Issue 13

DAEMS reporting
I learnt about flying from that…
Military Aviation Courses
AirClues
Issue 13
Spry says…
Competition
Air Clueless
Awards
Do you
believe what
your aircraft
says?
Regulation 18 Mythbusting
10
Air Clues
50
6
20
48
33
Contents
Spry’s view 4
Report today for a safer tomorrow
33
Blast from the past
… 5
Aberporth Danger Area Complex
36
December…fog…USAF…Wales… 6
Feedback…
40
I learnt about flying from that… 10
MAA Flight Safety Courses
42
Do you believe what your aircraft says? 16
Competition time
48
Airside Operations - Heathrow Airport 18
I learnt about writing DASORs and
flying from that…
50
I learnt about flying from that…
20
Regulation 18 - Mythbusting
24
Awards31
Back to Flying Business 54
55
Erratum The views expressed within Air Clues are those of the
authors concerned, and do not necessarily reflect those
of the Royal Air Force, or MOD. All rights reserved.
No part of this publication may be reproduced, stored
in a retrieval system, or transmitted in any form without
prior permission in writing from the editor. Unless by prior
arrangement, articles and photographs will not normally
be returned.
Write to the Editor: Air-SafetyCtre-Prom-SO3@mod.uk
ISSUE 13 contents
3
Air Clues
Spry’s view
It has now been some months since the RAF Safety Centre
reached Full Operating Capability and I am pleased to say we
have all hit the ground running (but not hard enough to merit
raising a H&S Report!). There are many changes afoot which
will enable a more streamlined and integrated Safety Centre
here at Spry Towers, but I will give you more detail in my
next issue. For now, though, I strongly recommend you have
a read of our new AP8000, the RAF Safety & Environmental
Management System. This supersedes the previous AP3207
and AP7002 and is intended as a ‘Safety for Dummies’; in other
words, a simplistic overview of how the RAF deals with Safety,
without undermining the importance it places on it. Links to
AP8000 can be found on the RAF Safety Centre MOSS-page
and online through the Intranet. For those of you serving
overseas, do not fret, we will have the document available
on disc in the not so distant future. In March, we hosted
the inaugural Total Safety Governance & Command Boards,
respectively chaired by DCom Ops and the Chief. These highlevel board meetings act as the coordinating body within AIR
to identify common themes across all areas of Total Safety and
provide strategic governance of risk, assurance, policy, process
and promotion. The Command Board meeting was presided
over by CAS in order to ensure the highest standards of Total
Safety are being set and maintained and that we deliver a
coherent and coordinated Total Safety policy.
I hope you find the articles in this edition of Airclues as
interesting as I did. I would ask you, in particular, to have a
read of my response to the letter on page 40 regarding self
medication. There has been a lot of discussion around the
bazaars, especially since I issued my recent Safety Note on this
topic, as directed by HM Coroner during the XX177 inquest.
However, let me make one thing clear - I wasn’t writing
anything new!! Self-medication, in all forms, has always been
forbidden. However, as you will read in my response, I have
listened to the debate and re-engaged with CAM in order to
elicit sensible guidance with regard to the time required for
any effects of the medication to have worn-off. The upshot is
that the medics consider 24 hrs sufficient to rid your system
of any of the adverse effects (and there ARE many!) of self-
4
sprys view ISSUE 13
medication. By the time you read this, I will have written to the
Groups directing them that aircrew should not use over-thecounter medicines, drugs, tablets or remedies within 24 hrs
of reporting for flying duties unless prescribed by a Military
Aviation Medical Examiner (MAME). Put simply, if, when within
24 hrs of flying, you feel ill and can’t get to a MAME, but
consider you need to ‘take something’, ie you self-med, then
you are to take yourself off the flying programme - if you stop
taking your self-med 24 hours before flying and you are FIT
TO FLY, you don’t need to come off the fly-pro. That said, I will
always stick to the overriding principle that if you are sick,
you should see a MAME, and not self-medicate, because if you
feel ill enough to take a remedy, then you are not fit to be in
the cockpit!
If you have an article you wish to be considered for
publication in one of our future editions of Airclues, please
don’t hesitate to get in touch. Please note that my email
address has now changed, along with the rest of the team at
Spry Towers.
You can contact me at Air-SafetyCtre-WgCdrSpry@mod.uk or
call 01494 495699.
Spry
Download the free Blippar App from Google Play, Blackberry App World
(For the new Blackberry Z10 Series phone) or App stores and scan the page
or image wherever you see the Blippar logo.
Air Clues
Blast from the past…
Extract from Tee Emm, October 1942
Here is an extract from a letter written by a pupil at an SFTS
(Service Flying Training School) to one of his officers at his
ITW (Initial Training Wing). It should be explained that upon
his first arrival at the ITW, this particular pupil was a bit of
a tough customer. He had done some flying already and
held the view that it was sheer waste of time for him to go
through the ITW Course! His letter shows that his views
have now been modified:
“Day before yesterday, I did my first solo in the Hurricane; they
are indeed a grand plane and it is little wonder that they have
gained the name they have. Luckily for us they are not as hard
to handle as the Master which may sound strange. They are
harder to land though, because of the narrow wheel base.
I got a rather big surprise when I came here, and that was the
mortality rate. There are quite a few deaths here, and this fact
has made me extremely careful in everything I do in the air.
I have come to the conclusion that most of the accidents are
caused by the things, carelessness and disobedience, known
in the RAF as breach of discipline. For some reason many
of the boys simply will not obey the orders that have been
given to them. I can give two good examples of this: A Dutch
boy was sent up to do aerobatics and was told not to do any
aerobatics under 7000 feet, yet with that order in his mind, he
started doing rolls at 2000 feet, got into a spin and was unable
to pull himself out, thus killing himself. Another case: a boy
on the more recent course went up with only two hours solo
and went 70 miles to ‘shoot-up’ his home. He crashed into
the house, killing himself and some others. He knew the
orders about low flying, yet he deliberately disobeyed them.
Of carelessness one sees accidents ranging from minor to
major ones nearly every day; fortunately most of them are not
very serious, and a plane is put out of use for a few days only,
but some terrible accidents have happened since I’ve been
here (all accidents due entirely to disobedience of orders).
You may wonder why I write about all this. Well, simply
to thank you for being strict when I was in the ITW.
That strictness has probably kept me alive. Secondly, I know
that because you know this you will be able to tell others that
they may profit by others’ mistakes. I know we all used
to grumble at the
discipline, but I know
that it was for our own
safety and our good.”
5
Air Clues
December…
fog…USAF…Wales…
By Sqn Ldr E Seymour, OC Ops Sqn, RAF Valley
RAF Valley, on 11 December 13, found itself unexpectedly hosting 13 armed F15Es
from the 494th Fighter Squadron, based at RAF Lakenheath.
The weather at Valley was excellent: Blue (BLU), forecast
BLU, whilst that over most of the rest of the UK was poor
and deteriorating. As a result, RAF Valley was the diversion
airfield for a number of aircraft whose crews wanted to make
the most of whatever weather was available. The only other
military airfield that remained unrestricted during the rest of
the day was RAF Lossiemouth.
ATM Force Orders state that: ‘When own weather colour state
is Blue or White and forecast to remain Blue or White, there
is no limit on the number of aircraft that can be accepted for
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december…fog…USAF…wales… issue 13
weather diversion’, and: ‘When own weather colour state is
Green or worse, and forecast to remain Green or worse, up
to a maximum of 30 aircraft per 15 minutes (‘quarter’) period
may be accepted provided that a runway precision aid is
available.’ Bearing that in mind, Valley was the diversion airfield
for the following:
••
••
••
••
Coningsby – 8 aircraft (mixed type)/quarter
Marham – 4 aircraft (GR4)/quarter
Boscombe Down – 4 aircraft (mixed type)/quarter
Shawbury – 2 aircraft (rotary)/quarter
Air Clues
•• Warton – 2 aircraft (non-Typhoon) total
•• Lakenheath – 6 aircraft (F15E) total
followed by 6 further pairs between 1327 and 1401. As the
aircraft landed, ATC were informed that all aircraft were in fact
armed with chaff and flares and 5 were armed with live guns.
The aircraft were marshalled to Airfield Servicing Platforms
(ASP) that had the maximum number of parking slots for
armed aircraft with safe headings.
At 1414, other airfields, for whose aircraft Valley was the
diversion airfield, were told that Valley was at diversion
capacity. Valley policy is to maintain the diversion for any
aircraft that are airborne although this intent was lost in
communications, as Valley was later informed that Coningsby
had conducted an airborne recall of its aircraft.
Fig 1. Colour states of UK areas 11 Dec 13 – the bad weather spread until
only RAF Lossiemouth and RAF Valley were operational.
Valley was told, having asked Lakenheath for the armament
status of the aircraft, that they were unarmed.
At approximately 1300, Valley ATC took a call from LATCC mil,
notifying us that they would be handing over 13 F15s for
‘weather divert’. At 1310, the first F15, callsign Gremlin, came
on frequency, declaring ‘pan for fuel’. At 1312, Gremlin landed,
As OC Ops Sqn, I received briefs from Stn Ops and from the
engineering staff who were on site at the other side of the
airfield where the aircraft were parked, before driving over
to assess the situation. On arrival, the aircraft were parked
according to safe procedures, with the ‘live’ guns on safe
headings. I was informed the guns had been pinned up by the
aircrew. However, owing to the aircrew requesting immediate
refuel, a bowser crew was busy refuelling the penultimate
aircraft, meanwhile the MT bus to take the aircrew to the Mess
was not even 100m behind one of the aircraft, and a USAF
crew, with good intent, were showing some personnel around
the aircraft. This was where the difference between air forces
came into play: to the USAF, chaff and flares do not mean that
aircraft are armed whereas to the RAF, they most definitely
issue 13 december…fog…USAF…wales…
7
Air Clues
do. Once on the ground, any aircraft equipped with chaff and
flares requires an exclusion zone as prescribed in the aircraft
safety and maintenance notes, with the exception of essential
maintenance staff and aircrew planning to fly. If the specific
aircraft safety and maintenance notes are unavailable, an
exclusion zone of 200m around the entire aircraft is to
be applied. The Maintenance of Airworthiness Process (MAP)
guidance is that all foreign aircraft, including those based in
the UK, are to be ‘assumed armed until it has been determined
that [they are] not’. For engineering personnel, this means
that no maintenance, including replenishment/refuelling, is
to take place before clearance from the Principal Engineer
(or equivalent) is granted. We cleared the pan of personnel,
however the 200m exclusion zone included some buildings
and the perimeter access road to the 24/7 Search and Rescue
(SAR) services of 22 Sqn C-Flt and RAF Valley Mountain Rescue
Team (MRT).
Of note, the F15s are much thirstier than Hawks and we were
now concerned, having filled up the F15 tanks, how many
days of supply of fuel for our own aircraft we had left.
The USAF crews had taken over the disused Visiting Aircraft
Section (VAS) building, using the one functioning landline in
order to contact their engineering staff and guarding
staff back at base. I was using my mobile phone to make all
other phone calls (noting weapons safety zones). The SAR
Force had sent over a liaison officer and he kindly offered the
SAR planning and rest facilities. RAF Valley had stood up a
guard force to enforce the cordon. In the event, with the
SAR force fully aware, all non-essential personnel finishing
the dayshift, and the USAF aircrews guarding their aircraft
until their own guard force arrived, it was deemed
unnecessary for the RAF Valley guard to be used.
Meanwhile, RAF Valley Ops and Spt Wings had ensured the
necessary support facilities, both operational and domestic,
were in place. The Lakenheath guarding and engineering
teams arrived overnight and the next day we ensured there
was a Stn Ops representative with the USAF crews to facilitate
any requirements and to keep Ops and the rest of the airfield
informed as appropriate. All F15s departed without further
incident the day after they arrived - after their mandated
12-hours of crew duty rest and the appearance of a suitable
weather window.
We admit that we were unprepared for the number and
type of aircraft; notably, ATM Force policy considers that ‘the
possibility of mass diversion of large numbers of aircraft …
is deemed remote.’ RAF Valley were pleased to be able to
host these unexpected visitors at such short notice, without
further incident and, despite the specific occurrences
mentioned above, the operation went very smoothly.
That said, we identified some important lessons from this that
we hope other stns can benefit from.
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december…fog…USAF…wales… issue 13
Key Lessons
•• Assume all foreign aircraft are armed until it is
established otherwise.
•• Ensure clear communications and confirm understanding
of information.
•• Know the armed parking slot locations and what effect
each type of armament will have on the airfield, including
access routes.
•• Do not replenish any visiting aircraft until given the goahead by the senior engineer on the airfield.
•• Support elements should consider broadcasting unusual
activity across the stn to inform all relevant parties and
ensure safety considerations are given the widest
possible publicity.
•• Be prepared to provide a cordon for the maintenance of
safe distances and inform all personnel that they should not
approach the airfield.
•• Provide Ops liaison personnel to any diverted detachment:
worth their weight in gold.
•• What is own sqns’ diversion policy? Does one fly to divert?
How will the diversion airfield cope with a mass diversion of
aircraft from your own airfield?
•• Aircrew should ensure awareness of base weather,
diversion criteria and facilities and your own aircraft’s
engineering requirements.
•• How much fuel will large numbers of aircraft need
(not ask for)? What impact may this have on your
own operations?
Post Script
Valley and Lakenheath were able to put into practice the
lessons identified much sooner than expected. On 21 Jan
14 RAF Valley received an early call from Lakenheath as they
were planning their day’s flying: could we accept a weather
diversion of 20 F15Es, armed with flares?
20 F15s would have meant evacuating buildings and
restricting access to a major part of the airfield, therefore we
negotiated the request down to 10 F15s. Since this was not
an emergency, there was time for the Ops assistant to take all
the details and to check the necessary elements at RAF Valley
before confirming with Lakenheath:
•• Latest met forecast locally and for the UK.
•• How many aircraft were we already acting as a diversion
airfield for and until what time?
•• Were the engineers happy to accept 10 aircraft with flares?
•• Did we have enough fuel to replenish 10 F15s and maintain
our own flying?
•• Was OC Ops Wg (and by extension the CO) happy
with the plan?
We were at colour state White, forecast Green and had already
agreed to act as diversion for 22 aircraft. The other answers
Air Clues
were in the affirmative therefore Lakenheath were informed
that yes, RAF Valley could accept a total of 10 aircraft, no more
than 8 per quarter.
Stn Ops then refreshed their memories of the checklist, were
any of the F15s to actually divert in:
•• Which slots would the F15s be parked in for minimal
disruption to the rest of the airfield? Confirm this with
the engineers.
•• Confirm that no refuelling would take place until the
Chief Engineer gave permission.
•• Prepare to tannoy that foreign aircraft would be landing
at RAF Valley and no personnel were to approach without
permission of the Chief Engineer.
•• Prepare to stand up small cordon guard to enforce the flares
exclusion zone.
•• Prepare to provide Ops liaison personnel, MT, food
and accommodation.
As it happened, no diversion was made. However, it was
a useful contingency exercise to reinforce the lessons
learnt a month previously. It was also cheering to note that
Lakenheath phoned us to discuss the plan – reinforcing the
good relations we already enjoy with the USAF.
Photos courtesy of Paul Heasman, RAFValley
issue 13 december…fog…USAF…wales…
9
Air Clues
I learnt about flying
from that…
Are you sure you are
ok to be in the cockpit…?
