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Blast from the Past - Foreword 4

Foreword - ACM Sir Stephen Dalton 5

Interview with Group Captain Tony Mills 6

Spry’s View 9

ASIMS - the dream becomes a reality 10

The human factor:- in theory & practice 11

The human factors centre, hq cfs 12 I learnt about flying, drinking and supervising from that .... 14

Fatigue and human performance 18

Doing your best & still making errors ... What’s up with that! 21

I learnt about fatigue from that .... 22

I learnt about hypoxia from that... 24

Per tornado ad astra 25

I learnt about instructing from that ... 28

The double edged sword 30

A close run thing 32

Lessons learned from Ben Macdui 34

Crash & smash no more 38

A junior officer’s exposure to fight safety during engineer officer foundation training 42

Foreign object debris 44

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On Operations the aim is to achieve the intended results with the minimum of deaths and injuries to non-combatants, the enemy and, of course, our own and allied forces. Critically, at home base or on exercises, we train to develop our skills and ability to fight and deliver those results effectively whilst minimising the risk to ourselves and anybody else. In so doing, we gain the experience to know when to press on and when to say “No”! Inevitably, we operate to finely judged tolerances of acceptable risk, but it is that judgement that is so very important both in peace and war. In peacetime, we aim to identify the potential risks and then train to know how to avoid them leading to incidents, or worse, accidents; on operations we use our training and experience to identify the most effective way of achieving the mission with the minimum of risk of losses. Our flying and technical

f o r e w o r dtraining are of the very highest quality and despite all the safety features designed into our aircraft and equipment, more often than not, it is the quality of training that we have received that has enabled us to identify potential risks and to mitigate them.

However, despite all the training and flight safety awareness that we undertake, incidents and accidents happen. It is our individual and collective responsibility to seek to identify risks and potential dangers and to do all that we can to remove or at worse reduce such risks so that they are as low as reasonably practicable. As part of that intent, I am very keen to see Air Clues re-launched as a significant tool in heightening Flight Safety awareness throughout the RAF – on the ground, in the air, everywhere we operate. Air Clues has a distinct role to play in the overall, ‘Can Do Safely’ Campaign. By sharing our experiences and talking openly about situations which have tested our operating abilities and our judgement, we reduce the risk of somebody else having to learn the same hard lesson and potentially losing their life or causing the loss of somebody else’s life. Air Clues has the ability to spread the lessons widely and effectively and I encourage all to share their experiences and so improve our collective awareness, operational effectiveness and performance both on operations and in training.

In encouraging you to share your lessons, let me re-assure you that such openness will only ever attract

my gratitude. We all make mistakes, unfortunately some mistakes lead to terrible consequences, BUT, if despite your honest and best professional endeavour you make a mistake which leads to an incident/accident, then I will support you with all the resources at my disposal. Whilst foolhardiness or unprofessional actions will attract the strongest disciplinary action, honest mistakes will not. Air Clues offers us the chance to learn from others and to review how we operate, whether that is in engineering, flying or controlling aircraft/vehicle movements – all of us share in this responsibility and all of you have an equal voice and duty to come forward and highlight your concerns whether that is in the air or on the ground.

In the spirit that takes us into the air and brings us safely back again, I strongly recommend Air Clues to you and encourage you to be open and honest so that we all might learn and operate the Royal Air Force safely!

By Air Chief Marshal Sir Stephen Dalton KCB ADC BSc FRAeS FCMI RAFChief of the Air Staff

Blast from the past - Foreword to the 1st Issue dated May 1946

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i n t e r v i e w w i t hGroup Captain Tony Mills, Gp Capt RAF Flight Safety

Sir, how did the new RAF Flight Safety (FS) organisation come about?Unfortunately, since 1996 the RAF FS organisation has been subject to a large reduction in personnel, and thus capacity. This was a direct result of the demise of the RAF Inspectorate of Flight Safety (IFS); the creation of the tri-Service Defence Aviation Safety Centre (now renamed the Directorate of Aviation Regulation and Safety (DARS)); and the steady demise of Gp FS staffs. This meant that the RAF FS function then rested with a small cadre of HQ personnel under a Wg Cdr, Cmd Aviation Safety Officer. It was soon recognised that this cadre, entitled the Aviation Safety Group (ASG) was under resourced and despite the efforts of some very hard working individuals, was only capable of providing a reactive FS over-watch. Whilst overall numbers of RAF aircraft and personnel have reduced, the level of FS risk, through increased operational tasking and their adverse effects on UK-based flying tasks, has arguably become greater, and so the inability of ASG to meet demand could not be allowed to

continue. In response, I was installed as the new Gp Capt Flight Safety on 1 June 09, responsible for the now renamed and enhanced RAF Flight Safety organisation.

So how will RAF FS ensure it will continue to meet the flight safety challenges of the contemporary operating environment?In April 2009 we held a Flight Safety Transformation workshop that involved over 50 personnel directly, or indirectly, concerned with FS from both inside and outside the RAF. The week long event captured a comprehensive record of the problems faced by the FS organisation and a long list of actions required to enhance its output. Since June we have enthusiastically set about eating the elephant one spoonful at a time!

What are the key outputs of the new RAF FS organisation?Well… I suppose I could reel off a list of tasks that are written in my TORs, things like implementation of Aviation Safety Management policy, developing an effective

FS publicity campaign, providing assurance through FS audits etc, etc but that’s a bit boring. I think it is best summed up by saying I see our responsibility as being the FS conscience for the RAF. It is our role to question, analyse and recommend where we believe an activity could be carried out with less risk. We are involved in policy development and we provide advice and guidance but we’re not the experts on everything and another important role for us is to get the lessons learned by others and accepted best practice passed to as wide an audience as possible. Ultimately, I hold a very privileged position within our Service and as the RAF’s FS conscience I can go straight to the CinC if I believe the case strong enough.

You mentioned earlier about the manpower drawdown that followed the demise of IFS, how are you managing that and still ensuring flight safety throughout the RAF?We have also been reorganising and restructuring our organisation in order to provide an improved

flight safety product for you. Gp FS staffs are being reintroduced and at the time of writing we are commissioning a study into the roles, responsibilities and training of U/SFSOs, who incidentally, I see as being the most important individuals in the FS team. We will in due course expand the review of FS trg to cover that required by staffs throughout the FS organisation. We will also be engaging with Manning staffs in order to progress towards having in place the right people with the right training to provide an unbroken FS chain from UFSO through to the Air Cmd Safety Management Board (ASMB).

Can you tell us more about the responsibilities of the ASMB?The ASMB is responsible for monitoring the performance of the Air Cmd Safety Management System (SMS). Before you ask, a SMS is the organisational structure, regulation, processes responsibilities, procedures and resources that enable us to meet safety requirements and safety policy objectives. It is a proactive process that adds to the significant traditional flight safety activity. Our SMS is based upon the simple model of 4 key elements; policy and principles, organisation, implementation and monitoring/measurement. We work our way round these 4 key elements in a continuous improvement loop. The RAF has for many years had mechanisms in place to manage safety but what it has lacked is some of the documented processes to support this activity and, therefore, we have been unable to assure ourselves and others that there are no gaps or conflictions in our safety activity. All of this information is contained within the Air Cmd Safety Management Plan which will be published shortly and which will eventually be included within a new single-Service FS document which

I am keen to re-introduce in the near future.

Is the ASMB the only AC body charged with Flight Safety?Within the HQ we are introducing a FS working group at SO1 level named the Safety Action Group (SAG). With representation from across Air Cmd, the SAG (no comments please) will be able to take direction from and raise issues to the ASMB. Just as importantly, it will assist in breaking down stove piping between 2* AORs, speed up the flow of FS information across the Cmd and improve the passage of Lessons Identified and the tracking of Service Inquiry recommendations.

What are the key work streams that you are engaged with at RAF FS?We have been involved in the introduction of several new initiatives that should assist in the quest to improve the RAF’s flight safety record. Of note are the RAF (Maintenance) Error Management System ((M)EMS) with which RAF FS staff have been fundamentally involved from conception to the current roll out across the RAF Engineering community. The development of the Aviation Safety Information Management System (ASIMS) led by the DARS, but involving significant input from RAF personnel. ASIMS provides you with a simple and accessible conduit through which you can report your near misses and, ‘there but for the grace of God..’ incidents. With your inputs, commitment and help we will stand a far better chance of being more proactive in addressing the underlying unsafe acts which ultimately lay the foundation for more serious accidents. Together with Gp FS personnel, we have begun the construction of the Air Cmd FS Risk Register. All of the above may sound

somewhat dry, but it is essential if we are going to be properly placed to continually improve our FS record. In terms of being more proactive, we have also reintroduced FS Assurance visits to stns and I am keen to free up as much time as possible for my staff to get out and about to the units. There is much more besides, but perhaps we could keep that for a later issue. What I will stress as being of immediate concern has been the requirement to complete work on the Air Command Safety Management System (SMS).

There has been much talk about Human Factors training being rolled out across key branches and trade groups in the RAF, why is this and what can we expect to see from RAF Flight Safety?The old adage that there are no new accidents only new people waiting to have the old accidents tends to ring true and as technology continues to advance the percentage of accidents and incidents involving Human Factors (HF) is continually rising. As a result, your RAF FS staff are heavily engaged with DARS in producing a new tri-Service HF policy and developing the concurrent RAF policy. It is now recognised that the RAF requires significant HF trg in addition to that being provided within the (M)EMS programme and we are confident that HF trg will be coming to a stn near you ‘ere too long.

With the establishment of the DARS is there still a requirement for Single Service Flight Safety?Without doubt; as much as ever before. The Directorate of Aviation Regulation and Safety is a central directorate responsible for developing the higher level overarching tri-Service FS policy. It has an important role to play, but beneath them so do we. DARS are not responsible for the implementation of the Flight Safety

Gp Capt Tony Mills joined the RAF in 1981 as a Pilot, before a medical problem forced his transfer to the Air Traffic Control branch. In a varied career he has served in Germany, Cyprus and at London ATCC; as well as 2 tours as a desk officer at RAF Innsworth and a tour as DS on the ACSC. Following a successful tour as OC Operations Wing at RAF Linton-on Ouse, he was promoted to Group Captain and served on the staff of the NATO Defence College in Rome. Since his return to the UK, Gp Capt Mills, has worked within the Ops Division at HQ Air; taking up his current appointment as Group Captain RAF Flight Safety in Jun 09.

s p r y ’s v i e wWelcome (back) to Air Clues.

To my RAF brethren I bid a hearty what-ho and a warm welcome to the first issue of the re-launched Air Clues magazine, the pre-eminent (albeit only) RAF flight safety publication. Some of you may not have heard of this magazine before; some will recognise the name and may vaguely associate it with Flight Safety, and others, like myself, who are greying slightly around the temples, will have clear recollections of the bang-on Royal Air Force flight safety magazine to which I previously contributed.

For reasons that are many and varied, but which I won’t bore you with here, Air Clues winged its way into the wild blue yonder in 2002 and with it, one could argue, went the public face of flight safety in the RAF. But I am not the kind of officer to let things lie and I was adamant, that like a phoenix, Flight Safety and Air Clues, would arise from the ashes. So after much banging on the doors of our lords and masters and subjecting them to the, ‘Spry view’, the glorious 1 June saw the establishment of an invigorated RAF Flight Safety organisation, with Air Clues resurrected as its voice. Spry resurgam!

Those of you who benefited from my missives and opinions in the old Air Clues will remember the often forthright manner in which I approached flight safety, particularly, those involving your flight safety cock-ups. Well I make no apology for my past crimes. Spry is, and will

always be a child of the robust school of management favoured during my formative years. What I will concede, however, is that time has mellowed me and as I race headlong toward my dotage you will find my comments far less prejudiced. But don’t be lulled into a false sense of security, Spry is no old fool, he knows that the best way to provoke flight safety discussion is to take a stand, raise my standard and sound the battle call. Some of you will rally to my colours, others will take the high ground opposing me. The side you take is unimportant, the crucial point is that you think critically about your part in flight safety, voice your opinion and make it heard!

Now for you non-Aircrew types, for whom I have the deepest respect, this magazine also belongs to you as much as to your breveted colleagues. In my youth, it was the dashing pilots and aircrew who did flight safety, often badly, with no-one else considered, other than ourselves. Now you can imagine my surprise and slight consternation, when it was pointed out to me over several beers in the mess, that all of you land-locked personnel can, and do have, a direct impact on the safety of personnel in the air and have done so, perhaps unwittingly, for decades now. All of those human factors issues which we Aircrew so religiously guarded under the banner of Crew Resource Management, are just as prevalent on the ground and have the same direct impact (forgive the pun!) on operations in the air. As such, this magazine will provide the conduit through which all specialisations can bring their flight safety issues to the fore, but to be effective it also

needs input from the broad gamut of RAF personnel.

Oscar Wilde once wrote that, ‘there is only one thing worse in life than being talked about, and that is not being talked about’; and this is particularly true when it comes to Flight Safety. For if we are not talking about it, thinking about it and most importantly, working it seamlessly into our daily business, then we are quite simply not doing our jobs. Flight Safety is the key to the RAF continuing to deliver operational capability; if we pay lip service to it, or ignore it completely, we do so to the detriment of our people, operational effect and our world class reputation.

I would, therefore, urge anyone who wishes to put pen to paper and offer their flight safety thoughts, or concerns to a wide audience to do so. Articles can be anything up to 2000 words (I do find the odd picture or photograph also goes down well with the readership as well) and may address any flight safety related topic. As an added incentive, there will be a cash prize of £50 for the best article published in each issue.

Well I now hand you over to the bold few who have contributed their experiences to these hallowed pages for the benefit of the many. I only ask that you are gracious enough to return the favour. As Mark Twain wrote, ‘our opinions do not really blossom into fruition until we have expressed them to someone else’. Over to you.

Yours aye,

SpryRAF Flight Safety(95 221) 3870

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nearly always courses of action that can mitigate potential harm and we are committed to reducing risk to ALARP. We are not Air Cmd’s narks nor are we the fun police. So what are we? We are a collection of individuals with a variety of professional skills from across the RAF, who are committed to making flying activity as safe as possible. I myself am an air trafficker and within the team we have representation from aircrew in the fast jet, multi-engine and rotary worlds. We have engineers and a trainer; we even have a navigator who has served in both the USAF and RAF! There is a lot going on out there; operations, training, time and finances can all test us to the limit but we are determined to provide you with advice and assistance whenever possible.

