Air Safety

He had made a pact with himself that he would file an Air Safety Incident Report despite what others may say. As soon as he swung open the front door, Frank offered him the customary cup of coffee and, just out of habit, asked how the flight went.

“It was ok Frank, a bit of clag down the coast from Moruya; my passengers were their normal obnoxious selves and, Oh. . . I had a slight conflict with another aircraft in the circuit!” “A WHAT. . . !”. Frank exclaimed, sharply looking up from his coffee and obviously startled by the casual manner in which David mentioned it. “Frank, I’m really tired; it’s been a long day. Two of us on final at Merimbula. I will tell you about it tomorrow. ” Frank decided to drop it for the time being because he suddenly noticed that David seemed a bit on edge. “It is quite late and no doubt you want to get home. Come out and see me during your lunch break tomorrow. We’ll talk about it then. ” David felt relieved. He had got through the first obstacle. Now for Beverly. She was sure to ask the same question. He felt the best course was to divert his wife as soon as he set foot inside the door.

“How were the twins today; teeth any better?”. Bev positively beamed when she was able to answer in the affirmative. It was quite a while since David returned from a charter and didn’t immediately dominate the conversation with all of the technical details which she not only didn’t understand but also wasn’t interested in. This gave her the opportunity to add that, as they had agreed, she had applied for a position with a local farm research organisation and, with a bit of luck, she would be back in the workforce adding a bit more disposable income to the household. David didn’t react apart from grunting and announcing that he was tired and off to bed.

His body told him how tired he was as soon as his head hit the pillow but he could not seem to stop his mind from going over the day’s events. Every time he closed his eyes all he could see was a F27 filling the windscreen of the Seneca and his violent control inputs. All he could hear was the scream of the Darts and Huxt- able-Smith’s outburst.

David wondered what would happen to him when he lodged an Incident Report. Were all the stories he had heard around the field right? He knew that prosecution would be one option for the Department and the last thing they could afford was a hefty fine and the loss of his commercial licence. Bev joined him in bed about an hour later and noticed that he wasn’t yet asleep. “What’s the matter David, I thought you would have been out to it by now?” David explained glossing over the detail, instead concentrating on what it would mean to the family not having the additional income if the Department decided to prosecute. “Well David, why lodge a whatever you call it report? You don’t have to put yourself in, do you?” He explained that he was required to but it wasn’t a question of that, since the pilots of the F27 were not aware of his presence right under their nose. It was more a question of his responsibility. He could have killed a lot of innocent people.

Bev thought she would never understand this aviation thing and the codes of behaviour. David asked her to drop it, he was going to discuss it further with Frank tomorrow.

They both drifted off to sleep and their own dreams. Bev of the possibility of being in an interesting job using her economics degree; David of a magistrate beating him with a rubber hose.

David arrived at work early the next morning and submitted a sick leave application for the day he had taken off to do the flight. He was aware that his supervisor didn’t believe he had a migraine but that seemed unimportant now.

During his morning tea break, he telephoned Wagga Flight Service to see what he had to do about lodging an Incident Report. The duty officer said he would post one out and, much to David’s surprise, didn’t ask why.

David thought he would explore the indemnity offered to pilots who lodge ‘225s’ themselves which he had read about in past issues of the ‘Aviation Safety Digest.

“It’s based upon a policy established some years ago by a previous Secretary of the Department designed to encourage pilots who get into difficulty to ask us for assistance or who bring to our attention an incident which otherwise would go unreported”, was the initial response. “I believe that the policy is still in operation and applied in most cases except where the pilot has put himself into a situation through a blatant and wilful disregard of the rules. ” Time to get off the telephone, David thought. This was not the case with his incident and he suddenly realised the significance of logging the flight as a private SARTIME instead of a charter. David thanked the FS Officer and hung up. He had better discuss this with Frank.

During his lunchtime, David went out to the aerodrome and explained to Frank what had happened the previous day. This time he gave Frank the full details including the fact that he had filed his plan as a private flight because the HF was not working. Frank went very quiet.

