Single Pilot CRM – A pilot runs out of fuel at night in an Ultralight

Overview

Almost 10 years ago to the day, Andrew Thorley was ferrying a Lightwing Sport ultralight from Ballina (on the far north coast of NSW) to the Oaks Airfield (about an hours drive to the west of Sydney). There were a number of aggregated errors and oversights throughout the flight that found Andy over the suburbs of Sydney at night with low fuel (around 30 minutes shy of his destination). The Lightwing eventually exhausted its fuel supply and Andy was forced to make a landing in a suburban soccer field.

We initially recorded a lengthy discussion with Andrew that was well over 90 minutes in duration. It wasn’t appropriate for inclusion in Flight Podcast due to time constraints, so we later recorded an abbreviated version that made its way into the release Flight Podcast . The audio below is the abbreviated version.



Details of the Flight

Andy was tasked with picking up a Lightwing ‘sport’ Ultralight aircraft from the northern NSW town of Ballina. The “mission”, as Andy refers to it, was to transport the aircraft back to The Oaks airfield situation about an hour drive to the West of Sydney, situated near the foot of the Blue Mountains.

After a long day littered with unexpected delays in an unfamiliar type, Andy found himself in the situation where he was flying over the northern suburbs of Sydney in darkness (ultralights aren’t allowed to fly at night) with low fuel and nowhere to go. It ultimately led to fuel starvation, and a successful glide approach was flown into a suburban soccer field.

Andy’s story is extremely interesting for any pilot regardless of experience… and the audio provides student pilots with an extremely effective learning tool – particularly since the Australian VFR Syllabus (issue 4 for aeroplanes and 3 for helicopters) now mandates (single pilot) Human Factors training and assessment as compulsory for virtually every category of student or pilot.

Summation of the flight

A brief, and far from complete, summation of the flight is as follows:

  • Early morning drive to Sydney Airport and regional commute to Ballina
  • Aircraft wasn’t prepared or even assembled when Andy arrived in Ballina
  • Andy had no experience on the aircraft type. A quick ‘three circuits’ and basic overview of systems was all that was provided
  • Late departure
  • Un-forecast headwind
  • Refuelling issues mid-flight. The refeuller and Andy both falsely believed that full fuel was provided.
  • Fatigue and lack of substance throughout the day
  • Extremely long day in ultralight cockpit – fatigue
  • Continued flight into darkness
  • Failure to interpret/understand & believe the fuel gauges
  • Poor radio communications

Andy was transiting the Bankstown (Sydney) Lane of Entry (LOE) at the time of the failure. The Sydney LOE is a corridor of airspace between Richmond military airspace (to the west) and Sydney airspace (to the east) and is designed to facilitate a flow of traffic north out of (or into) Sydney. To the north of the corridor is rugged bushland and waterways associated with the Hawkesbury River and to the South the area is populated with various Sydney residential suburbs. Andrew was very fortunate that the failure had not occurred a few minutes earlier.

Note that the approach to his chosen field was over high-tensile powerlines. Andy couldn’t see the powerlines since it was night, and it estimated that he came within just inches of colliding with them.

Single Pilot Threat & Error Management (TEM)

What are threats, errors and undesired aircraft states?

Threats are events or errors that occur beyond the influence of the line personnel. They increase operational complexity and must be managed to maintain the margins of safety.

Errors are generally defined as actions or inactions by the line personnel that lead to deviations from organisational or operational intentions or expectations. Unmanaged and/or mismanaged errors frequently lead to undesired states. Errors in the operational context thus tend to reduce the margins of safety and increase the probability of an undesirable event.

Undesired states are generally defined as operational conditions where an unintended situation results in a reduction in margins of safety. Undesired states that result from ineffective threat and/or error management may lead to compromised situations and reduce margins of safety aviation operations. Often considered the last stage before an incident or accident.

In Andy’s case, there were known threats that he had to address – and errors were poorly handled. As a result, the aircraft ultimately found itself in an undesired state.

It’s easy to let academic concepts cloud otherwise obvious principles. When we spoke to Andy about his incident he claimed that these TEM principles either didn’t exist or weren’t widely taught at the time of his incident. Sure – that is true – but risk management is something that professional pilots have always considered. As Andy freely admits, there is no excuse for his actions on the day of the flight in question.