So what is Air Clues?Those of you who like me, are slightly longer in the tooth will remember the times when ‘Air Clues’ appeared regularly in the crew rooms and tea bars around the RAF. First published in 1946 this Flight Safety (FS) magazine was in production continuously until 2002. It had a deserved reputation as a pre-eminent flight safety publication and it was one of the Service magazines that was eagerly anticipated by its readership.

Where does Air Clues fit in to the new RAF Flight Safety Organisation?In reintroducing Air Clues we are keen to recapture its former standard and provide you with valuable information in what we hope will be an entertaining publication. Air Clues is a magazine that is relevant to all of us, military and civilian, and whether your workplace is in the air or on the ground it can provide a means for disseminating valuable FS information to lessen the risks

inherent in our core business.

Will Air Clues be written by your team at RAF Flight Safety?No, quite the contrary. It is your professional knowledge, experiences, views and recommendations that can be disseminated to a wide audience and can play a part in reducing the risk of others coming to harm. Air Clues is your magazine and wherever we have visited there has been unanimous support for its reintroduction, but it will only ever be a success if you commit to it. Everybody involved in the flying business probably has at least one ‘I learned about….’ incident that makes them squirm when they recall it. No articles, no magazine - so please give us your full support and help your colleagues by sharing your knowledge and experiences.

Any final words?The RAF used to have an Inspectorate of Flight Safety that was the envy of many military aviators around the world. We dropped the ball to a degree, but now RAF Flight Safety is back. There are some very competent and committed individuals working in the organisation and we will do everything in our power to improve the output, but if we are to maximise our FS effectiveness we need the buy-in from everybody. I want to encourage people not to be afraid to pick up the phone and please find the time to fill in that report – you could be saving someone’s life.

Oh, before you go your readers will be delighted to learn that we have managed to persuade the legendary Wg Cdr Spry to return from his sabbatical. He is looking tanned and extremely chipper. The old warrior is refreshed and reinvigorated and contactable at any time on 95221-3870, or by e-mail to Air-WGCDRSPRY.

Work Rounds - Think Flight Safety! Change of Procedure -Think Flight Safety!

Management System. We do that job and in doing so we concentrate our efforts solely towards reducing FS risks to RAF personnel and aircraft. That is why I believe there is a strong argument for having a single RAF FS document which would complement the relevant JSPs. Indeed, all RAF specific material in JSP 551 could be moved to a single Service document and so we are investigating the reintroduction of such a document-perhaps we could call it AP3207! I might add that DARS support this aspiration.

RAF Flight Safety has set itself some ambitious targets, can it really make a significant difference?Unequivocally, yes, but we are not naïve. Risk is ever present in our lives and we can never eradicate it. Indeed, I would argue that life would be extremely dull without a regular injection of vitamin R as risk is sometimes referred to. Your FS team are not risk averse and appreciate that Operational Risk Management is a very different beast to risk management in a peacetime environment. Each bring their own hazards and challenges; moving from operating in one environment to the other brings hazards of its own. However, on all occasions there are

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After a great deal of hard work by many organisations and individuals across the Defence Aviation Community, DARS will shortly begin rolling out the Aviation Safety Information Management System (ASIMS). ASIMS began life in Feb 08, when the inaugural ASIMS WG first met to consider the future for Flight Safety Reporting. In Feb 09, a contract was signed with Bristol-based Vistair for the purchase of their Safetynet system. Safetynet is a proven Aviation Safety product, which was originally developed for Ryanair but is now in use with airlines including FlyBe, Tui Fly and Aer Lingus.

Before considering what ASIMS is, it worth first describing what it isn’t. ASIMS is not simply a database on which to raise and store flight safety reports. For it to be truly effective in improving safety, it needs to be far more than that. With that in mind, ASIMS has been developed to be exactly what its name suggests, “A Management System”. ASIMS will be hosted on the Defence Intranet (www.asims.r.mil.uk) to enable the Defence Aviation Community to perform the following:

Report all Flight Safety Occurrences. Without the need to actually logon to ASIMS, anyone in Defence Aviation with access to the MoD Intranet can raise a Defence Flight Safety Occurrence Report (D-FSOR). Having completed their D-FSOR, this will be forwarded to their own Unit/ Sqn/ Organisation’s Maintenance personnel for completion of the report. At any stage in the report process, files such as Pictures, Videos or Word/PDF documents can be added to amplify the D-FSOR.

Task Investigations and Follow Up Actions. Once the initial D-FSOR has been received by the Occurrence Manager, they are then able to task and track the progress of any investigations, or Follow Up actions. Initially, ASIMS will host the MEDA Investigation Report, but work is also underway to develop a replacement for the RN A25/ Army F5/ RAF F765B, which will also be available on ASIMS in the future. Again, any investigation work carried out can also be added as a file attachment to the original D-FSOR.

Track and Manage Recommendations. Having completed any form of investigation, recommendations associated with a D-FSOR can be entered into ASIMS, where they can be tracked and managed to completion.

Share and Trend Analyse Data. All historical PANDORA data will be uploaded into ASIMS. This information coupled with a burgeoning knowledge base of

D-FSOR data can then be accessed by all ASIMS users to identify trends and analyse all aspects of Flight Safety. Many organisations regularly generate graphs for analytical purpose and currently this can be very time consuming. Within ASIMS, users can save any graph templates that they regularly need for use at a moments notice.

Hopefully, you are now thinking, “This all sounds great but when can I get my hands on this thing you call ASIMS?” The Field Development Phase commenced at RAF Marham on 28 May 09 and this Phase has now extended to RNAS Yeovilton, RAF Aldergrove, RAF Linton-on-Ouse, RAF Northolt and BAE Systems Warton. Thus far, the feedback has been extremely positive and we will shortly extend the FDP to include 3 & 4 Regts AAC, RAF Benson and QinetiQ Boscombe. All being well, ASIMS will be rolled out across the rest of the Pan-Defence Aviation Community from 1 Oct 09.

Ahead of this roll-out, DARS have already held a number of ASIMS Briefing Days, but if your organisation has missed this first opportunity to find out more about this exciting development in Flight Safety or if you require more information regarding ASIMS, please contact either Sqn Ldr John Franklin or Sqn Ldr Stu Keenan on 95233 8081 or 0208 833 8081.

The Royal Aeronautical Society’s Human Factors Group was formed initially in 1990 and became a full sub group of the Society a few years later. Its aim was, and still is, to help the aviation industry understand more about human factors, to provide workable solutions and to provide a forum for like minded individuals to share experiences and best practice. Over 35 conferences have been held by the Group during this period which has drawn together all the main HF practitioners in the UK and overseas as well.

Since the beginning there has been a strong connection with the CAA, who have always sent several members to the various meeetings and conferences that have been held. In fact the role of the CRM Advisory Panel, which was formed from the HFG, is to provide direct guidance to the CAA on CRM training standards and CRM instructor accreditation. This guidance has almost always been followed and has resulted in a robust working relationship with the regulator, which has been of great benefit to the industry.

The CRM Instructor Accreditation programme was developed and is monitored by the CRMAP, with the

the human factor:

sole intention of improving CRM instructor standards in the UK. This was created from a recognition that, particularly in HF and CRM training, the competence and credibility of the instructor was paramount in order for the impact of CRM training to be maximised.

In additon to the CRMAP the HFG has a number of sub groups which address their domain specific issues, such as Engineering, Flight Deck CRM and Cabin Crew. These groups have been extremely active in bringing together interested people in their disciplines to discuss problems, share ideas and develop tools, techniques and resources for addressing these. The people involved in the HFG and its associated groups are all volunteers and are a mixture of operational personnel, consultant practitioners and academics who because of their considerable individual experience share a common belief that any solutions offered to industry must be practical, effective and meet any economic or legislative constraints.

Although the HFG has not had a military sub group, personnel from the RAF, Army and RN have been represented on both the main

committee and the other groups and several conferences have been held at military establishments, notably RAF Bentley Priory. The intention of the HFG in respect of military aviation has been to make comment on HF matters in the military and be available for advice if required, as well as being open to any good ideas that the military may offer.

The main work of the HFG is to keep a watchful eye on what is happening on the front line and with both UK and European regulation, to try and identify problems, and to provide solutions wherever possible either through publications such as CAP 737, which is now referenced worldwide, conferences or influencing legislation. Currently, the Group has been analysing recent accidents to ensure that key HF learning is not lost, and to disseminate this information to the industry.

Although, it is not possible to make a clear connection between the work of the HFG and any safety improvements, it is a fact that since 1990 the UK has an exemplary safety record in terms of Human Factors accidents.

ASIMS the dream real itybecomes a

Sqn Ldr John Franklin, DARS Occurrences SO2 describes how the new Aviation Safety Information Management System will provide an accessible and simplified mechanism for flight safety reporting.

in theory & practiceIn this the first of two articles on Human Factors in aviation, we examine the work done by Royal Aeronautical Society’s Human Factors Group, who as principal advisors to the Civil Aviation Authority, ultimately, have a crucial role to play in the development of military aviation policy. The second article focuses on the work of the RAF Human Factors Centre at RAF Cranwell, detailing how we as a Service are educating our people on the Human Factor.

By Mr Carey Edwards, Chairman of the Human Factors Group, RAeS.

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IntroductionAs a result of work carried out by the Defence Aviation Safety Centre (DASC) and Flying Training Development Wing in 2005, the Human Factors (HF) Centre, HQ CFS was established in Oct 07. The HF Centre was set up to provide HF and Airmanship training to aircrew students and flying instructors within 22(Trg) Gp and to act as a focal point for wider HF training and research within the RAF. The aim of this training was to increase mission success through improved individual and team performance.

In Jan 09 the HF Centre started training HF Facilitators for the RAF on behalf of the Aviation Safety Group, HQ Air (now RAF Flight Safety). Over the last 18 months a good working relationship has developed between the HF Centre, the RAF Centre for Aviation Medicine (CAM) and the Directorate of Aviation Regulation & Safety (DARS) with the result that from Jan 10 the HF Centre will take on sole responsibility of training all HF Facilitators for all 3 services; a task currently shared with DARS.

The 3 aircrew staff at the HF Centre cover all the aircrew specialisations: Pilot, WSO, WSOp, Fast-Jet (FJ), Rotary Wing (RW) and Multi-Engine (ME). They are supported by a Pers (Trg) officer and in, Sep 09, by a civilian Human Performance specialist.

The genesis of trainingYou will probably be aware of a number of HF related programmes and legacy flying training initiatives that were used within flying training over the last decade. The current courses we deliver have taken the relevant and useful elements of each of these, combined with the latest psychological research, and turned them into coherent and useful training packages that are directly applicable to modern flying. Examples of the legacy initiatives and research which the current training draws upon are below:

a. Traditional Crew Resource Management (CRM). The legacy training still in existence from the CRM initiative of the mid-1990s was uncontrolled in terms of both content and delivery. It had not advanced from its initial inception and was still based on old, civilian CRM training packages. Even so, there were parts of the training that remained relevant and needed to be included in the new training being developed.

b. Airmanship. The Airmanship Assessment Matrix had been in use since 2003. Formal training to FT students and instructors in airmanship skills related to this matrix began in early 2007.

c. Performance Improvement Training (PIT). PIT trials took place at 19 Sqn, RAF Valley and BFJT, RAF Linton-on-Ouse investigating the use of performance coaching techniques within the FT system. The results indicated that PIT needed to be formally incorporated into all FT streams.

d. Psychology of learning/teaching. e. Psychometric Tests. At the time of the establishment of the HF Centre 2 psychometric tools were being used within the RAF outside of the Officer and Aircrew Selection Centre; neither in any formalised way. These were the Myers-Briggs Type Indicator (MBTI) and the Strengths Deployment Inventory (SDI). Both tools had value as indicators of intra- and inter- personal behaviours, but required development for use within the flying environment. After a small trial it was decided to use and develop the MBTI tool with the help of OPP Ltd., the owners of the tool. Our current coursesThe HF Centre now delivers courses for Flying Training Students, Aircrew

Instructors, Aircrew Performance Coaches and HF Facilitators. Research and experience indicated that the training needed to be delivered by instructors who were deemed credible by the students. To this end courses are delivered by a combination of HF Centre staff and civilian instructors. The civilian instructors are provided under contract by Inzpire Ltd and OPP Ltd, depending on the course, and are supervised and standardised by the HF Centre. The courses we provide are: a. HF/Airmanship Foundation. This 5-day course is for all FT students and is delivered by Inzpire’s ex-military aircrew instructors.The course covers Intrapersonal/Interpersonal Skills, Airmanship, Stress, Fatigue and the Just Culture. b. Human Performance for Aircrew Instructors. This 5-day course forms the 1st week of the QFI, QHI and Aircrew Instructor courses and is delivered by staff from the HF Centre. The course covers the Role and Characteristics of the Instructor; Intrapersonal and Interpersonal Skills; Basic Psychology; Airmanship; Introduction to Performance Coaching; Stress & Stress Tolerance (including Hi Ropes training).

c. Aircrew Performance Coach Qualification Course. This 4 week course trains and qualifies Aircrew Instructor and Flying Training student performance coaches.

d. HF Facilitators. This 5-day course trains personnel in the skills of facilitation in an aviation HF environment. Qualified HF Facilitators will then be able to conduct case-study based HF training on their units iaw service policy.

Looking to the FutureAs the HF Centre takes on responsibility for tri-service HF Facilitator training in Jan 10 there is now an aspiration for the centre to expand to become, in partnership with CAM, the focus for all aviation HF training for all three services. Similarly, and to maintain relevance and best practice, the HF Centre carries out research into all areas that can improve human performance. All research is carried out with a practical training application in mind. Our current research is focused on, ‘Emotional Intelligence as an indicator of High Performance’ and, ‘Training Techniques to Improve Stress Tolerance’.

By Sqn Ldr Adrian Rycroft, OC Human Factors Training Sqn, CFS, RAF Cranwell

the human factors centre, hq cfs

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I began my flying career on the Puma at the start of the 90’s and was fortunate enough to be based in Germany for my first tour. The flying was great, mainly single pilot by day and, because of the use of NVG, twin-pilot by night. As the Flying Officer junior pilot on the Squadron, I racked up my fair share of ground runs, but drawing from a very small pool of Puma pilots also meant I was exposed to tasks that otherwise I may not have been given. By being keen for the mundane I was rewarded with the interesting; there was a lot of time away but this suited me fine.

