I am indebted to my predecessor, Peter Tait, for hiscomprehensive handover to me as the incomingChief Executive at CHIRP. As the enormity ofattempting to follow his hugely successful 18 yearsin charge sank in, I confess to having swallowed hardat the “you have control” moment. On behalf of all ofus in aviation, I would like to thank him for hisoutstanding work in promoting safety and wish himthe long and happy retirement he so richly deserves.

Despite his efforts, some of the issues Peter workedhard to resolve remain open. One of these is the useof sickness absence data in redundancy criteria. Wehave received four more reports on the subject,which I have not included in this issue of FEEDBACKas it was covered comprehensively in the previousedition. It seems clear that the perception thatsickness absence data might be used for thispurpose is incompatible with safety insofar as itdiscourages flight and cabin crew members fromreporting sick when unfit to fly.

DISPATCHER TRAINING

I operated into AAA earlier this year,and had issues with the lack of understanding andsevere lack of cooperation from the dispatcherassigned to my flight. The dispatcher seemeddisorganized, and failed to listen to instructions fromeither myself or my cabin crew, upsetting them in theprocess. He advised me well before departure timethat there would be a Last Minute Change (LMC) tothe loadsheet, which was in excess of that permittedby the company.

Company procedures required a completely newloadsheet to be completed by the dispatcher if theLMC limits were exceeded. I instructed thedispatcher of this, who responded in an indifferentand rude way, appearing not to understand, so I toldhim a second time what would be needed. Thedispatcher then disappeared, coming back to thecockpit about 10 minutes before push-back time,with the original loadsheet filled in with the LMC hepreviously mentioned: well in excess of what isallowed. I again explained the correct procedure,and was told bluntly to "sign, sign" (sign theloadsheet). I then explained politely for a fourth timewhat the LMC limits were, and that he would have to

complete a new form, in accordance with companyprocedures. He again refused, telling me to "sign".

At this point both my First Officer and I werebemused by this strange and ignorant behaviour,and were getting concerned we would be delayed. Ithen had to explain a fifth time, very firmly, that hewould need to do another load sheet or the flightwould not be departing that day. He then claimedthere were no airbus loadsheets in the airport! Iexplained that this meant a cancellation. At thispoint, he disappeared, coming back ten minuteslater with a newly completed loadsheet. Wedeparted about 10-15 minutes late, havingdebriefed the dispatcher about the requirements foraccurate load information, and the fact it was hisresponsibility to furnish the flight with a formproperly completed in accordance with the groundhandling manual.

I operated into AAA again yesterday and was met bya different dispatcher. Again there was an LMCmade to the loadsheet, which was incorrect (abaggage LMC of almost two tonnes). This, notsurprisingly, is well over what is allowed by thecompany without a new loadsheet, and equated tothe entire baggage load! Mistakes do happen, so Iexplained to the dispatcher that this was outsidewhat was allowed. His response? "Sign, sign". Iexplained to him what an LMC was, and the limitsand he asked me to just sign the form. It wasapparent he did not actually know 1) what an LMCwas, and 2) how an LMC was noted on the form, letalone what the limits were.

Having raised this very issue with my companythrough their ASR scheme, and been contradicted bythe investigator, I was faced with exactly the sameissue again.

Clearly the company does not wish to address theissue of ground staff training/knowledge at thisairport. Why? Ultimately, safety is the issue here,and it is just possible a crew that is late or rushingmight not spot the gross errors that appear to be thenorm at AAA. I have some sympathy with thedispatchers whom may be poorly paid and notproperly trained. I, for one, think safety is thenumber one priority, however, and I won'tcompromise on this - even if the company turn ablind eye.

Lessons Learned: Check the loadsheet very carefully,and don't be rushed by the dispatcher. If they don'tcooperate, explain slowly and clearly theconsequences e.g. this aircraft is not moving until

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you do this properly. Feedback safety information tothe operator, but don't expect them to act on it.

