T h e R A F F l i g h t S af e t y M a g a z i n e

airCLUES
october 2009 issue 1
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contents

Doing your best & still making errors ...

What’s up with that! 21

I learnt about fatigue from that .... 22

I learnt about hypoxia from that... 24

Per tornado ad astra 25

features I learnt about instructing from that ... 28

The double edged sword 30

Blast from the Past - Foreword 4 A close run thing 32

Foreword - ACM Sir Stephen Dalton 5 Lessons learned from Ben Macdui 34

Interview with Group Captain Tony Mills 6 Crash & smash no more 38

Spry’s View 9 A junior officer’s exposure to fight safety

during engineer officer
ASIMS - the dream becomes a reality 10 foundation training 42

The human factor: Foreign object debris 44

- in theory & practice 11

The human factors centre, hq cfs 12

I learnt about flying, drinking and

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supervising from that .... 14

Fatigue and human performance 18

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foreword
By Air Chief Marshal Sir Stephen Dalton KCB ADC BSc FRAeS FCMI RAF
Chief of the Air Staff
On Operations the aim is to
achieve the intended results with
the minimum of deaths and injuries
to non-combatants, the enemy
and, of course, our own and allied
forces. Critically, at home base or
on exercises, we train to develop our
skills and ability to fight and deliver
those results effectively whilst
minimising the risk to ourselves
and anybody else. In so doing, we
gain the experience to know when
to press on and when to say “No”!
Inevitably, we operate to finely
judged tolerances of acceptable
risk, but it is that judgement that is
so very important both in peace and
war. In peacetime, we aim to identify
the potential risks and then train to
know how to avoid them leading
to incidents, or worse, accidents;
on operations we use our training
and experience to identify the
most effective way of achieving the
mission with the minimum of risk
of losses. Our flying and technical
Blast from the past - Foreword to the 1st Issue dated May 1946
4 5
training are of the very highest
quality and despite all the safety
features designed into our aircraft
and equipment, more often than
not, it is the quality of training that
we have received that has enabled
us to identify potential risks and to
mitigate them.
However, despite all the training
and flight safety awareness that we
undertake, incidents and accidents
happen. It is our individual and
collective responsibility to seek to
identify risks and potential dangers
and to do all that we can to remove
or at worse reduce such risks so
that they are as low as reasonably
practicable. As part of that intent,
I am very keen to see Air Clues re-
launched as a significant tool in
heightening Flight Safety awareness
throughout the RAF – on the ground,
in the air, everywhere we operate. Air
Clues has a distinct role to play in the
overall, ‘Can Do Safely’ Campaign.
By sharing our experiences and
talking openly about situations which
have tested our operating abilities
and our judgement, we reduce the
risk of somebody else having to
learn the same hard lesson and
potentially losing their life or causing
the loss of somebody else’s life.
Air Clues has the ability to spread
the lessons widely and effectively
and I encourage all to share their
experiences and so improve our
collective awareness, operational
effectiveness and performance both
on operations and in training.
In encouraging you to share your
lessons, let me re-assure you that
such openness will only ever attract
my gratitude. We all make mistakes,
unfortunately some mistakes
lead to terrible consequences,
BUT, if despite your honest and
best professional endeavour you
make a mistake which leads to an
incident/accident, then I will support
you with all the resources at my
disposal. Whilst foolhardiness or
unprofessional actions will attract the
strongest disciplinary action, honest
mistakes will not. Air Clues offers us
the chance to learn from others and to
review how we operate, whether that
is in engineering, flying or controlling
aircraft/vehicle movements – all of
us share in this responsibility and all
of you have an equal voice and duty
to come forward and highlight your
concerns whether that is in the air or
on the ground.
In the spirit that takes us into the
air and brings us safely back again, I
strongly recommend Air Clues to you
and encourage you to be open and
honest so that we all might learn and
operate the Royal Air Force safely!
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flight safety product for you. Gp I am keen to re-introduce in the somewhat dry, but it is essential if

interview with
FS staffs are being reintroduced near future. we are going to be properly placed
and at the time of writing we are to continually improve our FS record.
commissioning a study into the roles, Is the ASMB the only AC body In terms of being more proactive, we
responsibilities and training of U/ charged with Flight Safety? have also reintroduced FS Assurance
SFSOs, who incidentally, I see as Within the HQ we are introducing a visits to stns and I am keen to free
being the most important individuals FS working group at SO1 level named up as much time as possible for
Group Captain Tony Mills, Gp Capt RAF Flight Safety
in the FS team. We will in due course the Safety Action Group (SAG). With my staff to get out and about to the
expand the review of FS trg to cover representation from across Air Cmd, units. There is much more besides,
Gp Capt Tony Mills joined the RAF in 1981 as a Pilot, before a medical that required by staffs throughout the SAG (no comments please) will but perhaps we could keep that for a
problem forced his transfer to the Air Traffic Control branch. In a varied the FS organisation. We will also be be able to take direction from and later issue. What I will stress as being
career he has served in Germany, Cyprus and at London ATCC; as well as engaging with Manning staffs in order raise issues to the ASMB. Just as of immediate concern has been the
2 tours as a desk officer at RAF Innsworth and a tour as DS on the ACSC. to progress towards having in place importantly, it will assist in breaking requirement to complete work on the
the right people with the right training down stove piping between 2* AORs, Air Command Safety Management
Following a successful tour as OC Operations Wing at RAF Linton-on
to provide an unbroken FS chain speed up the flow of FS information System (SMS).
Ouse, he was promoted to Group Captain and served on the staff of the
from UFSO through to the Air Cmd across the Cmd and improve the
NATO Defence College in Rome. Since his return to the UK, Gp Capt Safety Management Board (ASMB). passage of Lessons Identified There has been much talk about
Mills, has worked within the Ops Division at HQ Air; taking up his current and the tracking of Service Inquiry Human Factors training being
appointment as Group Captain RAF Flight Safety in Jun 09. Can you tell us more about the recommendations. rolled out across key branches
responsibilities of the ASMB? and trade groups in the RAF, why
The ASMB is responsible for What are the key work streams is this and what can we expect to
Sir, how did the new RAF Flight continue. In response, I was installed FS publicity campaign, providing monitoring the performance of that you are engaged with at see from RAF Flight Safety?
Safety (FS) organisation come as the new Gp Capt Flight Safety on assurance through FS audits etc, the Air Cmd Safety Management RAF FS? The old adage that there are no
about? 1 June 09, responsible for the now etc but that’s a bit boring. I think it System (SMS). Before you ask, We have been involved in the new accidents only new people
Unfortunately, since 1996 the RAF renamed and enhanced RAF Flight is best summed up by saying I see a SMS is the organisational introduction of several new waiting to have the old accidents
FS organisation has been subject to Safety organisation. our responsibility as being the FS structure, regulation, processes initiatives that should assist in the tends to ring true and as technology
a large reduction in personnel, and conscience for the RAF. It is our role responsibilities, procedures and quest to improve the RAF’s flight continues to advance the percentage
thus capacity. This was a direct result So how will RAF FS ensure it will to question, analyse and recommend resources that enable us to meet safety record. Of note are the RAF of accidents and incidents involving
of the demise of the RAF Inspectorate continue to meet the flight safety where we believe an activity could safety requirements and safety policy (Maintenance) Error Management Human Factors (HF) is continually
of Flight Safety (IFS); the creation challenges of the contemporary be carried out with less risk. We are objectives. It is a proactive process System ((M)EMS) with which RAF rising. As a result, your RAF FS staff
of the tri-Service Defence Aviation operating environment? involved in policy development and that adds to the significant traditional FS staff have been fundamentally are heavily engaged with DARS in
Safety Centre (now renamed the In April 2009 we held a Flight we provide advice and guidance but flight safety activity. Our SMS is involved from conception to the producing a new tri-Service HF policy
Directorate of Aviation Regulation Safety Transformation workshop we’re not the experts on everything based upon the simple model of 4 current roll out across the RAF and developing the concurrent RAF
and Safety (DARS)); and the steady that involved over 50 personnel and another important role for us is key elements; policy and principles, Engineering community. The policy. It is now recognised that the
demise of Gp FS staffs. This meant directly, or indirectly, concerned with to get the lessons learned by others organisation, implementation and development of the Aviation Safety RAF requires significant HF trg in
that the RAF FS function then rested FS from both inside and outside and accepted best practice passed monitoring/measurement. We work Information Management System addition to that being provided within
with a small cadre of HQ personnel the RAF. The week long event to as wide an audience as possible. our way round these 4 key elements (ASIMS) led by the DARS, but the (M)EMS programme and we are
under a Wg Cdr, Cmd Aviation Safety captured a comprehensive record Ultimately, I hold a very privileged in a continuous improvement loop. involving significant input from RAF confident that HF trg will be coming
Officer. It was soon recognised that of the problems faced by the FS position within our Service and as The RAF has for many years had personnel. ASIMS provides you with to a stn near you ‘ere too long.
this cadre, entitled the Aviation Safety organisation and a long list of actions the RAF’s FS conscience I can go mechanisms in place to manage a simple and accessible conduit
Group (ASG) was under resourced required to enhance its output. straight to the CinC if I believe the safety but what it has lacked is some through which you can report your With the establishment of the
and despite the efforts of some very Since June we have enthusiastically case strong enough. of the documented processes to near misses and, ‘there but for the DARS is there still a requirement
hard working individuals, was only set about eating the elephant one support this activity and, therefore, grace of God..’ incidents. With your for Single Service Flight Safety?
capable of providing a reactive FS spoonful at a time! You mentioned earlier about we have been unable to assure inputs, commitment and help we Without doubt; as much as ever
over-watch. Whilst overall numbers the manpower drawdown that ourselves and others that there are will stand a far better chance of before. The Directorate of Aviation
of RAF aircraft and personnel have What are the key outputs of the followed the demise of IFS, how no gaps or conflictions in our safety being more proactive in addressing Regulation and Safety is a central
reduced, the level of FS risk, through new RAF FS organisation? are you managing that and still activity. All of this information is the underlying unsafe acts which directorate responsible for developing
increased operational tasking and Well… I suppose I could reel off a ensuring flight safety throughout contained within the Air Cmd Safety ultimately lay the foundation for more the higher level overarching tri-
their adverse effects on UK-based list of tasks that are written in my the RAF? Management Plan which will be serious accidents. Together with Gp Service FS policy. It has an important
flying tasks, has arguably become TORs, things like implementation We have also been reorganising published shortly and which will FS personnel, we have begun the role to play, but beneath them so do
greater, and so the inability of ASG to of Aviation Safety Management and restructuring our organisation eventually be included within a new construction of the Air Cmd FS Risk we. DARS are not responsible for the
meet demand could not be allowed to policy, developing an effective in order to provide an improved single-Service FS document which Register. All of the above may sound implementation of the Flight Safety