Combat Ready status came and I was quickly dispatched to Belize for 2 months. With my conversion course peers stuck in Northern Ireland, Belize was epic. It was the sort of place were you stepped from the VC10 to be greeted by a smiling pilot holding a cool bottle of beer for you – though one of the reasons he was happy was that you were his ticket home; with only 4 pilots for the 4 aircraft you were not allowed to leave country until your replacement had arrived. There were 2 Army Battle Groups to support, so tasking was high and, while the Harriers had left taking the radar with them (leaving the Puma with little beyond the GPS), the work was rewarding, varied and fun. We tended to operate 2-3 task lines by day and had one pilot on standby at night. I didn’t think to question the logic that we trained

for twin-pilot ops by night but only held one pilot on standby. Things seemed OK and it was well known that the Boss – there on a 12-month tour – was usually around for any sort of callout.

Belize was the perfect mix of jungle and over-water flying

Within a few weeks I broke the rules on alcohol and flying on a night callout. I had been standing in the bar one night and had just had a couple of mouthfuls of beer when the Boss came in and announced that 15 soldiers and a boat had gone missing somewhere between Honduras and Belize. The Puma was poorly equipped for night winching, having a single landing light and a high strength floodlight called Nitesun,

which was difficult to control and too bright for close operations, though we practised using it for overland approaches when light levels were very low. The Boss asked me how much I had drunk and, after I advised him, he took me flying on a sortie that lasted until the following morning, with the successful recovery of the soldiers. At the time what I had done seemed right given the potential circumstances for the soldiers, but my failure was to highlight that I had broken a rule, to stand up and be judged for the decision to go flying and to look at the procedures to see what could be done to prevent it happening again – something I regret to this day.

Not many nights after the first callout, I found myself as the standby pilot for night flying. I remember waking around midnight when the Boss, already accompanied by one pilot, woke the third to drink in celebration of a, ‘certificate of appreciation’ that had been presented by the US Embassy following a CASEVAC of some injured missionaries before I had arrived. Thankfully, I was not called to these celebrations, which seemed to have already gone on for a while, and I drifted back to sleep. However, at about 0300 my phone rang and I was called into ops for a rescue. I arrived to be greeted by my crewman, the medical team and my Boss – very much under the influence and in a flying suit. I had been called in because a diver was reported as suffering from the ‘bends’ on one of the outlying islands and, according to the doctor, the diver could lose his life if he were not transported to the only decompression chamber in Belize, some considerable distance away from his current location.

Getting onto islands such as this one (with one of the bigger landing sites) was often difficult.

With the crewman and the Boss we looked at the situation. There

was a recce of a landing site on the island, but this was assessed as ‘emergency use only, daytime only’ – due to the difficulty of the site. There was no moon whatsoever and we knew from previous experience that, with no cultural lighting, this would be an uncomfortable and long transit without Night Vision Goggles (NVGs) and with an aircraft with no autopilot bar a simple stabilization system and a bar alt hold facility that you certainly could not trust at low-level over the sea. I knew nothing about the ‘bends’ apart from that low-level ops were preferable in order to avoid making the illness worse, but regardless, I had no other option, as there was heavy cloud, down to not much above 500’ and within the cloud were embedded tropical cumuli nimbus (‘CBs – clouds containing heavy up and downdrafts, severe turbulence and potentially lightning). In short, the weather was unfit, there was no light to assist, the landing site was unfit, we had no legal nav aids, or means of getting below cloud if we did go into it, and the only sober pilot was a young Flying Officer at the start of his first Belize tour after just achieving Combat Ready. In training, this is a no-brainer, but there was the

small matter of a life in danger...The Boss was the first to come

up with a plan. He was by far the most experienced and was also the only person that had been to the island. However, in recognition of his ‘situation’ his plan was that I would be aircraft captain in the right-hand seat (traditional for helicopters) and that he would occupy the left hand seat to ‘advise’ me. As politely as I could, I declined this offer and informed the Boss I did not believe he was fit to fly. I was gently rebuked by him and he stated that of course he wouldn’t be doing the flying – that would be my part – but instead he would come along to see that my flying was OK. Rewording my concerns, I stated that he was not fit to be in my aircraft and I did not want him with me in the air – I bitterly regretted the earlier rescue I had flown with him. The Boss then looked again at the situation, reinforcing the peril for the diver and his solution. In response, I offered an alternative that I would rather go on my own with the crewman and nobody else in the cockpit. The conversation deteriorated until I swore at my Boss and I was then dragged into a separate office for a good old fashioned telling off. I held my line and we drove together to the flight line (in retrospect I should not have let him drive me there!). The Boss then completed the authorisation sheets (I had no powers of my own to authorise a sortie) and it was only when I was called to sign them that I realised he had authorised me to conduct the sortie single pilot – the crewman and I were determined this was the only way we would go flying.

I conducted the pre-flight checks with the Boss just outside the aircraft telling me to speed up (so much for being in ‘the bubble’) and, as a result, forgot to strap myself to the dinghy pack in my seat. Then, along with the crewman, we departed the airfield and conducted

I learnt about flying, drinking and supervising

from that….

Belize was the perfect mix of jungle and over-water flying

Getting onto islands such as this one (with one of the bigger landing sites) was often difficult

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a Nitesun approach to collect the medical team and equipment. Nitesun approaches involved flying a descending, decelerating turn, below the minimum speed allowed for flight on a helicopter with sole reference to instruments, while looking over your right shoulder into a beam of light projected by the crewman using a control box near the cabin door. The idea was that this manoeuvre would end up with you in a hover-taxi and able to move into the landing site. If it sounded awful it is because it was.

After picking up the medical team we transited down the coast of Belize to a small town from where in order to have something to look at and assess the cloud base, which we believed was around 700’. We then coasted out to find our island, relying heavily on our sole nav aid, the excellent GPS. Unfortunately, with a map marked ‘1964 British Honduras’, the information for which came from a 1950’s aerial survey, the island wasn’t quite where it was marked on the map. However we found the landing site, aided by some torchlight from the island itself.

One of the larger landing sites in Belize, but with the tail still over the water.

We had looked at the landing site previously from a photo, but the reality was that things were a little more overgrown. Taking our time, we eventually conducted a Nitesun approach to the island, perhaps one of the more uncomfortable manoeuvres I have flown. We only managed to get the nose wheel on the beach due to the proximity of trees and we kept some power applied as the main wheels where in the shallow water off the beach. The crewman went out, assessing our distance from the trees as several metres, slightly less than we were allowed, and went to get the casualty. Not an educated man, I was amazed at the effect the bends had on the

patient, for by the time we got to him he was huge – I feared one small slip of an aircrew knife and nitrogen could fill the cabin. When I expressed my concerns I was gently (and kindly given my ignorance) advised by the doctor that the bends was in fact affecting the joints – it was just a coincidence that the man was fat. My feeling of stupidity was, however, masked by my lack of capacity to take in anything at the time – I was occupied by intense relief to be on the island and a building fear of what was to come. Eventually, a large group of people carried the only beached whale in Belize out to the aircraft and we were then ready to depart for the decompression chamber.

We conducted an instrument departure, using a technique designed for fog (i.e. with little visual references on take-off) and had been underway for about 5 minutes when we flew into base of a tropical CB. There was no lighting – and therefore no warning – but as we scudded along the bottom through incredibly heavy rain we were thrown about uncomfortably, all just several hundred feet over the water. Taking a 45 degree heading change, we popped out the side and I made a

mental note to discard that pair of underpants after landing. At this stage, I remained on instruments, but the crewman was occupying the centre seat and occasionally using his NVGs. In this way, the crewman identified the single points of light that would mark my route, highlighting which island they were. Eventually, we reached the chamber, dropped our patient (who lived to complain we were not gentle enough with him!) and returned to Belize airport. The relief was overpowering.

In the days that followed I pondered what to do. I was influenced by those that patted me on the back, by the occasional individual that advised I should not speak to senior officers like I had that night and by my Boss who advised that if I wrote the callout up as it had happened that the report would never leave the Unit. I am ashamed to say, I did nothing but serve out my time in Belize and get back to the welcoming arms of my unit in Germany.

Unlike traditional ‘I learnt about flying’ stories from Air Clues, my story is therefore about my own failing to take the issue to a conclusion, in order to prevent that sort of pressure from being applied to others. My actions

initially were more self-centred – I rarely drank afterwards and would always volunteer to hold standby on other tours when there was a big occasion, such as the Summer Ball – I never wanted to be in the situation where someone would be in danger and I would not be fit to help them. However, as I moved into supervisory positions myself my tone changed. I rigorously enforced the guidance on alcohol and flying. Of course, all supervisors would say the same, but have a think about 2 of the ways we have used in the past:

‘The Joker’. I have often heard the phrase that aircrew are allowed to ‘play a joker’ on a tour, implying that if they drink to excess and are unfit for work they can be excused from flying that day – no questions asked, but once only. I certainly believe people should not fly when unfit, but the problem with the ‘joker’ system is what do you do when someone repeat offends? If people make a mistake, be it genuine, stupid or whatever, then they should never fly. They must know that the punishment of attempting to cover up these mistakes by flying is far greater than admitting to them beforehand. The ‘joker’ system should not be used.

Are you fit to fly?’. I am sure all authorising officers will question a crew if they are fit to fly, but are we paying lip-service to that phrase? Is there a danger we are allowing the individual the opportunity for a subjective assessment about how he is feeling (‘I had some beers but I feel fit to fly’), potentially after a night out. As an alternative, if our authorising officers asked aircrew ‘Did you comply with the JSP550 regulations regarding alcohol and flying?’, would there be a slight discomfort from some of our aircrew that have perhaps strayed over the 5 units (about 2.5

pints of beer) of alcohol limit in the previous 24-hours?

Thankfully, the Service has come a long way since the start of my career and I hope that moments like my own in Belize many years ago are long gone. However, at a time when airline pilots are subjected to random alcohol tests, is the military culture still 10 years behind that of the civil culture? While we have Post Incident Drug and Alcohol Testing (PIDAT), why is it not mandatory post an incident (not just an accident)? As an optional system, has it ever been called, if only to assure us we do not have a problem? Do we still live in a ‘beer call’ culture and, if so, are we confident we are correctly managing the situations that can follow?

The Air Clues TestIn my career I admit I have broken rules. Examples include flying in Northern Ireland in weather that was unfit in order to extract troops that would otherwise be stuck on the ground; and in flying beyond the normal crew duty day to move a compassionate case to be with a dying relative. I am sure no-one would begrudge me these indiscretions, but other than back-briefing the supervisory chain on landing (or worse, keeping quiet) do we have a formal process to highlight these indiscretions, so that we can be judged by our actions? If not, perhaps we should imagine, ‘The Air Clues Test’. If your Boss forced you to write to Air Clues describing the situation and justifying your actions, would you be comfortable? If the answer is no, then it is probably not worth doing. On that horrible night in Belize I could never have justified flying with a drunk, but I still feel it was right to go flying to see if I could save a life, despite the conditions. Hence in applying my own test I have written this article. However, I am still embarrassed that I did not justify

myself at the time and put a stop to what was a clear supervisory hazard. It is only time that has allowed me to overcome my shame in that respect.

Wg Cdr Spry Says:The history of our beloved Service is replete with tales of courage in the air, the exploits of Ball, Embry, Bader and Gibson all perfect examples of how courage and leadership inspire our people and set the foundations for success. Yet, when it comes to moral courage (defined as the ability to take the right actions in the face of opposition, shame, scandal, or discouragement) are we as consistent in our actions? Do we have an equally proud tradition of rewarding moral courage? How many of us, when exercising our roles as leaders would consider moral courage in our subordinates as a positive thing, not just defiance? Alternatively, when acting as followers, how often do we have the courage to take a justified stand against our superordinates, particularly when faced with a boss who is prickly when challenged, or who is so experienced that surely he can’t make mistakes? In flight safety terms, 100s of lives have been lost because of a combination of bullish leadership and a lack of moral fibre in those in supporting roles. One, need only think of the Tenerife Air disaster in 1977 which cost the lives of 583 people. The incident that this article’s author describes is I’m sure not an isolated one and what concerns me most is whether we can, hand on heart, say that the courage to do the right thing is the norm? Do you think that the RAF has an organizational culture which is accepting of moral courage in all its glory, or do we adhere too rigidly to our rank structures and experience levels? Over to you!

One of the latger landing sites in Belize, but with the tail still over the water

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“After training and currency, the greatest contributor to human variability is fatigue. One of the primary hallmarks of fatigue is human variability. This is due to large amplitude and moment to moment fluctuations in attentiveness associated with fatigue.”1

Fatigue and Human PerformanceFatigue causes an increase in variability in performance; the greater the fatigue, the greater the variability. What is the practical meaning of, “variability” in this regard? The absence of variability results in consistency and accuracy in task performance, as in Figure 1. Figure 2 shows consistency but not accuracy. This is a systems problem. Everyone is doing the same thing, but it is wrong. Procedures, equipment or training need to be addressed. Figure 3 shows a result which is somewhat accurate, but inconsistent. We know what is wanted and how to do it, but the result is less than adequate. This is performance variability. Increasing fatigue increases the spread of the shot group. Thus any action which reduces aircrew fatigue will tighten the shot group. It will lessen the variability in their performance of their duties.

Chapanis (1951) cited in Reason J, ‘Human Error’.2

Regarding fatigue, it is known that activities which are mainly procedural are by their nature relatively resistant to detrimental effects of fatigue. In contrast, activities which require creative thinking, real time evaluation of changing scenarios, generating different possible courses of action, and quickly selecting the best course of action, are more susceptible to fatigue. For example, a mission involving simply flying a cargo of supplies from point A to point B in a relatively low threat environment is a basically procedural activity. We would expect the crew to do well, even if somewhat fatigued. In contrast, a helicopter crew who have taken off to deliver supplies, only to be diverted to pick up wounded troops in a high threat area, at night on NVGs, encountering enemy fire as they approach a dusty landing zone, is definitely in the creative thinking realm of activity. If the two hypothetical crews have the same level of fatigue, the second will be at much greater risk of making mission critical errors. It follows that any measures which can be taken to reduce fatigue will reduce both crews’ performance variability, and will increase the likelihood of successfully and safely completing their missions.