STANDARD OPERATING PROCEDURES

Each base has a Captain in charge ofstandards with oversight of the operation at locallevel. They appear to be requesting feedback fromlocal crews, collecting the information, then decidingwhat the "local SOP" should be on the issue withoutdisseminating that information network wide. [Thereporter cites a specific example of advice aboutoptions for Limited Visibility Operations beingpromulgated by e-mail.] Surely if a situation is notcurrently covered by an SOP and a change or newSOP is required then this should be discussed withthe post holder and a notice to crew be issuedbefore the next manual revision.

OPERATIONAL PLANNING - TURNROUND TIMES

I recently had a duty involving a delaythat raised issues and I contacted management overthem. I had what I regard as a poor answer.

On the day in question, BBB was affected by adverseweather and after a long delay it was decided tosend us to CCC instead. We do not normally operatethere and other operators had also chosen to gothere earlier in the day. So we were faced with a

destination that had freezing conditions and severelystretched ground handling services. We wereplanned for a 30 mins turnaround; it actually took1hr 30mins including the inevitable de-icing.

On this issue of realistic planning times, thecompany responded that plans are based on a 6-month average on block times and extendedturnround times for rebriefing, crew meals etc. Onthis occasion standard planning turnaround wasused based on the information provided by CCC. Itwas not clear how much time would have beenrequired for de-icing in the event that it was required.On this basis the Captain and First Officer were 10minutes within FTL and discretion was not foreseen.

It appears to me that the company concedes that itis systemically planning unrealistically with the resultthat we inevitably go into discretion over a disruptedtwo-sector duty. This is especially true over winter.The average would largely remove the winterdisruption effects.

I note that 30 mins is the minimum time allowed forturnaround anywhere and that was applied to thenight in question. (Despite some more difficultdestinations routinely allocated a longer turnroundon normal operations) Is this likely to be a genuineaverage? The minimum? I believe there was acertain 'whitewashing' in the company's reply as theyadmitted to me the handlers would be stretched andthe WX forecast was freezing conditions. Yet thecompany insisted that they had to use 30 mins, asthat was 'the system'. The plan was impractical fromoutset. It played exactly as I expected and had toldthe ops controller.

Strange the company states they could not planaround how long we needed for de-icing. So the planwas for none at all! (Is it just me who sees this asridiculous?)

So the question: Is this an acceptable practiceunder the CAA?

Even taking the whole at face value, I am especiallydubious about the idea of using an average figure forplanning then applying it to the actual case. It isdesigned to be too low on all occasions whendifficulties are encountered even if difficulties areknown or predictable before the flight(s). FTLs areactual, on the day limits, not averages. Does this notmean that the company are planning crew intodiscretion?

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FLIGHT TIME LIMITATIONS (FTLS)Recently my airline has acquired a new

type of aircraft that is designed to be operated withtwo pilots and has no crew rest facilities. Thecompany now uses 'augmented crew' rules to pushthe FDP out by another 45 mins. Under these rulesa third pilot is supposed to sit on the flight decksimply to be present. He or she is not there toprovide relief as there is no crew rest facility. Thispractice has been widely used in the charter worldand results in continuous abuse. Most crews willswap around and allow the operating crew a breakand in most cases this break is taken on the flightdeck floor with all manner of ingenious ideas beingintroduced (blow up Lilos, duvet mattresses etc). Ifthe public were aware of what goes on I am sure theywould be appalled but not withstanding this I havetwo issues that the authorities should be aware of.First, are they aware that crews rostered to operateunder 'augmented crew' rules are using theaugmented pilot as relief, without the required crewrest facilities? Second, and perhaps more to thepoint, how do the authorities calculate that somehowtwo pilots will be less fatigued if there is a third pilotpresent? This area of FTLs is being widely abusedand poorly controlled; most operators are abusing itsintended use for their own gain.

Lessons Learned: FTLs in respect of ‘augmentedcrew’ require review.