“David, you have worked on a casual basis for me for over two years. You know what standards I set. You stick to the Operations Manual or find a job elsewhere. I don’t need problems with the Department. With one or two minor exceptions, I have kept my nose clean. I want to keep it that way. ” “I take it you will be submitting a “225”, Frank added. “Well, I was thinking about it, but I thought I would seek you advice first. ” After some further discussion, David explained that he felt he owed it to a lot of people to submit a report, not the least himself and that his conversation with Frank had convinced him to go ahead. Maybe something good would come out of the whole mess.

The one-page yellow form arrived in the mail a couple of days later. The first thing he noticed was that it was no longer a ‘Form 225’ but a ‘DA2593′. He couldn’t help but think that someone in the Department had no sense of tradition.

He completed the form as per instructions providing the barest detail and despatched it to BASI. That out of his hair, he got back to trying to locate the owners of some stray cattle as his job with the Council required.

About a week later, he received a telephone call from a BASI Investigator from Canberra. It couldn’t be at the Central Office already? I must be really in strife David thought.

David took the call and immediately asked why the report was being investigated from Canberra. He was relieved to discover that the investigator worked for the Canberra/Sydney Field Office out of Canberra for geographical convenience. David couldn’t really explain why he was happier with this set-up. Maybe it was his natural tendency to assume that people who worked in the national capital couldn’t possibly understand what it’s like “to be in the real world”.

The voice on the other end of the telephone pointed out that most people who worked for the Department in Canberra had all worked elsewhere and were well aware of the rest of Australia. The investigator explained that he wanted to know more about the incident at Merimbula.

Before asking specific questions, he also made it clear that he wanted David to understand that it was not the role of BASI to apportion blame but rather to investigate the incident to establish the causes in the hope of preventing future occurrences. He said that David could start by recounting the history of the flight from the time he first arrived at the aerodrome until he shut down at Merimbula.

David did exactly this, paying special attention to the problems caused by his arch-foe, Huxtable-Smith.

“Seems you had an eventful trip all round, David. I would now like to ask you some questions to clarify a few points”. After providing information on times, visibility, ceiling and tracks, David was beginning to think that this was quite easy.

Then the investigator hit the spot that David was hoping that he would not target. “What communications were you doing?” David said that he was maintaining a listening watch on VHF because below 5000ft he would have lost contact with Sydney down parts of the coast. “What about HF?” “The HF was unserviceable and I had lodged a private SARTIM flight to avoid the need to remain in contact.” “Did you hear the other aircraft at any time?” “I may have, but I was being distracted by a passenger just out of Merimbula”.

David then volunteered that he understood the rules concerning charter flights but couldn’t think of any other way of getting his passenger to Merimbula.

The investigator paused while he made some notes. He then proceeded to ask questions about what lighting David had on at the time that he was approaching the circuit. At this question, David remembered the u/s beacon and had to admit that he had not turned any other lights on. His story must be making him seem like a real idiot.

The questions then took what to David was a surprising tum The investigator wanted to know whether he was happy a home, at his job, whether he had particular worries and whether he was sleeping alright. What impertinence. David was about to interrupt, but thought better of it.

The investigator explained that he understood why David was hesitating. “It’s not a question of prying, but you should be aware that of all the factors attributed to both accidents and incidents, about 70%-80% are what we call human factors. Fatigue worries at home because of money or other problems, pressures at work, and lack of sleep can all degrade a pilot’s skills and concentration so that he ends up in trouble of one form or another. ” “The way you have told me your story so far, coupled with your lack of recency, makes it probable that you were affected by some of these factors”, the investigator added.

David had to agree that he was having difficulties at home. His two youngest were teething and his wife needed to get back into the workforce earlier than they had planned because of house interest payment problems. He pointed out that he had a particular problem with his passengers which involved his work for the council.

As it appeared that the questions had ceased, David asked the question which had been preoccupying him for some days. “What’s going to happen now?” The investigator explained that he would complete a report on the incident and make appropriate safety recommendations. “What about me and my licence?”, David continued.

It was then pointed out that this was not up to BASI. The Bureau does not have regulatory powers at all; specifically, it cannot take any license action. The primary objective of BASI investigations is to identify the factors involved and make safety recommendations. It was up to the regulatory Divisions of the Department to act upon any recommendations that may flow from a specific investigation.

However, the investigator said that BASI had a responsibility to draw to these Divisions’ attention any cases where rules had been deliberately broken or ignored. David held his breath.

