frequency,
which will be the area frequency. It’s only on the area frequency
that you will get assistance if your aircraft cabin
fills full of smoke or your windscreen is covered in oil and you have to call
a PAN or a mayday. If you call a PAN or a mayday
on 126.7, or if you call a pan or mayday or call for assistance
on the CTAF frequency, the chances are that
no-one will hear you. It’s the published area frequency that you will get that assistance
from Airservices. So, “When in the vicinity,”
people often ask us, “what are the mandatory
radio calls?” The only thing that we mandate
in the regulations is that a pilot must make a broadcast
whenever they, and they alone, believe that it’s reasonably
necessary to do so to avoid a collision or the risk
of a collision with another aircraft. As far as mandating calls,
that’s the only thing we mandate. But we do go further than that. What we actually do is we recommend
a set of standard calls and we put that out in our
Civil Aviation Advisory Publication, CAAP 166. So, when in the vicinity
of a non-towered aerodrome, what are the recommended calls? We find that the vast, vast
majority of pilots make these calls in a fantastic way. They’re very judicious,
they’re very disciplined, but there’s always
room for improvement. So, what are these calls? A taxiing call, entering the runway, inbound by 10 nautical miles
or earlier. Remember our previous discussion –
if you’re flying a fast aircraft or you’re likely to come into
a busy airport, there’s nothing wrong with
making an inbound call earlier. Joining the circuit.
Basic calls that most people do make. We also recommend that if you are
doing something slightly different, or something slightly
out of the ordinary – for example, a straight-in approach, or you might be joining
on base leg of the circuit – it’s a good idea to let people know that you might be doing
something slightly different. So we certainly recommend
those types of calls. And finally, if you are
just passing the aerodrome, in the vicinity of that aerodrome,
just make a call on the CTAF to let people know know where
you are and what you are doing. And finally, a small hint that
I like to often give to IFR pilots. If you’re an IFR aircraft
flying an IFR sortie, especially when there’s likely to be
VFR aircraft in the vicinity, please don’t use
IFR base terminology. Think again what we said earlier
about your intended audience. The average VFR pilot might not know
what a sector entry is, they might not know
what an initial approach fix is for a GNSS approach. They don’t have to. Think about your intended audience. Give a direction from the airport,
a distance and a height, and your intentions, OK? Especially for the IFR pilots when there’s likely to be
VFR aircraft in the vicinity. The second part of our presentation focuses on this concept called
“situational awareness”. I spoke at the outset that situational awareness
is a huge topic on its own. Again, many people go to university and study this field of endeavour
for many years. But we’re just going to have
a quick look at situational awareness and emphasise the importance
that situational awareness has within the non-towered
aerodrome environment. Not just the non-towered
aerodrome environment, but even some of our busy
towered aerodromes, situational awareness is vital
for safe operations. So here’s a classic example –
Moorabbin Airport, basically the busiest airport
in Australia in terms of movements – somewhere up nudging
the 350,000 movements a year. What do we have here at Moorabbin? We have five runways,
all crisscrossing, and two runways are usually
in use at any one time. Busy airspace,
many people learning to fly, huge amounts of landings
and take-offs. Situational awareness
in an environment like Moorabbin is vital for aviation safety. What I’m going to show you now
is a video clip from an ATSB investigation of a very
close call at Moorabbin Airport where we see one pilot using
really good situational awareness, and another pilot where perhaps situational awareness
had broken down. So what we have here
is a piece of video footage shot out of the right-hand seat
of a Cessna aircraft. This Cessna aircraft was coming in
to land on Runway 13 Right. And as I play this piece of footage, I want you to keep your eye on
the top left-hand side of the screen as we play it through. So, the aircraft
is coming down final. Everything is going quite OK.