:

LOSS OF COMMUNICATIONS

On a routine flight from the UK toGermany, an experienced crew were approaching theend of a long, direct leg from the UK/Amsterdamboundary to Germinghausen (GMH). Reception onthe primary, radio in-use had fallen silent. Attemptsto contact Maastricht on the assigned frequencyfailed. The initial attempt at contact on 121.5 on thethird radio, which was being used to monitor Guard,was met with silence until it was realised that thevolume needed to be increased to obtain audible

reception. On being assigned a Rhein frequency, thecrew were horrified to discover that, whilst all hadseemed normal to them, interceptor aircraft had orwere about to be launched!

How had this come about? London gave a 'direct toGMH' and later the Maastricht frequency, 135.960,which was read back. However, Maastricht did nothear the crew check in on the assigned frequencybefore ATC agencies and other aircraft attempted tomake radio contact without success. On the aircraft,the missed check-in had somehow passed unnoticedand attempts by both ATC and other aircraft to makecontact were not heard. In a sequence of eventsaround the time of the handover to Maastricht: thevolume on 121.5 had to be reduced because ofprolonged voice activity on the Guard frequencyinterfering with normal radio communications, theAmsterdam weather was briefed to the PilotHandling, there was a call and conversation with thecabin crew. Somehow, these events combined forlong enough to interfere with a routine radio check-in. This situation, it seems, was exacerbated by aproblem with the radio. From the point at which thefrequency was changed, there was voice receptionthat sounded normal enough to the crew so as not toalert them to a radio problem but which was eitherintermittent or was from a frequency other than thatassigned. Later, the radio appeared to failcompletely.

Lessons Learned: Following the incident the crewassessed the incident in order to highlight potentialcontributory factors and the lessons that can bedrawn from the experience.

1. Both pilots are highly experienced on type andwith the route and company operation. Possibleeffect: We have a flight deck with a low commandgradient, which may have led to a reduced level ofvigilance and cross-monitoring due to mutualassumptions about performance levels.

2. Other aircraft appeared to be using 121.5 as acasual "Chat" frequency. If crews are forced to ceasetheir monitoring of 121.5 because of inappropriateuse acting as an unacceptable distraction, then it isunavailable for ATC to use as alternative frequency.

3. The incident aircraft is unusual in that it is fittedwith three VHF Transceivers rather than the moreusual two - this had widely been perceived as asafety benefit because we could always have the no.3 box tuned to 121.5 and monitoring Guard.Possible effect: The use of a unique transceiver formonitoring Guard creates a latent failure conditionsince there is nothing to remind the crew to restorethe volume to audible levels or to indicate a failure ofthe receiver.

4. The flight deck access procedures mandatedfollowing 9/11 invariably require one pilot todiscontinue their monitoring of radiocommunications to contact the cabin crew in orderto follow correct access protocols. If this occurs at

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the same time as other operational actions, there ispotential for work sequences to be broken andactions to be missed. The company and crew need toconsider the level of priority given to answeringroutine non-emergency cabin crew communicationswhen faced with other operational demands.

5. Following the incident flight, the Captain reporteda possible radio problem with VHF COM 1. Thecontrol heads of VHF COM 1 and VHF COM 2 wereinterchanged by the engineer for troubleshooting.The following day reception on VHF COM 2 (thecontrol head of which had been on VHF COM 1 whenthe loss of contact incident occurred) wasintermittent. Given the intermittent nature of thefailure, the crew may have been hearing enoughcommunications on the assigned frequency to givethem the impression that they had a functioningradio, but crucially may unwittingly have beenmissing specific calls to them.

6. Unusually, the aircraft was given a direct track toGMH VOR by London ATC. As this routing crossestwo FIR boundaries from London airspace, it isnormally only given by Maastricht ATC. Possibleeffect: The mental model created by the crew thatthey were in normal contact with Maastricht mighthave been subconsciously reinforced by the directrouting to GMH, the logic being "We are routing directto GMH, therefore we must be under positive controlby Maastricht".

