GAFB 97

So, just what are the main issues in GA?

You might be surprised by some of the problems and how to deal with them

As I write this editorial we’re just over halfway through the year so I thought it would be useful to give an idea of the main themes reported to CHIRP in the first 6 months.

The sundial chart at the end shows the associated top GA Key Issues on the inner circle and their relevant sub-issues on the outer wheel. Each report we receive can be ascribed more than one Key Issue or sub-issue and so care needs to be taken in interpreting the chart because one report might feature in a number of sectors but the aggregated results are informative in showing what the main themes have been so far this year.

In this respect, ‘Procedures’ represents the most common theme to date, representing 21% of the issues we’ve had reported. Most of the problems we’ve seen have been in the faulty application of, or did not follow, procedures. But a sizeable chunk also covers lack of understanding and poor knowledge so there’s definitely a case for reviewing some of those aspects of flying that you’re uncertain of or don’t encounter on a day-to-day basis so that you understand and are ready to apply the correct procedures whenever called on – time to review your aircraft’s pilot’s operating handbook and your home base airfield operations manual perhaps.

‘Defences’ refers to how well we are equipped to anticipate and deal with problems that arise. Some problems are difficult to anticipate because they may be insidious in their manifestation, but one of the things we can help ourselves with here is in conducting a thorough Threat and Error Management (TEM) process to assess what might go wrong and what risks might be present. Threats relate to the external things that might go wrong, whilst Errors relate to things that we might get wrong ourselves. TEM is the deliberate thought process that we should conduct before (and during) a flight so that we continually review what we’re about to do so that we can anticipate problems. There are of course endless things that one could list as potential problems but focusing on the existential ones is a good start: what would I do if my take-off performance doesn’t match expectations; what if the enroute weather isn’t as good as forecast; what would I do if the engine quits or runs rough; do I have a Plan B if my destination airfield is closed or weathered out; what would I do if I had a comms failure; have I properly studied the destination airfield topography and strip lengths etc?

‘Communications – External’ is all about making ourselves understood, and understanding what’s being said to us. I featured this in the recent GA FEEDBACK Ed 145 editorial so I won’t labour the point except to highlight the need to use the recognised phrases and pro-words on the radio rather than cool and trendy slang, and to speak clearly and deliberately so that everyone else has the chance to understand exactly what you’re saying. Safety Sense Leaflet 22 provides a good aide memoire about communications and radiotelephony in general that’s not too heavy going so it’s worth a read.

‘Situational Awareness’ and ‘Airmanship’ often go hand-in-hand so it’s not surprising that, together, they represent a largish chunk of the issues that we see. Improving Situational Awareness often comes down to taking advantage of all the information sources that are available to you so that you can synthesise the best understanding you can about what’s going on. Thorough pre-flight planning, electronic navigation aids, Electronic Conspicuity systems, being on a useful frequency, listening to and passing information to others, and making use of ATC when it’s available are all ways of building as comprehensive a picture as you can. Airmanship is then, to a large part, often about how you use that picture to best advantage through the 3 ‘C’s of Caution, Consideration and Courtesy for others, and then making appropriate decisions to choose the best course of action.

Finally, ‘Individual Error’ covers a wide range of actions that may or may not be circumstantial and are mostly unintentional. Never forget that you’re human, and humans make mistakes and errors, so it’s back to that TEM thing again where you need to be honest in your personal analysis of your weaknesses and potential lack of experience or currency! The exception being ‘complacency’, which is pretty much an own-goal in performance terms. ‘Don’t assume, check’, and ‘Assume makes an ass out of u and me’ are well worn phrases but their meaning is clear. Every day is a learning day in aviation so don’t accept poor planning, poor behaviours, ‘that doesn’t look right but I’ll carry on’ or ‘it’ll be OK this once’ because that’ll be the day something comes and bites you on the bum.

The bottom-line? CHIRP provides a vital safety net as another route to promote change when the normal channels of reporting aren’t delivering results, you don’t feel able to report through formal Occurrence Reporting systems, and for collecting reports with safety concerns that did not meet the threshold for normal reporting and would otherwise have gone unwritten. We rely on you to report Human Factors aviation-related safety concerns to us so that we can both help in their resolution and highlight relevant issues to others. Reporting is easy by using either our website portal or our App (scan the appropriate QR code shown or search for ‘CHIRP Aviation’ – avoiding the birdsong apps that come up!). In our reporting portal you’ll be presented with a series of fields to complete, of which you fill in as much as you feel is relevant – not every field is mandatory, but the more information you can give us the better. Although you’ll need to enter your email address to get access to the portal, none of your details are shared outside CHIRP, and we have our own independent secure database and IT systems to ensure confidentiality.