I also note that there is significant individual variation in people’s responses to fatigue. The military generally makes an effort, consciously or unconsciously, to select people with a certain degree of fatigue resistance. However, in operational

environments, this resistance (in those who possess it) can be easily stretched beyond their limits, and the bullet group begins to spread.

Fatigue ManagementIn my view, fatigue is a problem in that any fatigue will increase performance variability and increase the risk to operational success. Minimizing fatigue can be addressed by commanders/supervisors in the real operational world in simple, positive, relatively inexpensive, and practically useful ways. I refer to this as “nibbling at fatigue” since these measures are not massive changes from what we already know we should do. These measures do not constitute luxuries or mollycoddling of aircrew. They fall into four categories:

• Accommodation • Scheduling • Napping • Breaks

Accommodation: Cool (air conditioned), flat, dark, quiet surroundings coupled with appropriate mattresses, sheets, blankets, pillows. Each of these measures, when instituted, will incrementally tighten the shoot group and lessen human performance variability. This is a hugely important matter; sheets and pillows will improve performance. If one must sleep during the day and fight at night, the person requires the best sleeping accommodation possible. The questions should be, “We’ve been here seven weeks, why are we still sleeping on the ground instead of on camp beds.” “We’ve been here six months; why are we still sleeping on camp beds instead of proper beds?” We’ve been here two years; why are we still sleeping in tents instead of porta-cabins?” Permanent buildings? Individual rooms? Each increment in sleeping accommodation quality will tighten the shoot group.

Scheduling: Both the USAF Air Force Research Lab3 and the Royal College of Physicians in the UK have investigated and commented on the effects of fatigue on night time operations. These recommendations are not made with a military operational tempo in mind, but they reflect studied consideration of human performance in those required to work regularly at night. To summarize only a few of their recommendations:

- In peacetime 24/7 operations, no more than three nights in a row should be worked.

- In the medical environment, no more than four consecutive nights should be worked unless extreme circumstances require it, and then a maximum of seven.

- 24 hour shifts should not be imposed, unless there is a high chance of obtaining six or so hours sleep during the shift. There is abundant data that errors (especially in the maintenance world) increase greatly after twelve hours on duty.

“Of course I know they are fatigued. But they are getting the job done magnificently.

Fatigue is not a problem.”Dr David Stevenson Colonel, USAF (Rtd) RAF Centre of Aviation Medicine 30 Jul 09

1Miller, J C; Fundamentals of Shiftwork Scheduling, USAF Air Force Research Lab pub 20060508021 2Reason, J; Human Error, Cambridge University Press 1990 p.3

Miller, J C; Fundamentals of Shiftwork Scheduling, USAF Air Force Research Lab pub 20060508021 N Horrocks, R Pounder; Working the Night Shift; designing safer rotas for junior doctors, Royal College of Physicians, 2008

Figure 1 Figure 2 Figure 3

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price to pay is a compromise in flight safety. My question to you readers, would be how do we strike a successful balance between delivering operational capability and maintaining a workforce that is not so overly fatigued that mistakes are made? Can we meet our operational and training commitments if we implement a fatigue management policy which restricts working hours?

I would also add that fatigue is not the sole preserve of personnel on ops. From bitter experience the contention that procedural flying is, ‘relatively resistant to detrimental effects of fatigue’ is fundamentally wrong. I imagine that, like myself, all of you can recount horror stories of extended shifts to get the jets out, mistakes made when tired, even of nodding off on routine flights? The following two articles develop this further and show how easily fatigue and its unseen and insidious brother, complacency, can raise their ugly heads.

training I began to reflect on past incidents and accidents that not only happened to me, but also to my co-workers. I began to realize a substantial number were often linked to human factor causes.

One such incident I recall happened to me in Summerside, PEI, back in the early eighties. We frequently were responsible for early morning launches for fisheries patrols and usually the aircraft departed at 6:00 am; therefore our servicing crew was often at work before 5:00 am, to get the aircraft mission ready.

One morning after the early launch, I decided to help out the morning shift by before flight checking the other aircraft that were schedule to fly later in the day. In the next two hours, I had five additional aircraft “B” checked and was pleased with the recognition from the crewmembers as they showed up for work and to their surprise much of the morning work was completed. It wasn’t until 9:00 am that my MCpl came and talked to me and asked me to go with him to one of the aircraft I had inspected. He asked me to go in the right wheel well and see if I saw anything. I entered the wheel well and did not see anything out of the ordinary until he asked me to look over my right shoulder. It was then to my astonishment that I saw a hole puncture through the right main landing gear door. The damage was severe and if left un-noticed could have caused the landing gear to get hung up in flight. The aircraft was subsequently pulled from the flying

Writing a human factors article might be easy if you regurgitated someone’s research and filled the text with all kinds of statistics, but I believe personal experiences are much more interesting and beneficial. It wasn’t until late in my career that I started receiving human factors training as the newly appointed Flight Safety Warrant Officer in an extremely busy fighter squadron. Following the

program and under went two days of repair to correct the damage.

At the time I could not understand how I could have made such an obvious error and for months my confidence was affected by the incident. I truly believed at the time I was immune to errors and they only happened to less competent technicians, was I ever wrong.

For the next few years I worked on several different aircraft and was lucky that I did not run into any similar occurrences and over time I got my confidence back to where it once was. However, I never did forget the incident with the damaged main landing gear door and often tell the story to junior personnel as part of their human factors training.

Today when I think about this incident, I begin to realize that several human factors played a role in why I missed seeing something very obvious. Firstly, I was often working fatigued having young children that were up frequently in the night. Secondly, I was rushing the inspections as I had a specific process of doing my before flight checks and besides very rarely did I ever find anything wrong. Thirdly, I was extremely confident in my abilities and after all we got rewarded for working beyond what others could tolerate. I even had a letter of appreciation for working 23 hours in my personal file. Finally, and most importantly, I had no human factors training and had no idea how outside influences, circadian rhythm or how human engineering plays a role in error.

- Human beings are not nocturnal creatures; we need night time sleep from time to time to recover. Working continuous nights is not a good idea; it will result in accumulating a sleep debt and chronic fatigue.

- The next day after a night shift should not be considered an off day; the day after that is the first off day. A person needs a bare minimum of one full night’s sleep before resuming night duty. The more consecutive nights, the more days with night time sleep are needed.

Napping: Naps are a known and highly effective (and very inexpensive) way to refresh and improve performance which is deteriorating due to fatigue. A minimum of twenty minutes sleep is required; there is no limit on length. If a person is subject to being woken to manage an emergency, they should probably not nap since it takes some time to become fully awake (“sleep inertia”). I have heard of squadrons having separate, designated napping rooms with proper beds and bedding – a superb idea.

Breaks: Especially in an environment of continuous work (e.g. aircraft maintenance), breaks are a proven way of reducing errors and increasing efficiency. I have heard it said, “We are too busy to allow breaks.” There is excellent evidence that, in a busy work environment, one cannot afford not to take breaks.

The Final WordRegarding fatigue and methods to minimize it, it really is a matter of operational risk management. The more fatigued a person is, the greater the variability in their performance. A commander/supervisor must accept this fact and decide consciously how much risk is appropriate for a particular situation. It is always possible to reduce risk by looking at accommodation and scheduling in an intelligent and creative manner, instituting strategies of breaks and napping where feasible. These measures will reduce human variability in performance, and hugely increase the chances of operational success.

Wg Cdr Spry Says:If I had a pound for every time I had heard the phrase, ‘man up’ levelled at some baby pilot or engineer who had whinged about how tired he was in the crew room, I would be writing this particular missive from a yacht in the Bahamas! Yet for many years we accepted this attitude to human limitations as entirely acceptable; it was part of the, ‘can do’ attitude; we will always get the job done. But at what cost? How many times have accidents happened in the past which were directly attributable to fatigue? In terms of performance impairment the effect of fatigue, even at low levels is broadly comparable to that of alcohol, but whilst we would never contemplate turning up for work three sheets to the wind we are happy to ignore the signs of fatigue.

This particular RAFCAM piece raises some interesting points, and I dare say a few eyebrows at the same time: naps at work, comfy beds, well planned shift patterns, these things were the stuff of dreams when I was a young whipper snapper on ops. But times must, and should, change. Whilst we will always demand the very best of our people we can not do so if the

doing your best & stil l making errors...

…What’s Up With That!By Master Warrant Officer Gillis, 410 Tactical Fighter Operational Training Squadron, 4 Wing, Cold Lake, Alberta, Canada

air CLU

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This saga began at RAF Akrotiri before they had operating windows, with what should have been an undemanding long-range navigation exercise. We were to take a Vulcan of the Akrotiri Bomber Wing for a long weekend at RAF Gan, the RAF’s own tropical island.

The original plan was quite simple: depart Akrotiri on Thursday, night-stop at Masirah and fly to Gan on Friday and we would have three clear nights in paradise. The only planning factor was to arrive at Masirah by 1700 hrs local time. Masirah was 90 minutes ahead of Cyprus, so with a flight time of 4 hr 30 min, and allowing for the time difference, we could afford a gentlemanly departure from Cyprus at 1000 hrs local. We had one hour in hand for any delays.

The aircraft was unserviceable; we lost our window into Masirah. It was not worthwhile going for a 24-hour delay; as this would mean a Saturday arrival in Gan, and hardly worth the effort, so we entered a bargaining

phase with the engineers. Eventually it was agreed that we could take the aircraft and double stage the next day. Now we just had to fit the two legs to Gan into the airfield opening hours at both airfields.

We had to arrive at Gan before teatime, but could not land at Masirah before 0900 hrs Masirah time. Also we would have to leave Masirah by 1200 hrs local if we were to reach Gan, a further 90 minutes ahead of Masirah, in time. With a ‘book’ turnaround time of 3 hours, the plan was very tight.

The revised plan called for a departure from Akrotiri at 0300 hrs local on Friday morning. The new show time was midnight so we had 12 hours in which to rest. We had started work at 0700 hrs local and it was now nearer midday. With the temperature rising to a typical 30°C plus, and already fully rested, sleep was impossible.

The skipper and plotter repaired to their on-base quarters; the AEO probably went down to the beach;

the co-pilot and I, the Nav Radar, just did our own thing with the odd nap thrown in. Our crew chiefs, who had no active role during the flight, slaved to fix the jet.

By midnight we were ready for bed. We gathered for the pre-flight briefing, refreshed the plan and loaded the aircraft. We were perhaps too tired to make the proper decision – scrub. Even now things did not go entirely to plan and we had a crew-in snag and eventually departed at 0340 hrs local. We were now committed to a fast turnaround at Masirah. We had lost any flex. We set our northerly course for Turkey and our penetration route into Iran. The route was quite sporty, especially for a nuclear bomber, as it required us to negotiate the corridor between Syria and the USSR with the radar under

strict emission control. Our principal navigation aid, the radar, was the Lake Van Non Directional Beacon (NDB). There were two problems with this. The Russians were notorious for ‘meaconing’ and trying to seduce allied aircraft into their airspace and the Vulcan’s ADF receiver was notoriously poor.

At Van we were only 7 minutes flying time from the Soviet border. We reached Lake Van 1 hr 10 min after take-off. We were very alert. A quick radar fix over Lake Van, a bit of right hand down a bit, and we were on a safe course for Tehran. We relaxed.

We relaxed completely. The Nav Plotter did not relax his guard and beavered away checking and cross-checking our flight path. We arrived over Tehran almost 2 hours later. We

Originally printed in the final edition of Air Clues, April 2002.

I learnt about fat iguefrom that….

were to put in a lot of right-hand down a bit before taking up a southerly heading towards Shiraz, the Gulf, and Masirah. In best Nav school fashion the plotter passed all the next leg details two minutes before the turn. Silence. Thirty seconds to go he issued the instruction to turn. Silence. I only know this as he woke me up.

The AEO, apparently watching over the electrics has his head on one side and was fast asleep. I looked forward and both engineers were dead to the world. In the cockpit both pilots were crashed out. I may have woken them, but they were definitely in the sleep inertia phase. Fortunately in the Vulcan the navigator could steer the aircraft through the autopilot. He duly executed the 80-degree

turn. What he could not do then was transmit on the radio. He listened for the complaints from Tehran Control. Silence. Were they asleep too? We never found out.

A while later, the sun streaming through the windscreen, the pilots were fully refreshed and back in control oblivious to the drama that had nearly occurred.

The lessons? If it is not essential don’t push it. If your planned work day is likely to be delayed, go back into proper crew rest; don’t try and get tired first, store up more sleep. If you’re a self-auth, or a flight commander, consider a second opinion even if it means they have to be up in the middle of the night too. We had two flight commanders in the crew so we had plenty of experience! And the weekend? Great!

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It was another typical exercise sortie where we were due to man a CAP west of the Shetlands for a 2 hr ‘vul’ period, and, therefore, needed to tank in advance to meet the task. This of course dragged the take off time even further forward, calling for an, ‘Oh my lord’ take off time, leaving little flexibility for last minute hitches; which of course we had. Having got the ac almost ready to taxy, an engine management system problem cropped up, requiring a full shut-down and power recycle. On reapplying the power, the problem was still there so we started unstrap-ping to change ac, However, the Chief thought of one more fix which cured the snag and we were good to go. We hurriedly strapped in again and managed to launch on time to the tanker; no problems.

After an uneventful join on the tanker we took our place in the queue and waited our turn to plug-in. After about 30 mins airborne it was our turn and after some up-down-left-right from me, my pilot got in first time. To let him concentrate, we didn’t speak for a while and I found my mind wandering while looking at the snow covered Highlands below. Then I became aware that my vision was tunnelling in and my fingers were tingling, which I thought was strange. I was also aware that my breathing was shallow and I felt light headed. Putting it down to the early start, I tried taking a few deep breaths, but didn’t really feel any better.

As I felt progressively worse, my thoughts went back to one of my

numerous visits to AMTW (at my age I’m on my fourth 5 yearly refresher), and I correlated all my symptoms with the onset of Hypoxia. Looking down at the 2 oxygen MIs, I saw that my pilot was flicking white to black indicating that he was breathing happily, but my MI was a stubborn black. Before committing to pulling the emergency oxygen handle (the hypoxia bold face action), I flicked the regulator to 100% to see if I got a continuous flow; there was nothing. Quickly checking my oxygen hose, I found it hanging loose from my mask and not connected to the PEC bayonet. I connected it up, got the 100% flow and quite quickly felt better, so decided against pulling the emergency oxygen as it was quite clear why the problem had arisen.

