Primarily for general aviation discussion, but other aviation topics are also welcome.
#1656162
The safe conduct of any flight seems to me to be based on the number of options available to the pilot in the event that something goes wrong.

The single biggest factor limiting options available to this flight was low level ice-bearing clouds. F215 predictions of ice are, in my experience, somewhat hit-and-miss, but on this occasion, the prediction was fairly clear. I suspect its accuracy would have become quickly visible to them had they attempted to climb through cloud.

This sole factor obliged the flight to be lower than comfortable, and certainly below any reasonable MSA.

Being below MSA isn't a problem unless you are unsure of position and/or no longer in VMC (however limited). At that point an accident becomes highly likely.


Looked at as an IFR flight, the conditions at Gloucester were well above minima for the approaches available, and the commander had both experience and an instrument qualification. But for the ice, it would have been a very undemanding flight.

For me then, the two points of interest from this are:

- the need for extreme caution where icing at low level is concerned. This consideration alone should arguably have stopped this flight at the planning stage.

- that it is perplexing that such an experienced individual should have found themselves unsure of position on a route that could readily have been conducted at low level - however inadvisable.
#1656174
G-BLEW wrote:How did it work in medicine?

Ian


Well, since you ask: The closest equivalent in my speciality was a triennial review of deaths associated with pregnancy formerly known as the Confidential Enquiries into Maternal Mortality 19xx - xx). or similar.

At the time of my retirement it had been re-named with the punchy title of 'Why Mothers Die'.

Details of each case were anonymised but the report was freely available in the public domain.

Shortcomings in care were highlighted but blame was not apportioned.

It was discussed in hospitals all over the land but sure as hell wouldn't be discussed on any public internet forum.

Peter
#1656176
what can we learn?


To me it looked like another "I must get there by pushing the boundaries" case from another highly experienced pilot who has done this or similar routes many times before.

It's always sad to hear both IR and VFR-only pilots crashing into terrain.
#1656177
I have to say I'm with you on this Pete, 100%.

There will be links to this thread (full of amateur theories and opinions) sent to friends and family of the deceased, and I (and I'm sure others) find that a far more tasteless thing than banterous and harmless threads about BREXIT and female pilots that get locked within 5 minutes.
#1656180
PeteSpencer wrote:
G-BLEW wrote:How did it work in medicine?

Ian


Well, since you ask: The closest equivalent in my speciality was a triennial review of deaths associated with pregnancy formerly known as the Confidential Enquiries into Maternal Mortality 19xx - xx). or similar.

At the time of my retirement it had been re-named with the punchy title of 'Why Mothers Die'.

Details of each case were anonymised but the report was freely available in the public domain.

Shortcomings in care were highlighted but blame was not apportioned.

It was discussed in hospitals all over the land but sure as hell wouldn't be discussed on any public internet forum.

Peter


Maybe internet forums were not 'de rigeur' at that time but there now are usually lively debates on internet forums where there are cases in medicine with a clear public interest, and of course on medical forums too such as doctors.net.

And why not?
#1656181
2Donkeys wrote:Looked at as an IFR flight, the conditions at Gloucester were well above minima for the approaches available, and the commander had both experience and an instrument qualification. But for the ice, it would have been a very undemanding flight.
:
- that it is perplexing that such an experienced individual should have found themselves unsure of position on a route that could readily have been conducted at low level - however inadvisable.


From the AAIB report:

The instructor on the accident aircraft was accompanied by a student, who was approaching the navigation phase of his training, for whom this flight would provide some additional exposure. The student prepared a route on a 1:500,000 scale aeronautical chart following a standard route used by the school for such ferry flights.

So the ferry flight was turned into a nav-ex for the student which, in my opinion, was there to make the student pay for the flight rather than having "dead legs". It happens all the time when it comes to taking aircraft for maintenance or for other ferrying reasons. Having make this decision, then IFR was not a thought, and neither was using a moving map (maybe tablet based) GPS.

Part of a student nav-ex can involve letting the student get a little lost.
#1656182
PeteSpencer wrote:At the time of my retirement it had been re-named with the punchy title of 'Why Mothers Die'.


I believe it has been re-named again with the much better title of "Saving Mothers' Lives" :D

Better IMHO because that sets a positive, looking forward and learning agenda.

(I find it intriguing that influenza is a big killer in this context, incidentally)
#1656183
MBRRACE-UK: Saving Lives, Improving Mothers’ Care

Lessons learned to inform maternity care from the UK and Ireland Confidential Enquiries into Maternal Deaths and Morbidity 2014–16



Report here:

https://www.npeu.ox.ac.uk/mbrrace-uk/reports

It even has a lay summary - no doubt to make it more accessible for non-healthcare professionals.
#1656188
lobstaboy wrote:
PeteSpencer wrote:At the time of my retirement it had been re-named with the punchy title of 'Why Mothers Die'.


