ATC failings in fatal crash - VFR into IMC - Air accident case study

today I report on a fatal VFR flight into IMC did failings by two separate Air Traffic Control units contribute to the crash join me for this special episode of The Flying reporter [Music] hello I'm John Hunt A Private Pilot YouTuber and former BBC TV news reporter I like a lot of Pilots I suspect regularly read air accident reports to try and learn from the mistakes of others but I've never read a report concerning a general aviation incident so shocking as the one we're going to discuss today [Music] this report concerns the crash of Gulf Bravo x-ray Bravo uniform a mud recap 10B a low Wing aerobatic aircraft both the pilot and the aircraft were only certified for flight in visual meteorological conditions but they entered cloud and crashed in August 2021 at Somerset in England the actions of the air traffic services in this crash have come under intense scrutiny and we'll come on to that in a moment but first we'll look at the planned flight and the Pilot's decision making [Music] the pilot and his passenger set off from a grass Farm strip in Somerset at just after 7am on the 12th of August 2021 for a day trip to the Isles of silly at their Point of Departure the skies were clear with good visibility but the forecast from the Met Office on the form f215 which had been published four hours earlier showed that a front was moving through the Pilot's intended route during the course of the day which was forecast to bring rain poor visibility low cloud and occasional mist and fog at 6am the only relevant TAF or terminal area forecast available to the pilot was for new key and it read between 0 600 and 1500 hours winds light and from the southeast visibility good Cloud scattered at four thousand feet prop 30 Tempo between 0 600 and 1200 hours visibility 8 000 meters Cloud broken at 1200 feet The Meta at the time showed there to be a slight Southeast wind with broken Cloud at 1200 feet just half an hour later though and just 35 minutes before departure the weather had substantially deteriorated The Meta now showed that visibility was 9000 meters with broken Cloud at 600 feet the TAF was amended at the same time it was now forecasting an increased certainty of poorer visibility and included the possibility that clouds could lower to as low as 600 feet the TAF for Saint Mary's on the Isle of silly was also published at this time it also forecasts the possibility of a low cloud ceiling worsening visibility and wind gusts of 25 knots the investigation could not conclusively prove what pre-flight weather briefings the pilot obtained but those who knew him said he was a fair weather flyer after departure the aircraft picked up its planned route to the Southwest but just north of cold Rose it began a descent Over the Sea before turning back East northeasterly again while Over the Sea the aircraft reached a minimum altitude of just 320 feet it made three 180 degree turns and two 360 degree orbits it then tracked North back towards its Point of Departure climbing to an altitude of 8 200 feet at 905 the pilot made a pan call to dunk as well radio asking about the weather conditions there and stating that he was stuck above Cloud at dunk as well the cloud was at surface level with a 400 meter visibility and the radio operator suggested that the pilot call the distress and diversion cell on the emergency frequency one two one decimal five he did so making a pan call [Music] Exeter and there's very thick cloud and I'm above it and can't get below it according to dunk as well it's on the deck I don't know what to do I need to divert somewhere close to me where I can land x-ray uniform this is London Center on one two one decimal five your pan is acknowledged your position is approximately four miles to the west of charred what is your altitude altitude is currently 7500 and that is the cloud base golf Bravo x-ray x-ray Bravo uniform firm I am above Cloud at 7500. I've called dunk as well they say it's on the deck there I'm really quite anxious I don't know what to do golf Bravo uniform Roger golf brother uniform uniform uh one and a half hours golf Bravo uniform Roger Gulf Bravo uniform standby at the same time that the pilot was making his pan call to DND an air traffic control assistant at Exeter radar called DND on the landline Exeter had been dealing with a military aircraft with a call sign red five the accident report doesn't State this but the RAF display team the Red Arrows had been operating in the Exeter area that week and the aircraft Exeter was dealing with was quite possibly a red arrows Hawk jet the jet had suffered a technical fault with its undercarriage which had now been resolved the jet had not declared an emergency but it was circling between three and four thousand feet to burn off fuel to enable it to return back to Exeter Exeter had been concerned that the pilot of Gulf Bravo uniform the emergency aircraft might come into conflict with red five in their call to DND the Exeter air traffic control assistant asked what he was doing how excellent he's right in the way of red five would you what's he what's his intentions and his level I don't know his level but he's currently above Cloud and wanting to divert to the nearest era train well that would be us he's basically flown all the way up the coast and then across our extended Center Line twice in front of a military jet yet do you want to put him over to us by now golf Bravo uniform was squawking 7700 the internationally recognized transponder code for an emergency which was displaying on the Exeter controller screen however in recordings from the Exeter radar control room the air traffic control assistant Was Heard discussing the fact that the emergency aircraft had been in the way of the red five jet which one of you wants to work this aircraft inbound the inbound for weather the one that's been in the way for the last 10 minutes yeah yeah to compound matters for reasons unknown until being told to squawk emergency the transponder on golf Bravo uniform had not been transmitting his acquaintances had told investigators that he routinely flew with his transponder turned off and didn't usually request air traffic Services over the radio aircraft fitted with a serviceable transponder in the UK are required to use them to their fullest extent the Pilot's failure to do this on this flight until being told to squawk emergency prevented the extra controller from knowing his altitude and his position only displayed on their radar screen with a primary return this no doubt increased their concern about a possible conflict with the red 5 jet that was circling in