GAFB 103

When the Holes in the Cheese Align

Dusting off the flying gloves in preparation for Spring

Welcome to the early Spring edition of General Aviation FEEDBACK. I say Spring with a degree of optimism, and indeed a few brave bulbs are peeking their heads out. However, on a bitterly cold and rather dreary late February afternoon, just a few weeks into my tenure at CHIRP, the prospect of aviators blowing the cobwebs off their wings, chutes, planes and other craft still feels unlikely. But aviate we will and, for all but the hardened who’ve pressed on over Winter, this is a time for preparation, planning and revision. Even the most accomplished pilots, controllers and skydivers amongst us will get skill-fade after a lay-off, so an opportunity to get heads in the books, check out what’s changed in regulation land and refresh the essentials, will be time well spent. There’s plenty in this edition of FEEDBACK to give you food for thought in this area. Check out the ‘I Learned About Human Factors From That (ILAHFFT)’ honest account of a hornet infestation in an aircraft that had been left out without covers – a pretty close call for the pilot concerned. Then there’s a timely reminder about Air Traffic Services that are available and the differences between them. We also have a super link to videos of the circuits at Popham, complete with everything you need to know whilst flying them and a pilot’s eye view. You can literally ‘fly the circuit’ in real time from the safety of your own home, practising radio calls, checks and running through speeds etc – certainly a vast improvement on the cardboard cockpit and vivid imagination required when I was learning to fly in the mid-80s.

Which reminds me that I’ve not introduced myself yet as your new editor. I’ve recently taken over from the illustrious Steve Forward and have some seriously large shoes to fill. Whilst Steve may have retired from CHIRP Aviation after an impressive 5 years at the helm, he’s not left the world of safety altogether, having recently taken on a new voluntary role as a Director at the UK Flight Safety Committee. We’re delighted to retain Steve’s experience of and enthusiasm for all things Air Safety in the industry. Like Steve, my background is also the RAF, where I started learning to fly on Cambridge University Air Squadron, bashing the circuit in the venerable Bulldog. A life-long helicopter enthusiast, I was lucky enough to specialise in whirly birds, flying mostly Search and Rescue and later, in civil aviation, as an Air Ambulance pilot. I’ve even dabbled in a little paragliding when weather permitted. In latter years I’ve specialised in areas where I’ve long had a general interest: safety management and human factors. So, I join CHIRP with an existing passion for improving safety in aviation and am looking forward to the challenge and continuing where my predecessor left off.

A few of our selection of reports from this Quarter focus on the age-old thorny issue of communication. This facet of human factors is an absolute keystone in aviation with Accuracy, Brevity, Clarity being paramount. You may spot a thread of the phenomenon ‘it’s not what A says, it’s what B understands’ too. There are also a couple of examples of bad attitude, for which there’s never any place in aviation, having safety implications. When considering effective Communication, please also remember Consideration and Compassion in all your human interactions.

One of the great strengths of the GA arm of CHIRP is that we have access to safety lessons learned in every area of crewed aviation imaginable. Whilst on the face of it, ballooning, light aircraft, autogyros and skydiving for example may seem completely diverse, the human factors experiences will almost always read across. Not from a CHIRP report (although it would have been a brilliant one), I recently watched this hair-raising video (https://www.youtube.com/watch?v=csDRdqMH3Kk) about a hang glider pilot who mistakenly connected his carabiner to the velcro rather than the webbing of the extension hang loop. Entitled ‘The flight that almost killed me’, it’s a frank and courageous account of the sequence of events, including hanging initially from a piece of velcro that eventually and suddenly gave way (surprise, startle ++), that very nearly were fatal. Even though he checked his kit before launch, he missed the mistake. This could apply to any of us. How often have you looked at something and ‘seen’ what you expected to see? It’s a salutary reminder when doing safety checks to ‘look’ in a different, more inquisitive and questioning way. Equally, hats off to this pilot for posting a self-critical and honest assessment. We learn from our own mistakes, but so much better if we can learn from the mistakes of others.

The human factors and aviation safety world recently lost one of its greats – Dr James Reason. Amongst a plethora of ground-breaking work, his research profoundly influenced how the aviation industry approaches human error and risk management, highlighting the importance of understanding human factors in accidents. In the unlikely event that you’ve not heard of him, I implore you to undertake a little light research; you’ll certainly learn something thought-provoking that will enhance your own contribution to flight safety. In addition to the famous Swiss Cheese Model of accident causation (what defensive barriers and cheesy holes can you spot in this edition’s featured reports and ILAHFFT?), Dr Reason also proposed the 12 Principles of Human Error. So, my thought for this edition and one worth considering in everything we do, not just flying, is his first ‘principle’:

Human error is universal and inevitable – it is not a moral failing. While human fallibility can be moderated, it can never be entirely eliminated.”
Dr James Reason CBE, May 1938 – Feb 2025

Finally, I’d like to make another introduction and welcome Bill Dean to the CHIRP Aviation Team as the first ever CHIRP Advanced Air Mobility Programme Manager and Deputy Director Aviation. Bill is a former military fast jet pilot who has specialised in flight test and safety throughout his career, latterly with Rolls-Royce and Boeing. In addition to his work with CHIRP, he’s keeping his flying qualifications current by display flying warbirds with Navy Wings. Please read on for Bill’s thoughts about preparing for the very specialised demands of the upcoming display season.

Grab a coffee, relax and take some time out to enjoy this edition of FEEDBACK.

Nicky Smith, Director Aviation

Safety Reporting and Air Display Flying 

At this time of year, numerous air display teams across the UK, as well as private individuals, will be completing their winter maintenance activities and gearing up for another busy air show season. CAA organised or endorsed pre-season display symposia, held every year in Feb/March, complement the annual training preparations with a range of air safety and human factors focused presentations and workshops. We here at CHIRP are fortunate to have the GA Advisory Board members sourced from a wide range of aviation backgrounds, including flight instruction, air safety, as well as those with many years’ display flying experience. The air display community is wide reaching and includes not only pilots but engineers, event organisers, air display directors and operations teams, display authorisation examiners, commentators, ATC providers, the CAA oversight team, and the list goes on.
Please, if you are one of these key stakeholders in the UK air display community, working or volunteering in this upcoming season, do remember the resource we have here at CHIRP to confidentially, independently, and professionally handle any report you feel you want to submit, particularly those reports, for whatever reason, you are hesitant to submit or otherwise communicate within your team or organisation and, as is often the case, amongst colleagues generally.

Bill Dean, Deputy Director Aviation