Clearly when we had decided to crew out I had disconnected the bayonet, but not reconnected it when we decided that the ac was serviceable after all. I explained to my pilot what had happened, but emphasised that I was now perfectly OK and happy to continue. However, had I not had that repeated exposure to the aero medically trained doctors at North Luffenham, and latterly Henlow, who had drummed the symptoms of hypoxia in to me, it might have been a different story. I have been flying fast jets for 28 years now and have 2,300 hrs on the type in question, yet this was the first time I had ever become hypoxic outside of the oversight of a doctor. Luckily, their training had allowed me to recognise the fact.

Spry says:Being a member of the winged master race I have, in the past of course, been accused of paying lip service to the continuation training I have done. Surely, once I’m qualified I should be out there going up-diddley-up, not wedging my eyelids open to stop falling asleep during another tiresome lecture. However, it’s incidents like this that really remind me of why training is the better part of operations; because when the proverbial hits the fan it’s the training that saves your life. So next time you’re sat in a stuffy briefing room, simulator or wherever, look beyond the fact that you aren’t in the air and think of it is an investment in your future health!

In the summer of 2007 I was enjoying the start of my third tour on the Tornado GR4 on 14 Sqn at Exercise Anatolian Eagle. On the second Monday of the detachment I was called into the office for a chat with the Boss. I was told to RTB; my heart sank and I began to wonder what I had done? I was posted to 29(R) Squadron to undertake the Typhoon Operational Conversion Unit (OCU). I was thrilled and somewhat smug at the number of, ‘green eyed monsters’ that appeared when the decision was announced to the rest of the squadron.

Before attending the OCU I had to go through the extensive pre-employment training. This started with a trip to the Centre of Aviation Medicine (CAM) at RAF Henlow to

understand the physiological effects of flying such a high performance aircraft and get to grips with pressure breathing now that I would be able to easily attain FL550 in my new steed. I was also kitted out with my new Aircrew Equipment Assemblies (AEA) including a new G-suit – full coverage anti-g trouser (affectionately named: faggot) and pressure jerkin. The next step was to Farnborough to undergo centrifuge training, experiencing up to 9Gz and passing the mandatory high Gz qualification run to proceed with the training.

With my centrifuge experience fresh in my mind I was subject to two high-G sorties in the CAM Hawk aircraft based at Boscombe Down. This is performed in full Typhoon AEA and is designed to give you confidence

in the kit; I was pleasantly surprised to find that I could comfortably maintain 6Gz without any kind of straining and flying at 9Gz was easily achievable. My final port of call was to Swanwick (Mil) to be made aware of the pitfalls and advantages of the Typhoon’s exceptional rate of climb and service ceiling!

Eager to get my hands on the aircraft I was forced to wait a little longer as there was a 4 week ground school phase to attend at the Typhoon Training Facility at RAF Coningsby, the MOB HQ of the Typhoon Force. The Ground School phase consisted of 2 weeks of classroom technical instruction where the complexity of the aircraft and the various fleets of Typhoon became all too apparent; see Figure 1.

from that….I learnt about hypoxia per tornado ad astra

OC Typhoon Training Flight, Sqn Ldr Mannering describes the path to Combat Readiness on the Typhoon

Figure1: Table of Typhoon Aircraft Standards

BlockFlight Control

SystemAir to Air Capability

Air to Surface Capability

Avionics/ Approach Equipment

1Phase 3, 90% control authority, 8.1G with

override

Early radar software, hybrid ASRAAM, not

cleared for QRANil No ILS / TACAN

2BPhase 4, 90% control authority, 8.1G with no

override

Improved radar software with hybrid

ASRAAM and AMRAAM capable of

holding QRA

Nil

TACAN, Disorientation Recovery Facility,

basic Multi Function Information Distribution

System (MIDS)

5 / R2Phase 5, 100% control

with no overrideDigital ASRAAM,

AMRAAM

Austere A/S, Litening III LDP, Paveway /

E-Paveway II, (KFF / Cannon), SRP 4.2

TACAN, ILS, MLS, MIDS

8 (Basic Block 5 –

Improved processing but more limited A/S)

“ “ Paveway II Drop only TACAN, ILS, MIDS

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There was a graduated migration to the Typhoon simulators to undertake basic conversion and emergency procedure training. TTF utilises Aircrew Synthetic Training Aids (ASTA) a four nation project consisting of two Full Mission Simulators (FMS) and two Cockpit Trainers (CTs). The 4 week phase culminates in a simulator check ride consisting of an Instrument Flying training sortie with full emergency procedure training and examinations on Typhoon technical data and emergency procedures.

At last it was time to start the conversion (cvx) phase. My first sortie consisted of general handling followed by Instrument Flying

and circuit practice, but all I can really remember is grinning at the acceleration of the aircraft that was only in dry power but had the ability to climb at 20° nose up at 400KDAS. The other lasting impression is of a very clean uncluttered cockpit with 3 Multi-Function Head Down Displays (MHDDs) and wide angle HUD with all the information a pilot could wish for! The cvx consists of 5 sorties including an IRT then first solo, followed by a formation ride and a night check ride. The first solo on type usually in a single seat aircraft as opposed to a ‘tub’ (twin seat Typhoon) usually involves the pilot enjoying the awesome performance of the aircraft at low level either in the Lake District, or Wales followed by a transit at FL500 or above because you can. Such is the performance of the aircraft at low level that it is

imperative to use the Auto-throttle set to 420KDAS to avoid encroaching the transonic region and causing untold complaints!

With the cvx phase complete, it was time to start the tactical portion of the syllabus. The Typhoon Force Basic Counter Air Module (BCAM) OCU syllabus aims to teach the pilot basic Air Defence (AD) skills. The aim being for the pilot to be able to fight the aircraft firstly, within visual range (WVR) employing the ASRAAM, then work up to beyond visual range (BVR) utilising the AMRAAM, and then finally combining all the disciplines as a tactical pair. The WVR phase involved two synthetic events and 7 live flying events covering Offensive, Defensive and High-aspect fighter manoeuvring. This phase was highly demanding physically owing to the high Gz loading on your body and

the manipulation of the weapon system. Typhoon human-to-machine interface is ergonomically superior to many aircraft in service, utilising Voice Throttle and Stick (VTAS) inputs to control the weapon system; very much a home-away-from-home for the, ‘Playstation Generation’. The voice part of VTAS employs a Direct Voice Input capability within the aircraft to manipulate the radar, weapon targeting and cockpit domestics eg. radio changes.

The BVR Phase consisted of 3 synthetic events and 4 live flying events working up from 1 v 1 intercepts to 1 v 2 at low level employing AMRAAM then ASRAAM tactics. It was during this phase that I started to become aware of the vast amount of information that the aircraft had to offer, and the consequent temptation to stay, `heads-in’, soaking it all up.

The BVR Phase moved swiftly onto the Pairs Phase. This phase consisted of 3 synthetic events and 6 flying events culminating in a pair of Typhoons, with me as the wingman, fighting an unknown pair of hostile aircraft in a variety of different presentations. The pairs element of the OCU was undeniably the most tactical and most demanding with the introduction of Defensive Aids and Data link (MIDS/Link16) manipulation. The final part of the Course is the Quick Reaction Alert (QRA) Phase which enables a graduate from 29(R) Squadron to be declared Limited Combat Ready(Q) and thus able to undertake the 24/7, 10 minute notice-to-launch for NATO and UK duties.

Upon graduation, pilots are posted to either Nos 3(F), XI or 17(F) Squadrons at RAF Coningsby, and

towards the end of 2010, to No 6 Squadron at RAF Leuchars. Here the young graduate will go on to complete an Advanced Counter Air Module (ACAM), and for selected individuals, the Basic and Advanced Surface to Air Module (BSAM/ASAM). Upon declaration of Typhoon Force Multi-Role OED on 1 July 2008, Typhoon aircraft could deliver UK Paveway II, Enhanced Paveway II, Freefall 1000lb bombs and utilise the Litening III RD pod whilst performing its initial AD capability. At the time of writing this article, the Typhoon Force is preparing to deploy to the Falkland Islands to take over QRA duties there, and is focussing on further extending the Force to RAF Leuchars.

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“Practice engine failure go….” How many times have you heard that? How many times have you said it? It usually results in the student making their way through some form of emergency drill and then we all go home for tea and buns. In an attempt to maintain that happy status quo I have been asked to write this piece about an incident which happened to me and which almost did not result in us going home for tea and buns.

Some background will be of use to non-helicopter specialists. The Squirrel HT1/2 is a single engine conventional rotor helicopter used for basic and advanced helicopter flying training; we also use it here at CFS (H) to teach experienced helicopter pilots how to become instructors (QHIs). In common with many other single engine helicopters it is inadvisable to hover the Squirrel much above 5 feet because if the engine were to fail, it is unlikely that a successful landing could be made from up there. Successful landings can be made from around 5 feet without the benefit of the engine, and indeed they are practised regularly by staff QHIs. To make this practice more realistic the throttle may be retarded in the hover so that the engine plays no part in the subsequent landing. The throttle is operated by a twist-grip on the collective lever. When the throttle is retarded in the hover it is done so in one swift movement. The main rotor will begin to slow down immediately as it is no longer being driven, but because it still has a certain amount of inertia, a well-timed application of extra pitch will slow the rate of descent sufficiently to allow a soft landing; but the higher you are the further there is to fall, and from much above 5 feet the rate of descent will have built up so much that even the most well-timed application of extra pitch is unlikely to be effective enough to prevent a heavy landing. It is not possible to re-engage the engine until after the aircraft has landed. These practices are known as engine-off landings. However, this closing of the throttle is only ever done after a number of careful briefings both on the ground and in the air, and only then under specific circumstances, and even then the throttle is only ever closed by the person acting as the instructor. Other types of practice engine failures may be initiated by the same phrase “Practice engine failure go…” but the throttle is never closed unless this careful and protracted sequence of briefings have been carried out. I knew that, and I assumed that everyone else did…

Can you see where this is going yet? The incident itself was relatively quick, as these things often are, and the outcome was relatively benign, as these things so often sadly are not. The student was flying the aircraft at a relief landing ground (RLG); he had just completed an approach to the hover and was briefing the next manoeuvre. He inadvertently allowed the aircraft to drift upwards in the hover to about 30 feet. In order to draw his attention to this fact, I called “Practice engine failure go…”, fully expecting him to simply lower the collective slightly and conduct a powered run-on landing straight ahead, making a mental note as he did

so to monitor his hover height more carefully in the future. But he didn’t; he closed the throttle instead. I took control and cushioned the landing as well as I could. It turned out that no damage had been done and we subsequently flew the aircraft back to base after an engineering inspection.

So, what was the problem? Well, I allowed the aircraft to be placed about 22 feet or so above the height from which a successful engine-off landing is likely to be made; I then said something which inspired the student to close the throttle, and I was neither able to stop him doing so, nor was I able to re-open the throttle before landing.

A little of the non-technical background to this incident may now be of interest. The student in this case was actually a very experienced helicopter pilot recently returned from the latest of a large number of front-line detachments. He had also been a fixed wing instructor. Between the two of us in the cockpit that day we had over 15000 flying hours and over 50 years of experience in the military. Surely he must think the same way I do? He was learning to be a helicopter instructor. The previous day we had been practising hover engine-off landings as part of the course. As part of that previous sortie the student instructor is encouraged to use the throttle himself to initiate the engine-off landing, as he would have to if he had a real basic student on board with him. The engine-off sortie is carefully briefed on the ground beforehand, so that both crewmembers know exactly what will

Assumption is the mother of all ………. One flying instructors close shave with communications, flying and a healthy dose of, ‘I thought he understood’………

happen, who will initiate and who will carry out each engine-off landing. The engine-off landing sortie may only be carried out at certain airfields. Before each engine-off landing is carried out during the sortie, a further brief is conducted in which specific mention is made of the entry height, type of engine-off to be practised, who will close the throttle and who will carry out the engine-off landing. Each engine-off landing is initiated by the phrase, “Practice engine failure go….”.

This previous sortie had been carried out uneventfully. Today’s sortie was not to include engine-off landings. They were not mentioned in the pre-flight brief, and were not authorised. We were at an RLG where they are not permitted, and no engine-off landing checks were mentioned at any time during the flight. Would you therefore have expected your student to initiate an engine-off landing in response to the phrase, “Practice engine failure go…”? I didn’t. But I should have been ready for it, just in case…

So what are the lessons? Firstly, “expect the unexpected”. I’ve never thought that was a particularly helpful phrase. But in this case it could be interpreted as, “keep your hands close enough to the controls so that you can prevent the student doing anything which may become dangerous – however unlikely that

thing may be in your mind”. The more potentially dangerous the situation, the closer your hands should be to the critical control; and if you may need to prevent a swift movement of the throttle, your hand needs to be already on it. In this case, whilst I was able to take control quickly, I wasn’t able to prevent the throttle being closed.

Secondly, of the options available to me to highlight the student’s error, was calling, “Practice engine failure go…” the best one? Probably not. I did wish to make the point rather more memorable to him than just murmuring, “height”, but perhaps not quite as memorable as it now is.

Thirdly, this is yet another example of two people in the same cockpit having totally different interpretations of the same situation. Ask yourself, “Is what I have just said to the student totally unambiguous – is the student thinking what I am thinking – will he do what I think he will?”. Speak to your shiny new Aircrew Performance Coach, they will explain all about Neuro-Linguistic Programming.

Finally – it’s always the instructor’s fault. Whatever the student should, or should not have done, is irrelevant. I allowed the aircraft to end up in a position from which I was lucky to recover. A superior instructor would have used his superior judgement to prevent him from being there in the first place.

Spry Says:Christmas comes early for one instructor, and hasn’t he been a good boy? For Santa brings him the greatest gift of all ….. hindsight. In all seriousness, what this experience does highlight for me is the danger that we all face, regardless of branch, when we begin to get comfortable. You know what I mean; when you hear yourself saying things like ……‘Oh this is just a routine flight’, or, ‘I don’t need the MPs; I’ve done a ???? so many times I can do it in my sleep’. Complacency as we have seen elsewhere in this fine publication can be just as dangerous as inexperience. If there is one thing I have seen throughout my career is that the best people often make the worst mistakes; and 9 times out of 10 this is as a result of becoming blasé about the job. The Service asks us to give our best in situations that our often extremely demanding and unforgiving of even the slightest complacency. The challenge lies in identifying how we prevent complacency developing in the first place. I don’t pretend to know the answer, but I daresay you bright sparks out there do, so put pen to paper and give the gift of hindsight to others before the event!