No dramas here. The aircraft comes in over the
undershoot and over the piano keys and starts its landing sequence. Have a look at the top left-hand
side of the screen for me as we go through that footage. And what can you see? An aircraft coming out of nowhere,
a Cessna 172, that has punched across a holding
point onto an active runway. We’ll explain the details
as to how this occurred later. But with something like this,
let me put it to you, what do you think might have
happened next? Well, we have a choice. You could select the 172 to the left
might have stopped short. Or, alternatively, did the aircraft
collide on the runway? Or thirdly, maybe the
landing aircraft did a go-around. So have a think about it,
make your choice. And let’s see actually
what happened in reality. What happened in reality is that the very good situational awareness
of the landing aircraft pilot initiated a go-around. By using their situational awareness,
they managed to avoid what could have potentially been
a collision on the runway. That event was a very,
very close-run thing. Again, we’re not here to throw sticks
or stones at any of these pilots, or to make judgments. What we’re here to do is perhaps
look at the facts before us and take away some key learnings that
we can introduce into our own flying. So, what actually happened? We had two aircraft. The landing aircraft
was the pink aircraft on Runway 13 Right. But the aircraft that encroached
across the holding point had landed on Runway 13 Left slightly before the pink aircraft. As you can see here,
the aircraft on the blue runway had landed and
taxied off that runway and had encroached
across the holding point, as you can see on
the right-hand side of that picture. Interviews with the pilots of both
aircraft confirmed that one of the reasons why that aircraft
punched across the holding point was simply distraction. The aircraft that punched
across the holding point had two pilots on board –
it was an instructor and a student. And it was simply the fact that they had started their debrief
of their lesson while they were still taxiing
across all the runways. They weren’t, perhaps,
keeping an eye out, therefore missed the holding point
and punched across. We need our situational awareness
to be topnotch, especially when we’re flying around
busy aerodrome environments, be they a controlled aerodrome like
Moorabbin or Bankstown or Jandakot, or many of the CTAFs
around the country. Because, remember, at a CTAF, we
don’t have air traffic controllers. There’s not that second pair of eyes
that can assist us. There’s no-one to tell us
to line up. There’s no-one to give us a clearance
to take off or clearance to land. In the non-towered
aerodrome environment, we as pilots in command,
we make those decisions. There’s no ATC to help us. So, no video that we produce
would be complete without the obligatory cat video. So here’s another example
of a classic distraction that occurred when we can go flying. This, I understand,
occurred in Africa. A couple of people going flying
in a light sport home-built. Watch the top right-hand
side of the screen as we see a cat mysteriously
appear out of the wing. Cat’s quite happy, actually,
enjoying the flight. Comes closer to the edge
and just loves the view. Notice how the people haven’t seen
the cat yet, especially the pilot. But have a good look at his eyes when
he actually finally sees the cat. Not really something you’d expect
to see when you go flying. Another example of a distraction that
can potentially come out of the blue. Have a look at his eyes.