ROSTER MANAGEMENT

Not for the first time this summer, wewere running so late that I, my FO, and three of mycabin crew would all run over midnight into rostereddays off. The FO and I had worked 5 days and thecrew 6. Clumsy rostering often means that crew getrostered for a late duty on their last day, leaving littlemargin for delay before the first day off is infringed.This has been raised with XXX by the respectiveunions many times - but, ultimately 'legal' if notpotentially fatiguing, regardless of expecting peopleto work into day 7 - in the case of the crew. Beingappreciative of the risk of potential fatigue this

causes, I never ask the crew if they will work into dayseven - it has to be voluntary, and more importantlySAFE. Often crew say they can't/don't want to dothis, but are reticent to inform crewing as they saythey are afraid of retribution from their linemanagers. Crew state that refusing to work overmidnight into day seven regularly results in 'tea, nobiscuits meetings' in the office with the base crewmanagers, when they have to explain their actions!

Naturally, if we are concerned fatigue is the issue,the crew will not be asked to do this, but the realdifficulty of the situation is that they are far moreafraid of their manager than they are of workingwhen they should not. Specifically this type ofbehaviour means they are unwittingly putting theirdisciplinary record ahead of safety. I can't say forsure what goes on in these closed-door managementde-briefings with XXX cabin crew, but the effect onthe crew is very clear, and an example of the worsttype of fear culture that has no place in an airlinewith a healthy safety culture. Ultimately, the pilotsare powerless to stop the crew being treated likethis, and the likely outcome one day will be a seriouserror by a fatigued crewmember that causes anaccident. Or worse.

Lessons Learned: Unfortunately nothing will help theissue except a complete change in the cultureamongst company managers. Bullying of this natureis endemic.

ATIS INFORMATION BROADCASTS

This report relates not to one specificevent but to many constantly recurring events. Myflying is all regional short haul around the UK andEurope. Whilst the issue I raise may be of lessimportance to a long haul crew who may welcomethe prospect of listening to ATIS, to a short haul crewon multi-sector duties, often at lower levels, itpresents a real problem and flight safety risk. ATISbroadcasts used to be (indeed must be) concisereports of aerodrome actual weather, comprisingonly an identifier, a reporting time and the recentweather etc. However, over recent years the ATISbroadcast has become a vehicle for advising pilots ofmuch secondary and often tertiary information aboutthe airfield operation. Every second that PM (pilotmonitoring) is "away" obtaining destination andalternate weather, precludes him/her from carryingout their principle role of pilot monitoring. Thisleaves every crew open to the safety risk of incorrectheadings/levels/routings, being unable to monitor121.5, possible configuration deviation (over speed

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etc) and level busts to name but a few. For example,a recent EEE ATIS broadcast had less than 40% of itsduration devoted to weather information, theremaining 60% being devoted to items that had beenNOTAMed, or would be mitigated by ATC. FFF ATISstill reports a taxiway as closed; this is not onlyNOTAMed but it has been closed for several years.Many airports report the wind as, for example,010/01 - varying between 340 and 060. In thelatter example, one has to ask if this is at allrelevant? And bless the French for reporting"scattered clouds at 22000 feet". Recently manyairports have taken it upon themselves to ensurethat ATIS weather reports include a tag line along thelines of "pilots requesting departure clearanceshould contact 123.45. All pilots are to request starton 123.46. Pilots are not to request clearance until10 minutes before departure". Another typicalexample of the somewhat verbose ATIS informationthat we must all now listen to is the permanent"pilots are advised of increased bird activity withinthe airfield boundary". This list of examples given isfar from exhaustive but serves to illustrateadequately the issue at hand. In the writer's opinionit is about time that a European or worldwidestandard is devised as to exactly what must be, andonly be, reported in ATIS broadcasts.

GROUND-AIR COMMUNICATIONS

As a pilot I am concerned about theapparent lack of ATC training/monitoring provided tocontrollers concerning individual’s speech. In myhumblest of opinions the issue I am about tomention appears to be confined to the skies of theUK.

