The report referenced an unfortunate incident that, although we do not have all of the circumstances that pertained from the ATC perspective, appears sub-optimal in how they managed the situation. The pilot would most likely have been under a Traffic Service as they approached controlled airspace, and so there should have been ample opportunity for the controllers involved to plan ahead and ensure integration (or at least a location to orbit if they could not accept the aircraft at that point). But we don’t know all of the factors that may have influenced the situation and so there could have been any number of reasons why the late call was made. That being said, a last-minute cancellation of clearance, coupled with a downgrade to Basic Service at the CAS boundary is certainly not best practice, and we commend the supervising controller for their acknowledgment of this when the reporter contacted them after the event.

Ultimately, it was the On the Job Training Instructor’s (OJTI) responsibility to ensure that appropriate decisions were made and, although there are benefits to allowing students to make mistakes and then recover from difficult situations, the OJTI should always be able to step in and provide appropriate instructions at any time. Whilst the cancellation of the clearance at the last minute might well have been the OJTI salvaging the situation by trying to ensure that the aircraft did not enter busy airspace, simply cancelling IFR and applying a Basic Service with another aircraft following behind put the pilot in an unenviable situation. As part of that decision-making process, the fact that the pilot was IMC at the time might have been a piece of information that was missing in the controller’s decision to downgrade to a Basic Service and so, whilst not suggesting that this was necessarily the case in this instance, this reinforces the importance of good two-way information transfer so that the controllers are able to take all factors into account.

What would you have done in similar circumstances? The pilot was clearly aware of the other traffic in their vicinity and so we commend them for weighing up all of the options and deciding that the least worse outcome was to penetrate controlled airspace for a short period as they manoeuvred. Although this call was very late and there were few options available, always have a Plan B in mind in case entry to controlled airspace is denied. In this respect, Threat and Error Management (TEM) is the key to anticipating external things that might potentially cause difficulties (threats) or come about as a result of your own vulnerabilities, weaknesses or mistakes (errors). We’re not saying that every circumstance can be anticipated, but it certainly helps to have a bank of options available if things go pear-shaped.

No doubt the student controller received a thorough debriefing from the OJTI, but were any lessons promulgated more widely for the benefit of others to learn from? Given that the pilot had no choice but to effectively infringe the airspace as they reacted to the last-minute cancellation, and in the vein of promoting Just and Learning Cultures, they could have submitted an airspace infringement occurrence report or, perhaps more appropriate, a CAA Form FCS1522 (Airspace Access or Refusal of ATS, see QR code) which would have raised the issue with the CAA and provided an opportunity for other units to learn lessons. CAA Form FCS1522 is a simple way of reporting airspace access or service provision problems that we recommend all pilots consider using when appropriate: without such data, improvements in ATC resourcing or service availability will be unlikely to be forthcoming (CluedUp GA Update April 2023 also refers).

We commend the reporter for their frank and honest report; they didn’t need to tell anyone about what happened but their altruistic decision to do so provides us with the opportunity again to remind others about the need to make sure we don’t become task-focused at the expense of routine flying tasks.

Their report is also a good advert for talking to ATC, who were able to assist in avoiding the DZ. This is good practice whenever possible anyway, but especially if conducting activities such as getting test data when, despite being aware of the extra heads-in time, there is inevitably a degradation of capacity, situational awareness, and potentially lookout. In this respect, if you’re conducting such recording tasks in a multi-seat aircraft then also consider taking someone else in the cockpit to either record the information and/or assist with lookout whilst you concentrate on achieving the data points.

The reporter has identified many of the lessons themselves, and we concur that the issue of the tablet’s location was a part of the problem. We’ve commented before about fixing such devices securely in the cockpit in a suitable and appropriate location to be viewed easily, and CAA Safety Sense Leaflet 29 ‘VFR Moving Map Devices’ gives some additional thoughts on the positioning of devices and their prioritisation when using them as moving map displays.

The reporter’s lesson about assuming that the weather was too bad for parachutists should also be heeded because, as they comment themselves, this was a perilous assumption. Parachutists often jump in what some aviators would consider poor weather conditions but which are in fact suitable for parachuting. As a matter of good practice, conduct thorough pre-flight planning to note DZ locations and always route around them to avoid conflicts whenever possible, but especially if heads-in and recording information as in this case.