By Flt Lt JJ Caley, B Flt 22 Sqn, Wattisham
I am a 45 year old helicopter pilot, grey, balding and yes
overweight; I am indeed fond of chicken tikka madras and
an occasional Domino’s Pizza. I do Search and Rescue as a
job and I am a current QHI on the ‘Yellow Sea King’ based
in Suffolk, Lovejoy country. I do little exercise other than
swimming and lots of Scrabble when deployed to the
Falklands. Every 6 months I have to do a fitness test in the
form of a fast walk over a measured mile, which measures
elapsed time against heart rate. It is fair to say that physical
fitness has never been a favourite of mine, but I manage to
do just enough in order to pass the test. Uncharacteristically
one night prior to going to bed, I went to the gym at work
and did 30 minutes on the treadmill, (motivation came
10 I learnt about flying from that… issue 13
from my ‘electric 80’s CD’). Due to my fitness test being 4
days later, I again went to the gym the next morning prior
to taking over shift at 10 am. Once more I did a further 30
minutes of cardio vascular exercise raising my heart beat to
146 bpm. To be honest, I felt confident that I would pass the
test and then give my dodgy knee a well earned rest.
All SAR shifts are 24 hours and as a captain you have to be
very aware of fatigue. For instance, you could legally fly up
to 4 ½ hours training and then be tasked in the middle of
the night to do something quite special, in rubbish weather
with minimal time to plan or brief, whilst still waking up.
That morning we completed a winching exercise to a wind
Air Clues
turbine standing nearly 400 ft from propeller tip to sea; it was
completed without incident and lasted 80 minutes. The rest
of the shift unfolded as normal with a light lunch, followed
by an afternoon of admin, coordination with the engineers
and fielding the odd phone call, normally a random request
starting with the phrase ‘can you just…?’
I had planned to night fly that evening and so we were
going to eat dinner around 6pm, watch a bit of news on the
TV and then brief and walk for a sortie in the dark lasting
approximately 2 hours and 30 minutes. The Sea King Mk 3a
is an incredibly capable Search and Rescue platform, it is a
very robust helicopter backed up with some safe operational
flight profiles, solid radar and optical facilities. As a result of
the aircraft being so capable, this means that as a crew we
have to consistently practise a whole host of different skills
and disciplines, in order to be ‘second to none’. The crew
consists of four: Captain, Co-Pilot, Radar/Winch Operator and a
Winchman (Paramedic). I think it is only fair and honest of me
to mention that I have an enormous amount of respect and
admiration for the people with whom I work, they are total
professionals, each and everyone of them dedicated to saving
life. Night flying skills on reflection are just as important, if
not more than, day skills because executing a rescue at night
is in my mind much more taxing in terms of raw ability and
capacity. As a handling pilot, trying to hover over a moving
vessel at night with one of your best mates (whom you can’t
see), hanging on a wire beneath the cab, is not what you
would choose to do for rest and relaxation. I’m lucky enough
to have been doing this job for years and with nearly 6000
hours flying helos, I can promise you that just like golf, you
have to keep at it, otherwise the possibility of ‘skill fade’ might
rear its ugly head. I was particularly keen for this sortie to
go ahead because primarily I had a large proportion of my
compulsory training statistics to achieve with only one more
shift after this one available. Two nights prior to this one, I
was bitterly disappointed to abort a night sortie on take off.
On transitioning from the hover into forward flight, I felt a
harsh feedback force coming through the yaw pedals and the
airframe shook in sympathy. I stuck the aircraft on the ground
fairly sharpish and handed the aircraft back to the engineers,
saddened that another opportunity to make a dent in the
tally of night stats had slipped by. So all in all we needed to fly
tonight and do some radar work and primarily deck winching.
We took off and transited towards the North Sea coasting out
in the Felixstowe area taking on board radar control from the
Radar Operator and letting down to a nominal 200ft over the
sea. Both of us up front had NVGs mounted on our helmets
in accordance with standard operating procedures, the left
hand seat co-pilot had his goggles down for look out, but I
had elected to stay off goggles to simulate being in cloud
at low level, whilst solely maintaining an instrument scan.
Under this regime the Radar Operator is effectively ‘steering
the ship’ by telling the pilot to fly certain headings, thereby
allowing the aircraft to safely manoeuvre around a plot of
moving and stationary targets which he can see on the
Radar display in front of him. This procedure is practised all
the time because the ‘all weather Sea King’ has to be capable
of doing a fully coupled auto-pilot let down to an ejectee
in atrocious weather. The Rad Op was working particularly
hard, as that night there were several targets in the area of
operation and, as always, a whole host of navigational and
marker buoys, none of which can be over flown whilst under
internal radar control. We successfully carried out a letdown to
a large freighter, it was heading downwind and therefore far
from ideal because the power required (torque in a helo) was
greatly increased in order to keep a relative hover off the ship’s
port quarter. The Sea King does not hover on one engine
unless it’s very light and has a decent headwind component,
so sitting next to this ship with few options was not an ideal
place to be, let alone winching for exercise. Added to this
were difficult comms, language problems with the ship’s
master and smoke exhaust from the funnel, making the whole
thing untenable, so we departed the scene and climbed to
200ft and resumed internal radar control.
As planned, we had dinner, cooked by the co-pilot, and it was
delicious. On shift we are very independent and a member of
the crew always volunteers to be Keith Floyd. Perhaps foolishly
I had seconds because it was so tasty and after all, it would
be a shame to waste it. We then briefed and walked for the
aircraft, I was conscious that I hadn’t done much night training
recently and wanted to do well. I was wearing under garments
and an immersion suit, (compulsory when flying over the sea
at night even when the air temperature is quite mild, it can
certainly make you feel hot and stuffy in the cockpit).
issue 13 I learnt about flying from that… 11
We had now been airborne for approximately 50 minutes
to an hour and there was no doubt about it - I felt
uncomfortable. I had a full stomach, was feeling hot in the
immersion suit and I definitely did not feel sharp, in fact I was
feeling particularly rusty. My mind was notably preoccupied
by how tight across my chest my Mk 25A large LSJ was feeling.
I was sure that I was wearing the large jacket and not the
regular size, but my word did it feel tight across my chest.
Aligned with this discomfort was the fact that my breathing
was different and I did feel short of breath. The co-pilot is a
good friend of mine, a gifted individual and he is the only
natural pilot I have ever flown with, to say he is a ‘sharp cookie’
is an understatement. It didn’t take him long in the sortie
to notice that not all was well with me and he remarked to
that fact, “mate are you sure you are feeling alright because
you don’t sound like yourself?” I told him and the rest of the
crew that my jacket was causing me discomfort but I felt ok
to continue. I cannot deny that part of me was being task
driven; besides, how would it look if the Flt QHI was short on
stats? Plus, I needed the practise, so I elected to press on and
12 I learnt about flying from that… issue 13
we again let down to another ship - a huge container vessel.
On completion of the let down I had asked the co-pilot to
climb the aircraft from 50ft to 85ft using the hover height
controller but as he correctly pointed out we weren’t in hover
mode we were still in the transition down mode. I felt stupid,
this was a basic error and as the QHI I shouldn’t be making
such a mistake, I couldn’t be that rusty surely not, why was I
making these mistakes? Once alongside the vessel we arrived
at the briefing point with all the lights on and took stock for a
moment. For the third time the co-pilot clearly expressed that
he didn’t think I was my normal self and suggested that he
took control whilst I unbutton the three fasteners on my LSJ.
I did this and felt a definite release of pressure across my chest
and an easier breathing pattern. I thanked the crew for their
concerns but then assured them that I felt fit to carry on with
the sortie or so I thought at the time!!!
We stayed working with this ship for 45 minutes, it was huge
and carrying lots of containers stacked on top of each other,
so finding a clear winching area wasn’t easy.
Air Clues
We discussed the options as a crew and
ended up winching to a gap between
the containers of approximately 20ft.
In order to get into the overhead
we needed to be in a high hover of
145ft over the sea with the winchman
suspended on a lot of cable. We carried
out several parallel deck evolutions
of this, moving the aircraft into the 3
o’clock to place the winchman in the
gap and on the deck, it went well and
the rearcrew swapped over and did
reverse role. The sortie now seemed to
be going better and I felt more content
with my performance. As briefed, we
said goodbye to the ship and flew to
the local cliff training area at Walton
on the Naze. Night situation winching
offers different challenges but at least
they don’t move at 15 knots. We did one
winching exercise and then recovered
to Wattisham with the guys in the
tower providing us with a short pattern
PAR. We landed on at dispersal and
shutdown the rotor head but kept one
engine running whilst the cable was
run out and washed by the engineers.
Whilst still sat alone in the cockpit I
had 5 minutes to reflect on what had
happened. I consider myself to have a
reasonable ‘pair of hands’ but tonight’s
performance overall was definitely
below par, something wasn’t right and it
was frustrating me. I’m normally a jovial
laid back bloke but I was not feeling
content within myself, I shut down the engine and signed in
the aircraft. I took off my LSJ and placed it on the hook, it was
the correct large size jacket the one I always wear. ‘So why did
it feel so tight?’ I asked myself. We made a brew and sat down
in the crewroom and debriefed the sortie thoroughly, the copilot said that my performance was uncharacteristic, almost as
though I was happy to be led - food for thought.
It was bedtime now but the winchman and I stayed up just
a little longer discussing how I was feeling. I did not feel as
though I was firing on all cylinders, tired and maybe a little
vague but then I’d done a lot since that treadmill first thing
this morning. The winchman is a caring soul and deep down
he must have had more concern for my welfare than I had. He
said to me in his London boy accent, “ Heh Jezza, if you don’t
mind mate I’d like to plug you into the heart monitor and
just give you the once over”. He was right, after all what harm
could it do? So there I was sat in the crewroom chair, jersey
off looking like the 6 million dollar man, all plugged into the
Propac with an oxygen sensor hanging off my finger. Well, the
camera never lies! There it was for all to see, I had a heart rate
double what it should be, beating erratically and irregularly
and to top it all my oxygenation was low.
Put simply the winchman was an angel, he put tubes up my
nose and turned on the oxygen bottle and said in a very calm
way, “Mate I’m not happy with your heart, I’m taking you to
A&E”. The penny had dropped, I was obviously far from well,
from feeling a little under par I had now become a casualty!
The Flight was now down declared OFF STATE, pilot and
winchman en route hospital and there I was holding my
oxygen bottle being driven to Ipswich by the Opsy in the
Flt Astra - a short time ago I’d been in charge of a 9 tonne
helicopter with 4 pink bodies on board. On arrival at A&E I
was soon plugged into some A grade machinery where I was
monitored and assessed. I could watch for myself as my heart
trace created some random unsymmetrical linear artwork on
the screen and constantly the audio ‘your heart is not well’
alarm was sounding in sympathy. It soon became apparent
that things weren’t good, my heart rate was 120 bpm and my
SPO2 was 85%; in other words, slightly hypoxic. Lying there in
hospital pyjamas I felt exposed and concerned; ‘why and how
could this have happened?’ After several hours in A&E I was
taken to the cardiac ward where I was given some medication
and I fell asleep for a couple of hours around dawn. In the
morning a Dr (ex USAF) came to see me, a very calm and
professional Texan and he gave me the full Cardiologist
version of what was going on. My heart had gone into Atrial
Fibrillation (AF), a condition that causes an irregularly and
often abnormal fast heart rate. The upper chambers of the
heart (atria) contract randomly and sometimes so fast that
the heart muscle cannot relax properly between contractions,
this reduces the heart’s efficiency and performance. His main
concern was that this may cause clotting in the blood and
possibly induce a stroke. This all sounded a bit serious now
“I recently saw a psychiatrist, the
discussion revealed to me that in my
flying career I have had 9 incidents
that have seriously frightened me
including, an engine failure on a
deck winching exercise, airmisses
and having a winch cable break and
come up through the rotors. All of
these incidents put together have
made me wonder if I want to be
flying helos anymore or alternatively
that I am incredibly lucky and this is
what I do.”
issue 13 I learnt about flying from that… 13
Air Clues
and when I looked around the other patients who’d had a
cocktail of bypasses, strokes and heart attacks I felt vulnerable,
this wasn’t what I had in mind. I was given an injection to
the abdomen and put on Warfarin to thin the blood and all
the time kept on oxygen. Several hours later that day and
with great relief my heart was beating with symmetry and
uniformity again - thank you God, the NHS and, of course, my
winchman. My pulse was normal at around 67 bpm and the
oxygen level was a little low around 91%, all in all I was feeling
much better and bantering with the nurses. The NHS staff
were absolutely faultless and I cannot praise them enough
in the care and professionalism they showed to me. I was in
hospital for four days and a whole range of tests were carried
out including numerous blood tests, CT scan and audio scan
- the good news was that I had not suffered a heart attack.
The staff cannot say why I went into AF, indeed it may be a
combination of things but I remain pleased that the results of
the tests were good, my heart and arteries are in good shape
and my cholesterol is less than 5. I’ve never smoked and I don’t
drink anymore but my lifestyle could definitely be healthier,
so on discharge from the hospital I went to see the SMO and
she’s been really helpful. I now go to Slimming World and
the middle aged spread I had is now diminishing, I’ll never
be Charles Atlas, but losing a couple of stone will help me
14 I learnt about flying from that… issue 13
the next time I have to put on No 1s. I’m currently grounded
and on Beta blockers and in the mornings I regularly go
swimming, enjoy going to the pool on camp and besides,
you get a free bath.
As a seasoned aviator, this whole account still concerns
me, particularly as to why I didn’t realise that something
as potentially serious as this was happening to me, whilst
flying an aircraft with a winchman on the wire surrounded
by 20,000 tonnes of container ship. We can all pick the bones
out of this story about what I did wrong and how I could
and maybe should have done things differently. More than
anyone I thought I knew myself better than this but that’s
the key point to this article, we often don’t. For example, I
recently saw a psychiatrist, the discussion revealed to me that
in my flying career I have had 9 incidents that have seriously
frightened me including, an engine failure on a deck winching
exercise, airmisses and having a winch cable break and come
up through the rotors. All of these incidents put together
have made me wonder if I want to be flying helos anymore or
alternatively that I am incredibly lucky and this is what I do.
There are so many factors and injects in aviation that require
us to make a swift yet considered decision, balancing
the needs of the aircraft and crew against the task and its
Air Clues
surroundings. I think it would be unwise to comment on my
own CRM, you would have to ask my colleagues, but what
I will say is that I believe that in Search & Rescue it is vital to
create a relaxed and at ease cockpit.
The question that I ask myself most about this incident is,
although I had heard and processed the concerns about
my well being from my trusted co-pilot, I chose to carry on
thinking that I was fit enough, when hindsight clearly tells me
I wasn’t. I ponder about being task-driven to achieve the sortie
aims that night and what would people think about the QHI
not being stats-complete. In a way, and I would imagine we as
aviators have all done it to a greater or lesser degree, but how
often when you’ve had a cold or a bit of a sore throat have
you said I’ll be alright, besides if I go sick my mate will get the
phone call, “we need you to come in and cover, Bloggs has
gone sick” etc. It is a fine line indeed and different theatres will
dictate a different decision.
understand, give it back to the engineers, don’t do too much
diagnosis yourself because your summary may be incorrect
and that could have dire consequences. That night, my copilot and crew were my warning panel and I should have
acted differently, handed over control and returned home.
The message is clear, that even with 23 years of military
flying experience I can say that we don’t know ourselves as
well as we think we do. As individuals, we are probably the
worst people to admit when something is wrong
with ourselves.
I would hope from this experience that I have learnt not to
self diagnose, besides how was I to know what the symptoms
for AF are? Before this, I didn’t know it existed. Thinking back
to all those years to Av Med training at North Luffenham,
I remember being on the ground in the chamber and the
doctor sat there with us at altitude and before we took off
our oxygen masks, he described how the onset of hypoxia
creeps up on you and you don’t know it’s happening. This is
an extreme comparison I know but the point I want to make
is that where health is concerned there is no warning or
caution panel that says you are not fit because of this or that
reason. Just like an aircraft that has a snag which you can’t
Spry Says
Now that’s what I call real CRM.