GA Key Issues & sub-issues reported to CHIRP Jan-Jun 2023

  • GA1319

    Infringements – or what almost happened
    Infringements – or what almost happened

    The initial report and protracted subsequent responses and communications are published in précis due to lack of space. In summary, this report came to CHIRP in May 2022 and related to an airspace change involving the introduction of Class C airspace and changes to the vertical extent for the Daventry CTA and Clacton CTA. The reporter was from a flying school, and they had not been aware of the consultation for, or implementation of, the airspace changes (November 2021 and February 2022 respectively) due to the fact that they had not been flying over the period because of COVID/weather restrictions. By the time they had returned to flying in mid-March 2022, the associated NOTAM had been replaced by an AIC (AIC Y 006/2022) and the VFR chart had yet to be updated (the new Edition 48 Southern England and Wales 1/2mil map became available on 27th March).

    The long and the short of it was that they got airborne unaware of the change, and it was only by good fortune that they did not infringe the new airspace. Setting aside the issue of personal and organisational responsibilities to check AICs etc when they returned to flying, with regard to airspace changes the reporter opines that the introduction of the ‘Luton Airspace’ change wasn’t very well communicated, and they suggest that any such changes should remain as active NOTAMs until after the publication of the associated revised VFR chart. More specifically, the reporter commented that, in their opinion:

    It is second nature to start the day looking through the Met Office website and reading through the NOTAMS on the AIS website. The UK AIP is far too large a document to be comprehensively read before each flight; that’s why we have NOTAMS, or should have.When training in our local area, that’s most of our flights, we look at NOTAMs by selecting the Point PIB, typically with a radius of 25nm from our home base.

    I have not been a part of the consultation on the new airspace and I would say that I look to my representative organisations, the British Microlight Aircraft Association (BMAA), the Aircraft Owners and Pilots Association (AOPA), and the Light Aircraft Association (LAA) to comment on behalf of their members. Flying schools have little in the way of resources to comment on the numerous and lengthy consultation documents produced.

    Whilst on the topic of NATS promulgation of airspace information, NATS Briefing Sheets exist to cover events where they will occur at notice too short to be included in the AIRAC cycle. But the existence of Briefing Sheets is unknown to many GA pilots. Should a pilot be searching for Briefing Sheets on the NATS website they are not to be found under the expected heading of Briefings or the next logical heading of NOTAMS but under Publications.

    Overall, the reporter said that the issue was one of communications and that their recommendations were:

      1. To publish a document, for example, a yellow AIC on a website and not tell us about it when we need to know, that’s on the day we do our flight planning, is not useful. The imposition of a new block of controlled airspace should be notified as a NOTAM from the date of inception until it has appeared in the new editions of the relevant maps for such time as is required for the GA community to know of its existence. If NATS are concerned about a proliferation of NOTAMs, I recommend they discontinue publishing those referring to Ethiopia, Ukraine etc; they appear for months on end and are of no relevance to a circle of 25nm radius around an airfield.
      2. The existence of Briefing Sheets and how to access them should be publicised throughout the GA community.
      3. The CAA should review their oversight of NATS communication of NOTAM information to GA.
      4. The CAA should consider engaging an advertising agency to define the methods and media and style to be used in communication; they are experts in putting a complicated concept into simple form appropriate to the target audiences.

    The reporter also forwarded some of their comments to the BMAA, one of their representative associations.

    NATS Comments

    The airspace change followed an extensive public consultation from October 2020 to February 2021, which received feedback from more than 2,400 respondents. Therefore, the potential for an airspace change was known about for a substantial period. The announcement by the CAA on 24 November 2021 through aviation forums was expected and it would be reasonable to expect those in the local area to review what had been approved by the CAA between the November announcement and the February implementation. It would appear the reporter did not do this as they were unaware of the announcement.

