Please see below a list of recent MRFI’s reported – Click here to report new incident
|REF||DATE||TYPE||PHASE||SUMMARY FOR REPORT|
|20/001||4-Jan-20||K21||Ground||Safety officer: The club glider was made available following annual maintenance. Some days later when flying conditions improved it went through a standard DI. When the first crew of the day got into the glider, instructor discomfort prompted a look under the seat foam, where a screwdriver and the DI book were found.
Apparently, the DI book had been replaced because the original could not be found (because it was under the seat foam…).
It would be useful to check who carried out the DI….. some coaching is required plus a reminder to check for loose articles when carrying out the DI.
|20/002||5-Feb-20||TUG||Launch||Safety officer: The tug aircraft had an out of date chart which was not confirmed as valid prior to the flight. Action has been taken to ensure that current charts are available to the tug fleet.
It is noted that the tug FLARM was U/S at the time of the incident but this was non-contributory.
The tug pilot submitted a MOR to the CAA.
– Glider P1 has been retested on airspace.
– New maps provided for club gliders.
– Club will do more airspace briefing (pending Farnborough LOA)
– Revised combined airspace chart/part NCO SPEC checklist for the tugs provided.
– Charts were updated last year. As there have been no airspace changes in the local area for sometime it is unclear how a chart depicting airspace so out of date was in the aircraft.
– PIC is responsible for checking the chart depicts current airspace.
– ALL pilots flying as PIC will be reminded of their responsibilities regarding airspace infringement and carrying and using an appropriate chart; and also to allow a sufficient margin from CAS at all times; the CAA recommend ‘take 2’ ie 200ft and/or 2nm from CAS.
|20/003||5-Feb-20||K21||Ground||Safety Officer noted:
Over the winter there have been two instances of loose articles discovered in gliders after maintenance action. A new requirement has been introduced with immediate effect for an independant loose article check to be carried out before close up. The SGC OPS MANUAL will be updated in due course. All work on club gliders must have a written record and an informal duplicate inspection for tools etc must be carried out and recorded.
|20/004||5-Feb-20||TUG||Circuit||Safety Officer noted:
The returning tug had to widen the base leg to 22 due to a second tug having been given a late all out and was committed to its launch. P1 of the incident tug then crossed the trees 50ft too low resulting in the tow rope becoming entangled in the electric power lines and breaking the tow rope weak link.
This is a Reportable Incident. Form completed and submitted MAR20.
It is considered that the root cause of the incident was failure of the launch point controller to adequately assess the position of the in circuit tug and subsequently allowing a launch to take place. The tug pilot became distracted in avoiding the launching combination which resulted in a low approach and the tow rope striking an off airfield power line.
Risk mitigation actions
• Immediate action is to remind launch point controllers of the need for a clear and robust look out prior to releasing a launch, with clear radio calls from both launch point and approaching aircraft to provide better situational awareness.
• Remind tug pilots that they have the option to go around if necessary and should use this as the situation demands.
|20/005||16-May-20||TUG||Ground||Safety officer noted: A large screwdriver was left in the engine bay of the tug. It is surmised that it was left on top of cylinders where it is well hidden due to the height of the engine and then migrated with vibration turbulence etc.
The aircraft was attended by an engineer that morning following a period of short-term storage in the private member’s hangar. The pilot discovering the screwdriver was the third pilot to fly the aircraft that day and it had already carried out 11 tows.Suggested factors include – the acceptance of the aircraft from the engineer may have led to an assumption that a thorough pre-flight had already been carried out. – the engineer carrying out maintenance ‘in the field’ away from the hangar without normal tool storage solutions. – distraction caused by carrying out new cockpit cleaning procedures. – lack of currency.
Engineering has already introduced the need for a tool check after work is completed, but this was after the annual was completed.
|20/006||18-May-20||ASTIR||Airborne||Safety Officer noted:
P1 reported a ‘near miss’ with a club two seater whilst in wave, no risk of collision. Noted that P1 lookout was ‘not good enough’.
Further noted that FLARM was inop at that time due to a poor condition battery, which he reports as having been known previously.
First is a recognition of rustiness following the long lay off. Message reinforced to all club pilots.Technical Manager noted:
Battery condition was not apparent when COVID lockdown conditions were lifted. Members were asked to ensure that battreris for club gliders to be plugged in and left on so we know which are suspect. Replacements available.
|20/007||21-May-20||ASTIR CS||Other||Safety Officer notes:
Implementation of the Astir pushrod AD resulted in a bolt restricting elevator deflection on one aircraft (but not the other). The bolt was reversed on reinstallation as it was easier to fit that way around, but then fouled on structure in one aircraft. Restrictionwas identified because full control checks were carried out as required by the AD.A near miss which was caught by following the AD procedure properly by completing elevator deflection checks.
Reported to BGA CTO for further transmission.
|20/008||31-May-20||DG300||LDG||Safety Officer noted:
Well executed belly landing with only superficial damage to the glider.
Recommend the syndicate inspect the gear / selector mechanism to see if a root caiuse can be established assuming the lever was in the detent when selected..
|20/009||30-May-20||Shark 304FES||CONFLICT||XREF 20/012|
|20/010||2-Jun-20||ASTIR||LDG||Safety Officer note:
P1 was early solo, making his first flight in the club Astir.After becoming distracted in the circuit by another landing glider, P1 failed to lower the u/c.
Based on the MRFI, this incident is seems to be a result of
– Early solo pilot
– First flight on type
– First time using retractable u/c
– Distraction in circuit
It is reported that P1 was fully briefed before the flight. Distraction may have caused him to omit his pre landing checks.
Per CFIs comment, supervising instructors are encouraged to ensure that flights of this type are appropriately briefed, and that pilot fatigue is considered.CFI comment: P1 had already done 3 check flights that day, which was warm and sunny. He could have been tired by the time he was encouraged by his peers to convert to the Astir.
Peer pressure and fatigue are probably also factors.
|20/011||2-Jun-20||ASTIR||LDG||Safety Officer note:
P1 was early solo pilot. After landing attempted to vacate the landing area, which resulted in a low speed ground loop. The aircraft is equipped with a tailskid and needs to be handled with care on the ground.
P1 provided a very honest account of an unpleasant experience., and intends to get further checks before flying the Astir again.
|20/012||30-May-20||TUG||CONFLICT||Safety Officer comments:
The private single seater was returning to circuit., and noted a launching tug/glider combo. P1 made a late decision to land 22 in gusting easterly conditions and called downwind. Tug combo was climbing out for 1000ft aerotow to cct. P1 estimates combo within 200ft vertically and close to overhead so pulled full airbrake which compromised circuit to 22. Tug released and returned turning inside glider on final turn to land 22.
Wind direction had shifted so P1 landed downwind.20/009 and 20/012 are two accounts of the same series of incidents, from the glider pilot and tug pilot perspective respectively.
The glider pilot reports a perceived mid air collision risk with the tug/combo in circuit, which resulted in a compromised circuit and approach, with a downwind landing. P1 notes “I accept landing slightly further to the east might have been preferable.”
The tug pilot did not see the glider until after release at which point the tug pilot was happy with separation and proceeded to return to the airfield noting the glider in circuit. After landing the tug returned to the launch point where the tug pilot reported a risk of on ground collision as the glider stopped very close to the tug.
CFI comments: The 1000′ tows release about a kilometre from high key. In this case the tug ascended in the glider circuit area. An ascending combination launching to 1000′ meets a descending glider heading for high key at 700 – 800′