He’s absolutely shocked. No cat was actually harmed
in the filming of that video. The aircraft did manage
to come around and land, and they removed the cat. Maybe it might have said,
perhaps, something about the robustness of
the pilot’s pre-flight check, not sighting a cat in a wing. Classic example of a distraction. Distractions can come
in all sorts of ways. Distraction from ATC,
distraction from passengers, distraction, even from things like
a cat or a piece of wildlife. So, what is situational awareness and how on earth can we improve it
when we go flying? I want to break
situational awareness down basically into
its most simple concept. It’s essentially
a three-step process. The first step is
what has happened in the past. What is currently happening now? And what’s going to happen
in the future? We make those decisions
when we go flying often instantly,
without even thinking about it. We use our situational awareness
whenever we are consciously awake – when we’re driving a car, when
we’re walking down a set of stairs, when we’re making a cup of tea. Our brain goes through
this three-step process often without us even realising it. And when we go flying, we’re doing
that exact same three-step process. But because when we’re going flying, it’s a very dynamic environment,
isn’t it? It’s an environment that operates
in three dimensions. And, therefore, until we build up
our experience as aviators, we can have difficulty putting
these three steps together. Classic example is that at the moment I’m teaching
my 16-year-old daughter how to drive. She’s building her
situational awareness on the road. So that three-step process
is certainly happening for her, but it’s not as smooth as anyone that might have been driving,
like myself, for over 35 years. Here’s a different way of looking at
situational awareness. And there are many models out there that can help us
describe this concept. Let’s have a look at
this different model. First of all, we perceive what is out there around us. You might ask,
“Well, how do we perceive things?” Well, we use our five senses. Our five senses tell us what’s happening in time and space around us whenever we are consciously awake. So first of all,
we perceive what’s around us. In other words,
“Where is the aircraft?” The second step is to comprehend – “What does that mean for me?” OK? What is the aircraft actually doing? Is it climbing? Is it descending? Is it in a turn? Am I slowing down? Am I speeding up? Am I to the left of the runway
or the right of the runway? The third and final step, or stage 3 of situational awareness, is to project ahead into the future. In other words, “What’s going to happen?” “What’s going to happen
in the next 15 seconds?” “What’s going to happen when
I’ve reached a leg of the circuit?” “What’s going to happen
in the next hour?” Or maybe even for the Qantas pilot
flying home from the United States, “What’s going to happen or what will
my aircraft be in in 15 hours time?” Where those three things intersect, that’s the sweet spot
of situational awareness, as you can see in the diagram. So how does that relate, then, to someone who’s an experienced pilot who might have a very well-developed situational awareness versus someone
that’s perhaps learning to fly? Let’s have a look. Situational awareness. Go back to your very first flight, maybe your very first session
of circuits where you were probably having
a brain overload and struggling to keep up
with the aircraft. You had perception,
you certainly had comprehension and you were developing
your ability to project, so your situational awareness
was still in its infancy. But perhaps when you were doing
your first flight, your situational awareness in total,
where those three things intersect, was only very small. But a more experienced pilot
still does those three things but the sweet spot’s a lot greater. They have a greater grasp
on situational awareness. What does that mean? What that means is that with
a greater understanding or a greater sense
of situational awareness, we can devote
more cognitive brain space to working out what else is happening
around the aircraft, such as working out
where other traffic is, how I’m going to separate myself,
dealing with checklists, dealing with passengers
and those sorts of things. So, one of the things
I want you to think about when you’re watching our video today,
reflect on your own flying. “What are some of the clues
in my own flying “that might give me an inkling that “perhaps I’m losing
situational awareness?” And when we talk to most pilots,
and myself included, there have been many occasions where
we have lost situational awareness. So what are some of these red flags? The first one is ambiguity,
or even confusion. Classic case – “The iPad says that I’m here, “however, when I look out
of the cockpit, “it doesn’t match
what I’m seeing on my map.” Instant loss
of situational awareness. Secondly, fixation – that is fixating or concentrating
on one thing in the cockpit to the exclusion
of everything else, OK? A dangerous place to be because all our attention, all our cognitive thought processes are devoted to one particular thing, and we very quickly lose sight