On many occasions, pilots are faced with theprospect of being unable to contact an ATCfrequency due to their workload. This has beendiscussed before and we doff our caps to theexcellent job being done in keeping us safe.However, it is quite frustrating to sit waiting to checkin on a frequency and be unable to do so due to noperceivable gaps in the controller’s transmissions.We accept this when the controller’s workload

demands it, but to experience such, only to thenlisten to an extremely long silence (yes I have) makesone wonder if communications are being effectivelymanaged.

Another problem pilots face is the sheer speed of thecontrollers' speech. I would defer to a humanfactors/speech expert but it strikes me that speakingexcessively fast only increases the stress levels ofboth the speaker and the listener. Not only this butit increases the possibility of read-back error and, inconjunction with the first example, an error could gounnoticed for some time.

Excessively fast speech presents a flight safety riskthat is easily avoided. Speak fast but clear in anemergency by all means, but not routinely. It begsthe question; do controllers ever receive feedback ontheir standard/speed of speech during normaloperations and is their rate of speech everassessed?

INSTRUMENT APPROACHES IN CLASS GAIRSPACE

I wish to respond to the ‘InstrumentApproaches in Class 'G' Airspace’ report in the latestCHIRP. Class 'G' airspace is free to all users at themoment and I would suggest the approaches in ithave to be flown at the pilot's own risk whilemaintaining separation from other traffic by lookoutor radar service. For example, the GNSS approachfor Shoreham Airport commences at 2200 feet, fromthe west just north of Parham gliding site and fromthe east just north of Ringmer gliding site and is notshown on charts likely to be used by non-instrumentrated pilots. The base of the London TMA in thisarea is 2500 feet, it is also an extremely busycorridor for light aircraft transiting east-west aroundthe Gatwick zone, gliders and hanggliders/paragliders from the various South DownsLaunch sites, and yes they do get into the instrumentapproach area on thermic days. Is it reasonable toexpect all other traffic to avoid the airspace south of

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the Gatwick zone in case someone wants to make aninstrument approach to Shoreham? Many lightaircraft are probably only there to avoid theFarnborough bottleneck.

BROKEN PASSENGER SEAT

Boarding a full load of passengers, itwas discovered that a broken passenger seat wouldnot lock in the taxi/take off position and keptreclining when passenger was sitting in it; thepassenger had highlighted this to crew. Engineerswere called by the Senior Cabin Crew Member(SCCM); the engineers looked at the seat, reportedto the SCCM that it was fixed and left the aircraft. Bynow boarding had reached a late stage and thepassenger informed the crew that the seat was stillnot fixed. The SCCM informed Captain of thesituation, which could now impact on punctuality;offload of the passenger may occur if seat unusableand no empty seats to utilise. The engineersreturned but could not fix with time available and infront of passengers stated that the seat was notusable. The SCCM advised flight deck that situationwas unresolved; the response was that we needed toget going. The engineers then said seat was ok fortake off and we could go, even though no action tothe seat had taken place! The ground staff leftaircraft and the door was closed, leaving the SCCMto deal with an unhappy passenger sitting in a seatthat was not locked in the correct position, unsafe ina crash and powerless to do anything about it. Thepassenger eventually accepted we were leaving andthey had to put up with it. The passenger spoke withthe SCCM in flight and voiced concerns that theirsafety came second to other factors to which theSCCM agreed with them.

Lessons Learned: A SCCM is responsible for overallcabin safety on behalf of Captain. One minute theseat is unusable and then the next it is good to use!Punctuality seems to over ride everything these days.

Details of recently issued Information Notices areavailable on the CAA website.

2

aining in nusualircumstances andmergencies

is an annual mandatoryrequirement for ATCOs to maintaintheir ratings within their licenses.