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Management System. We do that job
and in doing so we concentrate our
efforts solely towards reducing FS
risks to RAF personnel and aircraft.
That is why I believe there is a strong
argument for having a single RAF FS
document which would complement
the relevant JSPs. Indeed, all RAF
specific material in JSP 551 could be
moved to a single Service document
and so we are investigating the
reintroduction of such a document-
perhaps we could call it AP3207!
I might add that DARS support
this aspiration.
RAF Flight Safety has set itself
some ambitious targets, can
it really make a significant
difference?
Unequivocally, yes, but we are not
naïve. Risk is ever present in our
lives and we can never eradicate
it. Indeed, I would argue that life
would be extremely dull without a
regular injection of vitamin R as
risk is sometimes referred to. Your
FS team are not risk averse and
appreciate that Operational Risk
Management is a very different beast
to risk management in a peacetime
environment. Each bring their own
hazards and challenges; moving
from operating in one environment to
the other brings hazards of its own.
However, on all occasions there are
8 Work Rounds - Think Flight Safety! Change of Procedure -Think Flight Safety!
nearly always courses of action that
can mitigate potential harm and we
are committed to reducing risk to
ALARP. We are not Air Cmd’s narks
nor are we the fun police. So what are
we? We are a collection of individuals
with a variety of professional skills
from across the RAF, who are
committed to making flying activity
as safe as possible. I myself am an
air trafficker and within the team we
have representation from aircrew in
the fast jet, multi-engine and rotary
worlds. We have engineers and a
trainer; we even have a navigator
who has served in both the USAF
and RAF! There is a lot going on out
there; operations, training, time and
finances can all test us to the limit
but we are determined to provide
you with advice and assistance
whenever possible.
So what is Air Clues?
Those of you who like me, are slightly
longer in the tooth will remember the
times when ‘Air Clues’ appeared
regularly in the crew rooms and
tea bars around the RAF. First
published in 1946 this Flight Safety
(FS) magazine was in production
continuously until 2002. It had
a deserved reputation as a pre-
eminent flight safety publication and
it was one of the Service magazines
that was eagerly anticipated by
its readership.
Where does Air Clues fit in
to the new RAF Flight Safety
Organisation?
In reintroducing Air Clues we are
keen to recapture its former standard
and provide you with valuable
information in what we hope will
be an entertaining publication. Air
Clues is a magazine that is relevant
to all of us, military and civilian, and
whether your workplace is in the air
or on the ground it can provide a
means for disseminating valuable
FS information to lessen the risks
inherent in our core business.
Will Air Clues be written by your
team at RAF Flight Safety?
No, quite the contrary. It is your
professional knowledge, experiences,
views and recommendations that
can be disseminated to a wide
audience and can play a part in
reducing the risk of others coming
to harm. Air Clues is your magazine
and wherever we have visited there
has been unanimous support for
its reintroduction, but it will only
ever be a success if you commit to
it. Everybody involved in the flying
business probably has at least one ‘I
learned about….’ incident that makes
them squirm when they recall it. No
articles, no magazine - so please
give us your full support and help
your colleagues by sharing your
knowledge and experiences.
Any final words?
The RAF used to have an
Inspectorate of Flight Safety that was
the envy of many military aviators
around the world. We dropped the
ball to a degree, but now RAF Flight
Safety is back. There are some very
competent and committed individuals
working in the organisation and we
will do everything in our power to
improve the output, but if we are to
maximise our FS effectiveness we
need the buy-in from everybody. I
want to encourage people not to be
afraid to pick up the phone and please
find the time to fill in that report – you
could be saving someone’s life.
Oh, before you go your readers
will be delighted to learn that we
have managed to persuade the
legendary Wg Cdr Spry to return
from his sabbatical. He is looking
tanned and extremely chipper.
The old warrior is refreshed and
reinvigorated and contactable at any
time on 95221-3870, or by e-mail to
Air-WGCDRSPRY.
s p r y ’s v i e w
Welcome (back) to Air Clues.
To my RAF brethren I bid a hearty
what-ho and a warm welcome to
the first issue of the re-launched Air
Clues magazine, the pre-eminent
(albeit only) RAF flight safety
publication. Some of you may not
have heard of this magazine before;
some will recognise the name and
may vaguely associate it with Flight
Safety, and others, like myself,
who are greying slightly around the
temples, will have clear recollections
of the bang-on Royal Air Force
flight safety magazine to which I
previously contributed.
For reasons that are many and
varied, but which I won’t bore you with
here, Air Clues winged its way into the
wild blue yonder in 2002 and with it,
one could argue, went the public face
of flight safety in the RAF. But I am not
the kind of officer to let things lie and
I was adamant, that like a phoenix,
Flight Safety and Air Clues, would
arise from the ashes. So after much
banging on the doors of our lords and
masters and subjecting them to the,
‘Spry view’, the glorious 1 June saw
the establishment of an invigorated
RAF Flight Safety organisation, with
Air Clues resurrected as its voice.
Spry resurgam!
Those of you who benefited
from my missives and opinions in
the old Air Clues will remember the
often forthright manner in which I
approached flight safety, particularly,
those involving your flight safety
cock-ups. Well I make no apology
for my past crimes. Spry is, and will
always be a child of the robust school
of management favoured during my
formative years. What I will concede,
however, is that time has mellowed
me and as I race headlong toward
my dotage you will find my comments
far less prejudiced. But don’t be lulled
into a false sense of security, Spry is
no old fool, he knows that the best way
to provoke flight safety discussion is
to take a stand, raise my standard
and sound the battle call. Some of
you will rally to my colours, others will
take the high ground opposing me.
The side you take is unimportant, the
crucial point is that you think critically
about your part in flight safety, voice
your opinion and make it heard!
Now for you non-Aircrew types,
for whom I have the deepest respect,
this magazine also belongs to you as
much as to your breveted colleagues.
In my youth, it was the dashing pilots
and aircrew who did flight safety, often
badly, with no-one else considered,
other than ourselves. Now you
can imagine my surprise and slight
consternation, when it was pointed
out to me over several beers in the
mess, that all of you land-locked
personnel can, and do have, a direct
impact on the safety of personnel in
the air and have done so, perhaps
unwittingly, for decades now. All of
those human factors issues which
we Aircrew so religiously guarded
under the banner of Crew Resource
Management, are just as prevalent
on the ground and have the same
direct impact (forgive the pun!) on
operations in the air. As such, this
magazine will provide the conduit
through which all specialisations
can bring their flight safety issues
to the fore, but to be effective it also
needs input from the broad gamut of
RAF personnel.
Oscar Wilde once wrote that,
‘there is only one thing worse in life
than being talked about, and that is
not being talked about’; and this is
particularly true when it comes to
Flight Safety. For if we are not talking
about it, thinking about it and most
importantly, working it seamlessly
into our daily business, then we
are quite simply not doing our jobs.
Flight Safety is the key to the RAF
continuing to deliver operational
capability; if we pay lip service to it, or
ignore it completely, we do so to the
detriment of our people, operational
effect and our world class reputation.
I would, therefore, urge anyone
who wishes to put pen to paper and
offer their flight safety thoughts, or
concerns to a wide audience to do
so. Articles can be anything up to
2000 words (I do find the odd picture
or photograph also goes down well
with the readership as well) and
may address any flight safety related
topic. As an added incentive, there
will be a cash prize of £50 for the best
article published in each issue.
Well I now hand you over to the
bold few who have contributed their
experiences to these hallowed pages
for the benefit of the many. I only
ask that you are gracious enough
to return the favour. As Mark Twain
wrote, ‘our opinions do not really
blossom into fruition until we have
expressed them to someone else’.
Over to you.
Yours aye,
Spry
RAF Flight Safety
(95 221) 3870
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After a great deal of hard work by many organisations and individuals across the
Defence Aviation Community, DARS will shortly begin rolling out the Aviation
Safety Information Management System (ASIMS). ASIMS began life in Feb
D-FSOR data can then be accessed
by all ASIMS users to identify trends
and analyse all aspects of Flight
the human factor:
in theory & practice
08, when the inaugural ASIMS WG first met to consider the future for Flight Safety. Many organisations regularly
Safety Reporting. In Feb 09, a contract was signed with Bristol-based Vistair generate graphs for analytical
for the purchase of their Safetynet system. Safetynet is a proven Aviation purpose and currently this can be
Safety product, which was originally developed for Ryanair but is now in use very time consuming. Within ASIMS,
with airlines including FlyBe, Tui Fly and Aer Lingus. users can save any graph templates In this the first of two articles on Human Factors in aviation, we
Before considering what ASIMS is, it worth first describing what it isn’t. that they regularly need for use at a examine the work done by Royal Aeronautical Society’s Human
ASIMS is not simply a database on which to raise and store flight safety reports. moments notice. Factors Group, who as principal advisors to the Civil Aviation
For it to be truly effective in improving safety, it needs to be far more than that.
Authority, ultimately, have a crucial role to play in the development
With that in mind, ASIMS has been developed to be exactly what its name Hopefully, you are now thinking,
suggests, “A Management System”. ASIMS will be hosted on the Defence “This all sounds great but when can
of military aviation policy. The second article focuses on the work of
Intranet (www.asims.r.mil.uk) to enable the Defence Aviation Community to I get my hands on this thing you call the RAF Human Factors Centre at RAF Cranwell, detailing how we
perform the following: ASIMS?” The Field Development as a Service are educating our people on the Human Factor.
Phase commenced at RAF Marham
Report all Flight Safety Occurrences. Without the need to actually logon to on 28 May 09 and this Phase has now
ASIMS, anyone in Defence Aviation with access to the MoD Intranet can raise extended to RNAS Yeovilton, RAF By Mr Carey Edwards, Chairman of the Human Factors Group, RAeS.
a Defence Flight Safety Occurrence Report (D-FSOR). Having completed Aldergrove, RAF Linton-on-Ouse,
their D-FSOR, this will be forwarded to their own Unit/ Sqn/ Organisation’s RAF Northolt and BAE Systems The Royal Aeronautical Society’s sole intention of improving CRM committee and the other groups and
Maintenance personnel for completion of the report. At any stage in the report Warton. Thus far, the feedback has Human Factors Group was formed instructor standards in the UK. This several conferences have been held
process, files such as Pictures, Videos or Word/PDF documents can be added been extremely positive and we will initially in 1990 and became a full was created from a recognition that, at military establishments, notably
to amplify the D-FSOR. shortly extend the FDP to include 3 sub group of the Society a few years particularly in HF and CRM training, RAF Bentley Priory. The intention
& 4 Regts AAC, RAF Benson and later. Its aim was, and still is, to help the competence and credibility of the of the HFG in respect of military
Task Investigations and Follow Up Actions. Once the initial D-FSOR has QinetiQ Boscombe. All being well, the aviation industry understand instructor was paramount in order aviation has been to make comment
been received by the Occurrence Manager, they are then able to task and track ASIMS will be rolled out across the more about human factors, to provide for the impact of CRM training to on HF matters in the military and be
the progress of any investigations, or Follow Up actions. Initially, ASIMS will rest of the Pan-Defence Aviation workable solutions and to provide a be maximised. available for advice if required, as
host the MEDA Investigation Report, but work is also underway to develop a Community from 1 Oct 09. forum for like minded individuals to In additon to the CRMAP the well as being open to any good ideas
replacement for the RN A25/ Army F5/ RAF F765B, which will also be available Ahead of this roll-out, DARS have share experiences and best practice. HFG has a number of sub groups that the military may offer.
on ASIMS in the future. Again, any investigation work carried out can also be already held a number of ASIMS Over 35 conferences have been held which address their domain specific The main work of the HFG is
added as a file attachment to the original D-FSOR. Briefing Days, but if your organisation by the Group during this period which issues, such as Engineering, Flight to keep a watchful eye on what is
has missed this first opportunity to has drawn together all the main HF Deck CRM and Cabin Crew. These happening on the front line and with
Track and Manage Recommendations. Having completed any form of find out more about this exciting practitioners in the UK and overseas groups have been extremely active both UK and European regulation,
investigation, recommendations associated with a D-FSOR can be entered development in Flight Safety or if you as well. in bringing together interested to try and identify problems, and to
into ASIMS, where they can be tracked and managed to completion. require more information regarding Since the beginning there has people in their disciplines to provide solutions wherever possible
ASIMS, please contact either been a strong connection with the discuss problems, share ideas either through publications such as
Share and Trend Analyse Data. All historical PANDORA data will be uploaded Sqn Ldr John Franklin or CAA, who have always sent several and develop tools, techniques and CAP 737, which is now referenced
into ASIMS. This information coupled with a burgeoning knowledge base of Sqn Ldr Stu Keenan on 95233 8081 members to the various meeetings resources for addressing these. The worldwide, conferences or influencing
or 0208 833 8081. and conferences that have been held. people involved in the HFG and its legislation. Currently, the Group has
In fact the role of the CRM Advisory associated groups are all volunteers been analysing recent accidents
Sqn Ldr John Franklin, DARS Occurrences SO2 describes how the to ensure that key HF learning is
Panel, which was formed from the and are a mixture of operational
new Aviation Safety Information Management System will provide an HFG, is to provide direct guidance to personnel, consultant practitioners not lost, and to disseminate this
accessible and simplified mechanism for flight safety reporting. the CAA on CRM training standards and academics who because of their information to the industry.
and CRM instructor accreditation. considerable individual experience Although, it is not possible to
This guidance has almost always share a common belief that any make a clear connection between

ASIMS the dream

been followed and has resulted in a solutions offered to industry must the work of the HFG and any safety
robust working relationship with the be practical, effective and meet any improvements, it is a fact that since
regulator, which has been of great economic or legislative constraints. 1990 the UK has an exemplary

reality
benefit to the industry. Although the HFG has not had safety record in terms of Human
The CRM Instructor Accreditation a military sub group, personnel Factors accidents.

becomes a programme was developed and is

monitored by the CRMAP, with the
from the RAF, Army and RN have
been represented on both the main

