An anonymous forum to allow you to share those moments in flying that caused you concern. You can post without registering a username, registered users can log out to post
#1840005
Flyin'Dutch' wrote:@Morten has got it.

Amen.

So that makes two of you that are completely convinced that the incident was primarily caused by the pilot not noticing something that you are completely sure that he should have noticed, in the absence of any actual information about the aircraft, or conditions on the day?

Hmm.
#1840013
Flyin'Dutch' wrote:Hmmm, I did not say that anywhere.

Well, @Morten assessed the incident thus (my emphasis):
Morten wrote:It's really not about forgetting to untie the tie-downs but about not noticing that they are tied on during any of the ground manoevring before take-off.

... and you agreed with him, quite emphatically. You can hardly blame me for interpreting this as you both assuming that he should have noticed the ground handling being different.

This may or may not be the case, depending on the aircraft, familiarity with it, the taxying surface and its condition. But without evidence, I think this is speculation.
What you and a few of others are saying is that this incident is the result of a momentary lapse of attention, just as not putting a tank top back on.

I absolutely am not saying this, and I don't think others are either.

I'm saying that given the momentary lapse of attention, there was nothing built into the process to pick it up. If you notice from @GrahamB 's comment, he now has a process to pick up forgetting to refit the fuel cap. In my case, I now have a process for ensuring that if I'm distracted during a walkaround, I re-check to ensure that nothing gets missed.

The momentary lapse of attention, and the absence of a fail-safe process to correct for such lapses, are not even remotely the same thing.

We all have momentary lapses of attention. It's how we allow for them that makes the difference.
#1840020
TopCat wrote:
The momentary lapse of attention, and the absence of a fail-safe process to correct for such lapses, are not even remotely the same thing.

We all have momentary lapses of attention. It's how we allow for them that makes the difference.


Indeed.

But the taking off with the balast tanks is not the result of a momentary lapse of attention.

It might have been if there was one bit still strapped on, not with two.

Just do the 5 Whys and come up with a remedial plan to guard against this and your conclusion will be the very same.

I have done a fair bit of RCA where things have gone pretty badly wrong and also reviewed investigations into things that have gone wrong.

From that I learned that mostly the fewer points identified as leading to the incident, the poorer the investigation had been done and if the remedy was 'must try harder' the problem would keep on repeating itself.
#1840023
Flyin'Dutch' wrote:But the taking off with the ballast tanks is not the result of a momentary lapse of attention.
It might have been if there was one bit still strapped on, not with two.

I wondered about this too.

However, "Remove the tie downs" may be one item on the external checklist rather than "Remove the left tie down" and "Remove the right tie down" as two separate ones.

If that got left out, and for some reason there was no reason to look again, both would end up still in place.

I think we've exhausted the analysis possible without more actual information.

And the longer we go without the OP coming back and contributing collaboratively to the process, the more I'm inclined to suspect a more general sloppiness, and the less inclined I am to give him the benefit of the doubt.

However I still think it is potentially quite dangerous to assume that there would be enough difference in the ground handling to guarantee that something like this should be noticed. And I still maintain that there was something wrong with the pre-flight process that prevented an omission like this coming to light before taxying away.
Last edited by TopCat on Mon Apr 12, 2021 4:46 pm, edited 1 time in total.
#1840026
Flyin'Dutch' wrote:I defo do not agree with that last sentiment!

Did we not have a thread some time ago where people were posting how they tried to avert becoming a statistic?

IF not maybe time for one.

Sorry, my edit crossed your reply.

Which last sentiment don't you agree with?
#1840038
Flyin'Dutch' wrote:Hmmm, I did not say that anywhere.

What you and a few of others are saying is that this incident is the result of a momentary lapse of attention, just as not putting a tank top back on.

It isn't.

As we are being picky, FTAOD I wasn't equating the two (although I may or may not have a think about whether they could/should be).

I was using taking off with a missing fuel cap as an example of something that I forgot, and as a consequence amended my SOPs to reduce the risk of it happening again.
JAFO, Flyin'Dutch' liked this
#1840070
TopCat wrote:
Flyin'Dutch' wrote:I defo do not agree with that last sentiment!

Did we not have a thread some time ago where people were posting how they tried to avert becoming a statistic?

IF not maybe time for one.

Sorry, my edit crossed your reply.

Which last sentiment don't you agree with?




And the longer we go without the OP coming back and contributing collaboratively to the process, the more I'm inclined to suspect a more general sloppiness, and the less inclined I am to give him the benefit of the doubt.
#1840076
I wrote:And the longer we go without the OP coming back and contributing collaboratively to the process, the more I'm inclined to suspect a more general sloppiness, and the less inclined I am to give him the benefit of the doubt.

... to which FD responded:
Flyin'Dutch' wrote:I defo do not agree with that last sentiment!

Yes, to be fair it's too early to say.