We run about 100 combinedfacilitated classroom and simulatorsessions each year to enhance ourcontrollers’ understanding andknowledge in dealing with abnormalcircumstances. These take place atour training facility in Hampshire andare greatly enhanced by having theinvolvement of commercial pilots.

If you would be interested in joining uson any of our TRUCE sessions, youwould get the opportunity to visitSwanwick Centre then share yourknowledge and experience during theclassroom and practical simulatorexercises.

As an added benefit, you will gain agreater understanding of the UK ATCenvironment and procedures, andhave an opportunity to discuss thehandling of abnormal situations withoperational controllers.

NATS will contribute towards fuel costsand refreshments.

If you are interested in attending or formore information please contact:

Address ChangesIf you receive FEEDBACK as a licensedpilot/ATCO/maintenance engineer please

. Please complete achange of address form which is available todownload from the CAA website and fax/post to:

The Change of address form is available from:www.caa.co.uk/docs/175/srg_fcl_changeofaddress.pdf

Please be advised that it can take a few weeks toregister your change of address.

Alternatively, you can e-mail your change of address tothe following relevant department (

:

Flight Crew................................ fclweb@caa.co.ukATCO/FISO................................ ats.licensing@caa.co.ukMaintenance Engineer............. eldweb@caa.co.uk

Contact Us

Flight Crew/ATC Reports

Maintenance/Engineer Reports

AdministrationCabin Crew Reports

--OOO--

fone (UK only): 0800 214645 orTelephone: +44 (0) 1252 378947Fax: +44 (0) 1252 378940 (secure)E-mail: confidential@chirp.co.uk

® reports are published as a contribution to safetyin the aviation industry. Extracts may be publishedwithout specific permission, providing that the source isduly acknowledged.

FEEDBACK is published quarterly and is circulated to UKlicensed pilots, air traffic control officers and maintenanceengineers.

Registered in England No: 3253764 Registered Charity: 105826

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CHIRPPILOT/FLIGHT CREW REPORT FORM

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continue on a separate piece of paper, if necessary

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2. On closing, this Report Form will be returned to you.

NO RECORD OF YOUR NAME AND ADDRESS WILL BE KEPT

3. CHIRP is a reporting programme for safety-relatedissues. We regret we are unable to accept reports thatrelate to industrial relations issues.

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PLEASE COMPLETE RELEVANT INFORMATION ABOUT THE EVENT/SITUATION

YOURSELF - CREW POSITION THE FLIGHT/EVENT

CAPTAIN FIRST OFFICER DATE OF OCCURRENCE TIME (LOCAL/GMT)

PILOT FLYING PILOT NOT FLYING LOCATION HEIGHT/ALT/FL

FLIGHT ENGINEER OTHER CREW MEMBER TYPE OF ATC SERVICE DAY NIGHT

THE AIRCRAFT TYPE OF FLIGHT TYPE OF OPERATION

TYPE/SERIES IFR VFR PASSENGER TRAINING

NUMBER OF CREW OTHER: FREIGHT OTHER:

EXPERIENCE/QUALIFICATION WEATHER FLIGHT PHASE

TOTAL HOURS HRS VMC IMC TAXI TAKE-OFF

HOURS ON TYPE HRS RAIN FOG CLIMB CRUISE

TRG CAPT TRE IRE ICE SNOW DESCENT APPROACH

OTHER QUALIFICATIONS: OTHER: LANDING GO AROUND

THE COMPANY MY MAIN POINTS ARE:

NAME OF COMPANY: A:

REPORT TOPIC B:

MY REPORT RELATES TO: C:

DESCRIPTION OF EVENT - PHOTOGRAPHS, DIAGRAMS ON A CD ARE WELCOME:

Your narrative will be reviewed by a member of the CHIRP staff who will remove all information such as dates/locations/names that might identify you. Bearin mind the following topics when preparing your narrative:

Chain of events • Communication • Decision Making • Equipment • Situational Awareness • Weather • Task Allocation • Teamwork • Training • Sleep Patterns