of that bigger picture. Failure to fly the aircraft. This is another big thing. Sometimes we use the adage that too many cooks spoil the broth – in other words, having two pilots
onboard an aircraft when there isn’t
a clear division of duties. When we read the accident report and the book about QF32, the A380 that blew up its engine
over Singapore. There was a lot of experience
on that flight deck. When that event occurred, there were EICAS messages going off, there were alarms and bells and all sorts of things
happening in that cockpit. But one of the first things
the crew did was that they nominated one particular person
to fly the aircraft and let everyone else deal with
the emergency and run the checklists. Fourthly, failure to look outside. And you might think to yourself, “Well, surely, that’s just a given.” But perhaps think back
to our initial scenario at Port Macquarie
with the Foxbat pilot. Maybe a more disciplined look-out might have saved the day. The AOPA, or the Aircraft Owners and Pilots
Association in the United States, did some research,
I understand, recently where they hooked up VFR pilots
with various biometric sensors where they could track
where their eyes were looking on a typical VFR flight. They found most pilots
on a typical VFR flight had their head inside the cockpit
over 50% of the time. Because there’s lots of things
to distract us in the cockpit – there’s all our instruments, there’s passengers,
there’s our iPads. There’s all sorts
of electronic flight instruments, which are very attractive
and can attract the eye. So failure to look outside’s
a big one. Maybe even back to
our Moorabbin example where the aircraft taxied
across the holding point. Failure to meet
estimated times of arrival. Failure to meet things like targets or speeds or altitudes will also give you an instant loss of situational awareness. So will failure to fly our aircraft within limitations or even the regs. What regulations do or what limitations do that we might find, for example,
in the flight manual is it provides us as pilots
with a frame of reference within which to operate. We go outside that frame of reference and we are really
in uncharted territory, especially when it comes to
things like our flight envelope and things like centre of gravity. When we fly outside those limits
in our flight manual, well, then congratulations because
we’ve just become test pilots. Because Mr Cessna and Mr Piper
and Mr Beechcraft, they wash their hands. You operate outside those limits,
you are essentially on your own. We don’t know how the aircraft
is going to handle, or how the aircraft
is going to react. And finally –
and we’ve spoken about this in our previous talk
about communication – failure to communicate effectively. If our language is vague, if the information
we’re giving is incomplete, or if there’s too much information. All of these things
should be red flags or identify with us as clues that perhaps our situational
awareness is starting to deteriorate. So when we next go flying,
have a think about these things, how we perhaps react to them, and let those be little triggers
in our mind that perhaps our situational
awareness is starting to reduce. How can we improve our situational
awareness when we go flying? There are things we can do. First of all, we have this saying – “If it feels wrong, it probably is.” You’re never going to find this rule
or that statement in any regulation or anywhere in rules that we publish, but it’s that old gut instinct. And especially if you’ve been
flying for quite a while and have sufficient experience, it’s amazing how accurate
that gut instinct is. And I’m sure most of us have
either been flying or driving or been in any other part
of our life and we get that feeling,
that inner sense that something
isn’t just quite right. It’s amazing how accurate
that can be. Secondly, a sterile cockpit rule. The airlines and the military are very hot on things
like sterile cockpit. All that really means is,
especially for the airlines, is that from basically push-back
to departure and climb through about 10,000 feet, the only conversation
on the flight deck is operational conversation only. We don’t talk about the footy scores or what we’re doing
on Saturday night. And the same on descent. From about 10,000 feet
until we’re at the gate, again, operationally relevant
conversation. Why? Because that’s the busy
part of the flight where distraction has the potential
to reduce our situational awareness. Now, I’m not saying that we have to
establish a sterile cockpit rule for our own private
or recreational flying, but you might want to think about
perhaps asking your passengers that perhaps,
“When we’re in the circuit area, “just keep the volume
of our conversation down “or even just stay quiet “unless you see something
that I need to be aware of.” Again, just in the circuit area or
in those very busy phases of flight. Thirdly, fly within
our personal limits. It might be personal limits
with regards to visibility or other weather-related phenomena. It could be personal limits
with regards to the way the aircraft handles,
such as crosswind limits. We go outside those personal limits, again, we do run the risk
of losing our situational awareness because we could
potentially find ourselves in an environment