Talk about looking out for each
other on the team!
Levity aside, this is a salutary tale which we could all
learn from to various degrees. I can say with some
certainty that we’ve come a long way from my early
days in the RAF when each squadron invariably had a
gnarly old spec-aircrew pilot with a faded, slightly tootight flying suit, who took great pride in announcing
himself as the “Sqn Sports Prevention Officer”. It is so
heartening (no pun intended) to see a much more
positive approach to health and fitness nowadays. But
we cannot rest or let complacency creep in – how many
of us accept the “scraped pass” on our fitness test? How
many of us nod sagely when the doc says we could do
with shifting a few pounds at our PME? How many of us
relate to the words “I had seconds” or “physical fitness
has never been a favourite of mine”?
issue 13 I learnt about flying from that… 15
Air Clues
docs
corner
Do you
believe
what your
aircraft
says?
By Dr David Stevenson & Ms Vicki Cutler, RAF CAM
The quotation left, which is not what the woman intended
to say, reflects in part our somewhat ambivalent attitudes
regarding the degree to which computers intrude into our
lives. These attitudes are also reflected in our responses to
computer generated warnings in aircraft.
During my many years studying aviation safety and aircraft
accidents, I have been particularly interested in controlled
flight into terrain (CFIT) accidents. CFIT continues to happen
at depressingly frequent intervals in spite of CFIT avoidance
technology being installed in all but the most inexpensive
aircraft. With equally depressing frequency, flight data
recorders reveal that many of these aircraft have struck the
ground to the sound of “PULL UP! PULL UP! TERRAIN! TERRAIN!”
or some such verbiage being broadcast to the flight deck by
the aircraft’s computers. Common threads which accompany
many CFIT incidents include:
Distraction
“I have never given a name
to any computer I have
ever known.” – a technology
correspondent’s reply on
being asked if she had ever
given a name to a gadget
or computer she had owned.
16 do you believe what your aircraft says? issue 13
Spatial disorientation
Giving more credence to the body’s sensory inputs rather
than flight instruments and/or verbal warnings (not listening
to your aircraft when it is trying to help you).
This combination of factors led directly to the fatal crash
of Afriqiyah Airways Airbus A330 Flight 771 during its
approach to Tripoli Airport in May 2010. The accident is well
summarized in the AeroSafety World, July 2013 cover story
regarding the accident, which is available on line at http://
flightsafety.org/aerosafety-world-magazine/july-2013/
fatal-hesitation. Spatial disorientation, in the form of the
somatogravic illusion, had a primary role in causing the
Air Clues
down control inputs. As the aircraft entered a descent under
full power, it accelerated even more, accentuating the nose
up illusion.
My dear reader, consider this very carefully. You are flying near
to the ground and accelerating. You have the gut-wrenchingly
powerful sensation that the nose of your aircraft is pitching
up, and I am telling you to pull back on the controls? In this
instance, yes. The Flight 771 A330 was clearly telling the
accident aircrew to pull back on the controls. As the situation
progressed, both the aural warning system and the aircraft’s
flight instruments would all have indicated that the aircraft
was descending, yet the crew relied on their erroneous
sensations of pitch up, leading to pitch down control inputs
and the deaths of 103 people.
Why did the crew not listen to their aircraft, which was trying
very hard to tell them what was happening? Why did they not
act on the aural warnings? Several human factors may have
played a part, such as distrust of technology and perhaps past
experience with false positive computer generated warnings.
accident. The article discusses the somatogravic illusion in
some depth, so I will not dwell on the physiology involved.
This illusion occurs when an aircraft accelerates or decelerates;
the change in aircraft velocity results in an inaccurate
sensation of pitch up or pitch down respectively. Now for
reality rather than theory:
Flight 771 was approaching Tripoli at night, with the co-pilot
flying on instruments. They were well below the minimum
descent altitude on the approach, which required visual
contact with the runway prior to receiving a landing clearance.
The pilot indicated to ATC that the runway was in sight, which
was impossible from their position at the time. The co-pilot
looked up, and could not see the runway. Apparently due to
this distracting contradiction and uncertainty regarding where
they were, the co-pilot request a go-around. The aircraft then
broadcasted “TOO LOW – TERRAIN” at which point the captain
commanded a go-around. Seconds after applying go-around
power, retracting flaps and landing gear and establishing a
climb, the co-pilot applied nose down input into his side stick
controller and the aircraft began to descend. “DON’T SINK”,
“TOO LOW TERRAIN” and “PULL UP” warnings sounded.
The captain took control of the aircraft, and - (Can you
anticipate what’s coming?) - applied further nose down
control inputs, flying the aircraft into the ground.
Analysis
The co-pilot was distracted and confused by the captain’s
indication that he had the runway in sight, when he did not.
As the aircraft accelerated away from the ground, the crew
felt as if the aircraft was pitching up more than it actually
was (the somatogravic illusion), and applied nose
The most important factor is that the accident aircrew relied
on an interpretation of reality based on their physiological
sensations rather than on interpretation of their instruments.
Spatial Disorientation 101 tells us that we cannot rely on
our physiologic motion and position sensors in flight, and
we are taught always to rely on our instruments. The crew
of Afriqiyah Airlines disregarded these teachings with
fatal consequences.
•• Believe your instruments rather than your body.
•• Illusions may be very powerful, and require huge effort
to overcome.
•• While powerful, they may also be very subtle, and take
one unawares.
•• Any distraction close to the ground should sound alarm
bells in your mind regarding terrain avoidance.
“When things start happening, you have to pay
attention to paying attention.”
Spry Says
As ever, some very wise words from the ‘doc’
that provide a timely reminder of the hazards
posed by disorientation and distraction.
If in doubt, admit your problem, get on
instruments and report the incident so others can
learn from your experience.
issue 13 do you believe what your aircraft says? 17
Air Clues
Airside Operations –
Heathrow Airport
By Simon Newbold, Airside Training Manager, Heathrow
The objective of an Airside Operations Team is to provide a
safe and efficient working airfield for all users at all times,
in all weather conditions and in all operating circumstances.
This involves providing resources and infrastructure, and
establishing and monitoring safe operating procedures
with constant liaison amongst all operating companies.
It is important to remember that airside safety extends
not only to aircraft but also to the personnel, vehicles and
other equipment that work and operate on the airfield.
The team ensures compliance with international and national
regulations for operating an international airport. This means
upholding the requirements of having a licence to operate, a
complex and detailed list of items. All of this happens when
working with up to 1,400 live aircraft movements, 200 towed
aircraft movements, 4000 vehicles moving around 50miles
of airside road and three vehicle tunnels within one of the
busiest and capacity-constrained airports in the world.
Every day we need to ensure that the airlines, aircraft and
nearly 200,000 passengers arrive and depart safely and on
time, every time. The Airside Operations team carry out a huge
range of tasks all to ensure optimum safety and efficiency.
The majority of these tasks are common with any other
airport, but here at Heathrow it’s all about the capacity
constraint and the sheer volume.
18 AIRSIDE OPERATIONS - HEATHROW AIRPORT issue 13
It’s a responsible job, with little margin for error, and requires
skills of awareness, technical understanding coupled with a
proactive attitude and, of course, a great interest in aircraft
and how they operate.
The training can take up to a year, but once signed off, the
team works four shifts on a 365 – 24/7 basis covering days and
nights. Even when the aircraft are not flying during the night
period, the airport is still busy with works parties carrying out
essential maintenance and construction that cannot take
place whilst aircraft are using the runways or taxiways.
There is so much to do every night just to prepare for that
first departure or arrival.
During the day, as well as all the planned tasks, the team
prepare for what’s ahead. This is largely dependent on
the weather and so a forecaster from the Met Office is
based within the control tower to ensure we have the
most up to date and accurate information. Strong winds,
fog, thunderstorms, snow and ice can all hugely affect the
operation, not just on the ground but in the air, for departures
and arrivals.
During extreme adverse weather and working closely
with the Met Office, Air Traffic Control and the airlines, the
operations staff will make decisions with regard to reducing or
Air Clues
moving the schedule of flights just to ensure that the airport
continues to operate. Once this is agreed, there is then a
base plan to work to, yet an unknown such as an emergency,
incident or world disaster can then have a huge impact on it.
The operational managers then need to be flexible and use
a combination of experience and support of stakeholders
to return everything back to normal as safely and as quickly
as possible.
Operational effectiveness is a key term that is used to describe
the product airside. As well as the unknowns of the weather
and emergencies there are a huge range of tasks that include
so much more than the popular image of someone waving
ping pong bats at an aircraft.
Firstly, the task described above is known as marshalling
– this is the manual guidance of an aeroplane. In reality
automated electronic parking aids guide the pilots to the
correct stopping position by the terminal. It’s only when these
systems fail or there is an obstruction, that a marshaller is
deployed. This affects only 2% of all arrivals, but is still required
to ensure the flow of the airport is maintained.
Safety inspections are a licencing requirement and are a
critical task to ensure the Air Traffic controllers know that all
areas are safe and fully serviceable for aircraft. This extends to
all parking stands, road systems and footpaths –to ensure
that no one and nothing is put at risk. The inspections
include checking the surfaces, building infrastructure, airfield
lights, of which there are 20,000 on the runways and taxiways
alone, and ensuring the airports operating and driving rules
are being upheld.
To ensure safe working on the apron, “policing” is a
very important task of the unit. Audit checks of aircraft
turnarounds, attendance at all vehicle incidents, monitoring
speed and patrolling helps ensure the free flow of
traffic and that all staff are behaving and operating in a
responsible manner.
Another licencing requirement is to provide a dedicated bird
management team. A bird striking a plane has been identified
as one of the top risks, therefore a team patrol the airfield
on a 24 hour basis, to deter birds from visiting Heathrow.
Grass management, bird-proofing of structures, minimising
or protecting water bodies, providing a presence out on the
airfield are all tasks that can prevent the airport appearing on
a bird’s holiday or residential wish list. The open space and
food sources at an airport are very attractive to birds!
Inevitably birds will fly here, despite the team’s efforts, and our
tactics will change from deterrence to dispersal. This must be
carried out in a controlled manner and will sometimes simply
involve monitoring numbers and behaviours.
Active
dispersal can include the playing of distress calls,
simple arm waving, sounding of a horn, or the use of pistols
firing blank shells or two stage fire crackers. The whole subject
of “birds” has a double edge in terms of safety – one for the
airfield, but just as importantly, one for the staff and the use of
handguns, and driving close to the runways, requires regular
specialist training and concentration.
Heathrow airport has been dubbed one of the world’s
largest building sites. At any one time there are over 100
different projects taking place from the construction of the
new Terminal 2, to the maintenance of lighting systems to
even resurfacing of the runways. All of these works must
be carefully managed so that the operation can continue
safely and that the contractors are protected. This is carried
out by the use of a permit system, the formal adherence
to operational rules. Once again this is regularly patrolled
to ensure safety. All of the works are managed by the
department and are given a high priority.
Working on the airfield at Heathrow is an exciting, dynamic
and vibrant job. Every day can be different and no two days
are ever the same. The Airside Team are passionate about their
patch and their roles in such a way that many of them stay
for their entire working career. Being at the leading edge of
the safe running of one of the world’s busiest airports really is
exciting, enjoyable and rewarding.
Spry Says
And you thought you worked at
a busy airfield?! I can tell you that
some of my colleagues and I were
invited to spend a day last year with
the Heathrow airside operations safety team, to
witness first-hand its efforts to maintain a safe working
environment. The sheer level of activity which is
needed to support 1400 aircraft movements a day (yes
a day!) and 200,000 passengers is a dizzying spectacle.
Despite the intensity of this effort, the work of the
airside safety team ensures that there are relatively few
safety-related occurrences. Reputationally the airport
and the airlines stand to be seriously damaged by any
serious safety incidents, and therefore invest a lot of
time and effort into ensuring that their regulation,
processes, procedures, training, reporting and safety
assurance are all carried out to the highest standards,
and rigorously enforced. I’m pleased to say that our
world is generally less frenetic, but strict adherence to
good practice and the principles listed above is no less
important. Moreover, there is no place for complacency
in the operating environment, whether you have one
movement a day or 1400!
issue 13 AIRSIDE OPERATIONS - HEATHROW AIRPORT 19
Air Clues
I learnt about flying
from that…
By Flt Lt P Farmer, RAF Odiham
In October 2013 I was the captain of the medical evacuation
Chinook in Afghanistan, on my seventh deployment on
Op HERRICK. During six previous tours I had the dubious
pleasure of being subjected to Surface to Air Missiles, AAA
fire, HMG, Small Arms and Mortar rounds. On numerous
occasions I had led formations on second attempts into
‘hot’ landing sites (following aborted first attempts due to
enemy fire) in order to extract ISAF troops. I (as is the case
for many Chinook crews) had previously landed on many
medevac landing sites under either enemy fire or the threat
of enemy fire. I make this point to provide an insight to
what I and the majority of Chinook crews have learnt from,
and experienced, in Afghanistan since 2006. That said, as
the campaign draws to a close the level of acceptable risk
has changed; what had previously been considered the
norm is no longer acceptable under today’s scrutiny of risk
versus reward.
20 I LEARNT ABOUT FLYING FROM THAT issue 13
During this particular sortie my crew and I did our absolute
best to save a Cat A (very seriously injured) casualty’s life
in the face of enemy fire and some difficult aircraft issues.
Every ‘risk’ was calculated and, with the information available
at the time, worth taking to save a life. If presented with
the same information as was available at the time, I would
make the same decisions again. However, with the benefit of
hindsight and the other pieces of the jigsaw that were not
available to me whilst airborne, I would have done things
very differently.
The following is an account of what happened:
Shortly after 0700 we received notification to launch on a
medevac mission. The crew ran for the aircraft and started in
good order. Halfway through the start, the co-pilot alerted
me to the fact that an element of the aircraft protection
Air Clues
During this particular sortie my
crew and I did our absolute best
to save a Cat A (very seriously
injured) casualty’s life in the face of
enemy fire and some difficult aircraft
issues. Every ‘risk’ was calculated
and, with the information available
at the time, worth taking to save a life.
system was not functioning correctly. Multiple ‘aircrew resets’
from both myself and the co-pilot failed to resolve the issue.
I quickly sought engineering advice, who reported that the
fault could not be rectified with the aircraft running.
Owing to the briefed severity of the casualty (CAT A with
head and facial injuries caused by an IED blast), I informed the
crew that we did not have time to swap to the spare aircraft
and would have to make the short trip with a degraded
aircraft protection capability at low level. This had previously
been common practice in such circumstances.
During the 150kts, 50ft transit to the pick up, one of the
radios failed, not an ideal situation with multiple ATC, ROZ
clearances, comms checks and medical information to be
passed in a very short period. Approximately 2 minutes from
the HLS the aircraft sustained small arms hits. The crewman
and I confirmed this to the rest of the crew. My immediate
action was to check that the crew were uninjured, thankfully
this was the case. Next I checked that the aircraft was flying
correctly and had the crew check all of the systems.
This
showed no apparent issues. Happy that the single round that
was heard had not affected the flying characteristics of the
aircraft, I instructed the crew to check the passengers. Again
this check had a positive outcome. My next thought was to
inform the Apache escort that we had taken small arms fire.
I elected not to call a contact because we were no longer
under effective fire.
Once safely on the HLS I instructed the crewmen to check the
outside of the aircraft, he informed me that there was a leak
from the number 2 engine but that no other damage was
obvious. The crewman advised me that the leak was minor
and a check of the engine Ts and Ps confirmed this to be the
case as both remained normal. Pressure and density altitude
were calculated and the performance figures consulted.
These showed the aircraft to be safe single engine above
32kts. Sadly, there was no option to top up the engine oil as
the ‘risbridger’ was not part of the aircraft role.