I believe it has been re-named again with the much better title of "Saving Mothers' Lives" :D

Better IMHO because that sets a positive, looking forward and learning agenda.

(I find it intriguing that influenza is a big killer in this context, incidentally)


Which is precisely why , as I am frequently reminded , that having retired over 13 years ago and having ‘handed in my ticket ‘ three years ago I have long since given up commenting on anything medical : I’ll leave it to those current and the great unwashed

Peter
#1656195
As with many of the accidents that appear in these reports the main learning point is that if you do not apply the knowledge and learning you have, you may not be lucky.

There is imho nothing new that 'needs to be done', it is just a case study of what happens if you don't do what is recommended (or required).

The report hints that 'uncertified apps and devices' could have helped but that's kind of like saying 'if you run out of fuel any field becomes a runway'. You should never be in a situation where you rely on an iPad to continue your journey.

By the way this accident reminds me of a case study in the USA where a lone pilot was scud running though mountain valleys, pushing on despite nearly everyone he spoke to advising him against it. Unfortunately that also ended in a fatality.

Basically I see this as a case where people have freedom to make decisions and an unfortunate consequence of that is that sometimes people make bad ones.
#1656199
This discussion comes round every time something like this is discussed. Its a broken record - decision has been made by the editorial team. I'd much rather this sort of discussion was here where people may know something about the topic and can treat it fairly, than on unmoderated places such as the book of faces. So long as the focus is "learning" rather than "blaming" it is useful to all.

To me, also, it seems unlikely that he was very lost. However the report suggests that the VOR was essentially not set to anything useful. This (I believe) is incorrect. The crash site is on the Daventry radial tuned. They are low level and 40nm from it - so I don't know about signal quality, but it is tuned and selected to where they are. That would be consistent with cross checking position.
The orbit just before it is regular, so this (to me) suggests it was the instructor flying.

Its the last mushroom shaped path that seems odd to me. My speculation is that he thought he was trying to route round that high ground, but misstook one of the hamlets for Pershore (very much speculation) or he thought he saw a gap in the clouds (a letter box). It looks like he made a decision to proceed in that direction, which is direct track towards Gloucester.

The aircraft was equipped with a panel mounted GPS system. It doesn't say what this is? If a GNS 430 (did someone mention that?) and it was terrain enabled, it would have shown yellow in almost all of where they were (terrain between 1000 and 100 feet below) and would have shown the area that they ended up in as Red. Don't think the report mentions whether it was terrain enabled or what zoom level it was at and it wouldn't have recorded anyway if it had been selected. https://www.manualslib.com/manual/30208 ... =48#manual
I don't like that the report is pushing hand-held GPS devices, yet doesn't make any real comment on the device that was in the cockpit in front and perhaps available to them, other than nothing was recorded about the track but it was turned on. That tool may have been able to keep them safe. It would have been good to at least rule it out as being useful.

Lots to learn from this.
#1656204
I think a key learning point from this is what my trusty IR revalidator always says. Use whatever you have available to get the best picture. So he might cover up the AI's and HSI, but I still have a turn and bank, two altimeters and a GTN 650, so no great problem.

Here they could have had a GNS430 and an ipad with SD (or similar) which would have given terrain warnings, but more important kept them on a pre-planned track that was below cloud but terrain safe and legal.

BTW when flying IFR the only really usable navigation equipment Is a GTN 650 and iPad (or similar). VORs and NDBs are of increasingly limited use.
#1656207
When I fly and I regularly fly in VFR minimum weather my primary means of navigation is skydemon. I’ll still print a plog and I will still draw a line on my chart. And I will ‘TTTT’ and I will fly the route working clock to map to ground. I will then update my plog using the magenta line to know the exact heading and ETA not one based on forecast winds made 8 hours ago.

I find VOR’s of little value for on route navigation largely because they are not located where I want to go. (Although that wasn’t always the case e.g. going into Newcastle when it had a VOR). The other problem is that locally I can’t even pick up one let alone two VOR’s at under 2000 feet. Also if I was lost and tried to get a position fix, drawing lines on charts takes at least a minute and is high workload and then its only accurate within what 3 nm?

Therefore at GA levels I find the much maligned NDB’s and if located at an airfield where a TDME/TACAN is present much more useful and I set this combination on every flight.

Also if fitted and even if its a lowly green screen Garmin GPS I would set this up as well .

Now I feel that this technique gives pretty good situational awareness and it has numerous falls backs if one system should fail.

There may be better ways but all I was taught as part of my PPL training was dead reckoning. Which I would never use as a primary means of navigation in minimal VFR weather.

I think the real failing is that GPS navigation isn’t examined as part of the PPL skills test as doing so would automatically make it part of PPL training. It might reduce the number of airspace busts as well.