Human Factors …

I’m writing this particular entry in the spirit of sharing (well as much as I can) and in the interests of ongoing learning and how ‘human factors’ can change the way we behave …

In August I was planning a series of circuits on a reasonably nice sunny day .. can’t particularly remember the wind but it was one of those nice days to get some circuits in and perhaps some higher work.

Checked out for an initial couple of circuits and duly took off on runway 26 banking out over Corbiere lighthouse and into the downwind and a hold at Noirmont as there was something bigger on approach. A couple of holds and then, with the newly devised ATC (neat solution to slow flying aircraft) was advanced to hold over St Aubins Fort .. which then leaves me only a short curving descent to finals.

As I broke out of the numerous tight turns over Noirmont I felt some slight vibration through the stick. Nothing massive .. but definitely a little something … checked all the gauges … RPM, CHT, Pressure, EGT all looking good so wasn’t really sure if I HAD felt it or it was something …

Slightly distracted by it .. but continuing the FIRST 2 bits of the aviation adage of Aviate, Navigate, Communicate …. I pulled out of the turn and routed towards the Fort over St Aubins bay … whilst still playing with different throttle settings to see if I could narrow down what was happening …

At this point … ATC were still thinking I was coming in for a Touch and Go and into the circuit .. as I hadn’t advised of anything …. Not Good news ..

A few more orbits and I was cleared to final .. so the vibration had been in evidence for around 2-3 minutes … rolled out eased back on the throttle and things seemed to settle so I lined up for final but declared that this would b to land … still hadn’t advised anyone outside the cockpit of why .. ‘this would be to land’

On landing .. usually really short and exit first taxiway .. I taxied into the club and pulled up outside the hanger and, brakes on, tried various throttle ranges and could feel the vibration at higher revs .. still all engine settings read absolutely fine .. so shut down to investigate.

As I climbed out and walked to the front … I saw the nosecone was pretty much in bits ! First thought was that I’d hit a bird over Norimont at around 800’ when I first felt the vibration.

I immediately called the tower to advise … not really knowing HOW or WHERE it happened but at least I now knew the WHAT. A sequence of events then happened which will be mentioned in a joint talk that ATC have asked me to co present with them in November.

Suffice to say from my perspective … there are a number of ‘Human factors’ that come to play.

  • I advised ATC that I ‘thought’ I had all the bits … was that wise without a full longer time checking ?
  • Would that ‘lead’ people to assume I was correct
  • I didn’t call ATC as soon as I felt the vibration
  • Why ? ..
  • True I was more intent on flying the problem if indeed it was a problem
  • Did I feel that I didn’t want to say that the little home built was having an issue .. so a bit of pride perhaps creeping in ?
  • Did I feel that I didn’t want to upset the smooth running of the airport .. partially yes .. I felt the ‘situation’ didn’t warrant it … I didn’t feel in immediate danger .. but perhaps I should … let’s face it .. you are after all over a fair bit of sea
  • Also .. I’m not the only one affected by ME having a problem .. as the review identified
  • Should I have shared the problem with ATC immediately .. Hell yes …
  • If I’d known (what I NOW know would be their reaction .. post my de briefing) would I have behaved the same way ?
  • Their reaction would be to hit the button … get crash crews at the end of the runway … clear any approaching aircraft out of the way by go around .. this also includes, because of where I was, a fire truck scrambled from town ! I guess in case I come down and don’t make the field ….
  • knowing all that .. would I be (more) reticent to make that call and inform ATC … probably yes if I’m honest … but the answer should be a BIG FAT NO
  • Talking all this through with Jersey ATC and understanding the knock ons that came out of this was a good learning exercise (for all)
  • How would I react to being told to go around to help a sick aircraft get in … INSTANT acquiescence of course …. would everyone ..

This left a very small piece of debris on the runway … small, flat, about 2” round fibreglass…. any delay in retrieval of that is not good … advising early and letting people decide what actions to follow is the best course of action..

In the end .. this incident caused a number of knock on learnings and reviews of documentation and procedures … all of which will ultimately make all our (flying) lives safer …


Would I do things differently next time .. YES of course …

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