With a perceived requirement to get a critically ill patient
to hospital as quickly as possible, I briefed the crew of my
intention to load the casualty, check the engine before lifting
to a high hover, then check the engine once more before
transitioning. The transition from a high hover gave a flyaway
option to clear the Forward Operating Base and achieve
safe single engine as soon as possible or reject the transition
should a problem with the engine occur. I ensured that the
crew were briefed on the engine shutdown drill, should
it be required. I transitioned as briefed and departed to
Bastion at height with the previously defective aircraft
protection system now serviceable. The aircraft was flown
gently throughout the transit with a keen eye kept on the
engine instruments.
During the transit, JAG Ops ordered me to fly the casualty
to another airfield that would have increased the distance
flown with a damaged aircraft; I explained the circumstances
and informed them that the aircraft would be landing at
Bastion. JAG Ops then ordered me to transfer the casualty
to a US military CSAR asset for onward transportation to the
aforementioned airfield. I passed this message to the Doctor
who informed me that the casualty needed to be taken to
Bastion. In the same conversation, I asked how stable the
casualty was and explained my intention to land on the
issue 13 I LEARNT ABOUT FLYING FROM THAT 21
Air Clues
helicopter landing strip and have an ambulance meet us
there, rather than at the hospital. The Doctor was content
with this course of action. The aircraft was landed from a
precautionary running landing and the engine shut down
immediately so as to prevent engine damage caused by a lack
of oil. I can report that the casualty survived his injuries and is
alive and well - a job well done? What about the last pieces
of the jigsaw…?
Further engineering investigation showed that the engine oil
leak was not caused as a result of the enemy fire but was a
complete coincidence. The engineers did however discover
that a further round had damaged a control run in the aft
pylon and the aft vertical shaft. Subsequent considered
engineering advice was that, had the control run or aft
vertical shaft failed, the aircraft would not have been flyable,
this would have inevitably lead to the loss of the aircraft and
all 12 on board. This is a danger faced and accepted by all
operational crews, especially those with a medical evacuation
role operating in Afghanistan.
Further medical investigation showed that the casualty was in
fact stable on our arrival at the HLS and could have remained
there for 24 hours. These final two pieces of the jigsaw change
things markedly. With the casualty no longer a CAT A and in
no desperate need of hospital treatment there was no need
to risk the aircraft or crew by flying a damaged helicopter
back to Bastion.
It is absolutely not the place of aircrew to question the
medical expertise or judgement of the doctors and medics
who classify patients and, in previous tours of HERRICK, I have
never felt the need to do this. But the fact remains that on
this occasion a damaged aircraft was flown further than was
required on the incorrect premise that the patient was in a
critical condition, and, had he not been delivered to hospital
ASAP, he might have died. Clarification of the imperative to
deliver the casualty to hospital may have provided the crew
with the final, vitally important piece of the jigsaw. Hindsight
is a wonderful thing. Had we been in possession of all of the
facts the answer is obvious; shutdown and call for a spare.
Spry Says
This article not only reminds us of the very real threat crews face on operations
but the difficult decisions they are forced to make in dangerous and dynamic
situations. It is critical that all parties understand the risks involved and
Deliberate Operations utilizing rotary wing is an area where land/air integration has led
the way. Full integration of the troops and crews at all stages of the planning has allowed the
development of a plan which exposes all sides to the minimum risk possible while still achieving
the military aims. Quick response to medical shouts should be no different and this article will
be shared with Army publications to shed some light on the thought processes that will happen
in situations like this.
22 I LEARNT ABOUT FLYING FROM THAT issue 13
Air Clues
issue 13 I LEARNT ABOUT FLYING FROM THAT 23
Air Clues
Regulation 18 Mythbusting
By Wg Cdr N Severs (MAA Legal Advisor) & Col M Smith (Hd Mil AAIB)
Most of you will have heard of “Regulation 18”.1 Over the course of the last couple of
years, DG MAA has convened a number of Service Inquiries (SIs) which the MilAAIB
have assisted in. It is clear to all of us that Regulation 18 has a serious perception
problem. The aim of this article is to tackle some urban myths surrounding
Regulation 18, explaining what it is for and, perhaps more importantly, what it is
not for. It is worth nothing that Regulation 18 not only applies to aircrew, but also
ground crew. This article is obviously based on MAA experience and ways of working
in relation to the examples and procedures described, but the legal principles hold
good for ground enquiries also.
1
“Reg 18” refers to Regulation number 18 of JSP 832 (Guide to Service Inquiries) which is copied verbatim at the end of this article.
Imagine your mate is involved in an SI. Is this how the conversation would go?:
1
2
What’s up?
I’ve been Reg 18d
by the service inquiry
3
It means I’ve
been placed under
Regulation 18.
Sounds serious, but
you didn’t answer the
question, what is it?
What’s that mean?
Does that sound familiar? This is a very common perception, as inaccurate as it may be.
24 REGULATION 18 MYTHBUSTING issue 13
I’m not entirely sure.
It’s complicated.
The SI panel explained
it – some guff about
my protection – but
what they’re really
saying I reckon is that
they think the accident
was all my fault, and
they’re out to get me.
Air Clues
What we are aiming for are more conversations like this:
1
2
What’s up?
3
It means I’ve been
placed under Regulation
18.
I’ve been Reg 18d by the
service inquiry panel.
It does sound serious,
but that’s because it’s
in legal speak. It’s part
of the Armed Forces
Act, so it’s law, and it’s
Regulation number 18
at the back of the JSP,
hence the name; but
it’s about protecting
individuals not
prosecuting them.
Sounds serious, but
you didn’t answer the
question, what is it?
What’s that mean?
Really?
4
5
Yes, part of the report
talks about me, albeit I
am not named, and the
SI president is of the
view that my character
or reputation could
be impugned.
Now that sounds
painful.
6
Alright, no more legal
speak. Basically, if the
SI president thinks that
someone reading the
report might question
my character or
professional reputation,
because of what it
says, then he has to
afford me Regulation
18 protection.
“Afford” is bordering
legal speak, but I’ll let
that one go. What sort
or protection?
I get to see whatever
evidence the panel has
that relates to me or my
actions, hear what they
intend to draw from
it, add any context or
additional information
that they might have
missed, and make
formal comment.
And what do they do
with that?
issue 13 REGULATION 18 MYTHBUSTING 25
Air Clues
7
8
Respond, formally, and
reconsider where they
see fit.
What’s the boss think?
Some bits, yes. Why
wouldn’t they? Not all
though, I guess. I’ll have
my say, but at the end
of the day it’s the SI
president’s call.
26 REGULATION 18 MYTHBUSTING issue 13
What about
disciplinary action?
Is he happy for you to
continue flying?
11
I don’t reckon so. If the SI
had found evidence that I
had committed an offence,
it has to report it to the
chain of command, so I
would know about that by
now. As for admin action,
the boss has been advised
to wait until the report
is complete before he
considers it, which makes
sense. The SI is a no-blame
safety investigation, so any
disciplinary or admin action
against me would have to
compile its own evidence.
Yes, as long as I feel
fit to fly. He doesn’t
know the full detail of
why I’ve been given the
protection but he knows
that DG MAA has to tell
him if the inquiry has
found evidence that
might call into question
my ability to hold safety
critical responsibilities.
He knows about it,
the SI president has
to inform him, but
only from a “duty of
care” perspective, the
accident was unsettling
enough, and this adds to
the stress factor.
Will they?
10
9
12
Bordering on legal
speak again, mate, last
warning. So when’s the
report out then?
Not for a while. I’ll
pretty much know what
it’s going to say about
me though, and I’ll get
told when the report is
going to be published.
Once the report is
complete, I will be
formally told that Reg 18
has finished.
So all’s well then?
Maybe, but the report
might highlight things
that I could or should
have done better.
That doesn’t make it
your fault though, nor is
this all about you.
Air Clues
13
Agreed. It’s no-blame
safety investigation designed
to prevent a recurrence of
the circumstances that led to
this accident, or any accident
for that matter. The facts
might make uncomfortable
reading but you’re right – it
isn’t all about me now that
SIs look at everything, the
whole system in fact; there’re
lots of areas that the SI will
cover and I will probably be
just one of a number on
Reg 18.
Well our two friends might not like legal speak, but this
is a legal process so we can’t really avoid it! Let’s unpick
the conversation:
“It’s part of the Armed Forces Act” The power to make
regulations governing SIs derives from section 343 of the
Armed Forces Act 2006, and the regulations themselves are
contained in the Armed Forces (Service Inquiry) Regulations
2008 which is a piece of secondary legislation. You can find
the regulations and more policy on how SIs are conducted in
JSP 832 (Guide to Service Inquiries).
“The SI president is of the view that my character or
reputation could be impugned” The threshold for this is
very low, and Regulation 18 is triggered if the character/
professional reputation may be affected by the findings of the
panel. “May” is very subjective and it’s up to the president to
decide if it has been met. If you think of the criminal standard
of proof used in disciplinary offences (beyond reasonable
doubt) as being at the top of your head, the civil standard
of proof used in administrative action (on the balance of
probabilities) being around your waist, the threshold for
triggering Regulation 18 (“may be affected”) would be barely
at ankle height! Therefore, it does not necessarily mean that an
individual has done something wrong warranting disciplinary
or admin action. An individual who is subject to Regulation 18
is called a “potentially affected person” (PAP).
“What sort of protection?” The regulations permit
the PAP access to the evidence in a number of ways. The
“traditional” Regulation 18 scenario envisages witness X saying
something adverse about witness Y, and witness Y being
invited (under Regulation 18) to listen if the panel decide to
re-interview witness X and cross-examine him/her. However,
in my experience, it is increasingly rare for this scenario –
straightforward adverse comment made by one witness
about another – to arise. The move towards investigating
human factors and wider systemic/organisational factors (as
recommended by Charles Haddon-Cave QC in the Nimrod
Review) has meant that often it is only where the investigation
is nearing completion and the totality of the evidence is
being analysed that the need for Regulation 18 is firmly
established. It is the comparing and contrasting of various
witness statements against other documentary evidence
(such as regulations and orders), and other evidence gleaned
from a wide variety of sources which informs the panel’s
findings. Therefore, the need for Regulation 18 may only
become apparent after all the witnesses have been spoken to.
In such cases, the PAP will be given access to all the evidence
which has triggered the Regulation 18, and to any pertinent
draft findings.
“And what do they do with that?” Once the panel receive
the PAP’s formal response, they will consider it carefully and
make appropriate amendments to their findings. That is not
to say that all the PAP’s comments will be incorporated – it’s
the president’s call. However, the PAP’s response in toto will
become evidence in its own right and will be placed on
record with the SI evidence pack.
“What does the boss think?” Although it’s not a specific
requirement of the regulations, the president will inform the
PAP’s chain of command about Regulation 18 being engaged.
Being involved in an accident, especially a fatal one, will be a
pretty stressful experience and your chain of command have
a duty of care towards you, which includes looking after your
welfare. For all the panel know, the PAP may be having huge
domestic difficulties, with the accident and Regulation 18 just
adding to the stress. By informing them about the Regulation
18, your chain of command will be better placed to keep an
eye on you.
“Is he happy for you to continue flying?” The mere fact
that Regulation 18 has been engaged does not mean that the
individual can no longer do their job, or is not fit to fly. If DG
MAA considers that the actions of an individual present an
ongoing risk to air safety, he will inform the chain of command
of this fact quite independently of any Regulation 18 action.
The chain of command, and the PAP’s peers, must retain a
sense of proportion; ensuring that they keep an eye on the
welfare of the individual, but guarding against jumping to
any erroneous conclusions that the PAP has become a danger
to themselves and others simply because of Regulation 18.
Remember the threshold for Regulation 18 is deliberately low,
so its initiation does not “prove” anything.
issue13 REGULATION 18 MYTHBUSTING 27
Air Clues
“What about disciplinary action?” The 2008 Regulations
prevent, by law, information given to a SI from being used
against someone in disciplinary proceedings. For example, a
witness statement given to the SI cannot be handed to the
police and used to sustain a charge under the Armed Forces
Act 2006. However, if the panel do come across information
which it believes could point towards an offence having been
committed they will have to consider very carefully whether
to report this to an individual’s CO. We are all striving towards
a just culture in aviation, and we recognise it is neither
beneficial nor appropriate to report (for disciplinary purposes)
each and every misdemeanour. However, if the panel believe
the actions of an individual have “crossed the red line”, they
are to report it to the CO. Once the CO becomes aware of a
potential offence, he must (in accordance with the Armed
Forces Act) investigate it. Whether he tasks the police or not is
a matter for him, not the SI or the MAA. If the police become
involved, they must gather their own evidence iaw their
strict legal procedures. The decision on whether to charge an
individual with an offence is a matter for the CO; the MAA has
no powers of discipline. The CO will take his own independent
legal advice on this – it’s standard chain of command
business. Once the chain of command has received a copy
of the SI report, it may decide to initiate administrative action
for, say, professional failings. There is nothing in law to prevent
the chain of command from basing its decision to raise a
QR1027 report (RAF admin action, or other single service
equivalent) upon the content of the SI but it must then gather
its own evidence and follow the process set down in QR
1027 (or equivalent). Again, remember that the threshold for
Regulation 18 is very low and is way below the standard of
proof required in disciplinary (beyond reasonable doubt) or
administrative (balance of probabilities) proceedings, so the
mere fact that Regulation 18 is in place does not necessarily
mean that disciplinary/administrative action is warranted, nor
should Regulation 18 be seen as an automatic pre-cursor to
such action.
“So when’s the report out then?”In a non-fatal accident,
the SI will be published on the MOD internet pretty soon
after completion, having been suitably redacted for the
public domain. The chain of command will see it slightly in
advance of that, to enable the immediate progression of any
recommendations made. With a fatal accident, there may be
a Coroner’s inquest or Fatal Accident Inquiry (in Scotland),
and MOD policy is to wait until those processes are complete
before publishing in the public domain (although NoK will
receive a copy prior to the inquest/FAI and the chain of
command will have a copy to enable recommendations to
be progressed).
“It’s a no blame safety investigation” One of the areas
we must work very hard on is ensuring that the report does
not explicitly attribute blame, as we are required to by the
Regulations. Whilst we can and do ensure that there is no
28 REGULATION 18 MYTHBUSTING issue 13
explicit blame attributed, it can be difficult to avoid the
inference of blame especially where the SI finds that human
factors played a significant part; quite often the facts will speak
for themselves and an element of culpability may be inferred.
In such cases, the individual would be made a PAP and given
access to the report in accordance with Regulation 18. I stress
again that initiating Regulation 18 in this situation does not
mean that action by the chain of command is automatically
justified; the fact that the panel believed the PAP could/should
have done things a bit better does not necessarily amount to
a professional failing warranting further action.
So, next time you hear about Regulation 18, remember:
•• It is a legal requirement for the panel;
•• It is a legal entitlement for the individual;
•• It is not a precursor to disciplinary or administrative action.
The SI process needs YOUR help to ensure that it is kept
in perspective, noting that:
•• It does not mean that the individual has done
something wrong;
•• It does not mean that disciplinary or administrative
action is needed;
•• It does not mean that the individual is not fit to fly
or perform their job.
If individuals who are PAPs, their peers and the chain
of command at all levels understand the drivers and
requirements for Regulation 18, and ensure that their
response is proportionate and supportive, we may start
to chip away at the perception and misconception that
surrounds it.
Regulation 18 from JSP 832
Persons entitled to attend
1.Subject to paragraph (2), a potentially affected person shall
be entitled to be present at the proceedings of a service
inquiry panel.