    In addition to the publicity, the date for introducing the additional CAS was aligned with the monthly AIRAC cycle update, which is routine.  On Feb 24th the relevant information was incorporated into the respective sections of the UK AIP. The information provided in the response is correct in that when a NOTAM search was conducted in March it would have limited information as the airspace change had been implemented into the UK AIP.  It is assumed the reporter did not access the AIC between November and February, probably because they were unaware of the airspace change.

    It should be noted the reporter refers to ‘Luton airspace’ on several occasions and concentrates on the Luton aspect of the NOTAM search. In fact, the airspace change was the introduction of Class C airspace and changes to the vertical extent for the Daventry CTA and Clacton CTA.  It is true the airspace facilitates arrivals at Luton, but the airspace is not named as ‘Luton’ although Luton was referred to in the publicity. If the reporter had accessed the AIC, the airspace classification and boundaries may have become more apparent.  The AIC referred to in the response was still available after Feb 24th.

    The suggestion that all changes promulgated by NOTAMs should remain valid until a yearly chart update is impracticable.  There is often extensive negative feedback and criticism around the number of NOTAMs provided to a pilot with when planning a flight, with comments such as not relevant or out-of-date. The proposal would make the number of NOTAMs valid before a new chart is published as vast and there would be a lot of negative feedback if this was introduced. It should be noted that electronic flight planning software producers update their products in line with the published AIRAC dates for this purpose.

    BMAA Comments

    As an organisation we signpost selected items of aviation news for our membership based on the widest applicability. We strongly encourage members to take personal responsibility for monitoring all other news items that may be relevant to their specific operation. The best and simplest way to do this is via the CAA SkyWise email service. However, we take note of the reporter’s comments, and we shall look at expanding our efforts with regards to airspace consultations in the future.

    Although we have sympathy regarding the perennial problem of airspace changes sometimes not being reflected on VFR charts for some time after they are invoked, pilots and organisations have an individual responsibility to ensure that they use charts that are up-to-date with the latest chart amendment standard (as shown on the NATS AIP website in the ‘Charts’ section) before every flight.  It is, however, acknowledged that there are often numerous amendments that are not always immediately obvious as to which part of the chart they apply.

    With regard to communication of such changes, we agree that the current system appears to rely heavily on aviators ‘pulling’ information from websites rather than NATS/CAA persistently ‘pushing’ the fact that a change has been made. The CAA SkyWise notification system is a good start for initially highlighting a change, but it relies on people being subscribed and, whilst most flying clubs and organisations may well be, individual pilots may not. With respect to publishing NOTAMs that contain airspace change information until the next edition of the relevant VFR chart is published, CHIRP’s view is that this is probably not ideal given that NOTAMs can only be in place for 3 months and it could in extremis be up to a year before the associated VFR chart is updated – we don’t want to increase the number of NOTAMs in what is already a fairly user-unfriendly system.

    But we do think that more should be done to provide an easily accessible resource that shows all airspace changes that have yet to be published on the VFR chart, along with NOTAM information.  Currently, the Chart Amendments section on the NATS website provides a list of changes but a graphical interface that could be zoomed and localised to a particular area to show chart and other airspace information changes would be of great benefit to the aviation community as a briefing resource, as would a better user-guide on how to access and filter NOTAMs. CHIRP engaged with NATS on information promulgation and received some detailed responses that we don’t have space to reproduce here but which can be accessed on our website Hot Topics.

    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.

    Resources – poor NATS AIS website user interface

    Awareness – the reporter was not aware of the airspace change

    Knowledge – the information was available but not obtained

    Communication – the NATS AIS system relies on users ‘pulling’ information by knowing where to look on the website; more pro-active and persistent publicising of changes using a graphical interface would help

    Complacency – the reporter did not review the AICs before returning to flying after a long layoff

    lack_of_resources, loss_of_awareness, lack_of_knowledge, complacency
  • GA1341

    NOTAM Information Missing or Incomplete
    NOTAM Information Missing or Incomplete