However if I'd made a bad mistake, and genuinely wanted some help evaluating it from people here, even if I wanted to do it anonymously (which is fair enough), I think I'd have been prepared to stick around and give enough detail about the aircraft and the other circumstances of the incident, so that people were able to give considered views without all this speculation.

I mean, if the aircraft was high-wing, then not noticing the tie-downs is a lot more culpable. Likewise if it was something powerful and heavy, not noticing the ground handling being different is much more understandable than if it was a tiny 3-axis microlight. What were the distractions? What does the checklist say?

Anyway, getting a bit bored now, as I'm sure you are.
#1840166
As the O.P. can I first off can I say that I had been somewhat concerned that I would simply be vilified for allowing such an event to happen, but am heartened that in the main the contributions have been well reasoned, encouraging and fair, and I have, and will continue to take these comments on board.

To add some detail which, understandably some have a asked for, it was a low wing aircraft, grass runway and taxiways.

As for the question in the title, I have decided not to pack it in at this stage but will not be flying again until I’ve had time to fully come to terms with what went wrong, and I’m no longer being deprived of sleep due to thought about what could have happened had one of these things detached in flight. I accept that there is a possibility this was more than just a momentary lapse in concentration and I need to assess this properly as it’s possible other things could be missed.
However my assessment at this moment is that my normally very rigid pre-flight check routine was not adhered to, why is the real question for me to answer, I was on my own, there was no-one else around so I can’t say I was distracted. I am however determined that I will never allow anything to interrupt a routine that has served me well for many many years.

As with all topics discussed on internet forums, everyone is entitled to express their opinion and we all respect that. However there has been an assertion in very strong terms that I would have noticed something was amiss during taxi and ground manoeuvring. Let me say that unless you have experienced the same thing yourself you would have no way of knowing for sure this would be the case. So please in this instance believe me when I say there was nothing untoward noticed at the time. Indeed a later thorough inspection of the taxi route and take off zone on the runway showed no signs of anything either. If you don’t believe me go and try it yourself! (without the take off bit of course).

In conclusion I’d like to thank everyone for their input and as said I will continue to take everything on board.
I sincerely hope no one else ever has the same happen to them but we are all reminded that everyone makes mistakes and everyone will continue to in future, let’s hope that this event has at least served to remind all of the need to avoid complacency.
Rob P, JAFO, Miscellaneous and 7 others liked this
#1840182
Anon wrote:As the O.P. can I first off can I say that I had been somewhat concerned that I would simply be vilified for allowing such an event to happen, but am heartened that in the main the contributions have been well reasoned, encouraging and fair, and I have, and will continue to take these comments on board.

However there has been an assertion in very strong terms that I would have noticed something was amiss during taxi and ground manoeuvring. Let me say that unless you have experienced the same thing yourself you would have no way of knowing for sure this would be the case. So please in this instance believe me when I say there was nothing untoward noticed at the time.


I think the point here wasn't really to assert that something had to have been wrong, but more to ask whether anything was wrong and whether there might have been opportunities to rectify it. If you say it wasn't noticeable then that's a huge learning point for others who might find themselves in the same situation.

If we're thinking constructively about this:

1) What was your day like before you arrived at the airfield?

Were you stressed or rushed? Did you want to be airborne by a particular time? Did you have any time pressures that might have encouraged you to move more quickly through the checks? Was your mind distracted by anything else going on?

2) Is the 'remove tie-downs' a single item on the checklist? Perhaps it should be two (remove left and then right) - less chance of not noticing it.

3) What could be done to make the same error noticeable in the future?

For example, if the tanks were filled with water, then if you kept the lids off rather than on, and began taxing, would they tip off sufficiently for the water to pour out and you'd then hear them banging about in the slipstream?

I think it's a huge leap to suggest you should hang up your headset. Weird stuff happens and everyone lived to tell the tale. You mustn't let a single bad event sway your thinking here. And you should get back flying as soon as you can.
#1840237
Anon

From the outset let me say, I would be far happier flying with you than some contributors on other similar current threads!

Take the time you need, but don’t dwell on this. That way lies demons! Ask me how I know! Engage with those you trust. A problem shared n’ all.

Flyingearly asks “what was your day like before you arrived at the airfield?” But this may not go back far enough. Having been the cause of a serious incident myself, the subsequent investigation invited me to start the examination of contributory factors whenever I wished. For me, that was 4 weeks beforehand! For you it might be even earlier?

It doesn’t surprise me in the slightest that having committed your single error of omission, you had no opportunity to realise what had happened until after you landed. An absolute classic omission in the airline industry is on the go-around, forgetting to raise the gear. Boy is it noisy, but even that doesn’t always necessarily help to appreciate why!

Dust yourself off, and take advantage of this good weather to get yourself back in the air. You’ve done every single reader a great service here! I’ve no doubt you are at least as good an aviator as the majority here, and probably better than before!

So stop hanging about! :thumleft:
JAFO, TopCat, T6Harvard and 1 others liked this