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A Broken Chain

12th June 2009 @ 7:07am – by Geoff Farr
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Have you ever thought whilst driving: "That was a bloody fool thing I just did."
"How can I put that right." Usually you can't put it right as the person you have just put at risk has now driven off shaking his/her head.

The next thought that follows is: "How can I prevent someone else falling into the trap I have just fallen in to." Again, usually you can't.

In aviation we are very lucky in that we have a mechanism for confessing our sins and possibly preventing others from making the same mistake. This mechanism works even to the extent of allowing us to anonymously acknowledge that we broke the law, if our confession helps to prevent another from doing the same.

Several times a year there is published a short bulletin called 'CHIRP feedback' in which mistakes and foolish blunders are published for ALL to learn from.

Spectacular cockupsNeedless to say, I have been involved in spectacular cockups on several occasions which might have ended differently, but happily did not.

It is a well known established fact that accidents occur at the end of a chain of bad decisions and / or misjudgements. It is rarely one single item which ends in disaster. It is therefore incumbent upon the aviator and motorist to recognise that a chain has begun to be established and effectively break that chain and in so doing prevent an accident.

At the risk of publicising my lawbreaking, what follows is a copy of my hitherto anonymous entry into the pages of Chirp. I do hope that the Civil Aviation Authority is not looking!

Issue Number 4 Chirp Feedback. June 2000Almost A Complete Chain: We have all read how it is a series of errors that usually lead to an accident. This series is sometimes referred to as a chain of events or circumstances. All of us have at some time gone some way down a chain and happily there was an interruption of the chain which saved us from an accident.

The following is my account of such a chain of events which, with one more link could have had a vastly different outcome.

I have for nearly thirty years flown from the same farm strip. During this time I have flown two aircraft of the same type, the present one for nineteen years. I am therefore very familiar with both strip and aircraft.

On this occasion the aircraft required two pieces of work. The brakes needed a little adjustment – the right brake was not coming on synchronised with the left so braking was causing the aircraft to pull to the left; also number two engine cylinder was leaking oil at the rocker cover gasket.

So, armed with my tool kit and a rocker cover gasket I went to remedy these matters. I would not need my Navigation bag, headsets or other accoutrements. The jobs did not take as long as I expected and there was a substantial part of the afternoon remaining when I was ready to push the airplane back into the hanger. This is where I picked up the first link in the chain.

Test flightIt has always been my guiding principle to make a test flight after even the smallest mechanical adjustment and if appropriate to make a ground engine run before taking off on such a test flight. It would also be an economy of time to do it now.

The weather conditions at the time were, good visibility but a boisterous wind blowing from 90 degrees across. I did not need a weather forecast as I could clearly see the weather I would be flying into, especially as I only intended to fly a single circuit.

However there was a squall coming up at about 3-4 miles range, which clearly could make a difference if I lingered too long.

I made the best use of my time carrying out a brisk daily inspection and taxiing out to the take off run. By this time the squall was definitely nearer, but I could get around once if I pulled my finger out. Mistake and link number two.

The take off was a bit lumpy. The Crosswind leg was towards the squall and downwind was bumpy. Final was hectic and I got it wrong. I would have to go round again and that was no fun at all. Final the second time was extremely uncomfortable with a real crosswind at the leading edge of the squall and by now I was almost at mine and the aircraft's limit. I HAD to land off this one or I was in trouble. However, fortune smiled on me and I made an arrival, if not a landing.

SubduedSomewhat subdued I commenced to taxi back to the hangar muttering that I would not do that again. That was when we came to another link for I had barely taxied the length of a cricket pitch when one of the lenses dropped out of my specs on to the floor of the cabin. With one eye closed I taxied to the hanger feeling even more subdued and knowing what an impossible situation I would have been in if that had happened a mere 30 seconds earlier.

The chain had not finished with me. After stopping in front of the hangar and by now being under a fully developed squall I recovered my lens and attempted to replace it in the frame. This I found I could not do without specs so I reached into the glove locker for my mandatory second pair, guess what! They weren't there!

I had recently been on holiday and taken them with me in case of accidents. Where were they ? Yes you have guessed, in my Navigation bag waiting to be taken back to their usual home in the aircraft.

This collection of poor decisions and seemingly unconnected circumstances had gathered into a chain which very nearly caught me out.......and I had almost convinced myself that by now I was one of the "Old pilots".

NoteThe reference to "old pilots" arises out of a saying in aviating circles which reads "There are old pilots and bold pilots but there are no Old Bold Pilots."

The publishers of "feedback" at the end of my piece made the succinct comment: "Age and experience do not, in themselves, provide immunity from an accident chain as the foregoing report describes." you all know what a thoughtless idiot I can be.

Golf Foxtrot Alpha Romeo Romeo

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