that we’re not used to, OK? Personal limits do play
a large factor especially for a lot of pilots
that might not fly that regularly, whose experience levels
or recency levels might not be fully as developed
as people that might fly every week. Learn to recognise those red flags. We spoke about them
on the previous slide. We each might react to
those red flags differently, but think about our own flying, think about the previous flights
that we’ve flown. Even when we’ve landed
after a flight, just spend some time thinking about
the flight we’ve just completed. “Was there any little red flag
on that flight that “could have potentially led me to a
reduction of situational awareness?” And finally, that old adage – prioritise what we do in the cockpit. We aviate first,
we fly the aircraft first, then we navigate and be aware of
our position and where we’re going, and finally in order,
we communicate our intentions. We go back to those old lessons
that still hold true today. Our final topic today is entitled
Threat and Error Management. Threat and error management has been a term around the aviation
industry for at least 20 years. It originally started back
in the early ’90s, I understand, out of the University of Texas. Essentially it’s a way
of looking at airmanship, that old concept
of airmanship anyway, but in more of an enhanced way. In some respects, “enhanced
airmanship” is a good name for it. I also look upon
threat and error management as almost like defensive flying in perhaps a similar way
that we look at defensive… ..the concept of defensive driving. And there are some terms, there are some terms
in threat and error management that we need to, perhaps,
just get straight in our head. And these are terms that we’ve heard,
I’m sure, around the traps. The first one is the terminology of
essentially “What is a threat?” A threat is essentially something that comes externally
towards the pilot that requires some action in order
to maintain a margin of safety. Now, those threats can be anything
from turbulence or bad weather. A threat can be something that might be going wrong
mechanically with the aircraft. Air traffic control in itself can perhaps be a threat
to the safety of the aircraft, especially if it introduces
a distraction. In some respects, we might
even be a threat to ourselves. How could we be a threat
to ourselves? Well, we might, for example,
go flying with a horrible head cold, or we might be going flying when, perhaps, we are not as current
or as recent as we’d like. So that’s the essential concept
of what we mean by threat. Now, the University of Texas
had introduced this concept called Line Oriented Safety Audits. Essentially, it’s something
the airlines use where they put an observer
in the cockpit of an airliner, not to form part
of the functioning crew, but just to watch
the crew’s interactions, and record how many or what type
of threats come at the pilot and how they deal with those threats. Do they cause or make an error
in dealing with those threats? And there’s some interesting data
that I thought I’d share with you, and we can perhaps
extrapolate some of this, or at least try and frame it
in the way that we go flying. What this line oriented safety data,
or LOSA data, has shown us with information coming in
from a huge variety of databases – so there’s a lot
of information here – is that 40% of all threats
coming at a flight crew usually come in the pre-departure
and the taxi phase, while 30% of threats
come at a flight crew in the descent, approach
and landing phase of flight. Each flight, on average, the crew has to deal with just over four threats on average, and they might be anything,
as we’ve said earlier, from weather or ATC-related threats. It might be turbulence. It could be anything. The most common threats
facing flight crew are usually to do with weather or air traffic control instructions, or trying to comply with
what ATC tell the crew to do. 85 to 95 of those threats are quite successfully
managed by the crew, but about 1 in 10 threats lead to some type of error by the flight crew in managing that error, OK? Or managing that threat. Mismanaged threats are mainly in the operation of the aircraft, ATC or weather-related. So in threat and error management, the other concept that you’ll hear
is just this terminology of error. Error is something that we commit
as human beings whenever we are consciously awake. We never wake up in the morning
saying to ourselves that we’re going to commit an error. It’s just a by-product
of being human. It’s something a pilot
in an aviation context might do or fail to do that results in a reduction
in safety margin. And we divide those errors up
into two things – an error of commission
or an error of omission. An error of commission is
when we do something in error. An error of omission is when
we might forget to do something. For example, we forget to
change a radio frequency. We may even forget
to put the landing gear down. They reduce our safety margins and they increase the probability
of our aircraft entering into an adverse event. So, here’s an example on our slide. A pilot inadvertently might select
126.8 instead of 126.7. Not done intentionally. It was just by pure accident.