2.A potentially affected person’s entitlement under
paragraph (1) shall be subject to such conditions and
exclusions as the president, after consulting the convening
authority, may reasonably impose from time to time. Such
exclusions may
a.include an exclusion from being present at such part of the
proceedings of the panel as the president may specify; and
b.be imposed before or at any time during the proceedings of
the panel.
3.Where under paragraph (1) a potentially affected person
is entitled to be present at any part of the proceedings of
the panel.
Air Clues
a.he may be represented at that part by a legal representative
or, with the consent of the president, he may be
represented by a person other than a legal representative;
b.he may give evidence, question witnesses or produce
any witness to give evidence, in each case as to any other
matter as to which, in the opinion of the president, the
potentially affected person may be affected in relation to
his character or professional reputation by the findings of
the panel;
c.where he is represented, his representative may question
witnesses and may, with the permission of the president,
address the panel; and
d.the president shall provide him with a copy of any part of
the record of the proceedings of the panel, if the president
considers it appropriate to do so.
Spry Says
All too frequently, at venues such as
the Flying Supervisors’ Course, I hear
the same questions arising about Reg
18 and I hope that this simple article puts
these common concerns into perspective. Reg 18
shouldn’t instil a paranoia that “this is a witch-hunt”,
and “they’re out to get you” - the default reaction
should be that Reg 18 is giving you extra input into
the Service Inquiry so that you get sight of what is
being investigated and can comment accordingly.
As with all culture-shifts, removing any perceived
stigma about Reg 18 will take time, but this excellent
article should help speed up that process.
4. In this regulation “potentially affected person” means a
person who in the opinion of the president may be affected
in relation to his character or professional reputation by the
findings of the panel.
issue 13 REGULATION 18 MYTHBUSTING 29
Air Clues
Real people, helping real people. Every day.
Imagine losing your leg. Imagine losing your sight. Now imagine, on top of that,
losing your job. That happens. And when it does, we’re there to relieve some of
the financial hardship that follows.
Supporting fallen heroes is not our day job; we volunteer to make life easier for
the people who serve our country. Can you volunteer too?
See our website for more info: www.soldieringon.org.
www.soldieringon.org
Air Clues
Awards
2012 LG Groves Memorial Awards
The LG Groves Memorial Award Ceremony was recently held at the Royal Navy Historic Flight, RNAS Yeovilton. The LG Groves
Memorial Awards were established in 1946 by Major Keith Groves and Mrs Groves in memory of their son, the late Sergeant
(Meteorological Air Observer) Louis Grimble Groves RAFVR, who lost his life on a meteorological sortie in September 1945.
The Awards are open to personnel from the Meteorological Office, Royal Navy, Army and Royal Air Force and their civilian
support staff. Following a fruitful trawl for nominations in Spring 2013, the selection committee had the difficult job of selecting
winners from a highly competitive field, itself an indication of the importance that the Met Office and each Service place on
Air Safety. In the end there were winners from the Met Office, Army and Royal Air Force which, when combined with the location
of the award ceremony, ensured that each Service was signified in some way to the representatives of the Groves family who
attended the awards in the atmospheric setting of the Royal Navy Historic Flight hangar.
LG Groves Memorial Awards Information
The aims of the scheme are:
1.To encourage the study of the problems of the
safety of aircraft and flying personnel.
2.To stimulate research in the science of meteorology
to aviation.
3.To recognize good work by personnel engaged
in meteorological observer duties, or other
duties relating to meteorology and in operational
meteorology.
There are 4 categories of Award:
•• Air Safety Prize. For the most important contribution
made during the previous year towards improving the
safety of personnel or aircraft in flight, or enhancing the
survival of aircrew.
•• Ground Safety Award. For the most important
contribution made during the previous year towards
improving the safety of personnel, aircraft or equipment
on the ground, either at a flying station or at an associated
unit elsewhere.
LG Groves Memorial Prize for
Ground Safety, for the most important
contribution made during the
previous year towards improving the
safety of personnel, aircraft or equipment
on the ground, either at a flying station or
at an associated unit, was awarded to 47 Air
Despatch Squadron, Royal Logistic Corps. 47
Air Despatch Squadron moved to RAF Brize
Norton in 2011 and undertook significant work
to integrate with their new parent station’s Air
Safety organization and develop a positive
safety culture.
•• Meteorology Prize. For important contributions to the
science of meteorology, the application of meteorology to
aviation or operational meteorology either by practical work
or by the publication of scientific papers.
•• Meteorological Observation Award. For outstanding work
in the field of meteorological observation, particularly where
flying duties or service at sea are involved.
The prizes/awards range from £500 - £1000, with an award
ceremony in September. Nominations should be sent to the
email addresses detailed below:
Air Safety Prize & Ground Safety Award: Submit to
Sqn Ldr Doug Fowler ACAS-RTSARW1SO2@mod.uk
Meteorology Prize & Meteorology Observation Award:
Submit to Miss Pip Gilbert pip.gilbert@metoffice.gov.uk
Further information can be found in GAI 1047.
Please note that the deadline for this years nominations
was 1 March 2014 however please keep this information
in mind for future nominations.
LG Groves Memorial Prize
for Meteorology, for important
contributions to the science of
meteorology, was awarded to Professor
Adam A. Scaife for his research into the
North Atlantic Oscillation. The North Atlantic
Oscillation dominates the winter climate over
Europe, the eastern USA and Canada; Professor
Scaife’s work has lead to major breakthroughs
and key insights into the future climate of the
UK and Europe.
(Photo - Professor John Mitchell, Principle Research Fellow,
pictured with the Met Office winners)
issue 13 AWARDS 31
Air Clues
LG Groves Memorial Award for
Air Safety, for the most important
contribution made during the previous
year towards improving the safety of
personnel or aircraft in flight, or enhancing
the survival of aircrew, was awarded
to Warrant Officer Peter Woodward.
Warrant Officer Woodward was the Parachute
Jump Instructor SME within the RAF Brize
Norton Duty Holder Support Cell and was
tireless in his work to ensure that military
parachuting is as safe as possible and the risks
allied to military parachuting are understood,
managed and mitigated as far as possible.
(Photo - Warrant Officer Peter Woodward pictured with Air
Commodore David Lee, Air Officer Air Mobility)
LG Groves Memorial Award for
Meteorological Observation, for
outstanding work in the field of
meteorological observation, particularly
where flying duties or service at sea are
involved, was awarded to Doctor Pete Francis
for his important contributions in the field
of exploiting satellite imagery for weather
forecasting and hazard monitoring.
Among the many products he has developed,
he led an effort in 2010, following the
eruption of Eyjafjallajokull in Iceland, to derive
quantitative data from satellite imagery to
support the advice issued to the London
Volcanic Ash Advisory Centre.
More Flight Safety Awards…
SAC(T) Aistrop
On the morning of Monday the 9th
September 2013 SAC(T) Aistrop
was tasked with supporting the flying
programme and was on the Southern HAS
site when he noticed that a Typhoon aircraft
had its nose wheel bay door pushed against
the nose landing gear leg. On approaching
the aircraft he noticed that a small bolt shaft
was protruding from the underside. On closer
inspection the bolt was observed to be caught
in the hinge line of a closed circuit breaker
panel bay. SAC(T) Aistrop, immediately
realising the seriousness of his discovery,
informed the Rectification Controller
who removed the aircraft from the flying
programme and instigated a full investigation.
SAC(T) Aistrop’s attention to the detail is
always exemplary, but on this morning his
actions far exceeded what would normally
have been expected and these actions
prevented a serious Flight Safety hazard
from developing. For his diligence, attention
to detail and subsequent actions, SAC(T)
Aistrop is awarded this AOC No1 Gp Safety
Commendation.
32 AWARDS issue13
Mr Powell
Mr Powell was the Aircraft Handler
responsible for supervising the start on
a Squirrel helicopter at Shawbury on
03 Jul 13. This was one of many starts he
supervised that day. This sortie was a ‘starts
and stops’ sortie for a CFS(H) student QHI with
a staff QHI supervising. When the aircraft was
started for the second time, Mr Powell was
cleared under the disk to complete a
routine leak check when he noticed that
the lower main servo mount nut was loose.
He immediately sought an engineer’s advice
and the aircraft was shut down. The lower
main servo mount on the Squirrel is located
on the side of the main gearbox and with the
panels closed for start is very difficult to see.
Mr Powell’s meticulous attention to detail to
spot something out of place was incredible.
The Flight Safety implications of servo jack
becoming detached in flight are extremely
serious as it would have resulted in the loss of
the aircraft and crew. Through his diligence
and conscientiousness Mr Powell prevented
a potentially catastrophic accident and was
presented with a Flight Safety award.
Air Clues
Report today for a
safer tomorrow
By Sqn Ldr Tony McLoughlin, SO2 AEMS, RAF Safety Centre
DAEMS reporting
The Defence Aviation Error Management System (DAEMS)
- what does it actually mean to you? It is not merely an IT
system, but, rather, a combination of policies, processes
and tools for reporting and analysing errors and near misses
in Defence aviation. The actual tool it uses is the existing
Aviation Safety Information Management System (ASIMS),
which is a computer-based reporting system, database and
analysis tool. The more Air Safety information that is stored
in ASIMS, the more effective the system is, so it is essential
that everybody reports any aviation related event, issue or
occurrence – this is known as a “Reporting Culture”.
Everybody who experiences an accident, incident or near-miss
must therefore ensure that they report it and, if it is related to
Air Safety, capture it on ASIMS; there are 2 ways of doing this:
**Raise a hand-written Aviation Error Management
System (AEMS) form, which is probably the only
method available to you if you don’t have easy access
to ASIMS.
or **Raise a Defence Aviation System Occurrence Report
(DASOR) directly into ASIMS.
Occasionally, the individual might not be sure if the incident
is aviation related; in these circumstances, submit an AEMS
anyway, as it will be passed to trained specialists who can
determine whether it is Air Safety-related or would be
more appropriately dealt with under the headings of
Health & Safety or Quality Assurance. In these last
two cases, they will pass the report to the appropriate
departments to deal with using their own systems.
issue 13 REPORT TODAY FOR A SAFER TOMORROW 33
Air Clues
Determine root cause
We need to find out why accidents, incidents and
near-misses happen, so we can prevent their re-occurrence.
Having reported the event, there may be a requirement
to conduct an investigation to determine the root cause.
If required, these investigations will be conducted by staff
specifically trained not only to determine the root cause, but
also to identify any contributory factors and make effective
recommendations to prevent reoccurrence.
Just Culture
The primary aim of reporting and investigating these events
is to learn from them and prevent them reoccurring; this
will only happen if our people are freely willing to submit
their reports, and fully appreciate that, by doing so, they are
contributing to improving safety. To create this Reporting
Culture all personnel need to be certain that the process
focuses on understanding behaviour and the drivers behind
people or organisations operating in ways which could
compromise Air Safety. In addition, we are also a Just
Culture, ie we recognise that humans make mistakes –
this should not be misinterpreted as a “No-Blame” culture.
The RAF’s Just Culture policy is explained in AP 8000, as is
the FAIR (an abbreviation of Flowchart Analysis of
Investigation Results) tool, which is copied below.
The investigators will look at Human Factors, including how
the behaviour of people or organisations which led to the
issue or occurrence, was influenced. However, it must be
emphasised that we will never tolerate reckless conduct
and when proven, appropriate action will be taken, as
depicted below.
Regional Air Safety Teams
The RAF Safety Centre has 3 regional teams of full-time
investigators which are there to support units and/or
Unit SEMSCOs within their region. As well as providing
support for investigations they support Occurrence
Review Groups (ORG ) and provide advice on policy
and how to get the most out of your EMS.
FAIR (Flowchart Analysis of Investigation Results) System
START
Was there a conscious
and unjustifiable
disregard for risk?
Was there
malicious intent?
Yes
Yes
Sabotage or
attempted sabotage
No
No
Recklessness
Were rules
intentionally broken?
Could the task have
been done in
accordance with
the rules
Yes
Yes
Was the action to
the benefit of the
organisation
No
No
Was a correct plan of
action selected?
Yes
No
Error
Rule-breaking for
personal gain
No
Was the situation
outside normal practice?
Mistake
34 REPORT TODAY FOR A SAFER TOMORROW issue 13
Yes
Exceptional
rule-breaking
Yes
Rule-breaking for
organisational gain
Air Clues
Spry Says
Aviation is complex and
people will make errors and
mistakes. In many cases the
‘system’ sets you up to fail, for
reasons such as poor procedures, time pressures
and lack of equipment. Reporting these issues
makes management aware and puts ownership
of the risk back at the right level. The RAF
Just Culture policy ensures that people who
make errors are treated fairly and that the
circumstances and pressures are understood.
This should encourage all of us to report
both our errors and the everyday issues that
make doing our job safely more difficult.
Ultimately, AEMS is generating a genuine
culture change within the RAF, so, whatever the
concern, report it and let’s make that change.
Northern Regional Team
RAF Leeming
REMSCO
Flt Sgt Rob McCormack (Des) - 95851 TBD
Flt Sgt Gordon Cooke - 95851 7230
RAF Lossiemouth
Flt Lt Mick Letch - 95161 7608
Chf Tech Steve Valentine - 95161 8820
Midland Regional Team
RAF Cranwell
REMSCO WO Martyn Bayley - 95751 6859
Flt Lt Graham Bruce - 95751 6989
Flt Lt Mick Lismore - 95751 6679
Flt Sgt Jules Harrison - 95237 7087
Flt Sgt Ralph Winstanley - 95751 6863
Chf Tech Si Birkwood - 95751 6680
Chf Tech Hugh Shaw - 95751 6679
Southern Regional Team
RAF Halton
REMSCO WO Steve Coleman - 95237 7091
Flt Lt John Wright - 95327 6583
Flt Sgt Steve Bevan - 95237 7127
Chf Tech Dave Edwards - 95237 7087
Sgt Michael Fletcher - 95237 7047
RAF Safety Centre Regional Error Management teams
Unintended Action
Unintended Consequence
Intended Action
Unintended Consequence
Situational
rule-breaking
Intended Action
Intended Consequence
Rule breaking
for personal gain
Exceptional
rule-breaking
Error
Mistake
Rule breaking for
organisational gain
Recklessness
Increasing
Assess
No Culpability
Sabotage
Culpability
The tests applied to determine level of capability:
1.Substitution Test: Would another ordinary person with the same competence, education,
training and experience behave in the same way under the same circumstances (time, goal
demands, organisational context?
2.Routine test: Does this happen often to 1. the individual 2. the organisation?
Proportionality Test: If culpability is evident, the proportionality test is applied to determine the
safety value of administrative disciplinary action.
Manage
Managed by improving performance influencing factors: person, task,
situation and environment. In some cases, dependant on the outcome of the
above tests, administrative disciplinary action may be necessary.
Likelihood that administrative or
disciplinary measures will be appropriate.
The improvement of performance
influencing factors should remain
a consideration.
issue 13 REPORT TODAY FOR A SAFER TOMORROW 35
Air Clues
Aberporth
Danger Area
Complex
EGD201
and EGD202
Things go whizz and bang
in here!D202
By Mr J Beckett, Air Traffic Control Officer, MOD Aberporth Range
MOD Aberporth is a busy, fully instrumented, weapons test
and evaluation range. The Range’s Danger Area Complexes
(EGD201 A-E and EGD202 A-C) are established over some
6,500km2 of Cardigan Bay from sea level to unlimited height
and overland from the western edge of the Sennybridge
Range (EGD203) westwards to the west coast of Wales.
These areas are no doubt familiar to most aviators as they
are published and feature on all airspace charts.
The Range has been in existence since 1939 and it is currently
operated by QinetiQ on behalf of UK MOD under what is
known as the Long Term Partnering Agreement (LTPA).