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the human factors centre,
hq cfs
By Sqn Ldr Adrian Rycroft, OC Human Factors Training Sqn, CFS, RAF Cranwell
Introduction
As a result of work carried out
by the Defence Aviation Safety
Centre (DASC) and Flying Training
Development Wing in 2005, the
Human Factors (HF) Centre, HQ
CFS was established in Oct 07. The
HF Centre was set up to provide HF
and Airmanship training to aircrew
students and flying instructors within
22(Trg) Gp and to act as a focal point
for wider HF training and research
within the RAF. The aim of this
training was to increase mission
success through improved individual
and team performance.
In Jan 09 the HF Centre started
training HF Facilitators for the RAF on
behalf of the Aviation Safety Group,
HQ Air (now RAF Flight Safety). Over
the last 18 months a good working
relationship has developed between
the HF Centre, the RAF Centre for
Aviation Medicine (CAM) and the
Directorate of Aviation Regulation &
Safety (DARS) with the result that
from Jan 10 the HF Centre will take
on sole responsibility of training all
HF Facilitators for all 3 services; a
task currently shared with DARS.
The 3 aircrew staff at the
HF Centre cover all the aircrew
specialisations: Pilot, WSO, WSOp,
Fast-Jet (FJ), Rotary Wing (RW)
and Multi-Engine (ME). They are
supported by a Pers (Trg) officer
and in, Sep 09, by a civilian Human
Performance specialist.
12
The genesis of training
You will probably be aware of a number of HF related programmes and legacy
flying training initiatives that were used within flying training over the last
decade. The current courses we deliver have taken the relevant and useful
elements of each of these, combined with the latest psychological research,
and turned them into coherent and useful training packages that are directly
applicable to modern flying. Examples of the legacy initiatives and research
which the current training draws upon are below:
a. Traditional Crew Resource Management (CRM). The legacy training
still in existence from the CRM initiative of the mid-1990s was uncontrolled
in terms of both content and delivery. It had not advanced from its initial
inception and was still based on old, civilian CRM training packages. Even
so, there were parts of the training that remained relevant and needed to be
included in the new training being developed.
b. Airmanship. The Airmanship Assessment Matrix had been in use since
2003. Formal training to FT students and instructors in airmanship skills
related to this matrix began in early 2007.
c. Performance Improvement Training (PIT). PIT trials took place at
19 Sqn, RAF Valley and BFJT, RAF Linton-on-Ouse investigating the use of
performance coaching techniques within the FT system. The results indicated
that PIT needed to be formally incorporated into all FT streams.
d. Psychology of learning/teaching.
e. Psychometric Tests. At the time of the establishment of the HF Centre
2 psychometric tools were being used within the RAF outside of the
Officer and Aircrew Selection Centre; neither in any formalised way. These
were the Myers-Briggs Type Indicator (MBTI) and the Strengths Deployment
Inventory (SDI). Both tools had value as indicators of intra- and inter-
personal behaviours, but required development for use within the flying
environment. After a small trial it was decided to use and develop the MBTI
tool with the help of OPP Ltd., the owners of the tool.
Our current courses
The HF Centre now delivers courses for Flying Training Students, Aircrew
Instructors, Aircrew Performance Coaches and HF Facilitators. Research and
experience indicated that the training needed to be delivered by instructors who
were deemed credible by the students. To this end courses are delivered by a
combination of HF Centre staff and civilian instructors. The civilian instructors
are provided under contract by Inzpire Ltd and OPP Ltd, depending on the
course, and are supervised and standardised by the HF Centre. The courses
we provide are:
a. HF/Airmanship Foundation. This 5-day course is for all FT students
and is delivered by Inzpire’s ex-military aircrew instructors.The course
covers Intrapersonal/Interpersonal Skills, Airmanship, Stress, Fatigue and
the Just Culture.
b. Human Performance for Aircrew Instructors. This 5-day course forms
the 1st week of the QFI, QHI and Aircrew Instructor courses and is delivered
by staff from the HF Centre. The course covers the Role and Characteristics
of the Instructor; Intrapersonal and Interpersonal Skills; Basic Psychology;
Airmanship; Introduction to Performance Coaching; Stress & Stress
Tolerance (including Hi Ropes training).
c. Aircrew Performance Coach Qualification Course. This 4 week course
trains and qualifies Aircrew Instructor and Flying Training student
performance coaches.
d. HF Facilitators. This 5-day course trains personnel in the skills of
facilitation in an aviation HF environment. Qualified HF Facilitators will then
be able to conduct case-study based HF training on their units iaw
service policy.
Looking to the Future
As the HF Centre takes on responsibility for tri-service HF Facilitator training
in Jan 10 there is now an aspiration for the centre to expand to become, in
partnership with CAM, the focus for all aviation HF training for all three services.
Similarly, and to maintain relevance and best practice, the HF Centre carries
out research into all areas that can improve human performance. All research
is carried out with a practical training application in mind. Our current research
is focused on, ‘Emotional Intelligence as an indicator of High Performance’
and, ‘Training Techniques to Improve Stress Tolerance’.
airCLUES
13
airCLUES
I learnt about flying,
drinking and supervising
I began my flying career on the
Puma at the start of the 90’s and
was fortunate enough to be based in
Germany for my first tour. The flying
was great, mainly single pilot by day
and, because of the use of NVG,
twin-pilot by night. As the Flying
Officer junior pilot on the Squadron,
I racked up my fair share of ground
runs, but drawing from a very small
pool of Puma pilots also meant I was
exposed to tasks that otherwise I may
not have been given. By being keen
for the mundane I was rewarded with
the interesting; there was a lot of time
away but this suited me fine.
Combat Ready status came and
I was quickly dispatched to Belize
for 2 months. With my conversion
course peers stuck in Northern
Ireland, Belize was epic. It was the
sort of place were you stepped from
the VC10 to be greeted by a smiling
pilot holding a cool bottle of beer for
you – though one of the reasons he
was happy was that you were his
ticket home; with only 4 pilots for the
4 aircraft you were not allowed to
leave country until your replacement
had arrived. There were 2 Army
Battle Groups to support, so tasking
was high and, while the Harriers
had left taking the radar with them
(leaving the Puma with little beyond
the GPS), the work was rewarding,
varied and fun. We tended to operate
2-3 task lines by day and had one
pilot on standby at night. I didn’t think
to question the logic that we trained
14
f ro m t h a t ….
Belize was the perfect mix of jungle and over-water flying
for twin-pilot ops by night but only
held one pilot on standby. Things
seemed OK and it was well known
that the Boss – there on a 12-month
tour – was usually around for any sort
of callout.
Belize was the perfect mix of
jungle and over-water flying
Within a few weeks I broke the
rules on alcohol and flying on a night
callout. I had been standing in the bar
one night and had just had a couple
of mouthfuls of beer when the Boss
came in and announced that 15
soldiers and a boat had gone missing
somewhere between Honduras
and Belize. The Puma was poorly
equipped for night winching, having
a single landing light and a high
strength floodlight called Nitesun,
which was difficult to control and too
bright for close operations, though
we practised using it for overland
approaches when light levels were
very low. The Boss asked me how
much I had drunk and, after I advised
him, he took me flying on a sortie that
lasted until the following morning,
with the successful recovery of the
soldiers. At the time what I had done
seemed right given the potential
circumstances for the soldiers, but
my failure was to highlight that I had
broken a rule, to stand up and be
judged for the decision to go flying
and to look at the procedures to see
what could be done to prevent it
happening again – something I regret
to this day.
Not many nights after the first
callout, I found myself as the standby
pilot for night flying. I remember waking
around midnight when the Boss,
already accompanied by one pilot,
woke the third to drink in celebration
of a, ‘certificate of appreciation’
that had been presented by the US
Embassy following a CASEVAC of
some injured missionaries before
I had arrived. Thankfully, I was not
called to these celebrations, which
seemed to have already gone on for
a while, and I drifted back to sleep.
However, at about 0300 my phone
rang and I was called into ops for a
rescue. I arrived to be greeted by my
crewman, the medical team and my
Boss – very much under the influence
and in a flying suit. I had been called
in because a diver was reported as
suffering from the ‘bends’ on one of
the outlying islands and, according to
the doctor, the diver could lose his life
if he were not transported to the only
decompression chamber in Belize,
some considerable distance away
from his current location.
Getting onto islands such as this
one (with one of the bigger landing
sites) was often difficult.
With the crewman and the Boss
we looked at the situation. There
Getting onto islands such as this one (with one of the bigger landing sites) was often difficult
was a recce of a landing site on the
island, but this was assessed as
‘emergency use only, daytime only’
– due to the difficulty of the site.
There was no moon whatsoever and
we knew from previous experience
that, with no cultural lighting, this
would be an uncomfortable and long
transit without Night Vision Goggles
(NVGs) and with an aircraft with no
autopilot bar a simple stabilization
system and a bar alt hold facility that
you certainly could not trust at low-
level over the sea. I knew nothing
about the ‘bends’ apart from that low-
level ops were preferable in order to
avoid making the illness worse, but
regardless, I had no other option,
as there was heavy cloud, down to
not much above 500’ and within the
cloud were embedded tropical cumuli
nimbus (‘CBs – clouds containing
heavy up and downdrafts, severe
turbulence and potentially lightning).
In short, the weather was unfit, there
was no light to assist, the landing site
was unfit, we had no legal nav aids,
or means of getting below cloud if
we did go into it, and the only sober
pilot was a young Flying Officer at the
start of his first Belize tour after just
achieving Combat Ready. In training,
this is a no-brainer, but there was the
small matter of a life in danger...
The Boss was the first to come
up with a plan. He was by far the
most experienced and was also the
only person that had been to the
island. However, in recognition of his
‘situation’ his plan was that I would be
aircraft captain in the right-hand seat
(traditional for helicopters) and that
he would occupy the left hand seat
to ‘advise’ me. As politely as I could,
I declined this offer and informed the
Boss I did not believe he was fit to
fly. I was gently rebuked by him and
he stated that of course he wouldn’t
be doing the flying – that would be
my part – but instead he would come
along to see that my flying was OK.
Rewording my concerns, I stated that
he was not fit to be in my aircraft and
I did not want him with me in the air –
I bitterly regretted the earlier rescue
I had flown with him. The Boss
then looked again at the situation,
reinforcing the peril for the diver and
his solution. In response, I offered an
alternative that I would rather go on
my own with the crewman and nobody
else in the cockpit. The conversation
deteriorated until I swore at my
Boss and I was then dragged into
a separate office for a good old
fashioned telling off. I held my line
and we drove together to the flight
line (in retrospect I should not have
let him drive me there!). The Boss
then completed the authorisation
sheets (I had no powers of my own
to authorise a sortie) and it was only
when I was called to sign them that
I realised he had authorised me to
conduct the sortie single pilot – the
crewman and I were determined this
was the only way we would go flying.
I conducted the pre-flight checks
with the Boss just outside the
aircraft telling me to speed up (so
much for being in ‘the bubble’) and,
as a result, forgot to strap myself
to the dinghy pack in my seat.
Then, along with the crewman, we
departed the airfield and conducted
15
airCLUES
a Nitesun approach to collect the
medical team and equipment.
Nitesun approaches involved flying a
descending, decelerating turn, below
the minimum speed allowed for flight
on a helicopter with sole reference to
instruments, while looking over your
right shoulder into a beam of light
projected by the crewman using a
control box near the cabin door. The
idea was that this manoeuvre would
end up with you in a hover-taxi and
able to move into the landing site. If
it sounded awful it is because it was.
After picking up the medical team
we transited down the coast of Belize
to a small town from where in order
to have something to look at and
assess the cloud base, which we
believed was around 700’. We then
coasted out to find our island, relying
heavily on our sole nav aid, the
excellent GPS. Unfortunately, with a
map marked ‘1964 British Honduras’,
the information for which came from
a 1950’s aerial survey, the island
wasn’t quite where it was marked
on the map. However we found the
landing site, aided by some torchlight
from the island itself.
One of the larger landing sites
in Belize, but with the tail still over
the water.
We had looked at the landing
site previously from a photo, but the
reality was that things were a little
more overgrown. Taking our time,
we eventually conducted a Nitesun
approach to the island, perhaps
one of the more uncomfortable
manoeuvres I have flown. We only
managed to get the nose wheel
on the beach due to the proximity
of trees and we kept some power
applied as the main wheels where in
the shallow water off the beach. The
crewman went out, assessing our
distance from the trees as several
metres, slightly less than we were
allowed, and went to get the casualty.
Not an educated man, I was amazed
at the effect the bends had on the
16
One of the latger landing sites in Belize, but with the tail still over the water
patient, for by the time we got to him
he was huge – I feared one small slip
of an aircrew knife and nitrogen could
fill the cabin. When I expressed my
concerns I was gently (and kindly
given my ignorance) advised by the
doctor that the bends was in fact
affecting the joints – it was just a
coincidence that the man was fat.
My feeling of stupidity was, however,
masked by my lack of capacity to
take in anything at the time – I was
occupied by intense relief to be on the
island and a building fear of what was
to come. Eventually, a large group
of people carried the only beached
whale in Belize out to the aircraft and
we were then ready to depart for the
decompression chamber.
We conducted an instrument
departure, using a technique
designed for fog (i.e. with little visual
references on take-off) and had
been underway for about 5 minutes
when we flew into base of a tropical
CB. There was no lighting – and
therefore no warning – but as we
scudded along the bottom through
incredibly heavy rain we were thrown
about uncomfortably, all just several
hundred feet over the water. Taking
a 45 degree heading change, we
popped out the side and I made a
initially were more self-centred – I
rarely drank afterwards and would
always volunteer to hold standby
on other tours when there was a big
occasion, such as the Summer Ball –
I never wanted to be in the situation
where someone would be in danger
and I would not be fit to help them.
However, as I moved into supervisory
positions myself my tone changed.
I rigorously enforced the guidance
on alcohol and flying. Of course, all
supervisors would say the same, but
have a think about 2 of the ways we
have used in the past:
‘The Joker’. I have often
heard the phrase that aircrew are
allowed to ‘play a joker’ on a tour,
implying that if they drink to excess
mental note to discard that pair of and are unfit for work they can
underpants after landing. At this be excused from flying that day
stage, I remained on instruments, – no questions asked, but once
but the crewman was occupying the only. I certainly believe people
centre seat and occasionally using should not fly when unfit, but the
his NVGs. In this way, the crewman problem with the ‘joker’ system is
identified the single points of light that what do you do when someone
would mark my route, highlighting repeat offends? If people make
which island they were. Eventually, a mistake, be it genuine, stupid
we reached the chamber, dropped or whatever, then they should
our patient (who lived to complain we never fly. They must know that the
were not gentle enough with him!) punishment of attempting to cover
and returned to Belize airport. The up these mistakes by flying is far
relief was overpowering. greater than admitting to them
In the days that followed I beforehand. The ‘joker’ system
pondered what to do. I was influenced should not be used.
by those that patted me on the back, Are you fit to fly?’. I am sure all
by the occasional individual that authorising officers will question a
advised I should not speak to senior crew if they are fit to fly, but are we
officers like I had that night and by paying lip-service to that phrase?
my Boss who advised that if I wrote Is there a danger we are allowing
the callout up as it had happened that the individual the opportunity for a
the report would never leave the Unit. subjective assessment about how
I am ashamed to say, I did nothing he is feeling (‘I had some beers
but serve out my time in Belize and but I feel fit to fly’), potentially after
get back to the welcoming arms of a night out. As an alternative, if
my unit in Germany. our authorising officers asked
Unlike traditional ‘I learnt about aircrew ‘Did you comply with the
flying’ stories from Air Clues, my story JSP550 regulations regarding
is therefore about my own failing to alcohol and flying?’, would there
take the issue to a conclusion, in order be a slight discomfort from some
to prevent that sort of pressure from of our aircrew that have perhaps
being applied to others. My actions strayed over the 5 units (about 2.5
pints of beer) of alcohol limit in the
previous 24-hours?
Thankfully, the Service has come
a long way since the start of my
career and I hope that moments like
my own in Belize many years ago
are long gone. However, at a time
when airline pilots are subjected to
random alcohol tests, is the military
culture still 10 years behind that of
the civil culture? While we have Post
Incident Drug and Alcohol Testing
(PIDAT), why is it not mandatory post
an incident (not just an accident)? As
an optional system, has it ever been
called, if only to assure us we do not
have a problem? Do we still live in a
‘beer call’ culture and, if so, are we
confident we are correctly managing
the situations that can follow?
The Air Clues Test
In my career I admit I have broken
rules. Examples include flying in
Northern Ireland in weather that
was unfit in order to extract troops
that would otherwise be stuck on
the ground; and in flying beyond
the normal crew duty day to move
a compassionate case to be with
a dying relative. I am sure no-
one would begrudge me these
indiscretions, but other than back-
briefing the supervisory chain on
landing (or worse, keeping quiet) do
we have a formal process to highlight
these indiscretions, so that we can
be judged by our actions? If not,
perhaps we should imagine, ‘The Air
Clues Test’. If your Boss forced you
to write to Air Clues describing the
situation and justifying your actions,
would you be comfortable? If the
answer is no, then it is probably not
worth doing. On that horrible night
in Belize I could never have justified
flying with a drunk, but I still feel it
was right to go flying to see if I could
save a life, despite the conditions.
Hence in applying my own test I have
written this article. However, I am
still embarrassed that I did not justify
myself at the time and put a stop to
what was a clear supervisory hazard.
It is only time that has allowed me to
overcome my shame in that respect.
Wg Cdr Spry Says:
The history of our beloved Service is
replete with tales of courage in the
air, the exploits of Ball, Embry, Bader
and Gibson all perfect examples of
how courage and leadership inspire
our people and set the foundations
for success. Yet, when it comes to
moral courage (defined as the ability
to take the right actions in the face
of opposition, shame, scandal, or
discouragement) are we as consistent
in our actions? Do we have an
equally proud tradition of rewarding
moral courage? How many of us,
when exercising our roles as leaders
would consider moral courage in our
subordinates as a positive thing, not
just defiance? Alternatively, when
acting as followers, how often do we
have the courage to take a justified
stand against our superordinates,
particularly when faced with a boss
who is prickly when challenged, or
who is so experienced that surely he
can’t make mistakes? In flight safety
terms, 100s of lives have been lost
because of a combination of bullish
leadership and a lack of moral fibre
in those in supporting roles. One,
need only think of the Tenerife Air
disaster in 1977 which cost the
lives of 583 people. The incident
that this article’s author describes
is I’m sure not an isolated one and
what concerns me most is whether
we can, hand on heart, say that the
courage to do the right thing is the
norm? Do you think that the RAF
has an organizational culture which
is accepting of moral courage in all
its glory, or do we adhere too rigidly
to our rank structures and experience
levels? Over to you!
17
airCLUES
“Of course I know they are fatigued.
But they are getting the job done magnificently.
Fatigue is not a problem.”
Dr David Stevenson Colonel, USAF (Rtd) RAF Centre of Aviation Medicine 30 Jul 09
“After training and currency, the greatest contributor to human variability is fatigue. One of the primary
hallmarks of fatigue is human variability. This is due to large amplitude and moment to moment fluctuations
in attentiveness associated with fatigue.”1
Fatigue and Human Performance
Fatigue causes an increase in variability in performance; the greater the fatigue, the greater the variability. What is the
practical meaning of, “variability” in this regard? The absence of variability results in consistency and accuracy in task
performance, as in Figure 1. Figure 2 shows consistency but not accuracy. This is a systems problem. Everyone is doing
the same thing, but it is wrong. Procedures, equipment or training need to be addressed. Figure 3 shows a result which
is somewhat accurate, but inconsistent. We know what is wanted and how to do it, but the result is less than adequate.
This is performance variability. Increasing fatigue increases the spread of the shot group. Thus any action which reduces
aircrew fatigue will tighten the shot group. It will lessen the variability in their performance of their duties.
Figure 1 Figure 2 Figure 3
Chapanis (1951) cited in Reason J, ‘Human Error’.2
Regarding fatigue, it is known that activities which are mainly procedural are by their nature relatively resistant to
detrimental effects of fatigue. In contrast, activities which require creative thinking, real time evaluation of changing
scenarios, generating different possible courses of action, and quickly selecting the best course of action, are more
susceptible to fatigue. For example, a mission involving simply flying a cargo of supplies from point A to point B in
a relatively low threat environment is a basically procedural activity. We would expect the crew to do well, even if
somewhat fatigued. In contrast, a helicopter crew who have taken off to deliver supplies, only to be diverted to pick up
wounded troops in a high threat area, at night on NVGs, encountering enemy fire as they approach a dusty landing zone,
is definitely in the creative thinking realm of activity. If the two hypothetical crews have the same level of fatigue, the
second will be at much greater risk of making mission critical errors. It follows that any measures which can be taken to
reduce fatigue will reduce both crews’ performance variability, and will increase the likelihood of successfully and safely
completing their missions.
I also note that there is significant individual variation in people’s responses to fatigue. The military generally makes an
effort, consciously or unconsciously, to select people with a certain degree of fatigue resistance. However, in operational
1
Miller, J C; Fundamentals of Shiftwork Scheduling, USAF Air Force Research Lab pub 20060508021
2
Reason, J; Human Error, Cambridge University Press 1990 p.3
18
environments, this resistance (in those who possess it) can be easily stretched
beyond their limits, and the bullet group begins to spread.
Fatigue Management
In my view, fatigue is a problem in that any fatigue will increase performance
variability and increase the risk to operational success. Minimizing fatigue
can be addressed by commanders/supervisors in the real operational world
in simple, positive, relatively inexpensive, and practically useful ways. I refer
to this as “nibbling at fatigue” since these measures are not massive changes
from what we already know we should do. These measures do not constitute
luxuries or mollycoddling of aircrew. They fall into four categories:
• Accommodation
• Scheduling
• Napping
• Breaks
Accommodation: Cool (air conditioned), flat, dark, quiet surroundings coupled
with appropriate mattresses, sheets, blankets, pillows. Each of these measures,
when instituted, will incrementally tighten the shoot group and lessen human
performance variability. This is a hugely important matter; sheets and pillows
will improve performance. If one must sleep during the day and fight at night,
the person requires the best sleeping accommodation possible. The questions
should be, “We’ve been here seven weeks, why are we still sleeping on the
ground instead of on camp beds.” “We’ve been here six months; why are we
still sleeping on camp beds instead of proper beds?” We’ve been here two
years; why are we still sleeping in tents instead of porta-cabins?” Permanent
buildings? Individual rooms? Each increment in sleeping accommodation
quality will tighten the shoot group.
Scheduling: Both the USAF Air Force Research Lab3 and the Royal College
of Physicians in the UK have investigated and commented on the effects of
fatigue on night time operations. These recommendations are not made with
a military operational tempo in mind, but they reflect studied consideration of
human performance in those required to work regularly at night. To summarize
only a few of their recommendations:
- In peacetime 24/7 operations, no more than three nights in a row
should be worked.
- In the medical environment, no more than four consecutive nights
should be worked unless extreme circumstances require it, and then a
maximum of seven.
- 24 hour shifts should not be imposed, unless there is a high chance
of obtaining six or so hours sleep during the shift. There is abundant
data that errors (especially in the maintenance world) increase greatly
after twelve hours on duty.
Miller, J C; Fundamentals of Shiftwork Scheduling, USAF Air Force Research Lab pub 20060508021
N Horrocks, R Pounder; Working the Night Shift; designing safer rotas for junior doctors, Royal College of Physicians, 2008
19
airCLUES