Classic example of a small error. Let’s think back
to our Foxbat example at the start of our presentation
in Port Macquarie. I’m sure the pilot didn’t
deliberately go flying with the volume turned down. That was an error. It’s a by-product of being human. So, let’s talk about errors in the
line oriented safety audit space that we’ve been
speaking about earlier. Interesting statistic here
with all this data is that 45% of errors
committed by flight crew actually go undetected by the crew. Why? Because we are human. OK? We’ve spoken, as you can see there, about errors of commission
and errors of omission. It’s the approach, descent
and landing phase where most errors are occurring. Anywhere up to about 40%,
as you can see from the statistics. 55% of all errors in that phase
are actually mismanaged by the crew. Quite significant numbers, really. And, in total, about a quarter of all
errors that occur on the flight deck are not managed properly. Now, these stats come out
of the airline world, but I thought it might be worthwhile for us to at least have a look
at this stuff and maybe think how this might apply to our general aviation
and recreational flying that we do. When we talk about error,
I think it’s also important to look at the other side of error
and that is the concept of violation. And the whole concept about violation
revolves around intent. Was it deliberate
or was it not deliberate? Violation is something
that is intentional. It is an intentional deviation
from some rule, from some standard
operating procedure or limitation that we do deliberately and it’s all done
or it’s all centred around intent. Classic example – a pilot didn’t decide to make a radio
call to avoid paying landing fees. Classic case of a violation. The real danger with violation is
when we are actually successful at it because when we are successful
at violating, what that does is that
it encourages us to do it again and to do it again
and do it again and do it again. And we continue
being successful at it until one day circumstances
might be slightly different and we end up with a major event. Classic case,
if you want a good read one night, is to open up and have a read of the accident report
of space shuttle ‘Challenger’. Classic case of what we call
the normalisation of deviance. In other words, where intentional violation over time
starts to become the norm. Now, in our own flying, for example, we might regularly fly
with our aircraft above its max take-off weight or it might be out of balance or we might regularly go flying when
the VMC conditions might not exist. We might get away with that. We might continue to get away
with that over the years. We might continue to be successful. But until one day, something
might be slightly different and it results in an accident. Now, all human beings violate. Again, I often think that
it’s also part of being human. And in our seminars, I will often ask the audience –
who here has violated? And you might only get
a few hands go up. So then I posed the question
to the audience – so who here has gone through
a roadwork zone at 45 instead of 40? We all have. We’ve made a deliberate decision that no, I’m not going to go through
that roadwork zone at 40. I’ll only go at 45. But it’s something
that we do intentionally and, again, especially in aviation or
other forms of transport, of course, the real danger is
when we’re successful at it. The final concept when we talk about the idea of threat
and error management is this term called
an undesired aircraft state. You might have heard this term
spoken around the flying club or have read it in magazines, seen it on
the Flight Safety Australia website. Accident reports, that type of thing. An undesired aircraft is simply
a position or an attitude or a configuration of an aircraft as a result of something that
the pilot does or doesn’t do that results
in a reduced margin of safety. So, what do we mean in reality
by an undesired aircraft state? An undesired aircraft state might be having an aircraft
in a stall configuration only a hundred feet
above the ground. That would be
an undesired aircraft state. Or be halfway across Bass Strait with
only five minutes of fuel remaining. Again, an undesired aircraft state. Or an aircraft that punches across a
holding point onto an active runway. In other words,
wrong place, wrong time. Significantly reduce safety margin. It’s what we call
an undesired aircraft state. And there’s an example there. The pilot might realise their error and hold short, taxi off the runway, realising that the aircraft
is in a position that safety is actually reduced. So, here’s a classic example. An aircraft on the left-hand side,
our blue aircraft, taxis past the holding point onto
the flight strip of an active runway. An aircraft on short final sees this aircraft
taxi across the holding point and readjusts its approach path
at the final minute and actually starts to land
within the flight strip. Classic case
