Confidential Human Factors
Incident Reporting Programme
The Charity
Aviation
Maritime
GA1380
Initial Report
Three aircraft were in the circuit at [Location]. I was holding because an aircraft had declared final (and was on short final); another aircraft was turning base.
An aircraft that was behind me, and also waiting to depart, asked me on the radio whether I was going to go. I told them no, as another aircraft had declared final. It would have been unsafe for me to do so. The aircraft then applied power and turned around us, overtaking us and going onto the runway. The radio station asked the aircraft why he was on the runway, when another aircraft had declared final. The aircraft just responded with “rolling”.
CHIRP Comment
The airfield concerned is a CAA licenced aerodrome with A/G radio only. This means that all airfield users need to be extra vigilant when taxying, entering, departing and crossing runways as well as during take-off and landing. This report highlights what can happen in an uncontrolled environment that does not have the added ‘eyes and ears’ of ATC contributing to the overall safety of ground and air operations.
Leap frogging in front of an aircraft at the holding point, as described in this report, in order to expedite one’s own take-off, is not only inconsiderate but carries a great deal of risk e.g. such an unexpected manoeuvre could have caused an over-reaction from the aircraft in front at the holding point. Moreover, this unusual manoeuvre indicates an element of impatience, even rushing, on the part of the pilot in command of the overtaking aircraft, which is often a precursor to poor decision making as well as other human performance influencing factors. Finally, the overtaking pilot could not rely 100% on their aircraft to take-off normally. We all know to be prepared for an engine failure or partial engine issue on departure; had this occurred it would have seriously compromised the aircraft on short finals.
CHIRP acknowledges that there are often pressures to get airborne at a particular time, for flight planning reasons, or to maximise time available for instructional flights, or reduce the amount of fuel used in holding. However, even these pressures must not contribute to poor decision making since this will likely result in an unsafe situation developing, as appeared to be the case here.
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.
Pressure – Leading to rushing and poor decision making.
Knowledge – Reliable and accurate information on landing aircraft.
Communication – A/G radio at the airfield not ATC.
Teamwork – Inconsiderate actions potentially endangering others