Mendip GC

2019 Safety Event

Sat 7th Dec 2019

v1.2

Death by PowerPoint…

https://www.youtube.com/watch?v=4iOoiEbtf2w

Purpose Quite simply, to improve OUR safety

Further promote the safety culture within MGC

Promote adoption of the BGA safety objectives:

Safe practices with the objective of facilitate a sport gliding environment where the levels of risk are as low as reasonably practicable.

BGA Priorities:

Continuing to reduce the fatal accident rate

No harm to any third parties

Avoiding any airspace infringements.

Managing Flying Risk aims to provide pilots and clubs with guidance on how to better understand, minimise and manage the hazards associated with gliding operations, including with powered gliders and tug aircraft. It does not replace any existing law, which should always take precedent.

What are we going to cover?

Focus on flight safety

(Y)OUR role in safety

Recent MGC Accidents and Incidents

Winching

Bailing Out

How are we going to cover?

BOO!

The intention is not to scare or drive you away from gliding!!

The clue is in the ‘we’ bit

…which kind of fits with the whole ethos here…

This is a (an on-going) discussion

OK, with a little bit of haranguing….

Will flag some club actions and intentions

Give you some study material – please do undertake it otherwise we will be here for hours

Do some practical stuff

Safety Culture: What is it?

Safety culture is the collection of the beliefs, perceptions and values that members share in relation to risks both within Mendip GC and our sport of gliding

Beliefs…?

Perceptions….?

Values….?

Risks……?

Example Risks: not the complete set!

Gust fronts

Thermic days with high cloud base

Thermal impact on ridge

Mis-rig

Emotional state

Poor recovery from launch failure

Late field selection

Mid air collision

Clutching hand

Open canopy

Curl over

Poor look out

Human Physiology – dehydration, cold, hypoxia

TAS vs IAS

Sink behind a ridge

Tow truck left attached to aircraft

Distractions prior to launch

Incomplete pre-flight checks

Etc, etc….

Risks…..Categorised (TEM) Flight: Threats, Weather & Interaction with Topography:

Gust fronts

Thermic days with high cloud base

Thermal impact on ridge

Clutching hand

Curl over

Sink behind a ridge

Cross wind

Flight: Pilot Error and Workload:

Poor recovery from launch failure

Late field selection

Mid air collision

Poor look out

TAS vs IAS

Flight and Ground: Threats inherent to the Human Engine – hardware and software:

Human Physiology – dehydration, cold, hypoxia

Distraction

Emotional state

Ground & Operations: Discipline and Professionalism Errors:

Mis-rig

Tow out

Open canopy

Incomplete checks

Your Contribution… OR…Good Airmanship

OR…Don’t forget the Basics

Defensive Flying:

Lookout

Winch launching – ALWAYS expect a failure, speeds, profile

Rules of the Ridge

Use of circuit plans and patterns

Thermal joining and use

Discipline and Structure:

Circuit nomination

Professional Checks (pre-cockpit entry, pre-launch, pre-manoeuvre, pre-circuit)

Launch Point discipline

Field selection: awareness, areas, field, decision to land

Visitors

Ground Handling – esp. glider towing

Moving on airfield – crossing runways

MGC Organisational Actions:

Re-introduce the Duty Pilot role; Ground training syllabus

Operations Manual

Enhanced early solo supervision

Card system

Must be Tea Time?

Back in….

The Safety Chain…

https://www.youtube.com/watch?v=zbGUE8g47-M

The safety cheese! (Prof J Reason, Swiss Cheese)

• Each layer is a ‘defence’

• Latent Layer ‘Holes’:

• Organizational layer: Maintenance?

• Supervision / training layer: AFR?

• Active Layer ‘Holes’:

• Layer of (unsafe) precondition: IMSAFE?

• The layer of unsafe acting: Judgement?

Alternatively “Event Chains” – rarely just one thing causes an accident

Jump, Jump Jump….

Before you can jump….

Some words from a man whose done it…. https://www.youtube.com/watch?v=cDXIxHAmSX0

MGC Recent Accidents & Incidents Difference between an accident and an incident?

Accidents:

K13 tail broken off – CCY

K13 – aileron horn damage

K13 – canopy opened during launch

Skylark4 – Heavy landing

Skylark4 collided with K13 on runway whilst landing

K8 hit tree on approach

Incidents:

Airbrake spring broke – discovered at All Out on winch launch

Aerotow abandoned with T/L after starting from wrong position

K8 Low Approach (multiple)

K13 canopy started to open on launch….

