GA1318

2nd September 2022

Possible Class D infringement

Initial Report

I had flown back from Belgium on Friday, and found then that my friends were taking their aircraft to [maintenance airfield] for avionics work on Monday. I emailed them on Sunday and offered to fetch them back, which was arranged for “after meeting for lunch at [Airfield]” owing to expected morning haze. I slept very badly Sunday night. My wife got up very early for golf and I remained asleep. My watch was left upside down in my electric watch winder and what I thought was after 0800 was almost 1330 when I got up. I telephoned my friends, but they had just landed at [maintenance airfield] – otherwise I would have said I would be unable to come.

I had checked NOTAMs, weather, and the [maintenance airfield] information in Jeppesen late Sunday night, and made a flight log using the forecast of upper level wind and TAF available on Sunday night. In view of the forecast light wind, and the Jeppesen information, I was expecting [runway] for landing. I had done my basic training at [maintenance airfield], and knew the entry procedure and taxi route to the old [maintenance location]. I set up only the [maintenance airfield] NDB, and a ‘Direct To’ on the GPS. I was surprised by the bad visibility, and wasted time looking for [entry point] whilst going west, not, it would appear, keeping the proper NW course. I then checked the ATIS using my old No1 25khz radio before calling App on my new No 2 8.33 radio. I was then very close to the CTR. Had I been on a better course I would have had more time. I was told to continue on a long final and call tower. For some unknown reason I tried to call tower on the No 1 radio, which was not successful, so only got onto Tower on quite short final. I then tried to go to the old [maintenance location] apron and missed my turn. I called ATC (I think Approach/Radar) as requested from the [maintenance location] telephone, but our conversation was interrupted by “an incident”.

I have viewed GPS tracking data from my Golze weather receiver. This only shows periodic fixes, not tracks, but indicates that I was 500 feet below the Class D when becoming aligned with the final approach track. I was not awake/alert enough to fly at the time; that was the main cause of this disgraceful incident. I should not have gone, or else taken an hour to wake up more and get some refreshment. Having both my radios 8.33 capable would have prevented me from trying to set an unavailable frequency. If feeling sleepy I should not be flying.

CHIRP Comment

Firstly, CHIRP commends the reporter for their frank and open report in describing an incident that was not their finest hour. It takes real courage to do so, and is in the finest traditions of making safety information available to all for the benefit of others who might otherwise fall into the same trap. The reporter identified a number of things that they might have been done differently in other circumstances and the important thing now is to take those lessons onboard and resist the same temptations again. Reports such as these about things that ‘nearly went wrong’ provide a host of lessons that are useful education for all so please do send them to CHIRP for wider publication – you do not need to be concerned about being identified, we take great efforts to disidentify any reports we publish so that reporters can feel safe in sending in their experiences and lessons for others without fear of personal condemnation.

Fatigue and fitness to fly is not just an issue for the commercial world but needs to be considered by all pilots so that we avoid making mistakes when we are tired. The handy mnemonic IAMSAFE is a good way of reviewing yourself to see if you are fit to fly, not only in respect of fatigue/tiredness but in other physiological aspects. But you must do so honestly and thoroughly. Personal performance and tiredness are notoriously difficult to self-evaluate (we all tend to over-estimate our abilities), and so it takes real discipline to admit to ourselves that we perhaps shouldn’t be flying, driving or operating machinery when we are below par. CHIRP thinks that the IAMSAFE mnemonic should be more widely publicised than the current ‘IM SAFE’ in the Skyway Code because IAMSAFE also includes the important ‘Attitude’ aspect of whether you are emotionally ready and focussed on the flight so we’ve written to the CAA to see if they might update their publications. Another factor in this incident was self-induced pressure to fly because of a sense of duty to friends or others who might be relying on you. Again, it’s easier said than done, but we must all resist such temptations to ‘press on’ out of a misplaced sense of duty when we’re unfit, the weather is poorer than expected, or some other problem arises that we know we shouldn’t overlook but are tempted to do so to ‘get the job done’ and not let others down.

 I – Illness (do I have any symptoms that might affect my ability to fly?)

A – Attitude (am I emotionally ready and fully focussed on the flight?)

M – Medication (am I taking any prescription or over-the-counter drugs that might affect my performance?)

S – Stress (am I under pressure or have any worries and anxieties?)

A – Alcohol (have I been drinking within the last 24 hours?)1

F – Fatigue (am I tired or not adequately rested?)

E – Eating (am I adequately nourished?)

 

[1] Railways and Transport Safety Act 2003 Part 5 ‘Aviation: Alcohol and Drugs’ S.93 ‘Prescribed limit’ states:

(1)  A person commits an offence if—

(a)  he performs an aviation function at a time when the proportion of alcohol in his breath, blood or urine exceeds the prescribed limit, or

(b). he carries out an activity which is ancillary to an aviation function at a time when the proportion of alcohol in his breath, blood or urine exceeds the prescribed limit.

(2). The prescribed limit of alcohol is (subject to subsection (3))—

(a). in the case of breath, 9 microgrammes of alcohol in 100 millilitres,

(b). in the case of blood, 20 milligrammes of alcohol in 100 millilitres, and

(c). in the case of urine, 27 milligrammes of alcohol in 100 millilitres.

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.

Fatigue – extreme tiredness from prolonged activity (not sufficiently rested and alert)

Pressure – compulsion or anxiety to satisfy demands (a sense of duty to others to fly)

Distraction – attention diverted from task by internal mis-prioritisation (Aviate, Navigate, Communicate rather than letting things like weather/ATIS/radios become the centre of attention)

Awareness – inputs not assimilated or sought (seeking assistance from others such as ATC when things don’t go to plan)

Complacency – disregard for risks, over-assumption of ability or habitual behaviour (thinking that being familiar with procedures/airfield will mitigate lack of detailed planning)

  • Awareness
  • Complacency
  • Distraction
  • Fatigue
  • Pressure

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