Upload
others
View
3
Download
0
Embed Size (px)
Citation preview
Mendip GC
2019 Safety Event
Sat 7th Dec 2019
v1.2
Death by PowerPoint…
https://www.youtube.com/watch?v=4iOoiEbtf2w
Purpose Quite simply, to improve OUR safety
Further promote the safety culture within MGC
Promote adoption of the BGA safety objectives:
Safe practices with the objective of facilitate a sport gliding environment where the levels of risk are as low as reasonably practicable.
BGA Priorities:
Continuing to reduce the fatal accident rate
No harm to any third parties
Avoiding any airspace infringements.
Managing Flying Risk aims to provide pilots and clubs with guidance on how to better understand, minimise and manage the hazards associated with gliding operations, including with powered gliders and tug aircraft. It does not replace any existing law, which should always take precedent.
What are we going to cover?
Focus on flight safety
(Y)OUR role in safety
Recent MGC Accidents and Incidents
Winching
Bailing Out
How are we going to cover?
BOO!
The intention is not to scare or drive you away from gliding!!
The clue is in the ‘we’ bit
…which kind of fits with the whole ethos here…
This is a (an on-going) discussion
OK, with a little bit of haranguing….
Will flag some club actions and intentions
Give you some study material – please do undertake it otherwise we will be here for hours
Do some practical stuff
Safety Culture: What is it?
Safety culture is the collection of the beliefs, perceptions and values that members share in relation to risks both within Mendip GC and our sport of gliding
Beliefs…?
Perceptions….?
Values….?
Risks……?
Example Risks: not the complete set!
Gust fronts
Thermic days with high cloud base
Thermal impact on ridge
Mis-rig
Emotional state
Poor recovery from launch failure
Late field selection
Mid air collision
Clutching hand
Open canopy
Curl over
Poor look out
Human Physiology – dehydration, cold, hypoxia
TAS vs IAS
Sink behind a ridge
Tow truck left attached to aircraft
Distractions prior to launch
Incomplete pre-flight checks
Etc, etc….
Risks…..Categorised (TEM) Flight: Threats, Weather & Interaction with Topography:
Gust fronts
Thermic days with high cloud base
Thermal impact on ridge
Clutching hand
Curl over
Sink behind a ridge
Cross wind
Flight: Pilot Error and Workload:
Poor recovery from launch failure
Late field selection
Mid air collision
Poor look out
TAS vs IAS
Flight and Ground: Threats inherent to the Human Engine – hardware and software:
Human Physiology – dehydration, cold, hypoxia
Distraction
Emotional state
Ground & Operations: Discipline and Professionalism Errors:
Mis-rig
Tow out
Open canopy
Incomplete checks
Your Contribution… OR…Good Airmanship
OR…Don’t forget the Basics
Defensive Flying:
Lookout
Winch launching – ALWAYS expect a failure, speeds, profile
Rules of the Ridge
Use of circuit plans and patterns
Thermal joining and use
Discipline and Structure:
Circuit nomination
Professional Checks (pre-cockpit entry, pre-launch, pre-manoeuvre, pre-circuit)
Launch Point discipline
Field selection: awareness, areas, field, decision to land
Visitors
Ground Handling – esp. glider towing
Moving on airfield – crossing runways
MGC Organisational Actions:
Re-introduce the Duty Pilot role; Ground training syllabus
Operations Manual
Enhanced early solo supervision
Card system
Must be Tea Time?
Back in….
The Safety Chain…
https://www.youtube.com/watch?v=zbGUE8g47-M
The safety cheese! (Prof J Reason, Swiss Cheese)
• Each layer is a ‘defence’
• Latent Layer ‘Holes’:
• Organizational layer: Maintenance?
• Supervision / training layer: AFR?
• Active Layer ‘Holes’:
• Layer of (unsafe) precondition: IMSAFE?
• The layer of unsafe acting: Judgement?
Alternatively “Event Chains” – rarely just one thing causes an accident
Jump, Jump Jump….
Before you can jump….
Some words from a man whose done it…. https://www.youtube.com/watch?v=cDXIxHAmSX0
MGC Recent Accidents & Incidents Difference between an accident and an incident?
Accidents:
K13 tail broken off – CCY
K13 – aileron horn damage
K13 – canopy opened during launch
Skylark4 – Heavy landing
Skylark4 collided with K13 on runway whilst landing
K8 hit tree on approach
Incidents:
Airbrake spring broke – discovered at All Out on winch launch
Aerotow abandoned with T/L after starting from wrong position
K8 Low Approach (multiple)
K13 canopy started to open on launch….