This is a very concerning report. The C150 has known performance issues that require it to be treated with caution and should certainly be the subject of an extensive pre-flight briefing, especially with a prospective new instructor of which the CFI would have had no prior knowledge.  Although it was recognised that pilots do not have to conduct Weight & Balance calculations for every flight, we strongly recommend that they do if any parameters have changed or additions been made since the last calculation. But the situation is different in the instructional context, and instructors should expect the student to do the calculation as a matter of course. In this respect, and as also stated in Safety Sense Leaflet 9 ‘Weight, Balance & Performance’, UK Regulation NCO.GEN.105 ‘Pilot-in-command responsibilities and authority’ requires that the pilot in command of Part 21 aircraft be satisfied that a flight can be safely made, and that the weight and centre of gravity location remains within the prescribed limitations for the aircraft. Article 69 of the Air Navigation Order 2016 applies the same requirement for flights involving non-Part 21 aircraft. In short, pilots must at least always satisfy themselves that the aircraft is being operated within CG, AUW and performance limits. It is CHIRP’s opinion that any check of a new instructor should certainly include their capability to do such calculations as a formal part of the assessment.

The CFI’s approach to the assessment seemed substantially lacking, and the poor impression that that created reflected on the culture likely to be present within the organisation. As a result, the reporter’s subsequent decision not to have anything to do with the organisation was understandable. If a CFI is checking out a new instructor then we’d certainly expect them to want to see and do everything required to confirm the instructor’s instructional and flying ability, not just for their professional satisfaction, but also to make sure that the potential new instructor was the sort of person who does things properly when it comes to students. Perhaps it’s understandable that the CFI was trying to make the most of an opportunity, but this was not really the time and place to act in such a manner.

We wondered when the last time the organisation was scrutinised by the CAA, and it seems that at the time they had not yet been audited in their current guise within the new DTO regime (although they may have been audited in a different incarnation previously).  When an organisation initially declares themselves as a DTO, they are able to commence operations immediately, prior to an audit taking place. The CAA states that, in general, DTO inspection frequency depends on the level of safety risk based on previous inspections, with the maximum oversight planning cycle not exceeding 6 years (see CAP1637 Para 6.7). This particular organisation was on a 36 month inspection cycle and has since been audited for the first time after this report was submitted. In addition to CAA inspections, DTOs are required to conduct their own annual reviews and submit their results to their allocated Licensing Standards Inspector.  CAP1637 Chapter 6 (DTO.GEN.270) details the required content of such annual self-assessments.

The issue of ensuring proper assessment of new instructors was previously the subject of ‘AIC P 022/2001 – Newly Qualified Flight Instructors’ (recently revoked) that had been issued in response to an AAIB investigation into a fatal accident involving a newly-qualified flight instructor conducting a trial lesson in a Piper PA-28-140 at Bournemouth (G-OSOW 18 December 1999). This accident had attracted an AAIB comment within their report that: “Whilst the pilot did receive briefings on various club matters, no formal check flight or assessment of his instructional or flying ability was required or carried out. The accident flight was the first occasion that the pilot had flown the PA28 Cherokee, all his previous flying was on the PA28 Warrior.”

AIC P022/2001 had referred to the need for thorough checks on new instructors to be carried out and “if the [training facility] operated a class or type of aeroplane not covered by the experience of the newly appointed instructor, specific differences should be identified to the instructor and the differences training recorded in his/her logbook.” Unfortunately, this particular AIC, which had conveyed a very useful flight safety message about new instructors, is now no longer available but the CAA state that the associated responsibilities for instructional staff are now captured in CAP1637 Chapter 3 (DTO.GEN.210) Para 3.2 under the responsibilities of the Head of Training. However, whilst this articulates responsibilities, it does not provide specific guidance as to content for the induction and ongoing assessment of instructors; there appears to be a gap in available guidance in this respect.

Making such things to pattern should only be done as a last resort (such practice is completely prohibited in the commercial world) because of the uncertainty in ensuring correct tolerances. Even if the reporter had chosen to use a micrometer to establish gasket thickness, the old gasket will have been crushed on initial installation and so any measurement would have given an inaccurate result (below thickness in this case).

Fundamentally, the lesson is to use manufacturer-approved materials whenever possible, but there ought to be some guidance as to what thickness gasket is required for those who have the skills to manufacture such materials themselves because it’s quite common for people to do so. We understand that Maintenance Manuals for GA aircraft can sometimes be rather lightweight in detail, and often allow the use of standard engineering practices, but this particular item should be in the manual due to the obvious close tolerances.