    The NOTAM Info web site at [website] has had a serious fault since late December 2022. Attempts to report this to the site owner have gone unanswered. The site shows no warning about the fault and appears to work correctly.  Pilots who habitually use the site may rely on it as their sole or main source of NOTAM information and may consequently be unaware of important NOTAMs resulting in entry to temporarily restricted airspace or even a collision. The nature of the error is that the software is designed to retrieve all the NOTAMs for the next 7 days. However, from 29th December 2022 onwards, NOTAMs are only retrieved for the next hour. It wasn’t until mid-January that I first realised that I wasn’t seeing all the NOTAMs relevant to my planned flights. I reported the problem using the CONTACT form on the web site. I have had no response so far and the error persists. I have alerted other pilots to the problem and now use the AIS web site to retrieve NOTAMs. [Note, the website has subsequently been corrected which is why we don’t mention its name]. I admit to taking the short cut of using a non-approved source to get my pre-flight NOTAM briefing. I mitigated that by calling the free AIS Information Line number 08085 354802 which is what made me realise that I wasn’t seeing all the relevant NOTAMs.

    Although this report refers to a specific website, the issue is much wider in that it highlights the risks of using uncertified 3rd-party NOTAM websites and electronic planning aids that might have errors or missing information. The definitive source of NOTAM information is the NATS AIS website but, in many respects, it’s not user-friendly and so this is why people use 3rd-party providers. CHIRP has engaged with NATS about this in the past, and improvements have been made in many aspects, but we are pressing them and the CAA to provide a more graphical, chart-based NOTAM and airspace change interface to make them much more user-friendly.

    The bottom-line is that although some 3rd-party NOTAM providers may well provide a more functional user interface, they are not the definitive source of NOTAM information and so should be used with extreme care.

    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.

    Resources – poor user interface for NATS NOTAM retrieval causing people to use 3rd-party websites

    Knowledge – potential for errors or omissions in 3rd-party NOTAM websites

    Complacency – assumption that 3rd-party NOTAM websites provide definitive NOTAM information

    lack_of_resources, lack_of_knowledge, complacency
  • GA1343

    Pitot cover left on
    Pitot cover left on

    A fellow group member and I had gone out for a lunch away on a fine flying day, with light winds and fluffy scattered Cu.  He took the outbound leg, and I brought us back to base.  We parked on the Visitors Line because I had arranged with an instructor that I’d go back out with him in a couple of hours’ time to do my biennial.  There was plenty of fuel aboard, and I didn’t bother with any “putting to bed” things like pitot cover, exhaust bungs, canopy cover, etc.

    Time came for the biennial flight and, after a briefing in the club house, we walked out to the aircraft, parked with its tail to us on the Visitors Line, climbed inside, and went through normal start-up procedures, taxi, checks, and take-off. All was normal until lift-off, when glancing at the ASI, I saw implausibly low figures. First disbelief, then confusion, then acceptance that I had no air speed indication. I guessed that the pitot cover might still be on, although I hadn’t put it on when leaving the aircraft earlier.

    Next, fly the aeroplane. Pitch and power and control pressure and sound, orchestrated to provide me reasonably good guidance on air speed. The instructor, to my right, gave me readouts on ground speed, as displayed on SkyDemon. We made one circuit and landed without drama. Shut down at the hold, and the instructor leapt out, went around to the port wing, and brought the pitot cover back to me. We took off again, with a good ASI, and had a very pleasant flight.

    Afterwards I surmised, and later confirmed, that after our earlier lunch-away flight, my friend had installed the pitot cover while I was doing post-flight paperwork and I hadn’t noticed. So when I walked out with the instructor for the later flight, I assumed the aeroplane was ready to fly. Long ago, a wizened old instructor informed me that “ASSUME” has no place in aviation, as it makes an ASS out of U and ME. This incident taught me that I should remember that maxim, and never skip a walk around after leaving and later returning to an aeroplane, assuming it will be as I left it.

    As the reporter infers, the pre-flight walk-round is an essential activity that must not be skipped; anything could have happened to the aircraft after it has been parked, ranging from a helpful person putting covers on as in this case to someone driving or taxying into it and causing damage. Given that the subsequent flight was a biennial check, one of the things that an instructor could usefully do is to accompany pilots when conducting their walk-rounds so that they can not only confirm that the right things are being looked at but also offer thoughts on other aspects of ground operations and aircraft readiness to fly.