- Human beings are not nocturnal creatures; we need night time sleep
from time to time to recover. Working continuous nights is not a good
price to pay is a compromise in flight
safety. My question to you readers,
doing your best & still making errors...
…What’s Up With That!
idea; it will result in accumulating a sleep debt and chronic fatigue. would be how do we strike a
successful balance between
- The next day after a night shift should not be considered an off day; delivering operational capability and

airCLUES
the day after that is the first off day. A person needs a bare minimum of maintaining a workforce that is not
one full night’s sleep before resuming night duty. The more consecutive so overly fatigued that mistakes are By Master Warrant Officer Gillis, 410 Tactical Fighter Operational Training Squadron,
nights, the more days with night time sleep are needed. made? Can we meet our operational 4 Wing, Cold Lake, Alberta, Canada
and training commitments if we
Napping: Naps are a known and highly effective (and very inexpensive) way implement a fatigue management
to refresh and improve performance which is deteriorating due to fatigue. policy which restricts working hours? training I began to reflect on past program and under went two days of
A minimum of twenty minutes sleep is required; there is no limit on length. I would also add that fatigue is incidents and accidents that not repair to correct the damage.
If a person is subject to being woken to manage an emergency, they should not the sole preserve of personnel only happened to me, but also to At the time I could not understand
probably not nap since it takes some time to become fully awake (“sleep on ops. From bitter experience the my co-workers. I began to realize a how I could have made such an
inertia”). I have heard of squadrons having separate, designated napping contention that procedural flying is, substantial number were often linked obvious error and for months my
rooms with proper beds and bedding – a superb idea. ‘relatively resistant to detrimental to human factor causes. confidence was affected by the
effects of fatigue’ is fundamentally One such incident I recall incident. I truly believed at the time
Breaks: Especially in an environment of continuous work (e.g. aircraft wrong. I imagine that, like myself, all happened to me in Summerside, I was immune to errors and they
maintenance), breaks are a proven way of reducing errors and increasing of you can recount horror stories of PEI, back in the early eighties. We only happened to less competent
efficiency. I have heard it said, “We are too busy to allow breaks.” There is extended shifts to get the jets out, frequently were responsible for early technicians, was I ever wrong.
excellent evidence that, in a busy work environment, one cannot afford not to mistakes made when tired, even morning launches for fisheries patrols For the next few years I worked
take breaks. of nodding off on routine flights? and usually the aircraft departed at on several different aircraft and was
The following two articles develop 6:00 am; therefore our servicing crew lucky that I did not run into any similar
The Final Word this further and show how easily was often at work before 5:00 am, to occurrences and over time I got my
Regarding fatigue and methods to minimize it, it really is a matter of operational fatigue and its unseen and insidious get the aircraft mission ready. confidence back to where it once
risk management. The more fatigued a person is, the greater the variability in brother, complacency, can raise their One morning after the early was. However, I never did forget
their performance. A commander/supervisor must accept this fact and decide ugly heads. launch, I decided to help out the the incident with the damaged main
consciously how much risk is appropriate for a particular situation. It is always morning shift by before flight checking landing gear door and often tell the
possible to reduce risk by looking at accommodation and scheduling in an the other aircraft that were schedule story to junior personnel as part of
intelligent and creative manner, instituting strategies of breaks and napping to fly later in the day. In the next two their human factors training.
where feasible. These measures will reduce human variability in performance, hours, I had five additional aircraft “B” Today when I think about this
and hugely increase the chances of operational success. checked and was pleased with the incident, I begin to realize that
recognition from the crewmembers several human factors played a role
Wg Cdr Spry Says: as they showed up for work and to in why I missed seeing something
If I had a pound for every time I had heard the phrase, ‘man their surprise much of the morning very obvious. Firstly, I was often
up’ levelled at some baby pilot or engineer who had whinged work was completed. It wasn’t until working fatigued having young
about how tired he was in the crew room, I would be writing 9:00 am that my MCpl came and children that were up frequently in the
this particular missive from a yacht in the Bahamas! Yet for talked to me and asked me to go night. Secondly, I was rushing the
many years we accepted this attitude to human limitations with him to one of the aircraft I had inspections as I had a specific process
as entirely acceptable; it was part of the, ‘can do’ attitude; we inspected. He asked me to go in of doing my before flight checks
will always get the job done. But at what cost? How many the right wheel well and see if I saw and besides very rarely did I ever
times have accidents happened in the past which were directly Writing a human factors article might anything. I entered the wheel well find anything wrong. Thirdly, I was
attributable to fatigue? In terms of performance impairment the be easy if you regurgitated someone’s and did not see anything out of the extremely confident in my abilities and
effect of fatigue, even at low levels is broadly comparable to that research and filled the text with ordinary until he asked me to look after all we got rewarded for working
of alcohol, but whilst we would never contemplate turning up for all kinds of statistics, but I believe over my right shoulder. It was then beyond what others could tolerate. I
work three sheets to the wind we are happy to ignore the signs of personal experiences are much more to my astonishment that I saw a even had a letter of appreciation for
fatigue. interesting and beneficial. It wasn’t hole puncture through the right main working 23 hours in my personal file.
This particular RAFCAM piece raises some interesting points, and I until late in my career that I started landing gear door. The damage was Finally, and most importantly, I had
dare say a few eyebrows at the same time: naps at work, comfy beds, well receiving human factors training as severe and if left un-noticed could no human factors training and had no
planned shift patterns, these things were the stuff of dreams when I was a the newly appointed Flight Safety have caused the landing gear to get idea how outside influences, circadian
young whipper snapper on ops. But times must, and should, change. Whilst Warrant Officer in an extremely hung up in flight. The aircraft was rhythm or how human engineering
we will always demand the very best of our people we can not do so if the busy fighter squadron. Following the subsequently pulled from the flying plays a role in error.

