Confidential Human Factors
Incident Reporting Programme
The Charity
Aviation
Maritime
GA1339
Initial Report
I was taxiing to the hold for take-off, and heard an aircraft call “short final”. I stopped at the hold and waited for an Auster to land. I announced I was lining up on [Runway], moved onto the runway when the Auster was at the bottom end of the runway and waited briefly for it to turn off the runway. As I was rolling to take off, I heard “going around” and around 10 seconds later saw the shadow from an aircraft passing above. The other aircraft (an RV6) called on the radio to say they had called final and I apologised for my error and said I would contact them on landing. I caught up with the RV6 pilot and passenger after the flight and they were very courteous and understanding of my error. The RV6 had flown in with the Auster and said they had seen me waiting at the hold and were then surprised to see me line up on the runway. Luckily they were able to make the decision to go around in plenty of time.
This has not happened to me before, so I am trying to explore the reasons for my error. I have listed what I see as main potential factors, although in hindsight I cannot confirm how significant the contribution was in each case:
Awareness: I missed the 2nd aircraft on approach (it had a white underside with red wing tips). I was also looking into sun (although it was not blinding). Was my scan rusty due to reduced flying over winter? Did I miss the RV6 call final or was it their “short final” call I heard when taxiing and assumed that was the Auster?
Awareness: Ensure I am not biased in my decision and keep an open mind to all possibilities. Just because I heard one call and saw one aircraft does not mean it was the same aircraft and that there was only one aircraft.
Complacency: This was my second flight of the day and the airfield had been quiet for the first one. Did I assume there was only one aircraft and so subconsciously not expect to see another aircraft on my scan? Non-radio is not uncommon at this (my home) airfield so I do not (normally) only rely on radio calls.
Distraction: I was performing a permit check-flight, with a recently rebuilt engine. Was I focused on the flight check and increased risk of engine failure at the expense of airmanship?
CHIRP Comment
By coincidence, in our last edition of FEEDBACK (Edition 95 – February 2023) we had a similar incident (GA1329) where we offered the advice: “…whilst waiting to line up, if possible do so with your aircraft pointing up the final approach/base leg (at an angle appropriate for best visibility depending on the wing configuration of your aircraft) rather than perpendicular pointing at the runway because this will aid your ability to see traffic on the approach”. The reporter in this second report confirmed that in this instance he did have a good view of final approach and base leg but our previous comments stand as good advice for all to consider.
Having formed a mental picture from radio calls, care must be taken not to succumb to Confirmation Bias when looking out thereby only seeing what you expect to see. The reporter makes this point themselves, even though you might think you know what is going on from radio calls, the purpose of looking is to ensure that you really do have all of the information and situational awareness. And when looking up the final approach, think about the potential for other aircraft with different approach angles (e.g. autogyros or para-dropping aircraft on steep approaches) or the possibility of non-radio or radio-failure aircraft that you might not have heard. Some recommend that a turn to position at the runway prior to lining up should always be done in the direction of the circuit pattern because this gives you a chance to see the whole of the circuit before you enter the runway thereby ensuring you have the maximum chance of spotting all other aircraft.
Finally, although not germane to this particular incident, take care when entering the runway to line up whilst you wait for other aircraft to clear. If you do so then you may be denying the runway to other aircraft, especially if you are not prompt in taking off when the runway does become clear: when entering a runway even to just line up you should always be ready and able to take off immediately so that you don’t baulk other aircraft in the circuit.
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.
Distraction – focusing on the flight ahead (permit check-flight) rather than the task at hand (take-off).
Awareness – did not assimilate that there was a second aircraft on final.
Complacency – relying on radio calls and seeing what was expected rather than thorough lookout.