the area the aircraft was transferred to Exeter even though the weather there was not suitable for a VFR Landing this shouldn't have happened the manual of air traffic Services part 1 States controllers shall offer as much assistance as possible to any aircraft that is considered to be in an emergency situation including weather information availability of aerochromes and Associated approach AIDS it further states that before transferring an aircraft controllers should obtain sufficient information from the pilot to be convinced that the aircraft will receive more assistance from another unit given the pilot situation his qualifications and the fact he was flying a VFR only airplane transferring him to Exeter when they had a reported 500-foot broken Cloud base was clearly a mistake military Aviation Authority regulations state that on notification that an air system is suffering an emergency controllers should inform the pilot of the most suitable Aerodrome considering weather conditions including winds terrain and obstructions and guidance for DND controller States they are to verify before handing operational control to another agency that the receiving controller has been given all the details despite this the aaab report States although the emergency squawk of 7700 was visible on the radar controller screen golf Bravo x-ray Bravo uniform was transferred to Exeter before anyone with controlling Authority at that Aerodrome had been made aware the aircraft was diverting in an emergency there was no formal radar Handover from the DND controller and the suitability of Exeter in particular the weather conditions at the Airfield were not just discussed at any point by either the Exeter assistant DND support controller or the DND controller on first contact with Exeter the pilot of Gulf Bravo uniform made it clear that he was in trouble extra golf x-ray Bravo uniform have been panpan have been diverted and we'll be victoring you for the ILS approach for runway 2-6 for Exeter an ILS approach is an instrument approach which the pilot cannot accept because he's a VFR only pilot sorry I I can't can you say again golf Bravo uniform I'll be vectoring you for the surveillance radar approach for Runway runways to flight heading 2 2 a surveillance radar approach is another form of instrument approach and so the pilot cannot accept this plan of action either what's your Cloud base golf Bravo uniform the weather at Exeter we've got six kilometers visibility and the cloud is broken at 500 feet golf Bravo uniform descent to altitude 2600 feet 0.017 1017 you were require me to descend to what altitude this would have required the pilot who had not been adequately trained to fly in Cloud to do just that and it carried a grave risk furthermore the minimum descent altitude for the surveillance radar Approach at Exeter was above the base of the reported cloud and so the pilot would have been unlikely to have successfully landed off that approach even if he knew how to do it the last call between the controller and the aircraft was at 9 18 am just eight minutes after his first pan pan call to DND two minutes later Devon and Cornwall police were notified of an aircraft crash [Music] the accident site was a field approximately 1.2 kilometers Northwest of Buckland Saint Mary in Somerset the aircraft struck the bowels of an oak tree and then the ground in the northern end of the field there were large amounts of debris scattered on a southerly path the left landing gear wheel was found in a sunken stream at the southern end of the field approximately 235 meters from the tree the engine was attached to the cockpit instrument panels and rear fuselage by flight control and electrical cables the right landing gear leg was found close to the rear fuselage section and was complete including a small section of wing Spa pilot and his passenger died [Music] the pilot had reported his endurance to be 90 minutes within that time the report suggests that the aircraft could have made it to Birmingham or gloucestershire according to the investigation both reported few clouds and good visibility [Music] aaib investigation concluded the following the aircraft collided with terrain because the weather conditions deteriorated beyond the capabilities of the pilot who was not trained or qualified to operate in poor weather forecasts available when the pilot assessed the weather did not accurately reflect the extent of the poor weather pilate found himself stuck above Cloud when the pilot requested assistance in finding an appropriate Aerodrome to land the level of ATC support from the DND cell and Exeter ATC was not sufficient to provide the assistance required by the pilot who is in a state of distress a breakdown in communication and teamwork occurred between the D and D cell Exeter ATC and the pilot which led to miscommunication incorrect assumptions and omission of critical information following published procedures would likely have allowed either the DND cell or Exeter app or ATC to establish the unsuitability of Exeter airport as a diversion Aerodrome the investigation identified shortcomings in the system in place in the UK to provide emergency support to aircraft in distress the air accident investigation Branch made Seven safety recommendations five for the CAA and two for the Department for transport the CAA told me we have received the report from the air accident investigation branch and we will now be considering the recommendations the RAF responsible for the distress and diversion cell say our thoughts remain with the family and friends of those who died at this difficult time the RAF has received the air accident investigation Branch report and is considering its findings and recommendations we continue to work alongside the Department for transport to ensure all air traffic providers offer appropriate services to airport and the department for transport have both been asked for comment if they respond following the publication of this video I will post those responses in the video description this aaib report tells a very very sad and troubling tale and there are many lessons to be learned given the highly sensitive nature of this subject and the risk of defamation you will not be able to comment on this video but if you appreciated its content then I'd appreciate you hitting the like button and subscribing to my channel thank you for watching the flying reporter and fly safely my friends

Channel: The Flying Reporter

Views: 38,193

Keywords: general aviation, air accident, air crash, The Flying Reporter, VFR into IMC, Flying

Id: qjYVfaNrMvw

Length: 16min 19sec (979 seconds)

Published: Sat Apr 29 2023