20 21
airCLUES
This saga began at RAF Akrotiri
before they had operating windows,
with what should have been an
undemanding long-range navigation
exercise. We were to take a Vulcan
of the Akrotiri Bomber Wing for a long
weekend at RAF Gan, the RAF’s own
tropical island.
The original plan was quite simple:
depart Akrotiri on Thursday, night-
stop at Masirah and fly to Gan on
Friday and we would have three clear
nights in paradise. The only planning
factor was to arrive at Masirah by
1700 hrs local time. Masirah was
90 minutes ahead of Cyprus, so
with a flight time of 4 hr 30 min, and
allowing for the time difference, we
could afford a gentlemanly departure
from Cyprus at 1000 hrs local. We
had one hour in hand for any delays.
The aircraft was unserviceable; we
lost our window into Masirah. It was
not worthwhile going for a 24-hour
delay; as this would mean a Saturday
arrival in Gan, and hardly worth the
effort, so we entered a bargaining
22
Originally printed in the final edition of Air Clues, April 2002.
phase with the engineers. Eventually
it was agreed that we could take the
aircraft and double stage the next
day. Now we just had to fit the two
legs to Gan into the airfield opening
hours at both airfields.
We had to arrive at Gan before
teatime, but could not land at Masirah
before 0900 hrs Masirah time. Also
we would have to leave Masirah by
1200 hrs local if we were to reach
Gan, a further 90 minutes ahead
of Masirah, in time. With a ‘book’
turnaround time of 3 hours, the plan
was very tight.
The revised plan called for a
departure from Akrotiri at 0300 hrs
local on Friday morning. The new
show time was midnight so we had
12 hours in which to rest. We had
started work at 0700 hrs local and
it was now nearer midday. With the
temperature rising to a typical 30°C
plus, and already fully rested, sleep
was impossible.
The skipper and plotter repaired
to their on-base quarters; the AEO
probably went down to the beach;
the co-pilot and I, the Nav Radar, just
did our own thing with the odd nap
thrown in. Our crew chiefs, who had
no active role during the flight, slaved
to fix the jet.
By midnight we were ready for
bed. We gathered for the pre-flight
briefing, refreshed the plan and
loaded the aircraft. We were perhaps
too tired to make the proper decision
– scrub. Even now things did not go
entirely to plan and we had a crew-
in snag and eventually departed
at 0340 hrs local. We were now
committed to a fast turnaround at
Masirah. We had lost any flex. We set
our northerly course for Turkey and
our penetration route into Iran. The
route was quite sporty, especially for
a nuclear bomber, as it required us to
negotiate the corridor between Syria
and the USSR with the radar under
I lear nt about fatigue
strict emission control. Our principal
navigation aid, the radar, was the
Lake Van Non Directional Beacon
(NDB). There were two problems with
this. The Russians were notorious
for ‘meaconing’ and trying to seduce
allied aircraft into their airspace
and the Vulcan’s ADF receiver was
notoriously poor.
At Van we were only 7 minutes
flying time from the Soviet border.
We reached Lake Van 1 hr 10 min
after take-off. We were very alert.
A quick radar fix over Lake Van, a
bit of right hand down a bit, and we
were on a safe course for Tehran.
We relaxed.
We relaxed completely. The Nav
Plotter did not relax his guard and
beavered away checking and cross-
checking our flight path. We arrived
over Tehran almost 2 hours later. We
from that….
were to put in a lot of right-hand down
a bit before taking up a southerly
heading towards Shiraz, the Gulf,
and Masirah. In best Nav school
fashion the plotter passed all the
next leg details two minutes before
the turn. Silence. Thirty seconds to
go he issued the instruction to turn.
Silence. I only know this as he woke
me up.
The AEO, apparently watching
over the electrics has his head
on one side and was fast asleep.
I looked forward and both engineers
were dead to the world. In the
cockpit both pilots were crashed
out. I may have woken them, but
they were definitely in the sleep
inertia phase. Fortunately in the
Vulcan the navigator could steer
the aircraft through the autopilot.
He duly executed the 80-degree
turn. What he could not do then was
transmit on the radio. He listened for
the complaints from Tehran Control.
Silence. Were they asleep too? We
never found out.
A while later, the sun streaming
through the windscreen, the pilots
were fully refreshed and back in
control oblivious to the drama that
had nearly occurred.
The lessons? If it is not essential
don’t push it. If your planned work
day is likely to be delayed, go back
into proper crew rest; don’t try
and get tired first, store up more
sleep. If you’re a self-auth, or a flight
commander, consider a second
opinion even if it means they have to
be up in the middle of the night too.
We had two flight commanders in the
crew so we had plenty of experience!
And the weekend? Great!
airCLUES
23
airCLUES
I learnt about hypoxia
It was another typical exercise sortie
where we were due to man a CAP
west of the Shetlands for a 2 hr ‘vul’
period, and, therefore, needed to
tank in advance to meet the task.
This of course dragged the take off
time even further forward, calling
for an, ‘Oh my lord’ take off time,
leaving little flexibility for last minute
hitches; which of course we had.
Having got the ac almost ready to
taxy, an engine management system
problem cropped up, requiring a full
shut-down and power recycle. On
reapplying the power, the problem
was still there so we started unstrap-
ping to change ac, However, the
Chief thought of one more fix which
cured the snag and we were good to
go. We hurriedly strapped in again
and managed to launch on time to
the tanker; no problems.
After an uneventful join on the
tanker we took our place in the
queue and waited our turn to plug-in.
After about 30 mins airborne it was
our turn and after some up-down-
left-right from me, my pilot got in
first time. To let him concentrate, we
didn’t speak for a while and I found
my mind wandering while looking at
the snow covered Highlands below.
Then I became aware that my vision
was tunnelling in and my fingers were
tingling, which I thought was strange.
I was also aware that my breathing
was shallow and I felt light headed.
Putting it down to the early start, I
tried taking a few deep breaths, but
didn’t really feel any better.
As I felt progressively worse, my
thoughts went back to one of my
24
f ro m t h a t ….
numerous visits to AMTW (at my age
I’m on my fourth 5 yearly refresher),
and I correlated all my symptoms
with the onset of Hypoxia. Looking
down at the 2 oxygen MIs, I saw that
my pilot was flicking white to black
indicating that he was breathing
happily, but my MI was a stubborn
black. Before committing to pulling
the emergency oxygen handle (the
hypoxia bold face action), I flicked
the regulator to 100% to see if I
got a continuous flow; there was
nothing. Quickly checking my oxygen
hose, I found it hanging loose from
my mask and not connected to the
PEC bayonet. I connected it up, got
the 100% flow and quite quickly felt
better, so decided against pulling the
emergency oxygen as it was quite
clear why the problem had arisen.
Clearly when we had decided
to crew out I had disconnected the
bayonet, but not reconnected it
when we decided that the ac was
serviceable after all. I explained to
my pilot what had happened, but
emphasised that I was now perfectly
OK and happy to continue. However,
had I not had that repeated exposure
to the aero medically trained doctors
at North Luffenham, and latterly
Henlow, who had drummed the
symptoms of hypoxia in to me, it
might have been a different story. I
have been flying fast jets for 28 years
now and have 2,300 hrs on the type
in question, yet this was the first time
I had ever become hypoxic outside of
the oversight of a doctor. Luckily, their
training had allowed me to recognise
the fact.
per tor nado ad astra
OC Typhoon Training Flight,
Sqn Ldr Mannering describes the path to Combat Readiness on the Typhoon
Spry says:
In the summer of 2007 I was enjoying understand the physiological effects in the kit; I was pleasantly surprised to
Being a member of the winged master
the start of my third tour on the of flying such a high performance find that I could comfortably maintain
race I have, in the past of course,
Tornado GR4 on 14 Sqn at Exercise aircraft and get to grips with pressure 6Gz without any kind of straining and
been accused of paying lip service
Anatolian Eagle. On the second breathing now that I would be able to flying at 9Gz was easily achievable.
to the continuation training I have
Monday of the detachment I was easily attain FL550 in my new steed. My final port of call was to Swanwick
done. Surely, once I’m qualified I
called into the office for a chat with I was also kitted out with my new (Mil) to be made aware of the pitfalls
should be out there going up-diddley-
the Boss. I was told to RTB; my heart Aircrew Equipment Assemblies (AEA) and advantages of the Typhoon’s
up, not wedging my eyelids open to
sank and I began to wonder what I including a new G-suit – full coverage exceptional rate of climb and
stop falling asleep during another
had done? I was posted to 29(R) anti-g trouser (affectionately named: service ceiling!
tiresome lecture. However, it’s
Squadron to undertake the Typhoon faggot) and pressure jerkin. The next Eager to get my hands on the
incidents like this that really remind
Operational Conversion Unit (OCU). step was to Farnborough to undergo aircraft I was forced to wait a little
me of why training is the better part
I was thrilled and somewhat smug at centrifuge training, experiencing up longer as there was a 4 week ground
of operations; because when the
the number of, ‘green eyed monsters’ to 9Gz and passing the mandatory school phase to attend at the Typhoon
proverbial hits the fan it’s the training
that appeared when the decision high Gz qualification run to proceed Training Facility at RAF Coningsby,
that saves your life. So next time
was announced to the rest of with the training. the MOB HQ of the Typhoon Force.
you’re sat in a stuffy briefing room,
the squadron. With my centrifuge experience The Ground School phase consisted
simulator or wherever, look beyond
Before attending the OCU I had fresh in my mind I was subject to of 2 weeks of classroom technical
the fact that you aren’t in the air and
to go through the extensive pre- two high-G sorties in the CAM Hawk instruction where the complexity of
think of it is an investment in your
employment training. This started aircraft based at Boscombe Down. the aircraft and the various fleets of
future health!
with a trip to the Centre of Aviation This is performed in full Typhoon AEA Typhoon became all too apparent;
Medicine (CAM) at RAF Henlow to and is designed to give you confidence see Figure 1.
Flight Control Air to Surface Avionics/
Block Air to Air Capability
System Capability Approach Equipment
Phase 3, 90% control Early radar software,
1 authority, 8.1G with hybrid ASRAAM, not Nil No ILS / TACAN
override cleared for QRA
Improved radar TACAN, Disorientation
Phase 4, 90% control software with hybrid Recovery Facility,
2B authority, 8.1G with no ASRAAM and Nil basic Multi Function
override AMRAAM capable of Information Distribution
holding QRA System (MIDS)
Austere A/S, Litening
Phase 5, 100% control Digital ASRAAM, III LDP, Paveway / TACAN, ILS, MLS,
5 / R2
with no override AMRAAM E-Paveway II, (KFF / MIDS
Cannon), SRP 4.2
8
(Basic Block 5 –
“ “ Paveway II Drop only TACAN, ILS, MIDS
Improved processing
but more limited A/S)
Figure1: Table of Typhoon Aircraft Standards
25
airCLUES
There was a graduated migration
to the Typhoon simulators to
undertake basic conversion and
emergency procedure training. TTF
utilises Aircrew Synthetic Training
Aids (ASTA) a four nation project
consisting of two Full Mission
Simulators (FMS) and two Cockpit
Trainers (CTs). The 4 week phase
culminates in a simulator check ride
consisting of an Instrument Flying
training sortie with full emergency
procedure training and examinations
on Typhoon technical data and
emergency procedures.
At last it was time to start the
conversion (cvx) phase. My first
sortie consisted of general handling
followed by Instrument Flying
26
and circuit practice, but all I can
really remember is grinning at the
acceleration of the aircraft that was
only in dry power but had the ability
to climb at 20° nose up at 400KDAS.
The other lasting impression is of
a very clean uncluttered cockpit
with 3 Multi-Function Head Down
Displays (MHDDs) and wide angle
HUD with all the information a pilot
could wish for! The cvx consists of
5 sorties including an IRT then first
solo, followed by a formation ride and
a night check ride. The first solo on
type usually in a single seat aircraft
as opposed to a ‘tub’ (twin seat
Typhoon) usually involves the pilot
enjoying the awesome performance
of the aircraft at low level either in the
Lake District, or Wales followed by a
transit at FL500 or above because
you can. Such is the performance
of the aircraft at low level that it is
imperative to use the Auto-throttle set
to 420KDAS to avoid encroaching
the transonic region and causing
untold complaints!
With the cvx phase complete, it
was time to start the tactical portion
of the syllabus. The Typhoon Force
Basic Counter Air Module (BCAM)
OCU syllabus aims to teach the pilot
basic Air Defence (AD) skills. The aim
being for the pilot to be able to fight
the aircraft firstly, within visual range
(WVR) employing the ASRAAM, then
work up to beyond visual range (BVR)
utilising the AMRAAM, and then
finally combining all the disciplines
as a tactical pair. The WVR phase
involved two synthetic events and 7
live flying events covering Offensive,
Defensive and High-aspect fighter
manoeuvring. This phase was highly
demanding physically owing to the
high Gz loading on your body and
the manipulation of the weapon
system. Typhoon human-to-machine
interface is ergonomically superior
to many aircraft in service, utilising
Voice Throttle and Stick (VTAS)
inputs to control the weapon system;
very much a home-away-from-home
for the, ‘Playstation Generation’.
The voice part of VTAS employs a
Direct Voice Input capability within
the aircraft to manipulate the radar,
weapon targeting and cockpit
domestics eg. radio changes.
The BVR Phase consisted of 3
synthetic events and 4 live flying
events working up from 1 v 1 intercepts
to 1 v 2 at low level employing
AMRAAM then ASRAAM tactics. It
was during this phase that I started
to become aware of the vast amount
of information that the aircraft had to
offer, and the consequent temptation
to stay, `heads-in’, soaking it all up.
The BVR Phase moved swiftly
onto the Pairs Phase. This phase
consisted of 3 synthetic events
and 6 flying events culminating in
a pair of Typhoons, with me as the
wingman, fighting an unknown pair of
hostile aircraft in a variety of different
presentations. The pairs element
of the OCU was undeniably the
most tactical and most demanding
with the introduction of Defensive
Aids and Data link (MIDS/Link16)
manipulation. The final part of the
Course is the Quick Reaction Alert
(QRA) Phase which enables a
graduate from 29(R) Squadron to be
declared Limited Combat Ready(Q)
and thus able to undertake the 24/7,
10 minute notice-to-launch for NATO
and UK duties.
Upon graduation, pilots are
posted to either Nos 3(F), XI or 17(F)
Squadrons at RAF Coningsby, and
towards the end of 2010, to No 6
Squadron at RAF Leuchars. Here the
young graduate will go on to complete
an Advanced Counter Air Module
(ACAM), and for selected individuals,
the Basic and Advanced Surface to
Air Module (BSAM/ASAM). Upon
declaration of Typhoon Force Multi-
Role OED on 1 July 2008, Typhoon
aircraft could deliver UK Paveway
II, Enhanced Paveway II, Freefall
1000lb bombs and utilise the Litening
III RD pod whilst performing its initial
AD capability. At the time of writing
this article, the Typhoon Force is
preparing to deploy to the Falkland
Islands to take over QRA duties there,
and is focussing on further extending
the Force to RAF Leuchars.
airCLUES
27
airCLUES
I learnt about instructing happen, who will initiate and who will
carry out each engine-off landing.
The engine-off landing sortie may
thing may be in your mind”. The more
potentially dangerous the situation,
the closer your hands should be to
Spry Says:
Christmas comes early for one
instructor, and hasn’t he been a

from that...
only be carried out at certain airfields. the critical control; and if you may good boy? For Santa brings him the
Before each engine-off landing is need to prevent a swift movement greatest gift of all ….. hindsight. In
carried out during the sortie, a further of the throttle, your hand needs to all seriousness, what this experience
Assumption is the mother of all ………. One flying instructors close shave with communications, flying and a healthy brief is conducted in which specific be already on it. In this case, whilst does highlight for me is the danger
dose of, ‘I thought he understood’……… mention is made of the entry height, I was able to take control quickly, I that we all face, regardless of branch,
type of engine-off to be practised, wasn’t able to prevent the throttle when we begin to get comfortable.
“Practice engine failure go….” How many times have you heard that? How so to monitor his hover height more who will close the throttle and who being closed. You know what I mean; when you
many times have you said it? It usually results in the student making their way carefully in the future. But he didn’t; will carry out the engine-off landing. Secondly, of the options available hear yourself saying things like
through some form of emergency drill and then we all go home for tea and he closed the throttle instead. I took Each engine-off landing is initiated by to me to highlight the student’s error, ……‘Oh this is just a routine flight’,
buns. In an attempt to maintain that happy status quo I have been asked to control and cushioned the landing the phrase, “Practice engine failure was calling, “Practice engine failure or, ‘I don’t need the MPs; I’ve done
write this piece about an incident which happened to me and which almost did as well as I could. It turned out that go….”. go…” the best one? Probably not. a ???? so many times I can do it
not result in us going home for tea and buns. no damage had been done and we This previous sortie had been I did wish to make the point rather in my sleep’. Complacency as we
Some background will be of use to non-helicopter specialists. The Squirrel subsequently flew the aircraft back to carried out uneventfully. Today’s more memorable to him than just have seen elsewhere in this fine
HT1/2 is a single engine conventional rotor helicopter used for basic and base after an engineering inspection. sortie was not to include engine-off murmuring, “height”, but perhaps not publication can be just as dangerous
advanced helicopter flying training; we also use it here at CFS (H) to teach So, what was the problem? Well, landings. They were not mentioned quite as memorable as it now is. as inexperience. If there is one
experienced helicopter pilots how to become instructors (QHIs). In common I allowed the aircraft to be placed in the pre-flight brief, and were not Thirdly, this is yet another example thing I have seen throughout my
with many other single engine helicopters it is inadvisable to hover the Squirrel about 22 feet or so above the height authorised. We were at an RLG of two people in the same cockpit career is that the best people often
much above 5 feet because if the engine were to fail, it is unlikely that a from which a successful engine-off where they are not permitted, and having totally different interpretations make the worst mistakes; and 9
successful landing could be made from up there. Successful landings can be landing is likely to be made; I then no engine-off landing checks were of the same situation. Ask yourself, times out of 10 this is as a result of
made from around 5 feet without the benefit of the engine, and indeed they said something which inspired the mentioned at any time during the “Is what I have just said to the student becoming blasé about the job. The
are practised regularly by staff QHIs. To make this practice more realistic the student to close the throttle, and I flight. Would you therefore have totally unambiguous – is the student Service asks us to give our best in
throttle may be retarded in the hover so that the engine plays no part in the was neither able to stop him doing expected your student to initiate an thinking what I am thinking – will he situations that our often extremely
subsequent landing. The throttle is operated by a twist-grip on the collective so, nor was I able to re-open the engine-off landing in response to do what I think he will?”. Speak to demanding and unforgiving of even
lever. When the throttle is retarded in the hover it is done so in one swift throttle before landing. the phrase, “Practice engine failure your shiny new Aircrew Performance the slightest complacency. The
movement. The main rotor will begin to slow down immediately as it is no A little of the non-technical go…”? I didn’t. But I should have Coach, they will explain all about challenge lies in identifying how we
longer being driven, but because it still has a certain amount of inertia, a well- background to this incident may now been ready for it, just in case… Neuro-Linguistic Programming. prevent complacency developing in
timed application of extra pitch will slow the rate of descent sufficiently to allow be of interest. The student in this Finally – it’s always the instructor’s the first place. I don’t pretend to know
a soft landing; but the higher you are the further there is to fall, and from much case was actually a very experienced So what are the lessons? fault. Whatever the student should, or the answer, but I daresay you bright
above 5 feet the rate of descent will have built up so much that even the most helicopter pilot recently returned from Firstly, “expect the unexpected”. I’ve should not have done, is irrelevant. sparks out there do, so put pen to
well-timed application of extra pitch is unlikely to be effective enough to prevent the latest of a large number of front- never thought that was a particularly I allowed the aircraft to end up in a paper and give the gift of hindsight to
a heavy landing. It is not possible to re-engage the engine until after the aircraft line detachments. He had also been helpful phrase. But in this case it position from which I was lucky to others before the event!
has landed. These practices are known as engine-off landings. However, this a fixed wing instructor. Between the could be interpreted as, “keep your recover. A superior instructor would
closing of the throttle is only ever done after a number of careful briefings both two of us in the cockpit that day we hands close enough to the controls have used his superior judgement to
on the ground and in the air, and only then under specific circumstances, and had over 15000 flying hours and over so that you can prevent the student prevent him from being there in the
even then the throttle is only ever closed by the person acting as the instructor. 50 years of experience in the military. doing anything which may become first place.
Other types of practice engine failures may be initiated by the same phrase Surely he must think the same dangerous – however unlikely that
“Practice engine failure go…” but the throttle is never closed unless this careful way I do? He was learning to be a
and protracted sequence of briefings have been carried out. I knew that, and I helicopter instructor. The previous
assumed that everyone else did… day we had been practising hover
engine-off landings as part of the
Can you see where this is going yet? course. As part of that previous sortie

airCLUES
The incident itself was relatively quick, as these things often are, and the the student instructor is encouraged
outcome was relatively benign, as these things so often sadly are not. The to use the throttle himself to initiate
student was flying the aircraft at a relief landing ground (RLG); he had just the engine-off landing, as he would
completed an approach to the hover and was briefing the next manoeuvre. have to if he had a real basic student
He inadvertently allowed the aircraft to drift upwards in the hover to about 30 on board with him. The engine-off
feet. In order to draw his attention to this fact, I called “Practice engine failure sortie is carefully briefed on the
go…”, fully expecting him to simply lower the collective slightly and conduct ground beforehand, so that both
a powered run-on landing straight ahead, making a mental note as he did crewmembers know exactly what will