I learnt about instructing from that...

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display able to provide the pilot with an array of options, using information provided by complex avionics. It all points towards information saturation. Every pilot experiences information overload at some stage in his flying career, and in modern fighter aircraft it is all too prevalent. The real skill in operating an aircraft like Typhoon, is in knowing where to look for information and being disciplined about when you look for it. It sounds obvious, but almost every Typhoon pilot will have experienced the feeling of being drawn into the Displays. From staring at the RADAR scope monitoring the targets, DASS and Link 16, to being engrossed in the LDP format watching the `time to impact’ count down - the danger is the same. You must adopt a disciplined approach to looking out of the cockpit for the same things you did before you flew a glass cockpit:

… The Defensive Aids Sub System (DASS) audio chirps loudly indicating a Surface to Air Missile (SAM) system has achieved lock on my Typhoon. In a matter of seconds the audio changes to tell me that the SAM has fired and is now guiding towards me. I look through the Head Up Display (HUD) and see the direction and classification of the SAM. The displays agree with the audio. My Combined Counter Measures (CCM) are telling me how to manoeuvre my aircraft to defeat the system and are ready to deploy the array of countermeasures. I snap-roll the aircraft and pull hard to follow the green writing in the HUD. At the same time, my automatic countermeasures deploy. Pull hard following green arrow. Green arrow to green box, pause, box disappears, new arrow in a different direction, pull, then nothing. The directions cease, the audio stops, the SAM has broken lock. I roll to the nearest horizon and level off.

It was then that I realised I didn’t know where the SAM was. All I had done for the last few seconds was be the stick monkey in the front who diligently followed the directions in the HUD. Where was the SAM? Where am I? Where is my Wingman? The display had been so compelling it was hard not to stare at it. The HUD

was my security blanket, providing me with the information it thought I needed. What I hadn’t done was aviate. Fortunately, I was conducting a trial and the SAM was simulated, however, it did make me question my priorities. Nice green writing/colour displays vs outside the window. As a result of operator feedback the CCM manoeuvres have been reduced significantly.

Two years later, I was sitting in the back of a 2-seat Typhoon with a student in the front … We are taking the long taxi from the ASP to the threshold and the speed is increasing. Typhoon has excess power in almost every environment, and on the ground is no exception. Our speed increases as the student is absorbed by the sheer quantity of information available to him, on the aesthetically pleasing displays. Now at a fast taxi speed I chirp up from the back, ‘Bloggs, how fast are we going?’ The student scours the head down displays for the information. ‘Eh’ is the response. ‘Look out the window’ I helpfully suggest (I hate instructors like me) and to his amazement, the grass whistling by the side of the aircraft, gave him the answer. He had dropped the basics because of his new glass environment.

The average transport aircraft in the mid-1970s had more than

one hundred cockpit instruments and controls. The increasing requirement for information meant that the displays were competing for cockpit space and pilot attention. As a result, NASA conducted research on displays that could process the raw aircraft system and flight data into an integrated, easily understood picture. The success of the NASA-led glass cockpit work is reflected in the total acceptance of electronic flight displays beginning with the introduction of the MD-80 in 1979. The RAF has seen cockpit modernization programmes across most of its fleet of aircraft, which almost always include addition of glass cockpit displays. Typhoon has been more fortunate in that it was designed from the outset with a glass cockpit. Even the reversionary instruments are glass.

The main reason for having a glass cockpit is to reduce pilot workload, and to increase safety. It does this by presenting the information in an eye-pleasing manner, which can change depending on phase of flight, or pilot workload. The pilot will also generally have a number of options to customize the displays to suit personal preference, or the task. As display technology has advanced, so too have aircraft sensors and data-links. The result is a very complex

the double edged sword

wingmen, threats, weather etc. And what happens when things

go wrong? The combinations of emergencies through either electrical failures or software problems are infinite. This provides glass cockpit operators with a conundrum: ‘what emergencies do you practice’, and, ‘what are just too unlikely?’ Either way, the operator must Aviate-Navigate-Communicate. The aircraft will not fall out of the sky just because all of the displays are blank. Another possibility is considering display failure and another emergency simultaneously. Once again unlikely, however, I recently had a loss of all displays whilst conducting Air Combat. I recovered the aircraft to the horizon and initiated my RTB. Whilst in the climb, I looked in the Canopy Mirror and noticed a significant quantity of fuel venting from the Fin, so I commenced the fuel-leak drill.

The Typhoon delivers state-of-the-art, automated avionics and combat systems that prioritise and display essential information to the pilot, but is this always good news?

Sqn Ldr Mc Meeking, OC STANEVAL for the Typhoon Force offers his thoughts on flying the glass cockpit……

Now I had a fuel leak and display failure simultaneously. A few minutes later the displays returned and I was informed by the FUEL page that fuel was leaking from the Vent pipe. Your aviation experience can’t stop just because you have had a display failure.

How far do we take glass cockpit displays? When are they essential instruments, and, when do we rely on them too much? Helmet Mounted Displays (HMD) present a further potential saturation, as even when you are looking out of the cockpit you are looking through a display. Operators must not forget the basics they learnt through flying training. Ultimately, glass cockpits are essential in modern aircraft with complex sensors, and if programmed correctly, they are compendious displays for competent, trained operators.

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addition to the aircraft over the export Hawk 100-series design, is the incorporation of a powerful nose light (a la Hawk T1), which has been proven to be a significant aid to seeing the aircraft, particularly when it is head on.

Procedures, rules, regulations and policies are put in place to ensure that the risks inherent in aviation are minimised – that’s what flight safety is. Whilst not a panacea, TCAS clearly has its part to play in preventing airprox (or worse). For all aircraft types, however, an awareness of risk factors (such as the specific ones above that we face at RAF Valley) can only help to focus attention on mitigating the airprox risk inherent in the Class G, “see and be seen” airspace in which we all operate.

Airprox, the word that strikes fear into the majority of aircrew, not just for the paperwork, but also for the potential outcomes. In today’s current operational and training climate, we are reminded regularly of the hazards that face us with the close proximity of not only our own aircraft, but civilian aircraft as well.

RAF Valley is a unique place, hosting the 2 fast-jet squadrons of No. 4 Flying Training School (4FTS) operating the Hawk T1/T1A and T2, the Search and Rescue Training Unit (SARTU) operating both the Griffin and now also the Augusta 139 training foreign students, 203 Sqn (the Sea King Operational Conversion Unit) and the operational SAR unit of C Flt, 22 Sqn. It is also home to Anglesey Airport, a civilian consortium running shuttles to Cardiff twice daily. Throughout the year, the Station sees numerous detachments taking advantage of the rotary Mountain Flying Training Area (MFTA) and low flying system in North Wales. Additionally, both 4 FTS and 203 Sqn utilise RAF Mona, a relief airfield approximately 5nm from Valley. The Station is arguably one of the busiest in the MOD, and as you can imagine, the local airspace gets mighty busy too. De-confliction in this airspace is a challenging task, particularly when you take into account the specific issues which affect us here.

Local problems, for local people?Students – In the Class G airspace in which we operate, effective lookout is vital. However, with students under intense pressure throughout AFT and TWU, flying increasingly complex composite, often multi-ship, sorties, lookout can be quickly compromised when the workload builds. It may be worthy of note that our students come from the Tucano, which has the traffic collision avoidance system (TCAS), whereas the Hawk T1 does not, so they have to rely entirely on effective lookout to generate situational awareness of aircraft in close proximity.

Landmarks - In a low level training area such as North Wales (Low Flying Area 7), there are inevitably some key landmarks which are used by 4 FTS during both planned black-line and free-navigation sorties. Some are point features which are used as turning points – the Hawk T1 relies solely on map and stopwatch navigation at low level – whilst others are natural funnel

features (some with and some without flow arrows). The navigation technique teaches, ‘big to small’ so it is no surprise that big features are used in this way. However, most other airspace users also exploit these specific prominent landmarks. Therefore, they rapidly become magnets for aircraft utilizing the low-level flying system. No. 4 FTS has its own low-level deconfliction process, which considerably reduces the risk of meeting another 4 FTS Hawk unexpectedly. However, we are unable to deconflict from other airspace users, so these magnet landmarks will continue as just that – magnets.

Weather - Weather is a major contributory factor to flying training here, and anyone who has been to Valley knows how quickly the weather can change. Our low-level flying training is therefore focussed into periods of fine weather, exacerbating the effects of geographic compression with time compression as well. Furthermore, the Hawk Nose light – which must be serviceable and on for flight at low level – and High Intensity Strobes become more difficult to see in bright lighting conditions.

Free Navigation – This is a vital aspect of fast-jet training, both as a skill in its own right, but also as a means of adapting the plan to still achieve a DCO when the weather isn’t as forecast. Such flexibility inevitably impacts on the efficacy of the pre-flight deconfliction process at 4 FTS, although this still provides a general awareness ‘in house’. An associated issue is that of increased cockpit workload during free-navigation. Whilst the paramount importance of effective lookout is stressed at all times, it is inevitable that this will suffer to some degree during these periods of increased workload.

Airspace Usage – The airspace over and around Anglesey and North Wales is perhaps busier now, and with a more diverse set of platforms, than ever. Not only are the Station’s indigenous assets operating here, but also numerous visiting aircraft and detachments make use of the excellent class G training airspace. With the reducing number of Main Operating Bases, concentrating military aircraft basing, and continual squeeze/reduction of class G airspace, it is almost inevitable that the density of operations will increase in those good, local training areas which are left. On top of that, it is important to educate those that fly to and from other airfields into the Class G airspace in North Wales, about the activities of 4 FTS (part of the reason for writing this article).

Civil Users – Whilst this hasn’t manifested itself as a major factor yet, we are nevertheless aware of the increased civilian use we have seen here since the establishment of Anglesey Airport just over 2 years ago. At present, Highland Airways operate a scheduled Jetstream 31 service to/from Cardiff only, although rumours abound of possible expansion plans. For the time being, however, the scheduled service integrates almost seamlessly into our other operations and hasn’t presented us the deconfliction issues we originally feared.

Thoughts on the problemIn recent months, RAF Valley has seen a significant increase in the number of airprox, both “blue on blue” and with other types, and at both medium and low level. Perhaps situations that used to be put down to experience are now being more vigorously reported upon, which can only be for the good. No one sets out to have an airprox, so we should have nothing to hide and allowing the UK Airprox Board to take an independent and thorough look offers us the best opportunity to learn from an event and to try and prevent future occurrences. And perhaps we need to think more about our trg ‘culture’. Nailing the numbers (speed, AOB, heading etc) is a key part of how we assess performance. Accurate flying is, of course, one of the basics that need to be mastered, but perhaps this also encourages students to go heads-in to check the numbers rather than getting their heads out with confidence. At the end of the day, the way that we assess has an impact on behaviour.

Looking to the futureAs we look to the future here, the introduction into service of the Hawk T Mk 2 offers both a step challenge and a step opportunity. With significantly more kit than the Hawk T1, there will be the possibility for more time to be spent, “heads-in”. However, whilst not a 100% solution, the TCAS fitted to the aircraft will at least significantly mitigate that risk and is already paying dividends in helping to avoid airprox situations. A less technological, but equally important

a close run th ingFlight Lieutenant Stuart Hicken, SFSO, RAF Valley analyses the particular hazards in the

skies above the Welsh station, which make Airprox a daily danger to its aviators.

“Airprox - a situation in which, in the opinion of a pilot, or controller, the distance between aircraft as well as their relative positions and speeds have been such that the safety of the

aircraft involved was, or may have been, compromised.”

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of these factors further. These areas are those that I see as pivotal, not necessarily to the cause of the crash, but as areas which we the organisation and individuals need to consider so that an incident similar to Ben Macdui does not reoccur.

Situational AwarenessAccording to CAP 737, situational awareness involves the conscious recognition of all the factors and conditions - operational, technical and human – which affect the safe operation of an aircraft. In order to establish situational awareness, human beings take in the information through the 5 senses – touch, hearing, smell, sight and taste – both subconsciously or intuitively. This information is then transformed by the brain into a mental model of the situation, a process known as perception. The perceptive process depends not only merely on current information for its evaluation of the situation but also takes account of past experience and sensations. Perception is therefore a product not only of immediate sensations but also of cultural and social influences acquired through a life time of experiences.

In this incident both the F15 pilots and the Air Traffic Controller had developed a perceptual model of the airspace and terrain around them based on: the data their instruments were feeding them; the prevailing environmental conditions; their past experiences; procedures and professional terminology they were familiar with; and ultimately, by the assumptions that were made on the functional responsibilities of each party, particularly as to who would provide terrain clearance. What is evident, particularly with hindsight, is that the perceptions of the pilots and the controller were inconsistent with each other and conspired to lead the formation into a loss of situational

On 26 Mar 2001, 2 USAF F-15C ac and their crews tragically crashed into the summit of Ben Macdui with the loss of both pilots. The ac in question had earlier departed RAF Lakenheath on a training sortie that included a transit to the Scottish Highlands and a subsequent planned descent to low level in the Ben Macdui area. The weather was not particularly good in the vicinity of their descent point with no obvious gaps in the cloud for them to make a visual descent. Although under the receipt of an ATC radar service at the time the BOI concluded that the accident occurred because the formation accepted an unsafe ATC instruction and descended without sufficient references to avoid hitting the ground. Reflecting upon the incident highlights a number of areas that are of current interest, which can hopefully be discussed in greater detail within this article. I intend to highlight the organisational culture differences between then and now and try to explain why it is so important for the RAF to embrace the Just Culture. I also want to briefly explain the meaning of the term Human Factors and then cherry pick two factors from this incident which I consider important for further discussion, specifically situational awareness and stress. I then intend to identify what, if anything, has changed in the succeeding years to ensure that incidents like Ben Macdui are prevented.

ORGANISATIONAL CULTUREThe Ben Macdui incident has been permanently etched into my memory as a shocking milestone event involving the Court Martial of a controller in what was

probably, one of the most expensive court cases conducted against an RAF Officer in history. The individual was subsequently cleared of the charges laid against him, but, to a degree, the damage had already been done with a loss of confidence between the “executive body” and the rank and file controllers within the Branch. The perception that a, blame culture existed in the RAF following the incident seriously affected the beliefs and practices of most of the military ATC personnel. The direct result of the court martial was a significant lowering of morale throughout the branch and a much more conservative style of day-to-day air traffic service being provided. This was not to say that controlling in early 2001 was cavalier at any stage, but merely described the fact that controllers were now fully aware of their potential culpability and thus controlled accordingly.

