GAFB 94

Common themes, common problems

Six key issues that provide food for thought

By the time this edition of FEEDBACK is published the year will be coming to an end and it’ll be a good time to look back at what has happened in 2022. Of the 550 reports that CHIRP has received in total to date (mid-November as I write this), which includes commercial aviation etc, there were 24 GA and 10 ATC reports. This probably reflects a slow start to the year’s GA flying post-pandemic and represents about half the level of GA reporting that we would expect in a ‘normal’ non-COVID year. In particular, GA reporting has markedly tailed off since the summer for some reason despite it being one of the best flying seasons for many years in weather terms. CHIRP doesn’t have access to any statistics for flying rates with which to normalise these figures and so we can’t determine whether there was simply less flying so fewer incidents, fewer Human Factors events from similar flying rates (unlikely given the impact of previous COVID-related lack of recency), or just a reticence to report for whatever reason.

Although we need to take care in extrapolating data from the relatively small number of reports we did receive, we can still draw some valuable themes to help us think about future safety. The sunburst diagram shows the top-6 key issues reported to CHIRP; Procedures, Handling/Operation, Situational Awareness, Individual Error, Communications, and Defences. Within these 6 key issues, the most common themes provide food for thought.

Application of Procedures is one area where, on the face of it, we could do better. Procedures are there to prevent errors and are one of the strengths of the aviation safety culture in making sure we all do the right thing the right way. Although there will always be situations that don’t quite fit, procedures provide the hand-rail for us all to use as the basis for our operations so perhaps now is a good time to dust off those operating manuals during the winter months and refresh ourselves on the way things should go.

Airmanship and Situational Awareness generally go hand-in-hand, it’s very hard to exercise good Airmanship without good Situational Awareness and vice-versa. But what is ‘good Airmanship’? The CAA Safety Sense Leaflet 01 (about to be re-issued I understand) has plenty of good tips and advice but, for me, Airmanship is much more than just experience; it’s akin to wisdom: an attribute built from careful thought, listening to others and the application of the 3Cs of Caution, Courtesy and Consideration for others.

Complacency featured quite regularly in the reports sent to us, and mostly self-identified with humility by those who reported. Ranging from a lack of thoroughness in planning or the use of checklists to an assumption that ‘it’ll be alright on the night’, complacency is another area where we can examine our own actions and, if we ever find ourselves glossing over important details or not paying attention to threats that we might identify because it’s inconvenient to change our plans, then that’s the time to stop, review what’s going on and make sure we really have covered the essentials of Threat and Error Management (TEM). Complacency (equivalent to making the error of not doing something in TEM terms) also has parallels with how we deal with ‘Defences’ (aka mitigating risks) where we can see that ‘Insufficiently Ready’, ‘Insufficiently Aware of Risks’ and ‘Threat Detection’ were all areas that could have been improved in 2022.

Finally, the perennial ‘Communication’ theme was ever-present. Ambiguous passage or misunderstanding of information is why we have a lexicon of pro-words and phrases intended to ensure that misunderstandings are minimised, so we must make every effort to use the right words at the right time rather than being ‘cool’ on the radio with slang, lingo and banter. But the most important thing is to use the radio to pass/receive information for the benefit of ourselves and others on the frequency or simply ask questions when we’re not sure. I’m not advocating hugely verbose R/T calls, but making the right calls at the right time is vital, and if you don’t understand what is being asked of you or what is going on then don’t be incurious or proud, ask the question in plain language to gain that situational awareness and give a boost to that airmanship.

If nothing else, a few quiet moments thinking of those 6 themes before each flight would be a useful way of spending a few minutes, and even better, another few minutes after each flight as well to honestly review your performance and log away some personal lessons for the next flight.

Safe flying in 2023,

Steve Forward, Director Aviation