Whilst we understand that the self-manufactured thinner gasket seems to work fine, we’d recommend that the reporter replaces the gasket with the manufacturer’s official versions; you just don’t know how close you might be to the tolerance limit with the self-made version. More importantly, it would also be apposite to check the fuel pump push-rod at the same time to ensure it is not worn or deformed because this could also be a problem rather than just the thickness of the gasket paper alone; the pump itself may well be at the limit of tolerances. We recommended that the reporter contact the LAA/BMAA as applicable to their aircraft type for advice, and it may well be worth them engaging an engineer to check the fuel pump for such wear, or just get a new pump if there’s any doubt.

On a handling note, well done to the reporter for reacting appropriately when encountering the rough-running engine, and for not subsequently assuming all was ok and trying to resume the climb once the rough-running had stopped in the descent. Reduced-power emergencies on climb-out can be real killers because, instead of making a decision to land and enacting that decision, people sometimes try to nurse the aircraft along and can end up in situations that they might not be able to recover. The reporter’s comments about checking fuel pressure before take-off speak for themselves; Ts & Ps don’t just apply to oil pressure; if you have a gauge, check the fuel pressure too.

The reporter’s suggestion of using the BHPA’s CANP app (or similar) for model aircraft flying would appear at first thought to have considerable merit. Although many such flights may not require formal notification, if the system was sufficiently easy to use and undemanding in application, then the increased awareness of model aircraft flying at BMFA and LMAA sites would potentially be of benefit to all. However, there are practical limitations in the potential numbers of such flights and the resources required to translate the CANP notifications into H-series NOTAMs. If the suggestion was taken up then it will probably be important at least initially to limit the associated CANPs to those activities above 400ft so as not to flood the CANP/NOTAM system with numerous entries for relatively frequent below-400ft activities that would not be so relevant to GA generally flying above 500ft.

Ultimately, using the new CANP/NOTAM approach would make any such NOTAMs more time-relevant, specific and hopefully encourage better NOTAMs to be submitted through a more user-friendly application. As the reporter states, in order to use the new app, the BMFA would have to upload their flying sites, but this was not thought to be an insurmountable issue.

Finally, rather than involve MAMC in translating CANP into H-series NOTAMs, an automated system would have great utility that could also extend beyond weekday-only NOTAM generation. Constraining the CANP app to defined outputs would probably be required in order to prevent spurious CANP entries being input in error and then being rejected by the automated NOTAM generator. There would also need to be some form of validation of user to ensure cyber security and prevent attacks.

UK Regulation (EU) 2019/947 ‘UAS Regulation’ (https://regulatorylibrary.caa.co.uk/2019-947-pdf/PDF.pdf), Appendix A – Article 16, GM1 Article 16(1) UAS Operations in the Framework of Model Aircraft Clubs and Associations, states:

NOTIFICATION OF MODEL AIRCRAFT ACTIVITY TO OTHER AIRSPACE USERS

Consideration should be given to the need to notify other airspace users of model aircraft activity, when operating within the terms of an Article 16 authorisation. This should be identified at the time of application, during the risk assessment process.

Generally, this includes when operating above 400ft AGL as part of a display, or when operating a large model aircraft above 400ft.

Model aircraft operating within an aerodrome FRZ may be notified to other airspace users, via a NOTAM. This is at the discretion of the aerodrome ATS unit, and the recommendations set out in AIP section ENR 1.1 – 4.1.8.13.

Generally, a VLOS [Visual Line of Sight] operation of a model aircraft does not require notification when above 400ft, when stated within the terms of the Article 16 authorisation and when outside controlled airspace.

The primary means of notification is via a NOTAM. A NOTAM highlights important operational information to pilots, which is checked as part of the brief before departure. NOTAMs are issued by the NOTAM office at NATS, and can be arranged by the CAA, individual operators, aerodromes or other agencies as necessary.

A NOTAM should be used to highlight unusual model aircraft activity to other pilots for awareness. This includes displays above 400ft, large model aircraft operating above 400ft and in some cases, when operating within an aerodrome FRZ. A NOTAM may be requested via the online form, available from the CAA website, or, for an aerodrome ATZ, by the aerodrome contacting the NOTAM office.

In general, a NOTAM should not be raised for an activity which is also notified within the AIP (section 5.5 (aerial sporting and recreational activities). However, it is acknowledged that some sites in some instances (large display events for example) may need additional notification, in order to improve their visibility to airspace users, particularly the VFR GA community. In this case, a NOTAM in addition to the AIP entry may be requested for ‘an intense area of model aircraft activity’. These should be requested when necessary via the online form, available here.