28 29
airCLUES
… The Defensive Aids Sub System
(DASS) audio chirps loudly indicating
a Surface to Air Missile (SAM) system
has achieved lock on my Typhoon.
In a matter of seconds the audio
changes to tell me that the SAM has
fired and is now guiding towards
me. I look through the Head Up
Display (HUD) and see the direction
and classification of the SAM. The
displays agree with the audio. My
Combined Counter Measures (CCM)
are telling me how to manoeuvre
my aircraft to defeat the system
and are ready to deploy the array
of countermeasures. I snap-roll the
aircraft and pull hard to follow the
green writing in the HUD. At the same
time, my automatic countermeasures
deploy. Pull hard following green
arrow. Green arrow to green box,
pause, box disappears, new arrow
in a different direction, pull, then
nothing. The directions cease, the
audio stops, the SAM has broken
lock. I roll to the nearest horizon and
level off.
It was then that I realised I didn’t
know where the SAM was. All I had
done for the last few seconds was
be the stick monkey in the front who
diligently followed the directions
in the HUD. Where was the SAM?
Where am I? Where is my Wingman?
The display had been so compelling
it was hard not to stare at it. The HUD
the double edged sword
The Typhoon delivers state-of-the-art, automated avionics and combat systems that prioritise and
display essential information to the pilot, but is this always good news?
Sqn Ldr Mc Meeking, OC STANEVAL for the Typhoon Force offers his thoughts on
flying the glass cockpit……
30
was my security blanket, providing
me with the information it thought
I needed. What I hadn’t done was
aviate. Fortunately, I was conducting
a trial and the SAM was simulated,
however, it did make me question my
priorities. Nice green writing/colour
displays vs outside the window. As
a result of operator feedback the
CCM manoeuvres have been
reduced significantly.
Two years later, I was sitting in
the back of a 2-seat Typhoon with
a student in the front … We are
taking the long taxi from the ASP
to the threshold and the speed is
increasing. Typhoon has excess
power in almost every environment,
and on the ground is no exception.
Our speed increases as the student
is absorbed by the sheer quantity of
information available to him, on the
aesthetically pleasing displays. Now
at a fast taxi speed I chirp up from the
back, ‘Bloggs, how fast are we going?’
The student scours the head down
displays for the information. ‘Eh’ is
the response. ‘Look out the window’
I helpfully suggest (I hate instructors
like me) and to his amazement, the
grass whistling by the side of the
aircraft, gave him the answer. He
had dropped the basics because of
his new glass environment.
The average transport aircraft
in the mid-1970s had more than
one hundred cockpit instruments
and controls. The increasing
requirement for information meant
that the displays were competing
for cockpit space and pilot attention.
As a result, NASA conducted
research on displays that could
process the raw aircraft system and
flight data into an integrated, easily
understood picture. The success of
the NASA-led glass cockpit work is
reflected in the total acceptance of
electronic flight displays beginning
with the introduction of the MD-80
in 1979. The RAF has seen cockpit
modernization programmes across
most of its fleet of aircraft, which
almost always include addition of
glass cockpit displays. Typhoon has
been more fortunate in that it was
designed from the outset with a
glass cockpit. Even the reversionary
instruments are glass.
The main reason for having a glass
cockpit is to reduce pilot workload,
and to increase safety. It does this
by presenting the information in an
eye-pleasing manner, which can
change depending on phase of flight,
or pilot workload. The pilot will also
generally have a number of options
to customize the displays to suit
personal preference, or the task. As
display technology has advanced, so
too have aircraft sensors and data-
links. The result is a very complex
display able to provide the pilot with
an array of options, using information
provided by complex avionics.
It all points towards information
saturation. Every pilot experiences
information overload at some stage
in his flying career, and in modern
fighter aircraft it is all too prevalent.
The real skill in operating an aircraft
like Typhoon, is in knowing where
to look for information and being
disciplined about when you look for it.
It sounds obvious, but almost every
Typhoon pilot will have experienced
the feeling of being drawn into the
Displays. From staring at the RADAR
scope monitoring the targets, DASS
and Link 16, to being engrossed in
the LDP format watching the `time
to impact’ count down - the danger
is the same. You must adopt a
disciplined approach to looking out of
the cockpit for the same things you
did before you flew a glass cockpit:
wingmen, threats, weather etc.
And what happens when things
go wrong? The combinations of
emergencies through either electrical
failures or software problems are
infinite. This provides glass cockpit
operators with a conundrum: ‘what
emergencies do you practice’, and,
‘what are just too unlikely?’ Either
way, the operator must Aviate-
Navigate-Communicate. The aircraft
will not fall out of the sky just because
all of the displays are blank. Another
possibility is considering display
failure and another emergency
simultaneously. Once again unlikely,
however, I recently had a loss of
all displays whilst conducting Air
Combat. I recovered the aircraft to the
horizon and initiated my RTB. Whilst
in the climb, I looked in the Canopy
Mirror and noticed a significant
quantity of fuel venting from the Fin,
so I commenced the fuel-leak drill.
Now I had a fuel leak and display
failure simultaneously. A few minutes
later the displays returned and I was
informed by the FUEL page that
fuel was leaking from the Vent pipe.
Your aviation experience can’t stop
just because you have had a
display failure.
How far do we take glass cockpit
displays? When are they essential
instruments, and, when do we
rely on them too much? Helmet
Mounted Displays (HMD) present
a further potential saturation, as
even when you are looking out of
the cockpit you are looking through
a display. Operators must not forget
the basics they learnt through
flying training. Ultimately, glass
cockpits are essential in modern
aircraft with complex sensors, and if
programmed correctly, they are
compendious displays for competent,
trained operators.
airCLUES
31
airCLUES
Free Navigation – This is a vital aspect of fast-jet training, both as a skill in its addition to the aircraft over the
own right, but also as a means of adapting the plan to still achieve a DCO when export Hawk 100-series design, is
the weather isn’t as forecast. Such flexibility inevitably impacts on the efficacy the incorporation of a powerful nose
of the pre-flight deconfliction process at 4 FTS, although this still provides a light (a la Hawk T1), which has been

a close r u n t h i n g
general awareness ‘in house’. An associated issue is that of increased cockpit proven to be a significant aid to
workload during free-navigation. Whilst the paramount importance of effective seeing the aircraft, particularly when
lookout is stressed at all times, it is inevitable that this will suffer to some degree it is head on.
during these periods of increased workload. Procedures, rules, regulations
and policies are put in place to
Flight Lieutenant Stuart Hicken, SFSO, RAF Valley analyses the particular hazards in the Airspace Usage – The airspace over and around Anglesey and North ensure that the risks inherent in
skies above the Welsh station, which make Airprox Wales is perhaps busier now, and with a more diverse set of platforms, aviation are minimised – that’s what
a daily danger to its aviators. than ever. Not only are the Station’s indigenous assets operating flight safety is. Whilst not a panacea,
here, but also numerous visiting aircraft and detachments make use TCAS clearly has its part to play
“Airprox - a situation in which, in the opinion of a pilot, or controller, the distance between
of the excellent class G training airspace. With the reducing number in preventing airprox (or worse).
aircraft as well as their relative positions and speeds have been such that the safety of the of Main Operating Bases, concentrating military aircraft basing, and For all aircraft types, however, an
aircraft involved was, or may have been, compromised.” continual squeeze/reduction of class G airspace, it is almost inevitable that the awareness of risk factors (such as
density of operations will increase in those good, local training areas which are the specific ones above that we face
left. On top of that, it is important to educate those that fly to and from other at RAF Valley) can only help to focus
Airprox, the word that strikes fear into the majority of aircrew, not just for the features (some with and some airfields into the Class G airspace in North Wales, about the activities of 4 FTS attention on mitigating the airprox
paperwork, but also for the potential outcomes. In today’s current operational without flow arrows). The navigation (part of the reason for writing this article). risk inherent in the Class G, “see
and training climate, we are reminded regularly of the hazards that face us technique teaches, ‘big to small’ so and be seen” airspace in which we
with the close proximity of not only our own aircraft, but civilian aircraft as well. it is no surprise that big features are Civil Users – Whilst this hasn’t manifested itself as a major factor yet, we are all operate.
RAF Valley is a unique place, hosting the 2 fast-jet squadrons of No. 4 used in this way. However, most nevertheless aware of the increased civilian use we have seen here since the
Flying Training School (4FTS) operating the Hawk T1/T1A and T2, the Search other airspace users also exploit establishment of Anglesey Airport just over 2 years ago. At present, Highland
and Rescue Training Unit (SARTU) operating both the Griffin and now also these specific prominent landmarks. Airways operate a scheduled Jetstream 31 service to/from Cardiff only, although
the Augusta 139 training foreign students, 203 Sqn (the Sea King Operational Therefore, they rapidly become rumours abound of possible expansion plans. For the time being, however, the
Conversion Unit) and the operational SAR unit of C Flt, 22 Sqn. It is also magnets for aircraft utilizing the scheduled service integrates almost seamlessly into our other operations and
home to Anglesey Airport, a civilian consortium running shuttles to Cardiff low-level flying system. No. 4 FTS hasn’t presented us the deconfliction issues we originally feared.
twice daily. Throughout the year, the Station sees numerous detachments has its own low-level deconfliction
taking advantage of the rotary Mountain Flying Training Area (MFTA) and low process, which considerably reduces Thoughts on the problem
flying system in North Wales. Additionally, both 4 FTS and 203 Sqn utilise the risk of meeting another 4 FTS In recent months, RAF Valley has seen a significant increase in the number
RAF Mona, a relief airfield approximately 5nm from Valley. The Station is Hawk unexpectedly. However, we of airprox, both “blue on blue” and with other types, and at both medium and
arguably one of the busiest in the MOD, and as you can imagine, the local are unable to deconflict from other low level. Perhaps situations that used to be put down to experience are
airspace gets mighty busy too. De-confliction in this airspace is a challenging airspace users, so these magnet now being more vigorously reported upon, which can only be for the good.
task, particularly when you take into account the specific issues which affect landmarks will continue as just No one sets out to have an airprox, so we should have nothing to hide
us here. that – magnets. and allowing the UK Airprox Board to take an independent and thorough
look offers us the best opportunity to learn from an event and to try and
Local problems, for local people? Weather - Weather is a major prevent future occurrences. And perhaps we need to think more about our
Students – In the Class G airspace in which we operate, effective lookout contributory factor to flying training trg ‘culture’. Nailing the numbers (speed, AOB, heading etc) is a key part
is vital. However, with students under intense pressure throughout AFT and here, and anyone who has been of how we assess performance. Accurate flying is, of course, one of the
TWU, flying increasingly complex composite, often multi-ship, sorties, lookout to Valley knows how quickly the basics that need to be mastered, but perhaps this also encourages students
can be quickly compromised when the workload builds. It may be worthy of weather can change. Our low- to go heads-in to check the numbers rather than getting their heads out with
note that our students come from the Tucano, which has the traffic collision level flying training is therefore confidence. At the end of the day, the way that we assess has an impact
avoidance system (TCAS), whereas the Hawk T1 does not, so they have to focussed into periods of fine on behaviour.
rely entirely on effective lookout to generate situational awareness of aircraft weather, exacerbating the effects of
in close proximity. geographic compression with time Looking to the future
compression as well. Furthermore, As we look to the future here, the introduction into service of the Hawk T Mk
Landmarks - In a low level training area such as North Wales (Low Flying the Hawk Nose light – which must be 2 offers both a step challenge and a step opportunity. With significantly more
Area 7), there are inevitably some key landmarks which are used by 4 FTS serviceable and on for flight at low kit than the Hawk T1, there will be the possibility for more time to be spent,
during both planned black-line and free-navigation sorties. Some are point level – and High Intensity Strobes “heads-in”. However, whilst not a 100% solution, the TCAS fitted to the aircraft
features which are used as turning points – the Hawk T1 relies solely on become more difficult to see in bright will at least significantly mitigate that risk and is already paying dividends in
map and stopwatch navigation at low level – whilst others are natural funnel lighting conditions. helping to avoid airprox situations. A less technological, but equally important