    As an aside, although the reporter coped well with the situation once airborne, don’t forget the value of checking that the airspeed is registering early in the take-off run. Had the reporter done so then they would likely have noticed that the ASI was not indicating and could have aborted the take-off prior to getting airborne. Although it’s not a formal rule, many use the rule-of-thumb that the aircraft must achieve 2/3 of the take-off speed within 1/3 of the calculated take-off distance.  It’s always a good idea to have a marker in your mind at the side of the runway if possible for this distance where you will check the airspeed has increased as expected. In doing so, you’ll not only detect things like pitot covers being left on, but will also detect things like an engine that isn’t operating correctly or the aircraft isn’t at the all-up weight you think it is. If you don’t achieve the 2/3, 1/3 rule then abort the take-off and investigate.

    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.

    Awareness – the pitot cover was there to be seen but wasn’t checked

    Teamwork – the instructor should have confirmed that walk-round checks had been completed

    Complacency – assumption that the aircraft was in the same state as it was left; not checking airspeed early in take-off run

    Deviation – walk-round checks not carried out

    loss_of_awareness, teamwork, complacency, normalisation_of_deviation
  • GA1344

    Pleasure Flights Within the Circuit
    Pleasure Flights Within the Circuit

    There was an [Aircraft] doing figure-of-8 patterns within the circuit over the runway at 500ft. An email had gone out to private owners declaring that the aircraft would be operating, but not that it would be in the overhead. I’m unaware if anything had been added to the PPR page on the website. A couple of other resident owners mentioned that they were somewhat surprised to see an aircraft flying in the opposite direction 300ft below whilst downwind in the circuit. Without a NOTAM in place, or someone in the Tower on radio, it seemed an unusual activity that represented ‘in my humble opinion’ an unacceptable risk should a visiting aircraft need to have ‘gone round’ and climbed into the pattern taken up by the [Aircraft]. The [Aircraft] was operating with a good radio and could be heard but, having said that, one shouldn’t assume that everyone’s radio installation is to the same standard, and there is always the opportunity for two stations to be transmitting at the same time and the message doesn’t get heard.

    Aerodrome Operator Comment

    In addition to our website, our entry in the AIP, section AD 2.20, Local Aerodrome Regulations, provides information and a warning on possible [non-standard] activities over the airfield with aircraft possibly operating non-radio. Other publications also refer to the need to PPR via our online booking system and detail potential airfield activity. The following information was posted on the PPR webpage for those seeking to fly-in, and resident pilots were also advised.

    Caution: 
 [Aircraft] will be carrying out multiple [non-standard] flights from the aerodrome. The [Aircraft] will be operating within the immediate vicinity of the airfield carrying out figures of 8, turns and orbits at 500ft AGL. All other traffic must use the standard circuit height of 800ft AGL for de-confliction and maintain a good look out.

    For operational reasons, it is not possible to prohibit arrivals/departures to accommodate the activity because the exact flight times are subject to variation on the day. For the future, we acknowledge a need for additional notification and will NOTAM accordingly. Also, wherever possible we will provide an Air Traffic Service.

    The airfield accepted that more could have been done to highlight the pleasure-flight activity by NOTAM to both resident and non-resident pilots, and that they will do so in future. Whilst it is true that the airfield’s website PPR page warns that all aircraft wishing to use the airfield should be aware that they must stay well clear of any aircraft carrying out display practices at the airfield, and we note the airfield operator’s comment that, “For operational reasons, it is not possible to prohibit arrivals/departures to accommodate the activity because the exact flight times are subject to variation on the day”, CHIRP thinks that there is a case that, given their potential for conflict in the circuit, activities such as figure-of-8 pleasure flights over the airfield should be constrained to specified, promulgated time slots that other pilots can then plan to avoid rather than operating at ad hoc times.

    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.

    Resources – availability of Tower/ATS during an unusual activity.

    Communication – a NOTAM highlighting the activity would have been preferable.

    Complacency – regular unusual activities may lead to an assumption that other pilots will be aware of the associated risks; unusual activities such as pleasure flights should be constrained to specified, promulgated time slots.

    lack_of_resources, poor_communication, complacency
  • GA1345

    PA28R Undercarriage Woes
    PA28R Undercarriage Woes

    I was a PPL scheduled on a flying school aircraft that I know well for a recreational flight to maintain currency. This was the first flight for the aircraft after coming out of maintenance.  I was, fortunately, unaccompanied. The plan was for 3 visual circuits then a departure to the south for an IFR RNAV re-join.