of some undesired aircraft states and let’s start to pick apart
this small example in terms of threat
and error management. So, what threats can you identify
with that scenario? First of all, the aircraft
that’s taxied onto the flight strip beyond the holding point is too close
to the landing aircraft and definitely represents a threat
to that landing aircraft. Secondly, the landing aircraft
is operating with reduced lateral separation
from the aircraft on the ground and represents a threat
to that aircraft on the ground. The other threat is that the landing
aircraft has a reduced lateral area available within which
to manoeuvre, OK? Or to deal with any other thing
that might come at that aircraft such as a cross wind
or a handling error. Again, represents a threat to that aircraft
that’s coming in to land. So what errors or violations
might have occurred in this example? OK. Let’s pick this apart. First of all, the pilot proceeded
passed a holding point with an aircraft on short final. Was that an error? Potentially. Could have also been a violation. Sometimes you have to dig
a bit deeper. What else do we have? The landing pilot didn’t go around. Didn’t actually commence
a go-around even though the aircraft
had approached into his runway. Now, there may have been
mitigating circumstances. The pilot coming into land may have
been running out of daylight. He may have been
running out of fuel. There’s a bit of light and shade
there as well. Could have been error,
could have been violation. The landing pilot has continued with
what we call an unstable approach with a rate of descent, altitude,
airspeed, aircraft configuration were not within defined parameters. Potential error, potential violation. And there were
some undesired aircraft states. Aircraft that were
in the wrong place at the wrong time. The aircraft is on the runway with
another aircraft on short final. That aircraft on the runway was
in the wrong place at the wrong time. A classic case
of an undesired aircraft state. That landing aircraft
was in an unstable configuration having to manoeuvre abruptly
on late final to avoid that aircraft. Again, undesired aircraft state. Wrong position on the runway during
the landing and touchdown phase. So, introducing some additional
threats in this scenario. The pilot on final approach sees the aircraft approach
across the holding point, says, “Yes, perhaps I could
have slowed my aircraft down “to give the other aircraft
time to vacate. “And whilst at that reduced speed, “maybe I could have conducted
some ‘S’ turns.” Again, to further lose time. Introducing what we call
the unstable approach. OK? So we run the risk of trying
to manage one threat and putting our aircraft
in an undesired aircraft state in trying to manage
an external threat. So what threats might impact
on that aircraft on final approach? Clearly reduced safety margin, manoeuvring too close to the ground
at low airspeed puts that aircraft very much
into an undesired aircraft state. Could very easily lead to things
like an inadvertent stall and then a spin close to the ground which would be unrecoverable
in the height remaining. We’ve spoken a lot about
undesired aircraft states. We’ve also spoken a lot
about unstable approaches. When we go through the ATSB database
and databases around the world, we find a continuing theme
that the vast majority of aircraft that run off the end of a runway or have a runway excursion
off the side of a runway, the genesis or the original
causal factors in that accident can usually be traced back
to an unstable approach. We can reduce the risk
of a runway excursion by having the discipline
when we go flying to ensure that our rate of descent,
our altitude, our aircraft configuration
and our aircraft speed are within certain defined parameters at various points
along our final approach. So what can we do to assist this? First of all, nominate
where we are going to touch down and have that point nicely sorted out
early in our final approach. Secondly, fly a constant profile. Not too high. Not too low. The last thing we want to be doing
is making major adjustments to our final approach path
as we get closer to land. Know the correct approach speed
for our aircraft. Most light and sport
and recreational aircraft pretty much have the same type of
approach speed regardless of weight. But as we go up in aircraft size
and aircraft weight, the ideal approach speed can
actually vary quite significantly. So it’s important
that we have a good knowledge of our aircraft flight manual, and the appropriate
and correct approach speeds to fly. That’s going to give us
the greatest chance of preventing a runway excursion
either off the end or off the side. And, finally, and this is where
it comes down to pilot discipline, if we are not stabilised in our
approach by a nominated height, then have the discipline
to go around. Don’t try and push a bad approach
because often it will end in tears as we spear off the side