Approaches over the Bus/Aircraft (multiple)
Overspeed on winch
K8 wing almost hit K13 canopy on launch point during retrieve
Retrieve rope wrapped around Astir main wheel towing downhill
Bristol Airspace Infringement
Safety Management System – Starting with enhanced incident reporting and club level analysis
MGC Recent Accidents
K8 approach:
An accident chain ‘case study’
Wind change since launch, now cross at 180/10
Attempting to thermal soar from far too low
No circuit
Resulting offset ‘straight in’ on downwind side of approach path
Winch launch, Feb 2019 (video part 1)
National Trends
Late Take Over – instructing accidents
Tug Upsets – a returning scourge
Trees!! (Parham Ridge Soaring, Hus Bos K21)
Accidents and Incidents: Prevention
Education and Awareness
Operations Manual
Standard Operating Procedures (SOPs)
Safety Management Systems – trends and targeted actions
Improved and formalized supervision
Currency standard; pre-license culture
Environment for earlier take over
I may need a few more
balloons today…
Winching
Is an efficient, cost effective and if flown correctly safe means of launching
Rotation rate: Is THE critical factor with respect to stall speed
Start Rotation from initial climb at 1.5 x Vs
Rotation to full climb 5 seconds
https://members.gliding.co.uk/bga-
safety-management/safe-
winching/simulations/
Winching: Other Risks (TEM)
Wing Drop:
Cross wind
Wing Holder is a safety critical role
Cartwheel
Insufficient recovery (airspeed) prior to turning
https://members.gliding.co.uk/bga-safety-management/safe-winching/simulations/
Winch Launch Failures
These are emergencies – whether simulated or not
The only important thing is that you can walk away from it
Using the aircraft again is a bonus
MGC launch failure part 2….
Landing Off Field is a very real option
Avoid a follow-on emergency!
Full Airbrake Approach and Landing: ask to do with an instructor
Winching : Risk Mitigations
‘Blindly staring into oblivion waiting to get to the top’
Approach every winch launch as if it will fail
Know your minimum winch launch speed (and Vw)
Look at the windsock as part of your Eventualities:
Cross or Tail wind?
Approach speed?
Lay off?
Hand on release: pull immediately if you can’t keep wings level on ground run
5 second Rotation into Full Climb after you reach 1.5 x Vs
Wing tip, ASI, Other wing tip, repeat….
Lay off only after achieving full climb
Recognise Launch Failures:
Too Fast/building speed – from ½ way up full climb
Too Slow/decaying speed
Bang!
Winch drivers – clearly mark the top of the launch
Winching – wind direction
Decision to stop winch launching in NE winds (040 to 070T)
To avoid dropping cables over New Road
Allows for ‘worst case’ scenario; break in cable at max. launch height
Aerotowing is not impacted
Homework (starred) and Resources Safety Chain, Risk and Error Management:
Swiss Cheese: https://aviatortraining.files.wordpress.com/2018/07/swiss-cheese-model-aviation.png
BGA Compound Errors Video: https://members.gliding.co.uk/library/general-safety-publications/multiple-compounding-risks/
BGA Managing Flying Risk: https://members.gliding.co.uk/library/bga-requirements-guidance/managing-flying-risk-guidance/
Safety Analysis article based on statistical analysis & psychological theory: https://chessintheair.com/does-soaring-have-to-be-so-dangerous/
BGA Safety in Adventurous Soaring: https://www.youtube.com/watch?v=h5iI2HlFfQg
BGA Safe Winching:
BGA Safe Winch Launching Booklet
How to Winch Launch Safely presentation 1: https://members.gliding.co.uk/library/safety/how-to-winch-launch-safely-movie-mp4/
How to Winch Launch Safely presentation 2: https://members.gliding.co.uk/library/safety/how-to-winch-launch-safely-video-part-2/
Winch Launching Quiz: https://members.gliding.co.uk/bga-safety-management/safe-winching/safe-winch-launching-quiz/
Launch Accident Simulations: https://members.gliding.co.uk/bga-safety-management/safe-winching/simulations/
Bailing Out:
BGA G Dales Presentation: https://www.youtube.com/watch?v=cDXIxHAmSX0
Soaring, Weather and Topography Publications: Suggested Reading List
Understanding the impact of weather and geography (the lumpy bits) on soaring and in particular associated TEM. All of below can be found on the BGA website shop and purchased from there and other outlets:
The Glider Pilot’s Manual 4th Edition: Ken Stewart
The Soaring Engine, Vols 1 & 2 (no. 3 to follow): G Dale
Gliding in Lift and G-SINK: Kevin Atkinson