    Take off and turn to downwind was uneventful and I commenced downwind checks. On turning base leg I checked for 3 greens and was surprised to see nil. I turned final and requested a low pass from Tower. Tower informed that they could see undercarriage down but professionally reminded me that “down” and “locked” were not the same. Another aircraft confirmed this visually. I requested and was granted transit to the south to “sort myself out” and shifted frequency as instructed from Tower to Radar.

    I retrieved the checklist “emergency gear down” and recalled from memory my retractable undercarriage conversion training. Accordingly, I checked the circuit breakers, deployed the emergency landing gear selector and yawed the aircraft from side to side. From the way the aircraft handled I actually had less confidence that the gear was down and locked using the emergency gear down control than when utilising the usual switch gear.

    The aircraft felt as she always did so I moved the gear lever to the “down” position and watched the “gear transitioning” light go out and the 3x “gear safe lights” not go on. I even tapped them hopefully. I then felt that I had done what I should have done and it was what it was.

    I called radar (who were providing a BASIC LARS) and informed them that I wished to declare an emergency. I was instructed to hold whilst conversations were held and then instructed to squawk 7700 and join via a left base. I performed a 2nd low pass across Tower (whose visual confirmation was as before), and re-joined the circuit that I had to myself by now, to land.  The sight of the airport fire service at full deployment managed, if possible, to raise my focus further. Having said that I really believed that I had an indicator problem, not an undercarriage problem, she was flying like a PA28R with the wheels down.

    So I reviewed and discarded the “Wheels up on landing check list”. The touchdown was the gentlest I could manage and all was good. I was given the option of hard parking, which I took – I wasn’t that interested in pushing my luck. I shut down the aircraft, took a deep breath in and out and telephoned the flying school. After expressions of support, I was asked if I had checked the panel light switch. I was at this stage on my own and so I rotated the panel switch upwards to max – no change to landing gear lights. Phew, what sort of idiot would you feel if you had declared an emergency because a light switch was at the incorrect setting? At this stage one of the FIs joined me, and turned the panel switch downwards, past a click point, and on came the gear safe lights. I can now tell you how that idiot feels. I then, in a quite fruity and unrestrained manner, expressed my thoughts that it would be a good idea if this manoeuvre of checking panel lights was on the check list. We then looked at the gear RETRACTION check list, which mentions this very point. I had only reviewed the gear lowering check list. As I write (the next day) this doesn’t seem as gormless as it did when I walked back to the flying school

    Feeling a little fragile (and gormless) I was much reassured by the supportive attitude of the Head of Training and miscellaneous FIs that were in the office. I took much comfort from the approach of “yes, you could have done something different, but from what you knew at the time, your actions were reasonable”. I will leave agreement or otherwise with that sentiment to readers. I also spoke to an old university friend, who is an immensely experienced professional pilot, who reminded me that there are two sorts of pilots, those that have made mistakes and those that are going to.

    Somebody built PA28Rs with the ability to make landing lights so dim they cannot be seen. Who would have thought this? It is in fact a well-known “gotcha”. The reason I had not come across this before was that I had not boarded the aircraft left in this condition before. But this was the first flight after maintenance…be aware that the aircraft (lights/GPS etc) may well not be as you expect. I am sure that somebody at some time, perhaps during night flying, has probably pointed out to me this quirk of the aircraft but, at the time, in the air, I was under pressure and unable to access this knowledge.

     

    The PA28R undercarriage indication quirk where they are effectively extinguished with the panel lights at anything other than off is a trap that many others have probably fallen into.  Why they designed it in such a manner is a mystery, but it’s clearly something that deserves to be publicised widely (both to ATC and pilots) – you don’t know what you don’t know and it shouldn’t be one of those things that only comes to light when old-and-bold pilots pass on the information in circumstances like those reported.  Similarly, the fact that the local emergency undercarriage lowering checklist doesn’t mention the light switch seems to be a serious omission. The picture of the POH shows that Piper are aware of the issue and have given guidance (my highlighting) but it may be that this has not translated into local checklists.

    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.

    Pressure – focusing on the immediate emergency to the detriment of thinking clearly

    Knowledge – information not available in the checklist

    Communication – the Piper warning information was not contained in the emergency landing gear extension checklist

    pressure, lack_of_knowledge, poor_communication