Despite Andy’s considerable experience at the time, and in spite of fact that he was the owner and Chief Instructor of the flying school taking delivery of the aircraft, he made countless mistakes as a result of poor risk management and ineffective decision making throughout the day. We’ve all heard of ‘push-on-itis’ – and Andy’s story is a classic example.

Most incident and accidents are attributable to a sequence of errors or bad decisions rather than a single mistake. Again, Andy’s story is a good example of how a number of unmitigated risks and mishandled errors were compounded to the point where circumstances eventually conspired against him when the engine stopped.

Considerations

Andy had significant real world commercial experience at the time of the incident so, as discussed in the audio, and as acknowledged by Andy, it’s possible that continued flight was by virtue of his general aviation qualifications. Andy is (and was, at the time) an experienced IFR pilot with several thousands hours of experience – much of it in larger multi-engine aircraft at night. It’s highly likely that a lower time pilot would have never continued flight. Andy says that it’s likely that he had one mindset that applied in general aviation aircraft and another in ultralight types. He stated that the nature of recreational flying likely caused an adjustment in the way he approached his flying… and perhaps caused him to compromise on the professionalism that would have applied in the regimented ranks of GA.

It was interesting to hear Andy referred to his flight as a mission from the beginning of our discussion. “Mission” is (generally) a military term that normally relates to a pass or fail task – normally implying death or defeat in military terms. In general aviation we don’t undertake missions…we go on “trips”, or simply undertake “flights”. Departing with a mission mindset – or adopting a mission mindset during a flight – when presented with mounting adversity increases risk because we become more focused on the destination than we are on babysitting the journey.

Pilots are goal orientated people; we have a destination and we often believe that we have the skills to get there despite weather and circumstances potentially conspiring against us. Andy’s trip is a good example of Reason’s Model in action (Swiss Cheese Model). He had countless opportunities to identify the risks of continued flight yet his goal (or mission) orientated behaviour led him to believe that he had the ‘superior skills’ necessary to reach his intended destination. Pilot error continues to be the most likely cause of incidents and accidents. We all have our name on an accident report the moment we start to let our better judgement lapse.

I was criticized by a couple of people (notably, non pilots) for making the comment along the lines of, “…if I were there, I would like to think that this wouldn’t have happened”. I was due to undertake this flight with Andy (I had only recently obtained my ultralight instructor ticket and was keen to familiarise myself with a few different types). It was only a lack of transport from Coolangatta to Ballina (after ferrying myself up from Bankstown, NSW, as a passenger on a freighter) that put an end to my plans. I still wonder if I could have, all those years ago, allowed myself to compromise on professional knowledge the same way that (single pilot) Andy did… and the truth is, I don’t – nor will I ever – know. Two pilots is always better than one, and it’s highly likely that the prospect of camping at a bar somewhere in northern NSW wouldn’t have seemed so bad had the two of us been there.

Thankyou to Andy Thorley

I undertook my instructor training with Andy many years ago. Cramped together in the confined and intimate space of the little Cessna 152 led to a lifelong friendship. A friendship based on professional and personal respect. Everything I’ve written is consistent with the spirit of our conversation and with an underlying tone of utter respect. The incident hasn’t compromised my absolute trust and respect for Andy in the slightest… in fact, the opposite applies. Andy is and will always be one of those people I hold in the absolute highest regard as a person, pilot, instructor and friend.

I thank Andy for taking the time out to talk to us so openly and honestly about an incident that has no doubt caused him personal grief. This was the first time Andy has shared this story with anybody.

Work Booklet

I’m aware of this audio being used in 18 flying schools (at least that’s the number of schools that made contact with us to obtain permission. The actual number could be much higher). Audio is an effective means of sharing safety information with students to ‘take away’, but it’s also a useful tool to guide classroom based discussion. Stopping the recording at various key points makes way for a dynamic discussion that is of value to any elementary classroom.

We will be producing a workbook and PowerPoint presentation to accompany the original full length Andy audio so that flying schools have another resource for their students. Please subscribe to the mailing list if you would like to be advised when this is available.

Update: Contact us for all learning material associated with this incident.

Below are some images of the field that Andy landed in.

Andy 1 Andy 2 Andy 3
Andy 4 Andy 5 Lightwing

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