Certainly discussion amongst my peers revealed significant cynicism within the controlling fraternity as to what protection, the RAF would provide in similar circumstances in the future. This probably isn’t an issue to the majority of controllers trained since 2001 as they were unaware of the significance of the event, but it still affected a large legacy population of controllers of pre-2001 vintage. It is interesting therefore to contemplate what, if anything, has changed over the last 8 years to amend these views.

The gradual change of ATC policy

from one of “trapping” to one of continued assurance has been a leap in the right direction. Though can one say if this has been enough? In addition, has the change from a perceived blame culture to one of an RAF-endorsed Just Culture actually filtered down to the shop floor? Unfortunately, without this open and just culture there will be a reluctance to submit the incident reports, on which the system relies to generate systemic and organisational improvements, for fear of reprisal. Certainly, speaking as one of the converted, my cynicism about the feasibility and benefits of a Just Culture no longer exists; though does that stand true for the majority of legacy controllers? Establishing the extent of the Just Culture’s permeation through the ranks of the Air Traffic community will be a task of critical importance for not only the ATC fraternity, but also the RAF FS organisation.

Analysing the Human FactorIn any aviation accident there are usually a number of clearly identifiable Error Promoting Conditions (EPCs) which conspire to cause it. Common examples of EPCs are when there is a lack of communication, knowledge, teamwork, resources, assertiveness or awareness; or the presence of complacency, distraction, fatigue, pressure, stress or norms. You will probably know these better as the, ‘Dirty Dozen’.

In the Ben Macdui incident it was evident that EPCs existed in a number of different ways, the outcome of which culminated in the tragic loss of men and machines. Hindsight is a wonderful thing, but the fact remained that at the time these EPCs were not clearly identifiable to the personnel directly involved in the incident and as such the downward spiral of events was able to continue to its end state.

According to the Board of Inquiry the accident occurred because the formation accepted an unsafe ATC instruction and descended without sufficient references to avoid hitting the ground. At the time the contributing factors to the incident were as follows:

a. The pilot’s use of the phrase, ”Min Vectoring Altitude”, which when

accepted by the controller, led the pilots to believe that ATC would provide terrain clearance.

b. The controller’s descent instruction to 4000 ft.

c. The pilot’s lack of situational awareness with regards to his position relative to high ground.

d. The lack of a ground collision avoidance system, ground proximity warning system or radar altimeter fitted to the F15C ac.

e. The formation’s descent below the ATC assigned altitude.

In addition, the BOI identified a further 8 possible contributory factors and 25 other factors. These ranged from the significant life stress levels in the controller’s personal life that could have led to a deterioration in his performance; a lack of formal guidance about how ATC managers should recognise significant life stress events amongst controllers, to the peculiarity of ATSOCAS to the UK, which increases the possibility of foreign aircrew making incorrect assumptions about UK ATC regulations. What this article intends to do is to analyse some

Lessons learned from Ben Macdui?

By Sqn Ldr Mark Barrett, SO2 ATC, RAF Flight Safety

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of any consultation with a doctor following the controller’s return to work, post sick leave, had no bearing on the accident. It did state however, that this was an area for consideration in the wider context of all personnel in flight safety critical areas. In my experience most line managers deal with individuals suffering from stress, be it family bereavement, marital problems, financial issues etc to name a few in a positive and supportive manner.

However, what are your views regarding clearance to work following time off on stress related issues? Should there be a requirement for a doctor’s certificate following a return to work, post a stress related incident? Do we/should we have a legal responsibility to ensure that an individual has been medically cleared fit for duty? Does someone have to take responsibility for bringing the individual back into ops, or is it the individual’s responsibility? In this litigious society, I personally believe it would be in the RAF’s interest to ensure that any individual in a flight safety critical area should have a medical clearance from the SMO prior to commencing work following a stress related period of leave. However, following discussions with the senior medics here at Air Cmd they consider it the responsibility of line management (Supervisor/Auth/ Watch Manager) and not a medical matter. In fact, discussion amongst the FS Desk Officers all came up with differing views on how to address this issue. There is currently clearly no hard and fast answer to this issue. Should there be one? Certainly there are definite left and right arcs, but what would be the best way of dealing with these kinds of issues?

ConclusionThe aim of the article was to raise awareness of the Just Culture and human factors, specifically,

situational awareness and stress and to promote discussion on how we as a Service deal with them. It also considered the profound effect the Ben Macdui incident had on the ATC community then and possibly now. As such, I feel it is important to consider that if the RAF Just Culture is to succeed, especially within the ATC/ASACS fraternity, that controllers feel confident that they can report the near incidents and, “bottom of the iceberg” issues without feeling they are shooting themselves in the foot. RAF FS would welcome feedback on any of the issues referred to in this article and hope that it will promote further discussion amongst the readership.

level of SA, there must also be a commitment from the organization to ensure it is maintained as well. In order to prevent another Ben Macdui, the priority must be training; training to make certain that users of our airspace are fully conversant with local and national procedures and changes made to them. This is particularly pertinent following the recent change of ATSOCAS rules which came into effect from 12 Mar 2009. I am unsure that, even now, it is clear who is responsible for ensuring that all foreign aircraft that fly in our airspace are fully conversant with these revised changes? In this particular case did we leave it to the Americans to do themselves? Are we/have we been proactive and sent UK aircrew and controllers from adjacent RAF bases/Air Traffic Control Radar Units (ATCRU)s to talk through these changes with them? Can we, the RAF, put a hand on our heart and say, “yes everyone flying in the UK is now aware of the new ATSOCAS changes; we can now stop the education process?” Is there an ongoing responsibility from us, us being ATC/Sqns/SFSOs /RAF FS, to continue to engage with not only the foreign nations flying from our shores, but those flying from the continent. In addition, should the General Aviation (GA) fraternity operating close to our MOBs be engaged to ensure that the revised ATSOCAS procedures are fully understood?

StressIn the Ben Macdui case, stress related factors were highlighted under, “possibly contributory” and, “other factors” which could have played an active part in the incident. The stress related factor considered was the very recent return to work of the Controller following a close family bereavement and period of sick leave. Following the investigation, the BOI considered that the lack

awareness and a controlled descent into terrain.

So what if anything can be done to mitigate against this type of incident reoccurring?

Certainly I was surprised to find that at the time of the incident the F15C was the only USAF FJ that did not have rad alt / ground proximity equipment fitted and to this day, according to USAF sources, there are no current plans to have them retrofitted. Obviously, equipment upgrades are one solution, but they do not address the underlying human factors which were implicated in the crash.

At the individual level, there is no panacea for poor situational awareness per se. The key to good SA must be to remain alert to the limitations of your cognitive perceptions and to never assume that the model you have is correct and/or held mutually by other parties you are operating with. Additionally, when we communicate with others, particularly, without the benefit of being face-to face, it is all too easy for the meaning of what we say to be misconstrued. Many is the well intended, humorous email that has been misinterpreted as argumentative, or provocative by the recipient. The point is that communication is a very subjective art; without common, unambiguous language the potential for accidents remains high. So in this case, uncertainty over control orders and terrain clearance responsibilities were not understood sufficiently clearly by the American aircrew whilst receiving a Radar Information Service (RIS) and when flying under Air Traffic Service Outside Controlled Airspace (ATSOCAS) rules. A relatively, simple misunderstanding that went unnoticed until the aircraft crashed.

Yet whilst it is beholden on any individual involved in aviation to maintain an accurate and informed

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The aircraft crash has long been an accepted consequence of the demanding nature of military aircraft operations. Whilst enemy action can factor in crash statistics from time to time, the complexity of military aircraft and the intensity of training for operations more often leads to the two most common causes; a human factors related failure or a technical fault. Since the early days of UK military aviation, aircraft operating units have salvaged crashed aircraft to clear operating surfaces, or to recover reusable spares. Nevertheless, during World War II, it is believed1 that many of the 10,000 plus UK, Allied nations and Luftwaffe aircraft that crashed on UK soil, went unsalvaged. However, with the advent of more detailed aircraft accident investigation, a more structured approach to aircraft recovery and as Aircraft Post Crash Management2 (APCM) evolved, today this role is undertaken on behalf of the UK MOD by JARTS.

BACKGROUNDJARTS was created on 1 May 07 from elements of the Forward Support IPT. The Aircraft Recovery & Transportation Flt (ARTF) at MOD St Athan, commonly referred to as, ‘Crash & Smash’, was RAF-manned and dealt with all Fixed Wing APCM. The Mobile Aircraft Support Unit (Transport & Salvage) section (MASU(T&S)) at Fleetlands in Gosport, comprised RN Fleet Air Arm personnel performing the corresponding Rotary Wing tasks. As JARTS, the two units have left behind their DLO/DE&S roots and are now an Air Combat Service Support Unit (ACSSU) under Air Command, subordinate to No. 85 (Expeditionary Logistics) Wg (85 (EL) Wg) at RAF Wittering, itself a part of the A4 Force Element.

JARTS is commanded by a RAF Sqn Ldr (Eng) with 2 Flight Commanders, an RAF Flt Lt (Eng) and a RN Lt (X(Av)). The Sqn is about 80 strong, with a 3/4 RAF to 1/4 RN makeup, and is predominantly split into three main trade areas:

• RAF A Tech M/RN AET(M)3 provide the aircraft technical expertise. The Aircraft Recovery Officers and aircraft transportation supervisors are taken from these personnel.

• RAF Logistics (Driver) and RN LGV Drivers fulfil the challenging role of road moving UK MOD aircraft, often including outsize and wide loads.

• JARTS holds a vast array of Ground Support Equipment in a large aircraft hangar to support both its crash recovery and transportation functions. RAF Gen Techs and RN AET(M)s maintain this equipment.

• JARTS also employs a number of civilian staff in key support roles. ROLESWhilst often viewed in its APCM capacity only, JARTS also uses its irreducible spare capacity and its expertise in aircraft recovery to provide a capability for the worldwide transportation4 of all operational MOD aircraft. JARTS also retains capability to lift and transport a whole variety of historic aircraft and gate guardians and, whilst these tasks may be of a low priority, they help to maintain the ‘skill at hand’ necessary to plan and undertake the more complex operational recoveries. Nevertheless, its new found status as an ACSSU recognises the significant tasking that JARTS receives in direct support of ongoing operations. Its core wartime role is to provide a Deployable Aircraft Recovery Team (DART) capability, but a large part of its day to day activities are centred around the transportation of helicopters, both in the UK by road and by air to operational theatres.

DARTJARTS’ primary role of providing specialist aircraft recovery personnel and equipment at a major staging airfield or forward operating base during an operational campaign is demonstrated through its capability to deploy up to 2 DARTs, each with the ability to operate independently and in separate theatres. A DART is normally held at high readiness in the UK but can be deployed during periods of high tempo air operations to be prepared to effect the rapid recovery of aircraft disabled on operating surfaces, including runways, minimising further damage to the air asset and returning the airfield to full operations as quickly as possible. JARTS personnel train in aircraft recovery techniques and in the use of airbag lifting equipment and so maintain the capability to recover any of the UK’s military aircraft, including C17 and Tristar.

AIRCRAFT POST CRASH MANAGEMENT (APCM)APCM is JARTS’ highest profile peacetime responsibility, or secondary role. The Directorate of Aviation Safety and Regulation (DARS) requires JARTS to be capable of responding to 4 concurrent military aircraft accidents; to do this a ‘Crash Team’ is kept on standby, prepared for immediate deployment to any location worldwide. The team is made up of an Aircraft Recovery Officer (ARO), taken from a number of Warrant Officers, RAF Flight Sergeants and RN Chief Petty Officers; and a broad cross-section of JARTS’ other personnel trained in numerous crash recovery techniques and authorised to operate or drive the array of JARTS equipment and vehicles. Another crash team comes to standby status once one is deployed and, as 2009 has proven, the concurrent deployment of 4 crash teams, of varying sizes, is a realistic scenario.

Once activated, the ARO will often travel to a crash site ahead of the Crash Team. This allows him to assess the situation and inform the JARTS Ops Cell of the manpower and equipment required to be called forward. In response to a typical accident, JARTS will deploy one vehicle loaded with crash recovery equipment, and another vehicle known as the CASBA5 . The ARO is responsible to the MOD Incident Officer for the management of the crash site inner cordon area, that which contains the aircraft wreckage and so poses the greatest threat to health and safety.

The CASBA is a multi-purpose facility on a site, its main purpose being to provide the controlled point of entry into the inner cordon and post activity

decontamination of personnel, but it also contains facilities for a basic kitchen with running water, an office space with fitted electrical power sockets and sufficient space for mandatory health and safety briefings.

The ARO’s first priority on arriving at a crash site is to ascertain the hazards present and determine the protective measures that will be required for all personnel involved with the recovery. He will be supported by duty personnel from the RAF Centre for Aviation Medicine (RAFCAM) or the Institute for Naval Medicine (INM) to assist with any assessment of biological or environmental risks that may be present. The team will provide control procedures for entry into the inner cordon and police this activity.

Once directed to do so by the President of the Service Inquiry, the JARTS team will begin wreckage recovery. A large crash site will be broken down into grids of manageable size and each piece of wreckage will be given a unique identifying number and have its location plotted using JARTS’ GPS-enabled Land Survey System (LSS). The LSS, accurate to a few millimetres, creates an electronic plan and 3D-representation of the crash site, wreckage, ground features and crash witness marks. The plot can be overlaid onto satellite photographs or Ordnance Survey maps and the associated software is held by the accident investigation agencies. This has proven to be a vital tool.

The ARO and his crash team are also responsible for locating, handling, storing and transporting the flight data recorder equipment and any other aircraft wreckage that is deemed relevant to the investigation as detailed by the Service Inquiry. They must also facilitate the removal of the remaining wreckage and any contaminated soil. This part of the

crash and smash no moreWelcome to the world of the Joint Aircraft Recovery and

Transportation Squadron (JARTS) By Squadron Leader Michael Nadin BEng CEng MIET RAF,

OC JARTS

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are undertaking 4 simultaneous recovery operations: wreckage recovery following the Tornado F3 crash in Scotland; recovery of a crashed civilian-registered Percival Provost aircraft in Lincolnshire; and the recovery of disabled Puma aircraft from 2 different overseas locations.