“David, it appears you may have flown an improper charter, tried to take shortcuts at your destination and as a result, involved an RPT aircraft in a serious conflict. I will have to report this to Flight Standards. ” He concluded the conversation by advising David that he would probably hear from someone from Flight Standards in Sydney shortly.

BASI’s summary of the incident arrived at Flight Standards a couple of days later. The examiner of airmen who had surveillance responsibility for the company glanced through the report and noticed that the operator was an old acquaintance from his own GA days. He also registered that the cause of the conflict at Merimbula appeared to be a collection of human factors – fatigue, distraction by a passenger, rushed procedures, failure to maintain adequate listening watch, failure to fly a proper circuit, etc. , etc.

Prior to discussing what action should be taken about the illegal charter, he decided to speak to the BASI investigator involved to establish whether David had any other records.

The investigator was able to tell him that BASI only held two other records concerning the pilot; one a weather-related incident and the other a landing accident both early in the pilot’s career. Nothing since. When prompted he also added that during the course of their discussions, the pilot had been very cooperative and open. David had appeared nervous but was certainly paying attention.

The next day, the examiner rang Frank who was expecting the call. They spent a little time talking about old times but Frank knew the purpose of the call and suggested that they get down to it. After Frank had responded to all the questions, he felt it important to mention that he found David a conscientious pilot who normally complied with the come ny ops. Manual and that he had never been aware of David ever risking his passenger’s safety. Yes, David had discussed the indent with him and he felt he would learn from it.

The next step was for Flight Standards to discuss what should be done. The examiner sat down with his supervisor and a colleague who had conducted David’s Class 1 class. No one denied the seriousness of the situation but David had been flying for some years without coming to the attention of the Department and the conflict had arisen because of a number of human factors unrelated to the illegal charter. It was also acknowledged that David qualified for the immunity provisions because he had reported the incident himself and the Department would not have been aware of it otherwise. Then followed the telephone call that David had been awaiting with some trepidation ever since his contact with BASI “David, in view of the circumstances of your recent flight to Merimbula, we would like to speak to you. in Sydney, if possible”. The examiner said.

David said that he would be in Sydney later in the week for a local government conference and he would be able to make some time available.

“Are you going to suspend my licence or prosecute”, he blurted out. “They are options but let’s wait until we see you in Sydney before we discuss the detail”. They arranged to meet the next Wednesday afternoon.

When David arrived at the Regional Office of the Department in downtown Sydney, he was told to wait a few minutes. He just knew they were planning an execution. At least the receptionist had got him a cup of coffee.

He was shown into an office where he recognised the officer who had conducted his last renewal. The other person introduced himself as the examiner he had spoken to on the telephone. David could feel the tension mount.

The examiner started out by explaining the options open to the Department concerning the illegal charter. He pointed out that licence action was considered to be safety enhancement and prosecution disciplinary. None of the ones mentioned much appealed to David, particularly the prosecution option. He then went on to say that, if the Department had decided to prosecute, David would have had certain rights.

Had he heard correctly: “If we had decided to prosecute. . ” Yes, he had. The two examiners explained why the Branch had come to this conclusion and that this was a counselling session. They said that he did qualify for immunity and they wished more pilots understood the system. He was told that they knew it wasn’t an easy decision to make but they were convinced that he also would learn from this mistake. They said that they couldn’t emphasise enough the importance of flying by the rules and that his actions at Merimbula was almost the start of a major accident investigation. They also stressed that it was more important to act as pilot in command rather than just list it on a flight plan. This was an obvious reference to Huxtable-Smith’s involvement and his failure to draw Frank’s attention to the problem with the HF.

By the time it was all over. David had a different appreciation of ‘pre-flight’ and the need to include himself in a pre-flight check; to make sure he was up to speed and in the right frame of mind. When he arrived home Bev was quietly waiting for him in the lounge, dressed up and the kids were nowhere in sight. Before he had a chance to tell her what had transpired in Sydney. Beverly said that she had arranged a babysitter and she was taking him out to dinner. She had got the job and started in a fortnight. It was to be a double celebration.

While he was getting ready, he made himself a promise. He would be more vigilant with all aspects of his flying in future.