32 33
airCLUES
Lessons learned
from Ben Macdui?
By Sqn Ldr Mark Barrett, SO2 ATC, RAF Flight Safety
probably, one of the most expensive
court cases conducted against an
RAF Officer in history. The individual
was subsequently cleared of the
charges laid against him, but, to a
degree, the damage had already
been done with a loss of confidence
between the “executive body” and
the rank and file controllers within
the Branch. The perception that a,
blame culture existed in the RAF
following the incident seriously
affected the beliefs and practices of
most of the military ATC personnel.
The direct result of the court martial
was a significant lowering of morale
throughout the branch and a much
more conservative style of day-to-
day air traffic service being provided.
On 26 Mar 2001, 2 USAF F-15C ac and their crews tragically crashed into This was not to say that controlling
the summit of Ben Macdui with the loss of both pilots. The ac in question had in early 2001 was cavalier at any
earlier departed RAF Lakenheath on a training sortie that included a transit stage, but merely described the fact
to the Scottish Highlands and a subsequent planned descent to low level in that controllers were now fully aware
the Ben Macdui area. The weather was not particularly good in the vicinity of of their potential culpability and thus
their descent point with no obvious gaps in the cloud for them to make a visual controlled accordingly.
descent. Although under the receipt of an ATC radar service at the time the Certainly discussion amongst my
BOI concluded that the accident occurred because the formation accepted an peers revealed significant cynicism
unsafe ATC instruction and descended without sufficient references to avoid within the controlling fraternity as
hitting the ground. Reflecting upon the incident highlights a number of areas to what protection, the RAF would
that are of current interest, which can hopefully be discussed in greater detail provide in similar circumstances in
within this article. I intend to highlight the organisational culture differences the future. This probably isn’t an issue
between then and now and try to explain why it is so important for the RAF to the majority of controllers trained
to embrace the Just Culture. I also want to briefly explain the meaning of the since 2001 as they were unaware of
term Human Factors and then cherry pick two factors from this incident which the significance of the event, but it still
I consider important for further discussion, specifically situational awareness affected a large legacy population of
and stress. I then intend to identify what, if anything, has changed in the controllers of pre-2001 vintage. It is
succeeding years to ensure that incidents like Ben Macdui are prevented. interesting therefore to contemplate
what, if anything, has changed
ORGANISATIONAL CULTURE over the last 8 years to amend
The Ben Macdui incident has been permanently etched into my memory as a these views.
shocking milestone event involving the Court Martial of a controller in what was The gradual change of ATC policy
34
from one of “trapping” to one of continued assurance has been a leap in the of these factors further. These
right direction. Though can one say if this has been enough? In addition, areas are those that I see as pivotal,
has the change from a perceived blame culture to one of an RAF-endorsed not necessarily to the cause of the
Just Culture actually filtered down to the shop floor? Unfortunately, without crash, but as areas which we the
this open and just culture there will be a reluctance to submit the incident organisation and individuals need to
reports, on which the system relies to generate systemic and organisational consider so that an incident similar to
improvements, for fear of reprisal. Certainly, speaking as one of the converted, Ben Macdui does not reoccur.
my cynicism about the feasibility and benefits of a Just Culture no longer
exists; though does that stand true for the majority of legacy controllers? Situational Awareness
Establishing the extent of the Just Culture’s permeation through the ranks According to CAP 737, situational
of the Air Traffic community will be a task of critical importance for not only awareness involves the conscious
the ATC fraternity, but also the RAF FS organisation. recognition of all the factors and
conditions - operational, technical
Analysing the Human Factor and human – which affect the safe
In any aviation accident there are usually a number of clearly identifiable Error operation of an aircraft. In order to
Promoting Conditions (EPCs) which conspire to cause it. Common examples establish situational awareness,
of EPCs are when there is a lack of communication, knowledge, teamwork, human beings take in the information
resources, assertiveness or awareness; or the presence of complacency, through the 5 senses – touch,
distraction, fatigue, pressure, stress or norms. You will probably know these hearing, smell, sight and taste –
better as the, ‘Dirty Dozen’. both subconsciously or intuitively.
In the Ben Macdui incident it was evident that EPCs existed in a number of This information is then transformed
different ways, the outcome of which culminated in the tragic loss of men and by the brain into a mental model of
machines. Hindsight is a wonderful thing, but the fact remained that at the time the situation, a process known as
these EPCs were not clearly identifiable to the personnel directly involved in perception. The perceptive process
the incident and as such the downward spiral of events was able to continue depends not only merely on current
to its end state. information for its evaluation of the
According to the Board of Inquiry the accident occurred because the situation but also takes account of
formation accepted an unsafe ATC instruction and descended without sufficient past experience and sensations.
references to avoid hitting the ground. At the time the contributing factors to Perception is therefore a product
the incident were as follows: not only of immediate sensations but
also of cultural and social influences
a. The pilot’s use of the phrase, ”Min Vectoring Altitude”, which when acquired through a life time
accepted by the controller, led the pilots to believe that ATC would of experiences.
provide terrain clearance. In this incident both the F15 pilots
and the Air Traffic Controller had
b. The controller’s descent instruction to 4000 ft. developed a perceptual model of the
airspace and terrain around them
c. The pilot’s lack of situational awareness with regards to his position based on: the data their instruments
relative to high ground. were feeding them; the prevailing
environmental conditions; their
d. The lack of a ground collision avoidance system, ground proximity past experiences; procedures and
warning system or radar altimeter fitted to the F15C ac. professional terminology they were
familiar with; and ultimately, by the
e. The formation’s descent below the ATC assigned altitude. assumptions that were made on the
functional responsibilities of each
In addition, the BOI identified a further 8 possible contributory factors and 25 party, particularly as to who would
other factors. These ranged from the significant life stress levels in the controller’s provide terrain clearance. What is
personal life that could have led to a deterioration in his performance; a lack evident, particularly with hindsight, is
of formal guidance about how ATC managers should recognise significant life that the perceptions of the pilots and
stress events amongst controllers, to the peculiarity of ATSOCAS to the UK, the controller were inconsistent with
which increases the possibility of foreign aircrew making incorrect assumptions each other and conspired to lead the
about UK ATC regulations. What this article intends to do is to analyse some formation into a loss of situational
35
airCLUES
awareness and a controlled descent
into terrain.
So what if anything can be done to
mitigate against this type of incident
reoccurring?
Certainly I was surprised to find
that at the time of the incident the
F15C was the only USAF FJ that did
not have rad alt / ground proximity
equipment fitted and to this day,
according to USAF sources, there
are no current plans to have them
retrofitted. Obviously, equipment
upgrades are one solution, but they
do not address the underlying human
factors which were implicated in
the crash.
At the individual level, there is
no panacea for poor situational
awareness per se. The key to
good SA must be to remain alert
to the limitations of your cognitive
perceptions and to never assume that
the model you have is correct and/or
held mutually by other parties you are
operating with. Additionally, when we
communicate with others, particularly,
without the benefit of being face-to
face, it is all too easy for the meaning
of what we say to be misconstrued.
Many is the well intended, humorous
email that has been misinterpreted
as argumentative, or provocative
by the recipient. The point is that
communication is a very subjective
art; without common, unambiguous
language the potential for accidents
remains high. So in this case,
uncertainty over control orders and
terrain clearance responsibilities
were not understood sufficiently
clearly by the American aircrew
whilst receiving a Radar Information
Service (RIS) and when flying under
Air Traffic Service Outside Controlled
Airspace (ATSOCAS) rules.
A relatively, simple misunderstanding
that went unnoticed until the
aircraft crashed.
Yet whilst it is beholden on any
individual involved in aviation to
maintain an accurate and informed
36
level of SA, there must also be a
commitment from the organization
to ensure it is maintained as well.
In order to prevent another Ben
Macdui, the priority must be training;
training to make certain that users
of our airspace are fully conversant
with local and national procedures
and changes made to them. This
is particularly pertinent following the
recent change of ATSOCAS rules
which came into effect from 12 Mar
2009. I am unsure that, even now,
it is clear who is responsible for
ensuring that all foreign aircraft that
fly in our airspace are fully conversant
with these revised changes? In this
particular case did we leave it to the
Americans to do themselves? Are
we/have we been proactive and
sent UK aircrew and controllers
from adjacent RAF bases/Air Traffic
Control Radar Units (ATCRU)s to talk
through these changes with them?
Can we, the RAF, put a hand on our
heart and say, “yes everyone flying
in the UK is now aware of the new
ATSOCAS changes; we can now
stop the education process?” Is there
an ongoing responsibility from us, us
being ATC/Sqns/SFSOs /RAF FS, to
continue to engage with not only the
foreign nations flying from our shores,
but those flying from the continent.
In addition, should the General
Aviation (GA) fraternity operating
close to our MOBs be engaged to
ensure that the revised ATSOCAS
procedures are fully understood?
Stress
In the Ben Macdui case, stress
related factors were highlighted
under, “possibly contributory” and,
“other factors” which could have
played an active part in the incident.
The stress related factor considered
was the very recent return to work of
the Controller following a close family
bereavement and period of sick
leave. Following the investigation,
the BOI considered that the lack
of any consultation with a doctor situational awareness and stress and
following the controller’s return to to promote discussion on how we
work, post sick leave, had no bearing as a Service deal with them. It also
on the accident. It did state however, considered the profound effect the
that this was an area for consideration Ben Macdui incident had on the ATC
in the wider context of all personnel community then and possibly now. As
in flight safety critical areas. In my such, I feel it is important to consider
experience most line managers that if the RAF Just Culture is to
deal with individuals suffering from succeed, especially within the ATC/
stress, be it family bereavement, ASACS fraternity, that controllers
marital problems, financial issues feel confident that they can report the
etc to name a few in a positive and near incidents and, “bottom of the
supportive manner. iceberg” issues without feeling they
However, what are your views are shooting themselves in the foot.
regarding clearance to work following RAF FS would welcome feedback
time off on stress related issues? on any of the issues referred to
Should there be a requirement for in this article and hope that it will
a doctor’s certificate following a promote further discussion amongst
return to work, post a stress related the readership.
incident? Do we/should we have a
legal responsibility to ensure that an
individual has been medically cleared
fit for duty? Does someone have to
take responsibility for bringing the
individual back into ops, or is it the
individual’s responsibility? In this
litigious society, I personally believe
it would be in the RAF’s interest to
ensure that any individual in a flight
safety critical area should have a
medical clearance from the SMO
prior to commencing work following
a stress related period of leave.
However, following discussions with
the senior medics here at Air Cmd
they consider it the responsibility of
line management (Supervisor/Auth/
Watch Manager) and not a medical
matter. In fact, discussion amongst
the FS Desk Officers all came up with
differing views on how to address this
issue. There is currently clearly no
hard and fast answer to this issue.
Should there be one? Certainly
airCLUES
there are definite left and right arcs,
but what would be the best way of
dealing with these kinds of issues?
Conclusion
The aim of the article was to raise
awareness of the Just Culture
and human factors, specifically,
37
airCLUES
• JARTS also employs a number of civilian staff in key support roles. decontamination of personnel,
but it also contains facilities for a

crash and smash no more ROLES

Whilst often viewed in its APCM capacity only, JARTS also uses its irreducible
spare capacity and its expertise in aircraft recovery to provide a capability
basic kitchen with running water,
an office space with fitted electrical
power sockets and sufficient space
for the worldwide transportation4 of all operational MOD aircraft. JARTS also for mandatory health and safety
retains capability to lift and transport a whole variety of historic aircraft and briefings.
gate guardians and, whilst these tasks may be of a low priority, they help to The ARO’s first priority on arriving
Welcome to the world of the Joint Aircraft Recovery and maintain the ‘skill at hand’ necessary to plan and undertake the more complex at a crash site is to ascertain the
Transportation Squadron (JARTS) operational recoveries. Nevertheless, its new found status as an ACSSU hazards present and determine the
By Squadron Leader Michael Nadin BEng CEng MIET RAF, recognises the significant tasking that JARTS receives in direct support of protective measures that will be
OC JARTS ongoing operations. Its core wartime role is to provide a Deployable Aircraft required for all personnel involved with
Recovery Team (DART) capability, but a large part of its day to day activities the recovery. He will be supported by
are centred around the transportation of helicopters, both in the UK by road duty personnel from the RAF Centre
The aircraft crash has long been an accepted consequence of the demanding and by air to operational theatres. for Aviation Medicine (RAFCAM)
nature of military aircraft operations. Whilst enemy action can factor in crash or the Institute for Naval Medicine
statistics from time to time, the complexity of military aircraft and the intensity DART (INM) to assist with any assessment
of training for operations more often leads to the two most common causes; JARTS’ primary role of providing specialist aircraft recovery personnel and of biological or environmental risks
a human factors related failure or a technical fault. Since the early days of equipment at a major staging airfield or forward operating base during an that may be present. The team will
UK military aviation, aircraft operating units have salvaged crashed aircraft to operational campaign is demonstrated through its capability to deploy up to 2 provide control procedures for entry
clear operating surfaces, or to recover reusable spares. Nevertheless, during DARTs, each with the ability to operate independently and in separate theatres. into the inner cordon and police
World War II, it is believed1 that many of the 10,000 plus UK, Allied nations and A DART is normally held at high readiness in the UK but can be deployed during this activity.
Luftwaffe aircraft that crashed on UK soil, went unsalvaged. However, with periods of high tempo air operations to be prepared to effect the rapid recovery Once directed to do so by the
the advent of more detailed aircraft accident investigation, a more structured of aircraft disabled on operating surfaces, including runways, minimising President of the Service Inquiry, the
approach to aircraft recovery and as Aircraft Post Crash Management2 (APCM) further damage to the air asset and returning the airfield to full operations as JARTS team will begin wreckage
evolved, today this role is undertaken on behalf of the UK MOD by JARTS. quickly as possible. JARTS personnel train in aircraft recovery techniques and recovery. A large crash site will be
in the use of airbag lifting equipment and so maintain the capability to recover broken down into grids of manageable
BACKGROUND any of the UK’s military aircraft, including C17 and Tristar. size and each piece of wreckage will
JARTS was created on 1 May 07 from elements of the Forward Support be given a unique identifying number
IPT. The Aircraft Recovery & Transportation Flt (ARTF) at MOD St Athan, AIRCRAFT POST CRASH MANAGEMENT (APCM) and have its location plotted using
commonly referred to as, ‘Crash & Smash’, was RAF-manned and dealt with APCM is JARTS’ highest profile peacetime responsibility, or secondary role. JARTS’ GPS-enabled Land Survey
all Fixed Wing APCM. The Mobile Aircraft Support Unit (Transport & Salvage) The Directorate of Aviation Safety and Regulation (DARS) requires JARTS System (LSS). The LSS, accurate to a
section (MASU(T&S)) at Fleetlands in Gosport, comprised RN Fleet Air Arm to be capable of responding to 4 concurrent military aircraft accidents; to do few millimetres, creates an electronic
personnel performing the corresponding Rotary Wing tasks. As JARTS, the this a ‘Crash Team’ is kept on standby, prepared for immediate deployment plan and 3D-representation of
two units have left behind their DLO/DE&S roots and are now an Air Combat to any location worldwide. The team is made up of an Aircraft Recovery the crash site, wreckage, ground
Service Support Unit (ACSSU) under Air Command, subordinate to No. 85 Officer (ARO), taken from a number of Warrant Officers, RAF Flight Sergeants features and crash witness marks.
(Expeditionary Logistics) Wg (85 (EL) Wg) at RAF Wittering, itself a part of the and RN Chief Petty Officers; and a broad cross-section of JARTS’ other The plot can be overlaid onto satellite
A4 Force Element. personnel trained in numerous crash recovery techniques and authorised photographs or Ordnance Survey
JARTS is commanded by a RAF Sqn Ldr (Eng) with 2 Flight Commanders, to operate or drive the array of JARTS equipment and vehicles. Another maps and the associated software
an RAF Flt Lt (Eng) and a RN Lt (X(Av)). The Sqn is about 80 strong, with a 3/4 crash team comes to standby status once one is deployed and, as 2009 has is held by the accident investigation
RAF to 1/4 RN makeup, and is predominantly split into three main trade areas: proven, the concurrent deployment of 4 crash teams, of varying sizes, is a agencies. This has proven to be a
realistic scenario. vital tool.
• RAF A Tech M/RN AET(M)3 provide the aircraft technical Once activated, the ARO will often travel to a crash site ahead of the Crash The ARO and his crash team
expertise. The Aircraft Recovery Officers and aircraft transportation Team. This allows him to assess the situation and inform the JARTS Ops Cell are also responsible for locating,
supervisors are taken from these personnel. of the manpower and equipment required to be called forward. In response handling, storing and transporting the
• RAF Logistics (Driver) and RN LGV Drivers fulfil the challenging to a typical accident, JARTS will deploy one vehicle loaded with crash flight data recorder equipment and
role of road moving UK MOD aircraft, often including outsize and recovery equipment, and another vehicle known as the CASBA5 . The ARO is any other aircraft wreckage that is
wide loads. responsible to the MOD Incident Officer for the management of the crash site deemed relevant to the investigation
inner cordon area, that which contains the aircraft wreckage and so poses the as detailed by the Service Inquiry.
• JARTS holds a vast array of Ground Support Equipment in a large greatest threat to health and safety. They must also facilitate the removal
aircraft hangar to support both its crash recovery and transportation The CASBA is a multi-purpose facility on a site, its main purpose being of the remaining wreckage and any
functions. RAF Gen Techs and RN AET(M)s maintain this equipment. to provide the controlled point of entry into the inner cordon and post activity contaminated soil. This part of the

