AAIB Bulletin G-SAJK and G-CDMH EW/C2019/08/03

G-CDMH was subsequently handed-over to Southend Radar. 1749 A PA-28 on a local flight was cleared to land on Runway 23. 1752 The PA-28 landed. 1753 An Operations vehicle was cleared to enter the Runway at C1 to complete an inspection. The vehicle entered the Runway initially in a south-westerly direction and on return vacated at Taxiway D at 1757 hrs. 1759 A Britten-Norman Islander was cleared to taxi to A1 and was then cleared to takeoff at 1801 hrs. The aircraft was recorded as airborne at 1803 hrs. 1811 G-SAJK was cleared to land. 1815 G-SAJK landed and the commander reported the aircraft had colliding with a general aviation towbar on the runway. 1817 An operations vehicle recovered the towbar adjacent to Taxiway B. 1825 ATC received a call from Farnborough Radar reporting the G-CDMH may not have removed their towbar prior to departure. Table 1 Summary of the timeline of the incident ATC reported that it was not possible to see the towbar from the control tower due to its size, shape and colour. They also reported that at the time of the event the location of the evening sun made it harder to see objects on the runway. 4 ©Crown copyright 2020 All times are U TC AAIB Bulletin G-SAJK and G-CDMH EW/C2019/08/03 Figure 1 Towbar recovered from the runway Runway inspection report At 1751 hrs a fire officer driving an airport operations vehicle requested permission to enter the runway for a wildlife inspection. Permission was granted at 1753 hrs. He entered the runway at C1 and preceded south-west toward the Runway 05 threshold. He reported that when he entered the runway there was no wildlife activity, so he carried out a surface inspection. From the Runway 05 threshold he recalled that he drove to the Runway 23 threshold then back to Taxiway D where he vacated. He did not see the towbar. He vacated the runway at 1757 hrs. It was reported that because his initial intention was to complete a wildlife inspection his attention may have been directed towards the sky rather than on the surface which may be why he did not see the towbar. 5 ©Crown copyright 2020 All times are U TC AAIB Bulletin G-SAJK and G-CDMH EW/C2019/08/03 Airfield information London Southend Airport has a single asphalt runway orientated 05/23 (Figure 2). Towbar location Figure 2 London Southend Airport Chart showing approximate location the towbar was found. The airport does not have any electronic means of detecting objects on the runway, taxiways or apron1 so relies on them being seen during runway inspections or being reported by other airfield users. London Southend Airport procedures specify a minimum of one runway inspection every four hours and two complete movement area inspections daily. On the day of the incident, airport records show that the last full runway inspection was completed at 1515 hrs. The inspection which occurred between the Cessna departing and the Embraer landing was intended to be a wildlife inspection and not considered a full runway inspection. Personnel The pilot of the Cessna 210 (G-CDMH) held a Private Pilot’s Licence with valid Single Engine Piston, Multi Engine Piston and Instrument (IR) ratings. He had a total of 1,930 flying hours with 169 hours on the Cessna 210. He had flown 10 hours in the last 28 days and 23 hours in the last 90 days. Footnote 1 Some larger airports have ‘foreign object detection radar’ which can detect objects on the runway and issue alerts to ATC. 6 ©Crown copyright 2020 All times are U TC AAIB Bulletin G-SAJK and G-CDMH EW/C2019/08/03 Pre-flight checklist During the airport’s investigation into this incident it was noted that the pre-flight checklist used by the pilot did not include any reference to ensuring the towbar, or other ground equipment, is removed before flight. Following the incident, the pilot amended his checklist to add a reminder to remove and stow the towbar. Additionally, he added a visual reminder in the cockpit of G-CDMH. Other human factors The pilot was involved in a motorcycle incident during his drive to the airport. He reported that this incident was “on his mind” during his pre-flight checks and probably contributed to him forgetting to remove the towbar. Additionally, he left two of his bags behind at the airport which also suggests he was distracted. A stressful or traumatic event can be distracting and difficult to put out of mind. It may be tempting to continue with a planned operation and not realise the effect of such an event on subsequent performance. The CAA Skyway Code2 highlights the importance of pilots assessing their fitness to fly before any flight. The code suggests using the ‘IM SAFE’ mnemonic for self-assessing fitness for flight (Figure 3). In this incident ‘stress’ from the earlier motorcycle incident was probably a key factor. Figure 3 ‘IM SAFE’ mnemonic highlighted in the CAA Skyway Code Ground equipment markings The towbar was painted in a dark blue paint (Figure 1) which made it difficult to see against the dark asphalt runway surface. Footnote 2 CAA skyway Code is available at https://www.caa.co.uk/General-aviation/Safety-information/The-Skyway- Code (accessed 16 October 2019) 7 ©Crown copyright 2020 All times are U TC AAIB Bulletin G-SAJK and G-CDMH EW/C2019/08/03 The International Air Transport Association (IATA) Airport Handling Manual (AHM)3 provides recommendations for aircraft ground support equipment. AMH 913 section 14 lists the following recommendations for non-motorised ground support equipment: ‘14.2.1 Non-motorised Ground Support Equipment should be visible to the operator(s) of any approaching Ground Support Equipment within the safety braking distance and under any angle of approach. 