The expedient recovery of damaged aircraft and equipment affords the maximum utilisation of available MOD resources, a capability that is absolutely essential in the current climate. The aircraft and environments that JARTS have the ability to deal with vary from a Cessna in the UK to a Harrier in Afghanistan. Moreover, JARTS has MOD’s only capability for the road transportation of its aircraft fleets with much of this activity currently being in direct support of operations.

The variety of tasks that JARTS undertake and the uncertain nature of employment on the Squadron, crash standby and worldwide transportation, requires a well trained, well equipped and dedicated workforce. There are many challenges ahead but in every scenario I have seen the JARTS personnel rise to the challenge and I am very proud to have been given the opportunity to command this new joint Squadron.

internal workshops facilities with the capability to manufacture items from scratch or to repair old unsupported assets. It surprises many visitors to JARTS that we hold a full-sized aircraft hangar full of equipment and over 70 vehicles and trailers. Significant rationalisation activities have been conducted over the last year to allow the integration of much of the Gosport equipment in to the hangar at St Athan but in reality this has been undertaken in preparation for the Squadron’s next challenge – Collocation.

THE FUTUREFollowing the creation of JARTS in 2007, Air Command began a re-basing study to determine the best location for the new Sqn. Uncertainty of tenure at St Athan6 and the sale of the Fleetlands site requiring MOD Lodger Units to vacate added urgency to this study and it was also recognised that JARTS would be better able to undertake its duties efficiently if collocated. A number of sites were considered, the driving factor being the need to be close to the core day-to-day business, that of RW road transportation (in south-central England); and eventually MOD Boscombe Down was chosen as the best value for money option. Collocation planning is now well underway; JARTS’ RN element from Gosport is likely to move in to temporary accommodation at Boscombe Down by January 2010 and the remainder of JARTS from St Athan are expected to move sometime in the second half of 2010.

SUMMARYJARTS and its preceding organisations have been involved in a considerable range and number of crashes. PanAm Flight 103, the Lockerbie disaster, and the Mull of Kintyre Chinook crash are 2 prime examples and as I write this, JARTS

task is arguably the most labour intensive and may include hiring heavy plant machinery such as cranes and excavators. The ARO, whilst carrying out the recovery, will have to ensure that there is no lasting environmental damage to the land. He will be liaising with RAFCAM or INM and the Defence Estates Officer (DEO) to establish what remediation is required. After the ARO, the DEO and the land-owner are satisfied that the crash site is free of aircraft wreckage and contamination, the site will be handed back to the land-owner. Only at this point can the ARO depart the scene. During his tour of duty, an ARO will have attended numerous aircraft crashes and have become an expert in this field of operations.

AAIBNot simply limited to military aircraft crashes, the Department of Transport’s Air Accident Investigation Branch (AAIB) is able to call on the services of JARTS under a Memorandum of Understanding. Within this agreement, JARTS assists in the recovery of crashed civilian aircraft in the UK, and in exchange the AAIB provides investigative assistance to RAF Service Inquires. Most tasks in support of the AAIB relate to light aircraft and small helicopters and so are short in duration. However, a notable example from 2008 was support to the recovery of the Boeing 777 at Heathrow airport. JARTS provided detailed crash site mapping using its LSS capability and recovered the wreckage trail that the aircraft had left on the grass behind it. The variety of aircraft types recovered in support of the AAIB assists JARTS in developing experience and expertise within its crash teams whilst providing the AAIB with a consistent aircraft recovery process that it is not able to call upon from any other agency.

TRANSPORTATIONSince its inception a little over 2 years ago, JARTS has transported in excess of 600 aircraft. These tasks range from single day activities, ie a Chinook road move from RAF Odiham to RAF Brize Norton with vehicles deployed from and returning to Gosport, to more complex moves such as a Harrier recovered by road and ferry from Sicily through France to RAF Cottesmore. Whilst many road, air and sea moves are routine, some require detailed planning and possibly even the manufacture of specialist transportation equipment. We rely on the DE&S Aircraft Teams for provision of equipment for in service platforms, however, when moving historic aircraft we can call upon our extensive

1English Heritage - Military Aircraft Crash Sites (Archaeological Guidance on their Significance and Future),Un-dated, Un-credited.2UK MOD APCM is conducted iaw JSP551 Vol 2.3Some Senior RN Ratings are from the legacy AEM(M) branch.4Transportation of Whole Aircraft and Large Un-crated Aircraft Parts iaw JAP100A-01 Chap 9.1.5Crash & Smash Basic Accommodation (CASBA). The combination of a modified helicopter support cabin and inflatable tents, JARTS has 2 complete CASBA facilities.6St Athan has been selected as the site for the tri-service Defence Technical College.

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EOFT aims to instil the Can Do Safely way of thinking at an early stage of training in order to help develop an effective safety culture in its engineer students. Be it in the classroom, or on the line as part of 284 Sqn at Training Consolidation Flight, we are taught to intelligently interpret the Policy and Regulations. We are also taught to question norms, ensuring that any findings are reported correctly and information is distributed swiftly; thereby reducing the chance that a trivial fault can combine with human factors to produce another preventable occurrence.

I am confident that on graduation from EOFT, Engineer Officers will be better prepared than ever before to tackle the problems associated with flight safety, but this doesn’t mean that we can rest on our laurels. With aviation continuing to develop, coupled with an intensive operational tempo, we need to continue to develop ways of improving flight safety and encourage training at all levels on a continual basis, otherwise the hard learnt lessons of the past will re-invent themselves as the accidents of the future.

As an ex Weapons Technician I spent many years working on a busy front line Squadron where I was well aware of the importance of flight safety and that it was everyone’s responsibility. However, I was unaware of the level of flight safety training given to others. This question was answered as I embarked on Initial Officer Training (IOT) at RAFC Cranwell having been offered a commission in the Engineer Aero Systems (AS) branch. During IOT it became apparent that new entry officers are given a very limited exposure to flight safety, consisting of little more than a brief and a booklet. Coupled with this, a Flight Safety Committee did their best to get the Officer Cadets thinking about Human Factors and how their actions can affect Flight Safety, but often this guidance fell on deaf ears, as cadets focused, understandably, on the next exam or leadership assessment. So as newly commissioned Officers leave IOT for their Phase 2 training, or holding post, flight safety faces its first challenge; how to spread the message to the commanders of tomorrow of the importance of flight safety in their sections?

I started Engineer Officer Foundation Training (EOFT) on 8 Jun 09 and quickly discovered that the role of an engineer is far more involved than I first imagined. Coupled with our primary task we also have the responsibility of spreading the flight safety message to personnel assigned, attached, or under our control, in support of flying operations. Within the first week we were introduced to flight safety and, more importantly, the consequence of what happens when it goes wrong. We were taught that during the relative short history of aviation, most of the mistakes that could have been made have been made. There are very few new accidents, just old accidents waiting to happen again. Why?...because we have forgotten the lessons we learnt in the past.

I understand that we work in an environment that results in frequent personnel changes and demanding operational requirements, but why are these flight safety lessons not being retained? To change this my fellow future AS Engineers and I have a challenging time ahead of us!

Assisting us in our task at EOFT is a comprehensive and holistic training package that covers flight safety policy and regulations, practical exposure, implementation of concepts and policy, and discussion of the, ‘Can Do Safely’ campaign. This package is delivered by Service and civilian instructors who not only have previous flight safety experience, but an awareness of ongoing issues within the RAF flight safety environment. Visits to units and liaising with organisations such as RAF Flight Safety at HQ Air Command and DARS at RAF Northolt, allow current issues to be discussed during lessons, and are of great benefit to the students. Can we do, ‘Can do Safely’?The ‘Can Do Safely’ campaign is of particular interest to me and I believe it is essential to the future of flight safety. For those not in the know yet, the initiative is defined as follows: ‘Can Do Safely’ – ‘Building on our ‘Can Do’ reputation whilst maintaining robust engineering standards and practices that continue to provide airworthy aircraft for the immediate flight and those in the future.’

The RAF is well known for its, ‘Can Do’ attitude and on numerous occasions this has got many a Squadron out of a potentially difficult situation, but what has been lacking is some form of safety management of the, ‘Can Do’ activities. By expanding on the definition above we can see that the, ‘Can Do Safely’ campaign relies on risk management. The idea focuses on two areas of risk:

Decision and Control. The Decision to take the risk is further broken down into the following areas; Reason, Information, Safety Assessment and Consequences (RISC), whilst Control is broken down into the following elements; Mitigate, Monitor and Manage (The 3 Ms). Although the balance of task and safety must be met, all personnel involved in aircraft maintenance need to apply these checks to help to reduce the risk inherent in military flying to a minimum.

By Fg Off Ian Carpenter, EOFT 14 (AS), DCAE Cranwell

a junior officer’s exposure to flight safety during engineer officer

foundation training

Risk Decision (RISC)

• Clarify task objective and hazard context?• Question need to take risk?• Seek alternatives and transfer option?

Information?• Identify all relevant facts?• Gain thorough understanding?• Determine if systematic or one-off?• Reflect on sufficiency of empowerment? - Competent enough? - Second opinion? … who?

Safety Assessment?• Think laterally?• Assess probability?• Assess impact?• Prioritize?

Consequences?• … of failure?• … on future actions?• ‘Defensible at the subsequent Inquiry?’

Risk Control (The 3 M’s)Mitigate!

• Place operating limitation• Reduce probability• Lessen impact• Consider Human Factors• Treat, and think ALARP • Conduct Expedient repair

Monitor!• Appoint owner risk• Set rules and limits of acceptability• Supplementary maintenance; ADF• Tolerate and ensure situation does not deteriorate

Manage!• Record decisions and actions• Provide feedback and plan to terminate risk – repair/fix• Identify lessons• Communicate

EOFT Students Examining FOD Damaged Compressor Assembly

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can get stuck to) before you enter the airfield.

Ensure that you remove all potential FOD from your pockets when on the airfield.

An often overlooked source of FOD is airfield incursions. Whilst they are more commonly associated with interfering with aircraft operations, one of their common side effects is that the offending vehicle is more likely to deposit FOD as it is not likely to have been subjected to a FOD inspection prior to entering the airfield. Therefore, every effort must be taken to not only prevent airfield incursions, but also to ensure that, if an incursion does take place, it is reported and the incursion site is checked for FOD. If you see or suspect an incursion you should immediately notify ATC and, if a FOD hazard is evident, the SFODPO.

As previously stated, FOD continues to cost the RAF and the MOD a great deal of money, which could be better spent elsewhere. Whilst it may not be possible to completely eradicate FOD, there remains scope for improvement. Your support will help to reduce the amount of FOD damage sustained on your station.

The problem of Foreign Object Debris (FOD) has not gone away. In fact, and in spite of the concerted efforts of RAF Station FOD Prevention Officers (SFODPOs), FOD is causing more problems and costing more today than at any stage in the last 5 years. So what is going wrong? One thing that is without doubt is that every SFODPO in the RAF is doing their best to minimise the impact of FOD on their stn and FOD would be an almost insurmountable challenge without their efforts. However, the simple truth is that they cannot do it all on their own. In order for them to play their crucial role in FOD Prevention they require 2 things:

Firstly, they require robust and succinct policy that provides them sufficient clear direction to enable them to do their job. (More on this in future editions of Airclues – Ed.).

Secondly, and more importantly, they require your support. The following paragraphs highlight some of the causes of FOD that are being dealt with across the RAF by SFODPOs, and the ways you can help your SFODPO to overcome them.

Environmental factorsWeather and the surrounding environment can play a major role in the migration of FOD. The following are all real examples of FOD that has been found in the past 12 months.

The estuary beside RAF X is home to a number of birds that feed on shellfish. In order to break the shells the birds have been known to drop them from height onto one of the main taxiways, leaving behind the shell remains once the fish has been eaten. These remains are often sharp enough to puncture aircraft tyres.

During a recent Flight Safety Visit to an overseas unit, a very heavy rain shower swept a large quantity of earth and stones onto numerous parts of the airfield, potentially presenting a FOD hazard to aircraft operations. The FOD was swept up immediately and the taxiways were fit for use shortly thereafter.

A refuse skip situated adjacent to a unit’s main ASP was emptied by contractors during a prolonged spell of strong winds. Unfortunately, the

skip’s location and the wind direction lead to lighter articles of refuse being carried by the wind across the ASP, in the direction of 3 parked aircraft.

There is not a great deal that can be done to prevent the first two occurrences. However, where prevention is not possible, then every effort must be taken to provide an effective cure. Therefore, if you spot FOD on, or near, your airfield then report it to your SFODPO and, if you are able to, remove it. Whilst there is an element of environmental factors in the final incident above, the overriding causal factors have a greater human element. With a little more forethought and cooperation between airfield users this incident could have been averted, despite the prevailing weather conditions. This incident serves as a timely reminder of what can happen when there is insufficient focus on FOD prevention.

Poor condition of airfields and unsuitable airfield proceduresIn addition to isolated areas of damage, airfield surfaces will suffer from normal wear and tear, which can lead to unwanted debris on operating surfaces. This debris will greatly increase the chance of FOD damage to aircraft. Therefore, all airfield damage, or signs of wear, must be reported at the earliest opportunity in order to allow remedial action to be taken before the problem worsens.

There are a number of measures that can be taken to avoid jet efflux, or rotor downwash damaging other aircraft. Taxiing separations should be kept to an appropriate minimum in areas where there is a known FOD problem in order to prevent FOD being blown at high speed into the path of oncoming aircraft. Similarly, if 2 or more aircraft are to be taxied onto a runway (for example prior to a streamed take off) every effort should be taken to avoid aircraft having to taxi through the efflux of another aircraft.

FOD Migration and Airfield iIncursions One of the most common sources of FOD is debris that has been deposited by vehicles (or people) that have entered the airfield. There are a number of quick and simple measures that can be taken to prevent the migration of FOD onto the airfield:

Avoid driving over grass verges in order to prevent the spread of mud and small stones into the path of vehicles bound for the airfield.

Check your tyres and other parts of your vehicle that can carry FOD (e.g. mud flaps, bumpers and any areas where mud and small stones

By Flight Lieutenant Fraser Tod, SO3 Eng, RAF Flight Safety

foreign object debristhe perennial threat to fl ight safety

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