Confidential Human Factors
Incident Reporting Programme
The Charity
Aviation
Maritime
GA1329
Initial Report
A training aircraft was landing whilst I waited at the runway hold. The student pilot was early in the flare, and this caught my attention, becoming a point of discussion in the cabin. I waited for the aircraft to touch-and-go and begin its turnout before declaring ready for departure. I am always careful to create a mental picture of the situation at the aerodrome by listening to the RT exchanges. No such transmissions were heard, I declared I was ready for departure (the aerodrome is A/G only), and the wind was provided. As soon as I stated I was entering the runway, A/G advised ‘hold’. I held immediately, wondering what the problem was. I checked the approach to find an aircraft on short final, partially obscured by trees very close to the threshold, having made no radio transmissions at any stage during its arrival to the airfield, and entering the ATZ by a straight-in approach, not overhead, which gave almost no warning of the aircraft’s presence. Concerned that I may have missed a crucial R/T call, I asked if my passenger had heard anything, who said they had not. I asked the A/G operator whether transmissions had been received from the arriving aircraft, and he confirmed they had not.
I can confirm the landing aircraft did not join overhead. Had it done so, it would have provided a much longer period to be spotted, and would have appeared against a sky backdrop, and not the high ground to its rear that helped mask it. A peculiarity was that, when I asked the A/G operator to advise, before lining-up and after the aircraft had cleared the active runway, whether it had sent transmissions (that I may not have heard) on arrival, the A/G operator responded ‘negative’ and the pilot of the now just-landed aircraft was prompted by this to send what were broken calls and, after what seemed like a ‘fiddle with the connections’, made a perfectly-readable apology for the incident. I simply responded briefly ‘no problem, these things happen’, and no more was heard of the matter.
Lessons learned:
(1) Avoid distraction at busy pre-departure stage; double-check the approach before entering.
(2) Recognise radios do fail
(3) If radio fails, join overhead, not straight in.
(4) Divert asap on radio failure; don’t just continue.
CHIRP Comment
Non-radio or radio-fail aircraft have a responsibility to ensure they can integrate safely into the pattern of traffic and this is best done through an overhead join if they are permitted at the airfield. However, it could be that the pilot of the other aircraft thought they were transmitting and were completing a straight-in join without realising that they had a radio failure or incorrect frequency; that being said, if they did not receive any response to their transmissions then that should have alerted them that something was amiss and that an overhead join would be a better course of action. Irrespective, the A/G operator is to be commended for their call to ‘Hold’ because, regardless of the normal rule preventing them from issuing instructions, this was a safety event that fully justified their intervention. The importance of avoiding distractions and conducting a final look up the approach path before lining up cannot be overstressed because there may be aircraft on final that are non-radio, you simply have not heard, or which may genuinely have a radio failure – aircraft on final have priority and it is your responsibility to only line up after they have landed. In this respect, whilst waiting to line up, if possible do so with your aircraft pointing up the final approach/base leg (at an angle appropriate for best visibility depending on the wing configuration of your aircraft) rather than perpendicular pointing at the runway because this will aid your ability to see traffic on the approach. Finally, the implications of the reporter’s ‘lesson learned’ to divert if experiencing a radio failure need to be carefully considered because this might simply export a problem to somewhere else and would also mean that any pilot doing so would then be transiting without the benefit of a radio (and hence any potential assistance from ATC). They might also potentially be landing at another airfield contrary to that which had previously been notified and so any tracing action might be compromised. If you become aware of a radio failure enroute then diversion is a sensible option to land as soon as practical but if it occurs near to your destination then continuing as planned is probably the best course of action (ideally through an overhead join but taking due regard of any radio-failure procedures that you should have reviewed during your pre-flight planning processes).
Key Issues relating to this report
Dirty Dozen Human Factors
The following ‘Dirty Dozen’ Human Factors elements were a key part of the CHIRP discussions about this report and are intended to provide food for thought when considering aspects that might be pertinent in similar circumstances.
Distraction – preparations for take-off and disadvantageous terrain background compromised lookout
Awareness – lookout, and no aural cues available that the ‘radio-failure’ aircraft was on final
Communication – ‘radio-failure’ aircraft compromised communication of intentions
Deviation – radio-failure aircraft should ideally conduct overhead joins if permitted