14.2.2 Colour schemes for markings of reflective material should be in compliance with the marking and illumination standards established by the local regulatory authorities. The reflective material shall be resistant to wear and tear. 14.2.3 Non-motorised Ground Support Equipment should have its presence accentuated by application of reflective material on all sides of the equipment inclusive of the tow-bar, outriggers or any other deployable devices. 14.2.4 Non-motorised Ground Support Equipment should have a minimum of 2 markings of reflective material on each side of the equipment with a maximum separation distance of 1.5 m (60 in) between each marking. Each marking should not be less than 100 cm2 (15.49 in2). 14.2.5 Markings of reflective material should also be applied on all comers of the equipment.’ Analysis The pilot of a Cessna 210 departing from Southend Airport inadvertently left the aircraft’s towbar attached to the nosewheel. As the aircraft took off the towbar fell off and landed on the runway. The towbar remained on the runway for approximately 30 minutes during which time another aircraft landed, another took off and an operations vehicle completed an inspection. A landing Embraer 145 ran over the towbar during its landing roll. The pilot of the Cessna reported that he was distracted by an early road traffic incident and this is probably why he forgot to remove the towbar. The incident highlights how stress from events unrelated to flying can cause a significant distraction and the importance of pilots honestly assessing their fitness for flight prior to every flight. The towbar was not seen on the runway by two other aircraft that used the runway nor by a fire officer conducting an inspection. It is not known exactly which part of the runway the two aircraft used, so it is possible they did not pass the towbar. Alternatively, their attention may have been on flying their aircraft. The inspection was initially intended to be a wildlife inspection, so it is possible that the driver’s attention was focused towards the sky rather than the runway surface. However, the towbar was painted in dark colours so it did not stand out against the runway surface. The towbar might have been seen sooner if it had reflective or other high visibility markings. Footnote 3 IATA Airport Handling Manual is available at https://www.iata.org/publications/store/Pages/airport-handling- manual.aspx (accessed 16 October 2019) 8 ©Crown copyright 2020 All times are U TC AAIB Bulletin G-SAJK and G-CDMH EW/C2019/08/03 Most airports do not currently have automatic means of detecting objects on the manoeuvring area, so they rely on them being seen during inspections or being seen by other airport users. Therefore, it is important that any equipment that could be left on a manoeuvring area is highly visible. The IATA AHM provides recommendations for ground handling equipment to ensure it is clearly visible. However, these are not widely applied across general aviation ground equipment. Making ground equipment more visible would reduce the likelihood of it being left attached to the aircraft and increase the chance of it being seen quickly if it is left on a runway or manoeuvring area. During this incident no damage was caused to the landing aircraft. However, objects on the manoeuvring area have the potential to cause serious harm to aircraft. Therefore, the following Safety Recommendation is made: Safety Recommendation 2020-004 It is recommended that the Civil Aviation Authority communicate to the general aviation community the importance of increasing the visibility of ground equipment. Conclusion A general aviation towbar was inadvertently left attached to an aircraft because the pilot had been distracted by an earlier stressful event during his journey to the airport. The towbar dropped onto the runway during the departure and remained there for approximately 30 minutes, during which two other aircraft used the runway and a runway inspection was completed. A landing aircraft then ran over it. The towbar was inconspicuous because it did not have any reflective or other high visibility markings. Safety action The CAA has stated that if, during the general aviation-specific audits and inspections it conducts, it observes ground equipment that due to its colour is not sufficiently visible, it will bring this to the attention of the relevant operator. Published: 23 January 2020.