36 ABERPORTH DANGER AREA COMPLEX issue 13
The purpose of the LTPA is to deliver defence test, evaluation
and training support services to ensure air launched weapon
systems, associated sub-systems and UAVs are safe and fit for
purpose. More information can be found on the LTPA website
(www.ltpa.co.uk).
National Air Traffic Services (NATS) Ltd. is contracted to
QinetiQ for the provision of all Air Traffic Control Services
within these Danger Areas and ATSOCAS (Air Traffic Services
Outside Controlled AirSpace) in the adjacent class G airspace.
Aberporth Air Traffic Control (ATC) provides a Danger Area
Activity Information Service (DAAIS) and Danger Area Crossing
Air Clues
Use of Airspace”. This changed the way in which the danger
area activity was promulgated. Before it was notified as
permanently active, nowadays activity is subject to daily
NOTAM action and disseminated accordingly to all airspace
users. Generally it is open 0900-1600 local time Mon-Fri, but
checking your NOTAMs is still vitally important as these hours
do change depending on the trials being carried out.
Danger area activity is sometimes termed in several different
ways, at Aberporth we use the standard terms of “Active” and
“Not Active”. Active means that the danger area is currently up
and running, with ATS personnel available for a DACS, DAAIS
or ATSOCAS. Not Active means that the airspace is available
and ATS, DAAIS or DACS may be available.
Infringements
These are still one of our biggest safety concerns and
preventing them remains at the forefront of the Range
Operators’ priorities. Infringements do have a significant
impact on our operations and we continue to try to reduce
the number, year on year.
Within the last 12 months, the Range has reported 16
infringements; this figure does not include the potential
infringements that we prevented using the techniques
described below.
Photograph © Geoffrey Lee, Plane Focus ltd
Service (DACS) coupled with an ATSOCAS when open. Air
Traffic Controllers are therefore licenced by both the MAA
(Military Aviation Authority) and the CAA (Civil Aviation
Authority). Working closely with other ATC radar service units,
NATS Aberporth provide ATC services to Civil and Military
Aircraft, and, within the Range, a bespoke service to multiple
aircraft, various types of UAVs and even surface vessels.
This bespoke service enables the Range
to operate air-to-air, air-to-surface,
surface-to-air and surface-to-surface
weapons testing and evaluation in
a safe and highly controlled environment.
NATS can also provide
other non-Range
airspace users with
ATSOCAS over most
of Wales, outside any
Controlled Airspace.
Recently (late 2012), D201 Complex
and its little brother (D202 complex) became
involved with the now familiar phase of, “Flexible
Unfortunately, we can’t reduce this number alone, we do
need airspace users to work with us to be mindful of the
potential impact that infringements may have and to consider
different ways of operating their aircraft close to the danger
area boundaries.
So how do we prevent infringements?
Range Air Traffic Controllers actively monitor the Range
boundaries during NOTAM’d periods of activity and by
using proactive and defensive controlling techniques; they
try to prevent infringements before they ever become actual
reportable events. We also actively promote the danger areas
in the wider aviation community, through safety evenings
and seminars around the local flying clubs and aerodromes,
whose operations are adjacent to, or within, our operating
areas. During these visits we actively pass on information to
occasional airspace users, who find the information adds to
their flying knowledge. For pilots who operate within our
operational area, we would expect them to be aware of
the danger area complexes though comprehensive flight
briefing, being aware of their exact position
at all times and requesting an ATSOCAS
service from an appropriate radar unit.
However, this isn’t always the case, as historic
data shows that even with GPS systems,
37
Air Clues
navigation software, and provision of radar ATSOCAS available,
pilots (both Military and Civil) are unfortunately still infringing
the danger areas.
The team at Aberporth are always keen to promote the
ATSOCAS that they can provide around the danger area
complexes boundaries and encourage any pilot to call for a
service, even if it is just to let Aberporth know that they are
operating in the area.
We would encourage all pilots to routinely call, as the
whole of Wales can be very busy with military low level
traffic and we can advise if any traffic is near their intended
flight path. When planning a route close to our danger
area boundaries, please don’t hesitate to call ahead to
discuss with ATC your plans. The number for Aberporth is
listed below.
What happens when an aircraft
infringes an active danger area?
Mandatory reporting action is carried out for all danger area
infringements and these events are thoroughly investigated.
Any recommendations will be acted upon in a timely manner.
In the event that an infringement does occur during a live
firing trial, Aberporth range controller immediately carry out
stringent safety “Stop Actions”, to ensure that the trial is made
safe. The trial team have to reset the trial in order to achieve its
objectives. This could involve vectoring the fighter and target
or it could involve aborting the trial because of aircraft fuel
constraints. This impacts both financially and operationally on
trials which are critical to the UK MOD.
Crossing the Danger Area
Can you cross an active danger area?
The danger area can be crossed when there is no trial activity
or when specific non-firing trial activity is taking place.
Depending on the nature of the Range activity, it may be
possible to allow aircraft to cross or enter the danger areas.
Each aircraft will be advised when the request to enter or
cross is made.
The crossing aircraft will have to be positively identified and
provided with an Air Traffic Service before a crossing clearance
will be issued. This clearance may also be requested from
another Air Traffic Control Radar Unit (ATCRU) e.g. RAF Valley
or London Military.
Outside any trial activity the DA may well still be classed as
“Active”, this means that the danger area is open but trials are
not taking place. A Range Air Controller will always be present
38 ABERPORTH DANGER AREA COMPLEX issue 13
whenever any part of the Ranges is notified as active and can
provide a DACS, DAAIS or ATSOCAS.
Summing up
We hope you have found this short article interesting and
that it has enhanced your knowledge of our operations within
D201/202, along with the impact that any infringement has
on it, has increased. We do hope that the next time you’re
flying over Wales; you take into consideration the services
available from the Range Air Traffic Controllers at Aberporth.
We will be happy to hear from you.
Contact details when planning a trip:
“Aberporth Radar” ATSOCAS Frequency VHF 119.65 MHz
or UHF 338.925 MHz
Aberporth Range Air Control 01239 813219
www.nats.co.uk | www.aberporth.qinetiq.com | General
enquiries: abeenquiries@qinetiq.com
Air Clues
Spry Says
This article provides
some useful information
with regard to air
operations in and around
D201/202. Previously strictly
off limits, the area is no longer a permanent
no-go area, however, all aviators are
reminded to make use of the comprehensive
radar service that is provided by Aberporth
ATC and they are encouraged to use the
range airspace when it is available.
issue 13 ABERPORTH DANGER AREA COMPLEX 39
Air Clues
Feedback…
tell us what you think about Air Clues
New Message
To: Air-Flt Safety Wg Cdr Spry
CC:
Subject: Stuffy nose
My dear Wg Cdr Spry,
I recently found myself on the receiving end of a mild cold, thoughtfully brought home to me by
my three year old daughter via her play group. Now, I was only slightly snotty and bunged and
could clear my ears without difficulty. I had to fly, for several reasons, and considered buying some
decongestants from the local chemist. Remembering the article on self-medication in the Summer
2012 issue of Airclues and having just read your recent Air Safety Matters, I thought better of it.
My question is, why are we so concerned about these widely used medications? It seems as if
everyone but aviators takes cold medicines.
Yours truly,
Flt Lt Stuffy Nostril
40 FEEDBACK issue 13
Air Clues
New Message
To:
Airclues Reader
CC:
Subject: RE: Stuffy nose
Let me repeat the response from our medical
experts when asked about taking over-thecounter medications:
Firstly, what is causing you to ask whether you
should take these meds? If you are ill enough to
want “something to help”, you are ill enough to
consult your aviation medicine trained doctor
prior to flying. This is for two reasons - to discuss
the flight safety aspects of the illness, as well as
any possible medical treatment for it.
Over-the-counter medications are considered
“verboten” to aircrew primarily due to two
types of side effects - commonly expected
and idiosyncratic. The first are those listed on
the labels and are self-explanatory; the more
worrisome are idiosyncratic – they are rare and
completely unpredictable. Whereas thousands
of people may take ColdCure “X” safely, a few
people will have unusual, and potentially
severe, side effects. This could be you, and it
could happen either when you take the first
dose or when you take subsequent doses, even
after having taken it successfully on previous
occasions. These are the reasons why the rules
on self-medication have been around so long.
Let me stress that my recent Air Safety Matters
wasn’t saying anything new – self-medication
has always been discouraged. The trouble
is, when a Coroner at an inquest into a fatal
accident questions our rules, as happened
recently, we have got to be clear – unless we
can be specific about the timescales for taking
self-medication, then the ban on them must be
interpreted as total. Such clarity was recently
asked of us by HM Coroner as these timescales
were not clear, hence my Air Safety Matters.
However, I have gone back to CAM and
discussed this topic further. They are content
that ‘not within 24 hrs of reporting for flying
duties’ is a realistic time-limit for the taking
of over-the-counter medications; the medics
consider that any potentially adverse side-effects
will be out of your system after 24 hours.
That is why by the time you read this, I will have
issued guidance to the Groups which directs
that aircrew should not use over-the-counter
medicines, drugs tablets or remedies within
24 hours of reporting for flying duties, unless
prescribed by a MAME. I have been reliably
informed that this advice will be seen in MAA
Regs by this summer.
So those of you who feel the need for an aspirin
on a Saturday morning after Friday night’s Happy
Hour won’t need to see the doc if you’re not at
work until Monday! Similarly, if you’re crippled
with “man-flu”, you can take B**chams or
Lem-S*p, but if you do so within 24 hrs of
reporting for flying, then you need to take
yourself off the fly-pro (then again, wasn’t that
always “best-practise”? – ie “Colds and flying
don’t mix”). However, if you know that you’re not
reporting for flying for over 24 hrs, crack on and
dose yourself up!
That said, my stance also remains aligned with
the current regulations, in that self-medication
is simply a very bad idea on several accounts.
It is an issue which has been raised in many
recent Service Inquiries. If you are ill, visit your
friendly doctor in the Station Medical Centre and
discuss the situation, even if the illness seems
relatively minor. The risk of side effects adversely
affecting safety of flight is real and significant.
There may be more things going on medically
than you appreciate, which the good doctor
might discover before he discusses medications.
However, if you feel compelled to self-medicate
and are within 24 hrs of reporting for flying
duties, do NOT do so if you wish to remain on
the fly-pro, unless the medications have been
cleared by a MAME.
Spry
issue 13 feedback 41
Air Clues
Military Aviation
Authority (MAA)
Air Safety Courses
Air Safety training assists in mitigation of Risk of Life. It increases safety awareness
and supports the establishment and maintanance of an Air Safety culture.
The following courses are held at the Centre of Air Safety Trg, Defence Academy of
the UK, Shrivenham. If you wish to apply for a course, email MAA-Courses@mod.uk
Further in formation can be found at
http://defenceintranet.diif.r.mil.uk/Organisations/Orgs/HOCS/Organisations/Orgs/MAA/Pages/MAACentreofAirSafety
Training.aspx
or http://www.maa.mod.uk/training/index.htm
Training Contacts:
For courses based at Shrivenham contact the MAA Centre of Air Safety Training (CoAST) email: MAA-Courses@mod.uk
For courses based at Cranwell contact Human Factors Admin on +44 (0)1400 268190
International Defence Training on +44 (0) 1296 656 162
Duty Holders Air Safety Course - DHASC
Course Aim
Duration
The DHASC aims to improve Defence Air Safety by
ensuring that DHs are fully conversant with their role
and responsibilities in the safe management of
Defence aviation.
2 days
Validity: 5 years further details in RA1440 at http://www.
maa.mod.uk/regulation/index.htm
Outline of Syllabus
Course dates
The course is aimed at Operational Duty Holders (ODHs)
and Delivery Duty Holders (DDHs) but will be of value
to Senior Duty Holders (SDHs), Senior Operators (SOs)
and Chief Air Engineers (CAEs). Personnel filling other
senior engineering or operational posts may apply.
Related regulatory documents can be found on the MAA
intranet site.
••
••
••
••
42 MILITARY AVIATION AUTHORITY AIR SAFETY COURSES issue 13
10: 1-2 May 14
11: 3-4 Jul 14
12: 22-23 Sep 14
13: 3-4 Dec 14
For more information please call +44 (0) 1793 314183
Air Clues
Flying Supervisors’ Course - FSC
Course Aim
Duration
To prepare flying unit executives for their forthcoming
flying supervisory roles.
3.5 days
Validity: 5 years further details in RA1440 at http://www.
maa.mod.uk/regulation/index.htm
Outline of Syllabus
The course is aimed at Sqn Cdrs and Flt Cdrs of OF3
rank and above who are appointed to flying posts.
Applications are also welcomed from senior engineering
and air traffic control officers. Suitably experienced junior
officers may also apply although justification from their
commanding officer will be necessary.
Contractors and overseas applicants are to apply through
International Defence Training.
Course dates
••
••
••
••
••
••
373: 19-22 May 14
375: 14-17 Jul 14
376: 15-18 Sep 14
377: 13-16 Oct 14
378: 17-20 Nov 14
379: 01-04 Dec 14
For more information please call +44 (0) 1793 314183
Flying Authorisers’ Course - FLAC
Course Aim
To prepare Junior Officer (JO) and SNCO aircrew for their
duties as flying authorisers and junior supervisors.
Outline of Syllabus
Validity: 5 years further details in RA1440 at http://www.
maa.mod.uk/regulation/index.htm
Course dates
Contractors and overseas applicants are to apply through
International Defence Training.
••
••
••
••
••
••
Duration
For more information please call +44 (0) 1793 314183
This course is only for JO and SNCO aircrew who have
been selected to become flying authorisers.
284: 22-24 Apr 14
285: 24-26 Jun 14
286: 22-24 Jul 14
287: 02-04 Sep 14
288: 21-23 Oct 14
289: 25-27 Nov 14
3 days
Flight Safety Officers’ Course - FSOC
Duration
Course Aim
4.5 days
Validity: 5 years further details in RA1440 at http://www.
maa.mod.uk/regulation/index.htm
To prepare individuals to carry out the duties of the Stn
and Unit Flight Safety Officer.
Outline of Syllabus
Applicants should be appointed to Flight Safety
related posts.
Contractors and overseas applicants are to apply through
International Defence Training.
Course dates
••
••
••
••
••
241: 12-16 May 14
243: 07-11 Jul 14
244: 08-12 Sep 14
245: 06-10 Oct 14
289: 25-27 Nov 14
For more information please call +44 (0) 1793 314183
issue 13 MILITARY AVIATION AUTHORITY AIR SAFETY COURSES 43
Air Clues
Post-Crash Management Incident
Officers’ Course - PCMIOC
Course Aim
Course dates
To train military personnel and MOD civilian or contracted
personnel who have been designated to fulfil the role of
Post Crash Management Incident Officer (PCMIO) in the UK.
••
••
••
••
••
Outline of Syllabus
The PCMIOC is not pre-employment training for Theatre
personnel, although the core skills covered will provide
a solid base for PCM duties overseas. The course also
provides essential information for those who will be
exercising command and control of PCMIOs. Personnel not
designated to fulfil PCMIO duties are to provide additional
justification (on the application form), for their attendance
on this course.
114: 08-09 May 14
115: 05-06 Jun 14
116: 01-02 Jul 14
117: 05-06 Aug 14
118: 23-24 Sep 14
For more information please call +44 (0)1793 314178
Non UK PCM
Personnel who are required to fulfil PCMIO duties outside
of UK, not at a PJOB, should contact MAA-MAAIB-PCM@
mod.uk for a briefing.
Contractors and overseas applicants are to apply through
International Defence Training.
Duration
1.5 days
Propulsion Integrity Course – PIC
Course Aim
The Propulsion Integrity Course (PIC) provides Officers,
SNCOs and MOD civilians from the PTs engine EAs
community with a more in-depth understanding of the
principles of gas-turbine aero-engine regulation and lifing
aspects of propulsion integrity.