Approaches over the Bus/Aircraft (multiple)

Overspeed on winch

K8 wing almost hit K13 canopy on launch point during retrieve

Retrieve rope wrapped around Astir main wheel towing downhill

Bristol Airspace Infringement

Safety Management System – Starting with enhanced incident reporting and club level analysis

MGC Recent Accidents

K8 approach:

An accident chain ‘case study’

Wind change since launch, now cross at 180/10

Attempting to thermal soar from far too low

No circuit

Resulting offset ‘straight in’ on downwind side of approach path

Winch launch, Feb 2019 (video part 1)

National Trends

Late Take Over – instructing accidents

Tug Upsets – a returning scourge

Trees!! (Parham Ridge Soaring, Hus Bos K21)

Accidents and Incidents: Prevention

Education and Awareness

Operations Manual

Standard Operating Procedures (SOPs)

Safety Management Systems – trends and targeted actions

Improved and formalized supervision

Currency standard; pre-license culture

Environment for earlier take over

I may need a few more

balloons today…

Winching

Is an efficient, cost effective and if flown correctly safe means of launching

Rotation rate: Is THE critical factor with respect to stall speed

Start Rotation from initial climb at 1.5 x Vs

Rotation to full climb 5 seconds

https://members.gliding.co.uk/bga-

safety-management/safe-

winching/simulations/

Winching: Other Risks (TEM)

Wing Drop:

Cross wind

Wing Holder is a safety critical role

Cartwheel

Insufficient recovery (airspeed) prior to turning

https://members.gliding.co.uk/bga-safety-management/safe-winching/simulations/

Winch Launch Failures

These are emergencies – whether simulated or not

The only important thing is that you can walk away from it

Using the aircraft again is a bonus

MGC launch failure part 2….

Landing Off Field is a very real option

Avoid a follow-on emergency!

Full Airbrake Approach and Landing: ask to do with an instructor

Winching : Risk Mitigations

‘Blindly staring into oblivion waiting to get to the top’

Approach every winch launch as if it will fail

Know your minimum winch launch speed (and Vw)

Look at the windsock as part of your Eventualities:

Cross or Tail wind?

Approach speed?

Lay off?

Hand on release: pull immediately if you can’t keep wings level on ground run

5 second Rotation into Full Climb after you reach 1.5 x Vs

Wing tip, ASI, Other wing tip, repeat….

Lay off only after achieving full climb

Recognise Launch Failures:

Too Fast/building speed – from ½ way up full climb

Too Slow/decaying speed

Bang!

Winch drivers – clearly mark the top of the launch

Winching – wind direction

Decision to stop winch launching in NE winds (040 to 070T)

To avoid dropping cables over New Road

Allows for ‘worst case’ scenario; break in cable at max. launch height

Aerotowing is not impacted

Homework (starred) and Resources Safety Chain, Risk and Error Management:

Swiss Cheese: https://aviatortraining.files.wordpress.com/2018/07/swiss-cheese-model-aviation.png

BGA Compound Errors Video: https://members.gliding.co.uk/library/general-safety-publications/multiple-compounding-risks/

BGA Managing Flying Risk: https://members.gliding.co.uk/library/bga-requirements-guidance/managing-flying-risk-guidance/

Safety Analysis article based on statistical analysis & psychological theory: https://chessintheair.com/does-soaring-have-to-be-so-dangerous/

BGA Safety in Adventurous Soaring: https://www.youtube.com/watch?v=h5iI2HlFfQg

BGA Safe Winching:

BGA Safe Winch Launching Booklet

How to Winch Launch Safely presentation 1: https://members.gliding.co.uk/library/safety/how-to-winch-launch-safely-movie-mp4/

How to Winch Launch Safely presentation 2: https://members.gliding.co.uk/library/safety/how-to-winch-launch-safely-video-part-2/

Winch Launching Quiz: https://members.gliding.co.uk/bga-safety-management/safe-winching/safe-winch-launching-quiz/

Launch Accident Simulations: https://members.gliding.co.uk/bga-safety-management/safe-winching/simulations/

Bailing Out:

BGA G Dales Presentation: https://www.youtube.com/watch?v=cDXIxHAmSX0

Soaring, Weather and Topography Publications: Suggested Reading List

Understanding the impact of weather and geography (the lumpy bits) on soaring and in particular associated TEM. All of below can be found on the BGA website shop and purchased from there and other outlets:

The Glider Pilot’s Manual 4th Edition: Ken Stewart

The Soaring Engine, Vols 1 & 2 (no. 3 to follow): G Dale

Gliding in Lift and G-SINK: Kevin Atkinson