38 39
airCLUES
task is arguably the most labour intensive and may include hiring heavy plant internal workshops facilities with the
machinery such as cranes and excavators. The ARO, whilst carrying out the capability to manufacture items from
recovery, will have to ensure that there is no lasting environmental damage scratch or to repair old unsupported
to the land. He will be liaising with RAFCAM or INM and the Defence Estates assets. It surprises many visitors
Officer (DEO) to establish what remediation is required. After the ARO, the to JARTS that we hold a full-sized
DEO and the land-owner are satisfied that the crash site is free of aircraft aircraft hangar full of equipment
wreckage and contamination, the site will be handed back to the land-owner. and over 70 vehicles and trailers.
Only at this point can the ARO depart the scene. During his tour of duty, an Significant rationalisation activities
ARO will have attended numerous aircraft crashes and have become an expert have been conducted over the
in this field of operations. last year to allow the integration
of much of the Gosport equipment
AAIB in to the hangar at St Athan but in
Not simply limited to military aircraft crashes, the Department of Transport’s Air reality this has been undertaken in
Accident Investigation Branch (AAIB) is able to call on the services of JARTS preparation for the Squadron’s next
under a Memorandum of Understanding. Within this agreement, JARTS challenge – Collocation.
assists in the recovery of crashed civilian aircraft in the UK, and in exchange
the AAIB provides investigative assistance to RAF Service Inquires. Most THE FUTURE
tasks in support of the AAIB relate to light aircraft and small helicopters and so Following the creation of JARTS
are short in duration. However, a notable example from 2008 was support to in 2007, Air Command began a re-
the recovery of the Boeing 777 at Heathrow airport. JARTS provided detailed basing study to determine the best
crash site mapping using its LSS capability and recovered the wreckage trail location for the new Sqn. Uncertainty
that the aircraft had left on the grass behind it. The variety of aircraft types of tenure at St Athan6 and the sale
recovered in support of the AAIB assists JARTS in developing experience and of the Fleetlands site requiring
expertise within its crash teams whilst providing the AAIB with a consistent MOD Lodger Units to vacate added
aircraft recovery process that it is not able to call upon from any other agency. urgency to this study and it was also
recognised that JARTS would be
better able to undertake its duties
efficiently if collocated. A number of
sites were considered, the driving
factor being the need to be close to
the core day-to-day business, that
of RW road transportation (in south-
central England); and eventually
MOD Boscombe Down was chosen
as the best value for money option.
Collocation planning is now well
underway; JARTS’ RN element
from Gosport is likely to move in
to temporary accommodation at
Boscombe Down by January 2010
and the remainder of JARTS from
St Athan are expected to move
TRANSPORTATION sometime in the second half of 2010.
Since its inception a little over 2 years ago, JARTS has transported in excess
of 600 aircraft. These tasks range from single day activities, ie a Chinook road SUMMARY
move from RAF Odiham to RAF Brize Norton with vehicles deployed from and JARTS and its preceding
returning to Gosport, to more complex moves such as a Harrier recovered by organisations have been involved in
road and ferry from Sicily through France to RAF Cottesmore. Whilst many a considerable range and number
road, air and sea moves are routine, some require detailed planning and of crashes. PanAm Flight 103, the
possibly even the manufacture of specialist transportation equipment. We rely Lockerbie disaster, and the Mull of
on the DE&S Aircraft Teams for provision of equipment for in service platforms, Kintyre Chinook crash are 2 prime
however, when moving historic aircraft we can call upon our extensive examples and as I write this, JARTS
40
are undertaking 4 simultaneous
recovery operations: wreckage
recovery following the Tornado F3
crash in Scotland; recovery of a
crashed civilian-registered Percival
Provost aircraft in Lincolnshire; and
the recovery of disabled Puma aircraft
from 2 different overseas locations.
The expedient recovery of
damaged aircraft and equipment
affords the maximum utilisation
of available MOD resources, a
capability that is absolutely essential
in the current climate. The aircraft
and environments that JARTS have
the ability to deal with vary from a
Cessna in the UK to a Harrier in
Afghanistan. Moreover, JARTS has
MOD’s only capability for the road
transportation of its aircraft fleets with
much of this activity currently being in
direct support of operations.
The variety of tasks that JARTS
undertake and the uncertain nature of
employment on the Squadron, crash
standby and worldwide transportation,
requires a well trained, well equipped
and dedicated workforce. There are
many challenges ahead but in every
scenario I have seen the JARTS
personnel rise to the challenge and
I am very proud to have been given
the opportunity to command this new
joint Squadron.
airCLUES
1
English Heritage - Military Aircraft Crash Sites (Archaeological Guidance on their Significance and Future),Un-dated, Un-credited.
2
UK MOD APCM is conducted iaw JSP551 Vol 2.
3
Some Senior RN Ratings are from the legacy AEM(M) branch.
4
Transportation of Whole Aircraft and Large Un-crated Aircraft Parts iaw JAP100A-01 Chap 9.1.
5
Crash & Smash Basic Accommodation (CASBA). The combination of a modified helicopter support cabin and inflatable tents,
JARTS has 2 complete CASBA facilities.
6
St Athan has been selected as the site for the tri-service Defence Technical College.
41
airCLUES
a junior officer’s exposure to flight
safety during engineer officer
foundation training
By Fg Off Ian Carpenter, EOFT 14 (AS), DCAE Cranwell
As an ex Weapons Technician I spent many years working on a busy front line Assisting us in our task at EOFT
Squadron where I was well aware of the importance of flight safety and that is a comprehensive and holistic
it was everyone’s responsibility. However, I was unaware of the level of flight training package that covers flight
safety training given to others. This question was answered as I embarked safety policy and regulations,
on Initial Officer Training (IOT) at RAFC Cranwell having been offered a practical exposure, implementation
commission in the Engineer Aero Systems (AS) branch. During IOT it became of concepts and policy, and
apparent that new entry officers are given a very limited exposure to flight discussion of the, ‘Can Do Safely’
safety, consisting of little more than a brief and a booklet. Coupled with this, campaign. This package is delivered
a Flight Safety Committee did their best to get the Officer Cadets thinking by Service and civilian instructors
about Human Factors and how their actions can affect Flight Safety, but often who not only have previous flight
this guidance fell on deaf ears, as cadets focused, understandably, on the safety experience, but an awareness
next exam or leadership assessment. So as newly commissioned Officers of ongoing issues within the RAF
leave IOT for their Phase 2 training, or holding post, flight safety faces its first flight safety environment. Visits to
challenge; how to spread the message to the commanders of tomorrow of the units and liaising with organisations
importance of flight safety in their sections? such as RAF Flight Safety at HQ
I started Engineer Officer Foundation Training (EOFT) on 8 Jun 09 and Air Command and DARS at RAF
quickly discovered that the role of an engineer is far more involved than I Northolt, allow current issues to be
first imagined. Coupled with our primary task we also have the responsibility discussed during lessons, and are of
of spreading the flight safety message to personnel assigned, attached, or great benefit to the students.
under our control, in support of flying operations. Within the first week we were
introduced to flight safety and, more importantly, the consequence of what Can we do, ‘Can do Safely’?
happens when it goes wrong. We were taught that during the relative short The ‘Can Do Safely’ campaign is of
history of aviation, most of the mistakes that could have been made have been particular interest to me and I believe
made. There are very few new accidents, just old accidents waiting to happen it is essential to the future of flight
again. Why?...because we have forgotten the lessons we learnt in the past. safety. For those not in the know yet,
I understand that we work in an environment that results in frequent the initiative is defined as follows:
personnel changes and demanding operational requirements, but why are ‘Can Do Safely’ – ‘Building on our
these flight safety lessons not being retained? To change this my fellow future ‘Can Do’ reputation whilst maintaining
AS Engineers and I have a challenging time ahead of us! robust engineering standards and
practices that continue to provide
airworthy aircraft for the immediate
flight and those in the future.’
The RAF is well known for its,
‘Can Do’ attitude and on numerous
occasions this has got many a
Squadron out of a potentially difficult
situation, but what has been lacking is
some form of safety management of
the, ‘Can Do’ activities. By expanding
on the definition above we can see
that the, ‘Can Do Safely’ campaign
relies on risk management. The
idea focuses on two areas of risk:
EOFT Students Examining FOD Damaged Compressor Assembly
42
Decision and Control. The Decision
to take the risk is further broken down
into the following areas; Reason,
Risk Decision (RISC) Risk Control (The 3 M’s)
Mitigate!
Information, Safety Assessment
and Consequences (RISC), whilst
• Clarify task objective and
hazard context?
•
•
Place operating limitation
Reduce probability
• Question need to take risk? • Lessen impact
Control is broken down into the
following elements; Mitigate, Monitor • Seek alternatives and transfer • Consider Human Factors
and Manage (The 3 Ms). Although option? • Treat, and think ALARP
the balance of task and safety must Information? • Conduct Expedient repair
be met, all personnel involved in • Identify all relevant facts? Monitor!
aircraft maintenance need to apply • Gain thorough understanding? • Appoint owner risk
these checks to help to reduce • Determine if systematic or • Set rules and limits of
the risk inherent in military flying to one-off? acceptability
a minimum. • Reflect on sufficiency of • Supplementary maintenance;
EOFT aims to instil the Can Do empowerment? ADF
Safely way of thinking at an early - Competent enough? • Tolerate and ensure situation
stage of training in order to help - Second opinion? … who? does not deteriorate
develop an effective safety culture Safety Assessment?
in its engineer students. Be it in the • Think laterally? Manage!
classroom, or on the line as part of • Assess probability? • Record decisions and actions
284 Sqn at Training Consolidation • Assess impact? • Provide feedback and plan to
Flight, we are taught to intelligently • Prioritize? terminate risk – repair/fix
interpret the Policy and Regulations. • Identify lessons
Consequences?
We are also taught to question • … of failure? • Communicate
norms, ensuring that any findings • … on future actions?
are reported correctly and information • ‘Defensible at the subsequent
is distributed swiftly; thereby Inquiry?’
reducing the chance that a trivial
fault can combine with human
factors to produce another
preventable occurrence.
I am confident that on graduation
from EOFT, Engineer Officers will be
better prepared than ever before to
tackle the problems associated with
flight safety, but this doesn’t mean
that we can rest on our laurels.
With aviation continuing to develop,
coupled with an intensive operational
tempo, we need to continue to
develop ways of improving flight
safety and encourage training at all
levels on a continual basis, otherwise
the hard learnt lessons of the past
airCLUES
will re-invent themselves as the
accidents of the future.
43
airCLUES
skip’s location and the wind direction lead to lighter articles of refuse being can get stuck to) before you

foreign object debris carried by the wind across the ASP, in the direction of 3 parked aircraft.
There is not a great deal that can be done to prevent the first two
occurrences. However, where prevention is not possible, then every effort must
enter the airfield.

Ensure that you remove all

potential FOD from your
the perennial threat to flight safety be taken to provide an effective cure. Therefore, if you spot FOD on, or near,
your airfield then report it to your SFODPO and, if you are able to, remove it.
Whilst there is an element of environmental factors in the final incident above,
pockets when on the airfield.

By Flight Lieutenant Fraser Tod, SO3 Eng, RAF Flight Safety An often overlooked source of FOD
the overriding causal factors have a greater human element. With a little more
forethought and cooperation between airfield users this incident could have is airfield incursions. Whilst they
The problem of Foreign Object Debris (FOD) has not gone away. In fact, Environmental factors are more commonly associated with
been averted, despite the prevailing weather conditions. This incident serves
and in spite of the concerted efforts of RAF Station FOD Prevention Officers Weather and the surrounding interfering with aircraft operations,
as a timely reminder of what can happen when there is insufficient focus on
(SFODPOs), FOD is causing more problems and costing more today than environment can play a major role in one of their common side effects is
FOD prevention.
at any stage in the last 5 years. So what is going wrong? One thing that is the migration of FOD. The following that the offending vehicle is more
without doubt is that every SFODPO in the RAF is doing their best to minimise are all real examples of FOD that has likely to deposit FOD as it is not
Poor condition of airfields and unsuitable airfield procedures
the impact of FOD on their stn and FOD would be an almost insurmountable been found in the past 12 months. likely to have been subjected to a
In addition to isolated areas of damage, airfield surfaces will suffer from normal
challenge without their efforts. However, the simple truth is that they cannot do The estuary beside RAF X is FOD inspection prior to entering the
wear and tear, which can lead to unwanted debris on operating surfaces. This
it all on their own. In order for them to play their crucial role in FOD Prevention home to a number of birds that feed airfield. Therefore, every effort must
debris will greatly increase the chance of FOD damage to aircraft. Therefore, all
they require 2 things: on shellfish. In order to break the be taken to not only prevent airfield
airfield damage, or signs of wear, must be reported at the earliest opportunity
Firstly, they require robust and succinct policy that provides them sufficient shells the birds have been known to incursions, but also to ensure that,
in order to allow remedial action to be taken before the problem worsens.
clear direction to enable them to do their job. (More on this in future editions of drop them from height onto one of if an incursion does take place, it
There are a number of measures that can be taken to avoid jet efflux, or
Airclues – Ed.). the main taxiways, leaving behind is reported and the incursion site
rotor downwash damaging other aircraft. Taxiing separations should be kept to
Secondly, and more importantly, they require your support. The following the shell remains once the fish has is checked for FOD. If you see or
an appropriate minimum in areas where there is a known FOD problem in order
paragraphs highlight some of the causes of FOD that are being dealt with been eaten. These remains are often suspect an incursion you should
to prevent FOD being blown at high speed into the path of oncoming aircraft.
across the RAF by SFODPOs, and the ways you can help your SFODPO to sharp enough to puncture aircraft immediately notify ATC and, if a FOD
Similarly, if 2 or more aircraft are to be taxied onto a runway (for example prior
overcome them. tyres. hazard is evident, the SFODPO.
to a streamed take off) every effort should be taken to avoid aircraft having to
During a recent Flight Safety Visit As previously stated, FOD
taxi through the efflux of another aircraft.
to an overseas unit, a very heavy continues to cost the RAF and the
rain shower swept a large quantity MOD a great deal of money, which
FOD Migration and Airfield iIncursions
of earth and stones onto numerous could be better spent elsewhere.
One of the most common sources of FOD is debris that has been deposited
parts of the airfield, potentially Whilst it may not be possible to
by vehicles (or people) that have entered the airfield. There are a number of
presenting a FOD hazard to aircraft completely eradicate FOD, there
quick and simple measures that can be taken to prevent the migration of FOD
operations. The FOD was swept up remains scope for improvement.
onto the airfield:
immediately and the taxiways were fit Your support will help to reduce the
for use shortly thereafter. Avoid driving over grass verges in order to prevent the spread of mud amount of FOD damage sustained
A refuse skip situated adjacent to and small stones into the path of vehicles bound for the airfield. on your station.
a unit’s main ASP was emptied by
contractors during a prolonged spell Check your tyres and other parts of your vehicle that can carry FOD
of strong winds. Unfortunately, the (e.g. mud flaps, bumpers and any areas where mud and small stones

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44 45
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