Outline of Syllabus
Lectures are provided during the course by representatives
from the MAA, DE&S, DSAE and Rolls-Royce plc.
Topics covered include life management plans, critical and
non-critical components, materials and failure mechanisms,
damage under complex loading, lifing statistics, fatigue
testing and service samples, health and usage monitoring,
exchange rate calculation, safety and risk management,
and future policy.
44 MILITARY AVIATION AUTHORITY AIR SAFETY COURSES issue 13
Duration
3 days
For course dates please check the MAA website or contact
+44 (0)3067 984325
Air Clues
Aircraft Structural Integrity Course - ASIC
Course Aim
Entry Requirements
To provide a synopsis of the latest available information
on aircraft structural integrity (SI) matters. This course
is primarily suited to military officers, Senior Non
Commissioned Officers and civil servants, serving as Project
Engineers, airframe/structures engineers or fleet managers.
Officers, SNCOs and civilians posted to the following
appointments are eligible to attend the course. DE&S PT
Project Engineers, Fleet Managers and Engineers in airframe/
structures posts who have responsibility for structural
integrity or aircraft engineering. RN, Army and RAF Air Staff
at Command or Group Headquarters. Station, Unit and
Squadron Engineering appointments. Staff in Flight Safety
Appointments. Appointees involved with fatigue budgeting,
processing and analysis. Appropriate staff from within the
Defence Support Group (DSG). DSTL and QinetiQ staff with
airworthiness responsibilities. Invited Design Authority
representatives. Up to 70 students will be selected from
nominations submitted to the course sponsor.
Outline of Syllabus
Structural issues, such as fatigue and ageing aircraft, are now
the limiting factors that determine the life of many aircraft
and major aero engine components. Other factors such as
corrosion, also have a significant impact on aircraft structural
integrity. The understanding of fatigue has improved over
recent years, as have techniques used in structural testing,
inspection and monitoring. The ASIC is designed to update
Officers and civil servants on the latest developments
relating to structural integrity issues and to highlight the
importance of effective structural integrity management.
The course material is delivered by specialists from the UK
MOD, QinetiQ and industry and addresses the following
subjects: An Introduction to Structural Integrity; Theory of
Fatigue; Structural Airworthiness Requirements for Fatigue
Design; Generic Helicopter HUMS; A Design Authority
Perspective on Helicopter Fatigue and Qualification;
Helicopter Structural Integrity; Corrosion and Corrosion
Protection; Composite Materials. In-Service Fatigue
Management; Ageing Aircraft and Sampling Programmes;
Non-Destructive Testing for UK Military Aerosystems and
Equipment; Aircraft Repair.
Places may also be available on this course to officers
from overseas military forces who meet the criteria above.
Where English is not the first language, students must pass
written and spoken English language tests and achieve
a minimum score of 5.5 in each part of the International
English Language Test System (IELTS) before being accepted
for training.
Duration
2.5 days
Course dates
118: 23-24 Sep 14
For course dates please check the MAA website or contact
+44 (0)3067 984325
Effective Error Management – EEM
Course Aim
The overall aim of this course is to enable delegates to
engage and manage the Error Management System in
their Area of Responsibility on a day to day basis focusing
on the handling of reports, coordination and guidance of
investigators, Review Groups, Communications, proactive
error management and continuation training.
Applicability
The course is aimed at Error Management System
Coordinators, Local Error Management System
Coordinators, Flight Safety-responsible persons
and any appointed to roles ‘championing’ the Error
Management System.
Prerequisite
Human Factors and Error Management Foundation Training
Duration
1 day
Course dates
••
••
••
••
••
••
••
•• 16 Sep 14
23 Apr 14
•• 30 Sep 14
7 May 14
•• 14 Oct 14
20 May 14
•• 4 Nov 14
10 Jun 14
•• 18 Nov 14
24 Jun 14
•• 2 Dec 14
1 July 14
•• 7 Jan 15
3 Sep 14
••
••
••
••
20 Jan 15
3 Feb 15
3 Mar 15
17 Mar 15
For more information please contact +44(0) 3067 984325
or MAA-courses@mod.uk
issue 13 MILITARY AVIATION AUTHORITY AIR SAFETY COURSES 45
Air Clues
Occurrence Investigator – OI
Course Aim
Course dates
The overall aim and objective of this course is to enable
delegates to carry out an effective occurrence safety
investigation, by conducting effective information
gathering via interview, data gathering, and photographic
methods and presenting recommendations to reduce
the likelihood of reoccurrence, in order to contribute to
increased safety, quality and operational efficiency levels.
••
••
••
••
••
••
••
••
••
••
••
••
••
••
••
••
••
Applicability
The course is aimed at all nominated personnel
(Mixed ranks and trades).
Prerequisite
Human Factors and Error Management
Foundation Training
Duration
1-3 Apr 14
29 Apr-1 May 14
3-5 Jun 14
17-19 Jun 14
8-10 Jul 14
9-11 Sep 14
23-25 Sep 14
7-9 Oct 14
21-23 Oct 14
11-13 Nov 14
25-27 Nov 14
9-11 Dec 14
13-15 Jan 15
27-29 Jan 15
10-12 Feb 15
24-26 Feb 15
10-12 Mar 15
3 days
For more information please contact +44 (0)3067 984325
or MAA-courses@mod.uk
Occurrence Review Group – ORG
Course Aim
Course dates
The overall aim and objective of this course is to
enable delegates to engage meaningfully with an
Error Management System process and to discuss
and determine risk with regards to Occurrence Safety
Investigations and trend analysis output, and practically
apply a consistent rigour in the potential determination of
culpability in order to contribute to increased safety, quality
and operational effectiveness. It should also focus on the
important internal assurance role of the ORG.
••
••
••
••
••
••
••
••
••
••
••
••
••
••
••
••
••
••
Applicability
The course is aimed at all nominated personnel (Mixed
ranks and trades).
Prerequisite
Human Factors and Error Management Foundation Training
Duration
1 day
For more information please contact +44 (0)3067 984325
or MAA-courses@mod.uk
46 MILITARY AVIATION AUTHORITY AIR SAFETY COURSES issue 13
24 April 14
7 May 14
21 May 14
11 Jun 14
25 Jun 14
2 Jul 14
4 Sep 14
17 Sep 14
1 Oct 14
15 Oct 14
5 Nov 14
19 Nov 14
3 Dec 14
8 Jan 15
21 Jan 15
4 Feb 15
4 Mar 15
18 Mar 15
Air Clues
Defence Human Factors Facilitator and
Instructor Course - HFFIC (RAF Cranwell)
Course Aim
Duration
To increase an individual’s HF knowledge to enable them
to achieve Level 3 of the HF Competency Framework
(HFCF) and thus become competent HF Instructors and
Facilitators. The course assumes that all students are
experienced workplace HF practitioners.
4.5 days
Outline of Syllabus
this course is aimed at:
a. Those people filling or posted to instructional
appointments within Phase 1, 2 and 3 training
establishments.
b. Those people delivering HF Continuation training.
Course dates
Courses Apr-Jul Fully Booked
13/14:08-12 Sep 14 Limited Space available
14/14: 29 Sep-03 Oct 14 Limited Space available
15/14: 13-17 Oct 14 Space available
16/14: 03-07 Nov 14 Space available
17/14: 01-05 Dec 14 Space available
18/14: 15-19 Dec 14 Space available
For more information please contact +44 (0)1400 268190
Defence Human Factors Examiners
Course - HFEC (RAF Cranwell)
Course Aim
To train ab-initio HF Examiners in the process of HF
Facilitator assessment and support and to increase HF
knowledge to Level 4 of the HFCF.
Outline of Syllabus
This course is aimed at individuals filling posts within
their DDH or Unit HQ. It is essential that all applicants are
experienced workplace HF practitioners and facilitators.
In line with current policy all students will have to complete
the Defence Instructor Assessment and Development
(DIAD) course. This can be done after attending their HFEC
although they will be required to provide details of the
DIAD course they are due to attend.
Duration
3 days
Course dates
2/14: 13-15 May 14 Spaces available
3/14: 16-18 Sep 14 Spaces available
4/14: 18-20 Nov 14 Spaces available
For more information please contact +44 (0)1400 268190
issue 13 MILITARY AVIATION AUTHORITY AIR SAFETY COURSES 47
Air Clues
Competition time
Win…
The competition this time is to send me your funny
and amusing stories or jokes (anonymously if you
wish) for inclusion in the Airclueless section of the
magazine. The best story will receive a certificate,
courtesy of CAE at RAF Benson which will allow
for you and 3 guests to have a tour of their
simulator facility.
The deadline for entries is Friday 30th May 2014.
Congratulations to last
editions winner…
Percy
Entries can either
be mailed to:
Plt Off Prune
RAF Flight Safety
HQ Air Command
Lancaster Block
RAF High Wycombe
Bucks
HP14 4UE
SE N D
The winner of one of our Haynes RAF Typhoon Owners
Workshop Manuals was Flt Lt JJ Caley from B Flt, 22
Sqn. You can read JJ’s article on page 10 of this edition.
Please keep your I learnt about articles coming in,
as usual we will endeavour to publish everything
we receive.
48 COMPETITION TIME issue 13
Or emailed to:
Air-SafetyCtre-WgCdrSpry@
mod.uk
Air Clues
Wing Commander S H P Spry DFC AFC DFM RAF
Wing Commander S H P Spry DSO DFC AFC DFM RAF was the youngest son of a Brigadier from
a Guards regiment. Born during the First World War (1916 is the best estimate from records)
he enjoyed a privileged background (Norland nanny, clockwork train set, and 2 oranges in his
stocking at Christmas) and attending public school.
Unlike his brothers who all joined their father’s
who was deemed to be responsible for an
regiment, Spry rebelled. He has no desire to wear
incident or accident. Operations and engineering
puttees, spurs and a stripe down his trouser leg but
personnel as well as aircrew would live in fear of
instead yearned to be a fighter pilot in the RAF.
a Wing Commander Spry comment, criticism or
He would often gaze into the Summer skies and
devastating summary of an accident or incident.
watch the fighter pilots practice their up-diddly-up-
These comments quickly attracted criticism
ups and decided that this would be the life for him.
from some quarters. In November 1957, a Wing
He refused to accept his allocated place to study
Commander serving in the Air Ministry wrote
the classics at Oxbridge, choosing instead to feed
the following:
his craving for aviation matters by joining the Royal
Air Force in 1934.
After flying training he quickly achieved his
Will Wing Commander Spry never come down
off that high horse of his? After more than a year of
reading his pompous, ‘holier-than-thou’ comments
ambition to be a fighter pilot and was posted to
I am so exasperated that I must ask if he has ever
fly the Hawker Fury at Tangmere. As his expertise
been an ordinary human sort of pilot himself. Did
developed so did his fame and his successes
the Wing Commander never have an accident, or
during the Second World War won him the DSO,
at least has he never been able to say “There but for
were followed by “and further remarks of mine
DFC and DFM. He gained a reputation for superior
the grace of God go I”? It seems not. He discusses
would probably be censored by the Editor!” On this
airmanship and was never shot down.
them with such ominous severity that it would
10th anniversary in post, it was noted that he hoped
seem a criminal act to be involved in a mishap.
“to continue being rude, dogmatic and pedantic
fighters and despite his aircraft being severely
Accidents, surely, are accidents. Everyone tries to
for a further 10 years – as he doesn’t care whom
damaged, on one occasion beyond all recognition,
avoid them, and they occur despite what people try
he upsets as long as the Flight Safety statistics
he would always manage to land the aircraft on
to do. The most effective way to real Flight Safety
continue to improve.”
British soil and walk away from the wreckage.
is to encourage the type of effort by which it is
By the 1970’s the “I learnt About Flying from
The post-war years saw Spry involved with the
achieved. Let us forget about recrimination for a
that ...” articles had really taken off and were clearly
test flying of aircraft and he gained an enormous
change and hand out a few pats on the back.
well received by the readers of Airclues. In June
On many occasions he was attacked by enemy
number of aircraft types in his log book. In June
Wing Commander Spry, shaken but not stirred
1976 Spry made one of many such pleas for this
1956 after 20 years of flying, Spry joined the staff at
by these comments, sought to reply. Whilst he
sort of article and frequently, for the next 25 years,
the Air Ministry.
admitted that he had a far from spotless record he
these articles were the most read in Airclues.
His reputation for sound common sense, his
argued that this was not a requirement to make
“Sprys Column” was also a familiar feature in the
vast experience in aeronautical matters and his
Flight Safety comment. He stated that it was not
magazine. A couple of Flight Safety themes would
forthright observations on the matters he was well
the individual cases of error that were of interest
be the focus of each issue: FOD, refuelling errors,
qualified to speak about made him a natural choice
but the fact that incidents and accidents illustrated
meteorological phenomena and tyre bursts
to become the leading commentator on Flight
common errors.
being examples.
Safety matters in the RAF.
Names were always omitted from articles as
Moving on to recent times, Spry has given
they were unimportant; however it was important
his personal assurance that he is taking a great
notice and was to the effect that if the Air Ministry
to publicise the ignorance, carelessness, or laziness
interest in the adherence to the Just Culture model
wanted some mahogany bound fighter pilot to do
of personnel who made the mistakes that led to an
throughout the RAF. Whilst he has observed the
their equivocating for them they could dammed
aircraft accident. Harsh words but perhaps
significant leaps forward we have made since he
well look somewhere else.
not surprising as the RAF had well over 200 aircraft
entered the service, he still believes that there is
accidents in 1956. Indiscipline and non-adherence
still some way to go in order to fully engender
assurances that he would be free to express his own
to procedures were often identified as the cause.
this mindset. Spry is a solid advocate of the open
opinions, derived from his wealth of experience and
And so unperturbed by the criticism and with
and honest reporting system which allows him to
expert judgement, without fear or favour. And he
the aim of publicising incidents so that others could
identify unsuitable equipment, clumsy regulation,
has continued to do just that, shunning all offers
learn from them, Spry continued his work.
unworkable processes and undue pressures which
His very first comment was regarding his posting
Thankfully he was persuaded with the
of retirement.
Many of Spry’s early comments in Airclues
Ten years later, Spry’s comments were slightly
more restrained. An occasional “well done” or even
allows for others to avoid the same traps.
Spry now endures as the Editor of Airclues,
reflected the blame culture prevalent
a congratulatory comment was sometimes seen in
campaigning to ensure safety is paramount
throughout the RAF at the time and would make
print. However, Spry’s exasperation was still evident
across the RAF. He works well into the small hours,
most readers’ eyes water today. “This airman,
on occasions when he perceived that personnel
penning his missives to ensure that the lessons
by his incompetence ...”; “I am getting fed up to
were making “stupid mistakes”.
learnt over the many preceding decades are not
the back teeth with this loose article business”
would be common expletives for the scapegoat
On one occasion, following a Jet Provost
undercarriage overstress, one or two mild remarks
forgotten but are reinforced still in today’s capable
and agile Air Force.
issue 13 WG CDR SPRY BIOGRAPHY 49
Air Clues
I learnt
about
writing
DASORs
and flying
from that...
A few months ago I made a couple of mistakes: one flying related and the other, more notably, was not writing a DASOR
about it. However, Winston Churchill once said ‘All men make
mistakes, but only wise men learn from their mistakes.’…so
let’s learn from mine.
It was a dark night in the Helmand Valley. As a pair of
Chinooks, we had been shot at by some heavy machine gun
fire before inserting troops into a wadi close to the Green
Zone. The landing itself was a challenging one that included
very few references. It was one of those in which, after you
land and the dust finally clears, you discover a ditch only
feet away from the aircraft; a little more to starboard and we
probably would have lost some of our undercarriage. No one
on the crew saw the ditch and it certainly didn’t show up on
any imagery! (Maybe that was worthy of a DASOR itself?)