of the runway or we land too long and we go off the end of the runway. The airlines, for example,
are very hot on this. If the approach isn’t stabilised
by certain gates on final approach, it’s a standard operating procedure
to conduct a go-around, bring the aircraft round
and have another go at landing. Us, as the recreational
or the private pilot, should be doing this as well. There’s no shame in going round. And if it isn’t right, it’s a normal type of manoeuvre that
we should be practising regularly and that alone will help us
with our threat and error management, especially when we’re close
to the ground. I’ll leave you with a final example of some threat and error management
gone wrong. This was an example at Caloundra
in a home-built aircraft. The pilot was coming into
Runway 05 at Caloundra, recognised that there was an external
threat that they had to manage. That external threat were
parachutists that were under canopy and the pilot was concerned that those parachutists may drift
across onto the runway strip. So the pilot therefore
manoeuvred the aircraft to the right of the runway strip
to perhaps give themselves more room. The pilot ended up too high
on profile. So, therefore,
too high above the ground, too late in the final approach. Instead of commencing a go-around, the pilot found themselves
in that situation and tried, therefore,
in the final stages of approach, to regain the correct profile
by entering a sideslip manoeuvre. The pilot entered
the sideslip manoeuvre very close to the ground, but in coming out
of that sideslip manoeuvre, mishandled the aircraft. The pilot, unfortunately, mishandled
the aircraft to such an extent, the pilot lost control
of the aircraft in flight and, unfortunately,
that was the result. Four people were seriously injured.
The pilot especially so. Classic case of an external threat perhaps being managed
inappropriately and errors were made
in the management of that threat. Of course, it didn’t help
that the aircraft, unfortunately, was also loaded
beyond its aft centre of gravity which increased the chances of the
aircraft losing control in flight. Loss of control in flight accidents the statistics tell us are accidents
that often end up with fatalities. It’s not the type of accident
that we want to have. So let’s review where we’ve been. You’ve joined me on a journey
through three significant topics – communication, situational awareness and, finally,
threat and error management. So, in communication, the main document that I recommend
pilots go to and review is CAAP 166 which talks about operating at and in
the vicinity of non-towered airports. Remember, non-towered airports, we don’t have
air traffic control there. As a consequence, the communication that we provide
on the radio is even more important. That communication needs to use
standard phraseology wherever practicable. Of course, use plain language
if you have to, but, for all intents and purposes, that standard phraseology
is very important. Think what we are about to transmit. Think about the audience
that we are transmitting to. Am I likely to increase
people’s situational awareness or detract from it? And we have the greatest chance
of spotting other aircraft in the CTAF environment if we use appropriate radio calls combined with a disciplined look-out
and a scan for other traffic using our eyesight. Secondly, that communication led on to the building
of situational awareness. Remember, we spoke about
that three-step process. Where has the aircraft been?
Where am I now? Where will I be into the future? A process that
doesn’t come naturally, but as we gain more experience becomes more and more intuitive
to the pilot. With situational awareness, it’s that one thing that will help
us keep ourselves safe and alive at these non-towered
aerodrome environments. Also with situational awareness,
have a look at our own flying. Learn to recognise the red flags
in our own operation. What are some of those
little triggers that I need to keep an eye out for that may indicate to me that
I’m losing situational awareness? And, finally,
we put all this together in our discussion
of threat and error management. Whenever we go flying, it might be a flight
to the other side of the country or a local flight in our circuit, before we launch, think about
what are the potential threats that might come at me
externally as a pilot? It might be weather related.
It might be airspace related. It might be air traffic control. It might be distraction
from other passengers. Think about the threats
that we’re likely to face and how are we going to manage them? Do I have a plan A? Do I have
a plan B? Do I even have a plan C? We often liken
threat and error management to enhanced airmanship or maybe
even defensive flying, if you like. So that concludes
our seminar series for 2018-2019. Thank you very much for joining us. We look forward to seeing you next
year with our following seminar.

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