Post the drop off, we flew to a Forward Operating Base (FOB)
to lay-up and wait for the exfil. En-route to the FOB, I chose
to engage the barometric altitude hold function, but I made
a mistake by forgetting to disengage it as we approached
200ft on finals. This wasn’t an issue during the approach, hover
positioning or landing, as I was manually overriding the hold
by my normal application of the collective lever. We landed
on the refuel spot and I cleared the rear crewman to unstrap
his harness and leave the aircraft to connect the refuel hose.
However, the static pressure must have changed causing the
altimeter to drop. To counteract this, the hold function raised
the collective lever to climb the aircraft back to the set datum.
At that precise moment, my hand was off the lever. The lever
rose automatically thus applying power to the engines and
as a result the aircraft lifted itself off the ground. I immediately
and positively took control, established a low hover, and made
sure all of the crew were still on board and ok. I then landed
the helicopter, realised the mistake and promptly disengaged
the hold. It turned out that my rear crewman was standing on
the ramp hinge and, as the aircraft lifted, he was forced onto a
50 I LEARNT ABOUT WRITING DASORS AND FLYING FROM THAT issue 13
Air Clues
knee causing a large scratch on his leg, although afterward he
told me that he’d suffered worse playing rugby… Now, is this
whole incident worthy of a DASOR? Of course it is, but I didn’t
submit one.
Having returned to base we subsequently debriefed all of
the evening’s events thoroughly which included the above
incident. The question was then asked, “Should we submit a
DASOR?” Various comments came out in the de-brief such as,
‘people are already aware of the issue’, ‘nothing will likely come
of it’, not really worthy of a DASOR’, ‘we’ve all been reminded
of it, so let’s leave it at that’… unfortunately, we (or to be
exact, I) decided not to. But why? I’ll come to my
conclusions later, but first I’d like to focus on the after
issue 13 I LEARNT ABOUT WRITING DASORS AND FLYING FROM THAT 51
Air Clues
effects of not submitting the DASOR, and what I’ve
subsequently discovered.
Six weeks later while I was boarding my flight home from
Bastion, I was taken out of the departure lounge to take a
phone call from my Boss in the UK. Of course the first thing
that went through my mind was: “oh no (or words not fit for
publication in Airclues), we’ve lost an aircraft”. Fortunately we
hadn’t. He strangely asked about an alleged incident in theatre
where a crewman had fallen from an aircraft at 40 feet! To cut
a long story short, someone had overheard a story about our
incident and had submitted a false account directly into our
2* HQ during an Air Safety meeting! Needless to say this did
not look good as phrases like ‘cover-up’ were being thrown
around. Even though we believed the incident to be minor,
the subsequent rumours, Chinese whispers and inaccurate
reporting all unfortunately resulted in an OSI to determine
that facts which wasted everybody’s valuable time. If only I’d
submitted a DASOR…
Of course a DASOR should have been submitted to both
remind Chinook crews of the issue and to increase our
awareness of the phenomenon. It would have also served to
prevent any inaccurate reporting of the event. However, whilst
the OSI was being conducted I was surprised by the number
of aircrew (from various aircraft types and some people senior
to me) who said they had experienced their fair share of
incidents and had not submitted a report. “I’ve probably had
worse happen to me in LFA1 with the ‘stabs’ out!” said one
person. I was also surprised at the number of experienced
aircrew - on different aircraft types - who said they have, or
probably would have, done the same in my situation. Really?
A few weeks later, as the OSI was drawing to a close, we were
on exercise in the US. During one particular night sortie I
witnessed an Airprox with a V-22 whilst I was a passenger
in the back of the Chinook. During the subsequent debrief,
the incident was discussed in detail, but then the inevitable
question came: “should we submit a DASOR?” Listening to
the conversion I heard comments such as, ‘nothing will likely
come of it’, ‘we could upset our relationship with the host
nation’ etc, at which point I interrupted the debrief.
I emphasised that, irrespective of any potential impacts, a
DASOR has to be submitted to remind others of the issues of
flying in foreign airspace at low level, and to add more weight
for us to have a form of TCAS; not to mention the issues that
could arise if rumors and incorrect reporting should leak
out…in summary, “Don’t make the same mistake I did!”
A month later we were working with the Royal Navy
conducting night formation with their Lynx Mk 8s. It was a
very dark night over the sea with no discernible horizon, and
the formation references on the Lynx were difficult to observe
due to the intensity of their IR lights. It transpired that the
Lynx crew had no cockpit control over these IR lights: the
lights are battered powered, turned on externally during
the pre-flight walk around, and the intensity is directly related
to the battery life! However, the Lynx crews were aware of
the issue and use their Brightstar IR lamp to illuminate the
lead aircraft. We subsequently tried it and were pleasantly
surprised at the effect of this simple technique. I started
talking about submitting a DASOR regarding the whole issue
and guess what I heard from the Royal Navy? ‘There’s no point,
nothing will likely come of it’, ‘the PT don’t have any money’;
‘everything is focused toward Wildcat now’... That made
me even more determined to submit a DASOR! I’ve since
been told that the OEU are going to come and discuss the
Brightstar procedure….is that the ‘system’ actually working?
So why did I not submit a DASOR, and why have I heard all of
these comments since? Well I believe it’s due to 2 reasons:
1.Perceived Pressure. Did I mention that I had only just taken
over command as the Sqn OC at the time of our incident?
Did I really want the perceived pressure from the DH chain,
and the embarrassment of a basic mistake by the Sqn OC
made public with people laughing at me in crewrooms?
My other crew had also recently been the subject of an
OSI for an undercarriage incident and maybe we
subconsciously didn’t want the extra focus on the Sqn.
As we came down on the side of not submitting a DASOR,
there must have been members of my crews who knew it
was the wrong decision. So why didn’t they speak up?
Was there a perceived pressure that ‘it’s the Boss and he
must be right’, or ‘I don’t want to speak up in front of the
Boss’? I sincerely hope not, but I’ve learnt that the best
intentions of commanders can easily be perceived in a
different way. The simple lesson here to all the JOs and
NCA is that if it feels wrong, it generally is. Learn to trust
your instincts and have the moral courage to stand up for
what is right. I’d like to think I’ve done this all my life, but
unfortunately I made a mistake on this occasion.
2.‘DASOR Fatigue’. Are all of us in Military aviation suffering
from ‘DASOR Fatigue’? We tend to see our inboxes clogged
up with numerous DASORs, some of which add little or
no value to our actions on the front line. Do we really care
that a piece of removed soundproofing wasn’t recorded in
the F700? I would imagine most of you delete a lot of the
emails from the MAA whilst cursing them for wasting your
time. Are there some of you who don’t even log in to ASIMS
because you’re pressed for time? We’ve approached the
MAA and asked if they could include the DASOR content
paragraph in the email they distribute to make the process
more user friendly. This would hopefully allow you to absorb
the issue and most of the information in 30secs rather than
taking extra time logging into ASIMS, unless of course you
need extra detail on the occurrence.
52 I LEARNT ABOUT WRITING DASORS AND FLYING FROM THAT issue 13
Air Clues
We also don’t tend to receive any feedback on the DASORs we
submit. Does this lead to an attitude of ‘what’s the point?’, or a
cynical belief that ‘nothing will happen’. Surely a more robust
feedback system would benefit those on the front line to
show that their efforts in writing a DASOR - coupled with all of
the additional pressures modern service life and flying provide
- are actually worth it?
Overall, I believe the best way to learn is through experience.
It’s even better if you can learn through other people’s
experiences, so I hope you gained something from this article.
In summary, if you, or anyone on the crew, or anyone in the
supervisory chain has asked the infamous question, ‘Should
we submit a DASOR’?’, Then the answer of course is YES!
have perhaps cleared away some of the doubt by others
about the finer details of the incident, as well as informing
future capability development. However, whatever our role on
units, we will all encounter a time when we may have done
something differently when looking back – the real test is
perhaps how we respond when we face up to that realization.
As such, I’m hugely grateful to the author for sharing his
experience with us and for demonstrating such a positive
approach to sharing and learning.
Force Commander’s comments
I’m grateful to the author for this fascinating insight into
some of our most demanding work. It is certainly easy to
understand how, when faced with significant operational
risks at the cutting edge of our helicopter activity, a lesser
event that resulted in no significant injuries or damage can
seem relatively mundane. With hindsight, of course, we can
all see how a DASOR would have been helpful and would
Spry Says
Hear, hear! What a thought-provoking article and my thanks to the author for being so open and
honest. As I mentioned earlier in the Reg 18 Article, we have got to dispel any paranoia that the
admission of our errors will reflect badly upon us - we all make mistakes! But we have to learn from
them. Let’s look again at three of the basic elements of a Safety Culture
Learning Culture: We must learn from errors and mistakes in order to avoid their repetition - and remember, we’re
not talking here about the catastrophic lessons that Service Inquiries identify from major accidents, ie the ‘tip’ of
Heinrich’s iceberg; rather, we’re talking about the hundreds of little things, as exemplified in this article, that are
lurking under the waterline.
Reporting Culture: We have to avoid the hesitation and uncertainty about whether or not to submit a DASOR;
if you’re in any doubt about whether you think your DASOR might be worthwhile, then there should be no doubt REPORT! Who’s to know how much analytical, collective benefit, months or years down the line, could be achieved
from all the snippets that are submitted?
Just Culture: Possibly most importantly, however, we have to inculcate an atmosphere of trust and fairness - if you
admit a genuine error, you shouldn’t be punished severely (9 times out of 10, the inevitable red face should suffice!)
and the fear of an unfair, disproportionate punishment should not be the factor that stops you from submitting
the report.
I appreciate we are all busy, but this shouldn’t prevent us submitting DASORs; likewise, ‘being busy’ shouldn’t stop
those reading the reports from providing feedback to those submitting them, be that only to express appreciation
for their time spent writing them.
issue 13 I LEARNT ABOUT WRITING DASORS AND FLYING FROM THAT 53
Air Clues
Back to Flying Business
Royal Air Force Wittering is an active airfield once more.
At 10.40 am on Monday 14th April 2014, three Grob Tutor
aircraft landed at Wittering, marking a new phase in the life
of the famous RAF station.
The historic airfield has seen no significant aircraft activity
since the retirement of the Harrier in Dec 2010. Now, with
the resumption of air traffic services and re-activation of the
Military Air Traffic Zone, RAF Wittering has become a flying
station once more.
The reopening of the airfield comes as part of a relocation
plan for several University Air Squadrons and elements of
the Central Flying School. Fittingly, the first aircraft to touch
down was piloted by Squadron Leader Christopher Kane, the
Commanding Officer of Cambridge University Air Squadron
(UAS), currently based at RAF Wyton just outside Huntingdon.
Wing Commander James Lapsley, Officer Commanding
RAF Wittering Operations Wing, said; “Today has been the
culmination of months of virtually non-stop work to get
us ready for flying. My team has been superb, and it’s an
outstanding achievement. Our priority has been a safe
air environment and that’s what they’ve delivered.
The Tutors have a safe base to operate from, and we’re
a flying station again.”
54 back to flying business ISSUE 13
The Tutor, a two-seat piston engine aircraft used for basic
flying training, will be a regular feature in the skies above
RAF Wittering from now on, as trainee pilots are put through
their paces. The airfield will initially act as a relief landing
ground for RAFC Cranwell and Wyton-based Tutors, but RAF
Wittering will see a gradual increase in flying activity over
the coming year and, by mid 2015, it will be the home of five
Tutor squadrons: Cambridge UAS; University of London Air
Squadron; East Midlands UAS; 115 (Reserve) Squadron; and
No. 5 Air Experience Flight.
Though currently operating under Visual Flight Rules only,
it is anticipated that surveillance radar will be available by
the end of November 14. RAF Wittering Air Traffic Control
will not provide a Lower Airspace Radar Service but Ground
Controlled Approaches will be available once the radar is back
on line. In the mean time, Wittering is able to accept Practice
Diversions with a limited Crash Category of 1A.
Wing Commander Lapsley said; “The sound of aircraft is really
the beating heart of an RAF base; so to have aeroplanes back
is fantastic. It’s the beginning of a new and very positive
chapter for RAF Wittering.”
RAF Wittering hours of operation are from 0830 to 1700L,
Mon to Fri and to date airfield information and frequencies
are available on the AIDU website.
Air Clues
Erratum
It has been said that I have been around for quite a while and the question
has been asked regarding my immortality. I can assure you all that I am a
mere mortal, and like yourselves I can make the occasional mistake when
compiling my editions of Air Clues. To this end I will happily publish errata
correcting and errors, such as:
before
“ ay
“Day
y befor
bef
effoor yesterday,
efo
y s rday,
a I did
did
my
y first
f rs ssolo in
i the Hurricane;
Hurrica
urr a ;
they
h y ar
are indeed
i deed a gra
grand
d
pplane
a ea
and
d iit is little
iitt e wonder
d
derr
that
ha
a they
h y ha
have
a e gai
ga
gained
ed
d the
h
name
a they
ame
h y ha
have.
have
e Luckily
ucki
u y fforr us
they
h y are
hey
ar nott hard
d tto ha
handle
d e as
the Master
aster
which
hich
may
sound
s
u
d
Dear Wg
Cdr Spry
,
strange.
strange
stra
ge They
are
harder to
t
land though,
g , because of the
narrow wheel base.
base
I got a rather big
ig
g surprse
pprs
rss
when I came heree a
and tthat
h
was
as the m
mortality
rta ity rate
rate.
t T
Th
There
are quite a fe
few deaths here,
here
and this
a
his fa
fact has made
a me extremely careful in everything
ything
y
yt
t
thing
I do iin the
h air.
air I ha
have ccom
come
o to
the cconclusion
c usi that m
most
st off th
tthe
h
accidents
accide
ts are caused by the
things
things,
g carelessness
el
el
and d
disodis
bedience, know
n in the RAF as
breach of d
dis
discipline.
s
For some
Wg Cdr
Spr
RAF Fligh y
t Safety
HQ Air C
ommand
Lancaste
rB
RAF High lock
Wycomb
e
Bucks
HP14 4U
E
Whilst re
ading Air
Clues Issu
“Erratum
e 12 of 2
s”. You sh
013, I
o
uld be aw
(Concise
are that th noted the page e
OED, 8 th E
ntitled
e plural o
dition).
f erratum
is
errata
Regards,
George
Wg Cdr G
e
orge List
on
Spry Say
s
Not at all
, and tha
nk you fo
as accusa
r your em
tory.
ail. It ce
rtainly did
n’t come
across
I have dir
ected Pe
rc
y
to refresh
mind the
h
use of ‘Err
atum’ in th is knowledge of la
tin. I hop
is edition
e you do
as we on
n’t
ly have o
ne correc
tion.
issue 13 ERRATUM 55
R AF AEMS
Aviation | Error | Management | System
Report Today for a Safer Tomorrow
I observed a hazard
I spent a few minutes writing
my concern on one of those
AEMS forms
You
I posted the form to my LEMSCo
Feedback
I let the reporter
know that their
concerns are
being looked
at further
I received an AEMS Form
through the internal mail
LEMSCo
Feedback
I instigated some corrective
local-level mitigations
I passed the AEMS Form
on to the SEMSCo
I received an RAF AEMS form from the
LEMSCo. The issue was air safety related
so I raised a DASOR on ASIMS
SEMSCo
You
Due to the air safety implications,
the Stn Cdr instigated an Occurrence
Safety Investigation (OSI)
The investigation provided
the justification for funding
to fix the issue
I observed change
LEMSCo = Local Error Management System Coordinator
SEMSCo = Station Error Management System Coordinator
Produced by Air Media Centre, HQ Air Command. 0984_13LAL
© UK MOD Crown Copyright, 2013