Safety culture at the 2017 World Gliding Competition at Benalla, Victoria

The Gliding Federation of Australia Inc (GFA), the organisation responsible for the administration of sport and recreational gliding and sailplane activities in Australia, was supplied with the report. The following is a version of the GFA’s investigation report:

The Gliding Federation of Australia Inc. has investigated the reported concerns, namely that:

• the competition organisers ‘encouraged and allowed to continue at the recent World Gliding Competition held at Benalla in January 2017’ a negative safety culture.
• ‘there was known risk taking and aggressive flying from competitors which has resulted in at least two mid-air collisions during the competition.’
• there were ‘videos posted on the competition YouTube channel taken by pilots holding hand held cameras in the cockpit of a single seat glider while flying in a thermal with multiple gliders in the area.’
• ‘these ‘videos are an example of the known behaviours, which were allowed to continue during the competition – being rewarded by posting on the competition channel – rather than the pilot being educated on the safety implications.’

Agreed issues

The Gliding Federation of Australia Inc (GFA) agrees that there were two mid-air collisions between gliders during the 2017 World Gliding Championships (WGC2017). These are the subject of investigation by GFA, and were reported to ATSB and CASA in accordance with our agreements and obligations.

The first accident resulted in minor air-to-air contact, with both gliders landing safely and pilots uninjured. The second accident resulted in loss of both gliders, bail-out action by both pilots and some consequential injuries. These facts are not disputed.

GFA agrees that there are YouTube videos taken by pilots flying single-seater gliders while flying in thermal gaggles with multiple other gliders in the area, including on the WGC2017 YouTube channel. The presence of gliding inflight videos and related comments on social media is not disputed.

Disagreed issues

GFA specifically disagrees with allegations that the World Gliding Championships 2017 organisers have either:

• encouraged or allowed to continue an unsafe safety culture
• encouraged or allowed to continue unsafe airmanship standards and operational practices
• encouraged risk taking and aggressive flying practices
• rewarded pilots for unsafe behaviours, rather than pilots being educated on safety implications.

This response provides context on:

• how safety and operations in the 2017 World Gliding Championships were managed
• specific pilot safety briefing topics and presentations, addressing risks in gaggle flying and flying in close proximity to other gliders in competition, and pilot behaviour and risk appetite
• task setting arrangements and other responses to reduce the risks of large gaggles forming or collisions with other aircraft
• the primacy of Pilot In-Command responsibility for in-flight actions and decisions.

Overview

Sensationalised reports, although very good at generating public attention, are seldom balanced or objective and this report is believed to be no exception.

Our investigation did not reveal any evidence to support the allegation that the organisers were fostering a negative safety culture. To the contrary, investigations revealed that the organisers had a strong focus on risk management during the competition period as we will elaborate further.

During the course of the competition, there were two mid-air collisions and two near misses.

Each of these are being investigated, and analysis suggests the limitations of both single pilot operations and ‘see-and-avoid’, coupled with blind arcs and field of view limitations contributed to these events. While the reporter was correct that there were videos posted on social media by pilots using hand-held cameras, the use of hand-held cameras was the exception rather than the rule. When it was brought to the attention of the organisers, pilots were briefed not to use them and, to the organiser’s knowledge, all pilots complied.

Dangerous recreational activity

Gliding is a ‘dangerous recreational activity’ because it involves the significant risk of physical harm and a risk will be ‘significant’ if there is a real chance that it will materialise.

Some level of physical risk is implicit to any sport and recreation. Like many sports and recreational activities, gliding involves high-speed, extreme effort, exposure to height, close proximity to other aircraft and environmental factors such as the weather.

To the outside observer, such risks may be considered unacceptable. However, participants accept that risk is involved when participating in these activities. At the same time, the organisers are aware of their responsibility and take steps to support the safety of participants, spectators, volunteers and the general public.

Competition statistics

The competition commenced on 5 January 2017 with the first of three practice days. These practice days allowed the organisers to fine tune their operations and identify risks that were not previously foreseen.

The competition commenced in earnest on 10 January 2017 and over the course of the next ten days, pilots flew tasks on eight days, although some classes flew more task days than others due to poor weather conditions precluding the launch of the entire fleet.

During the course of the event, the organisers were launching, from a single runway strip, up to 115 gliders each day in under 90 minutes. Over the course of the event, the thirteen tow planes conducted 1,019 glider launches, and self-launching sailplanes flew 105 launches.

There were a total of 3,267 movements at Benalla airfield, Victoria (Vic.), over the 17 days of the competition. The glider pilots flew tasks of up to 750 kilometres in distance and covered over 450,000 kilometres during the period; flying as far afield as Rankin Springs and West Wyalong, NSW to the North, Mount Beauty, Vic. to the East, Thornton, Vic. to the South and St Arnaud, Vic. to the West.

Competition risk management

The organisation

Planning for the 2017 World Championship spanned more than two years and a robust Risk Management Plan was developed and tested during the January 2016 ‘pre-world’ championship event that was also run from Benalla, Vic. The organisers applied a clear process to identify risks, set an acceptable level for risks and took steps to keep risks at that level. Risks were managed by assessing potential consequences and likelihood, working out clear actions and designing a response plan. The organisers also met with emergency service personnel, CASA staff and the aerodrome operator to assist in the development of the risk management plan.

Key responsibilities were assigned to specific people in areas such as operations management, task setting, marshalling gliders and launch operations. Risk review processes were implemented, registers of occurrences and complaints were maintained and monitored, risks were reviewed, communication and consultation processes were implemented, and all team members were trained on risk management. In fact, all of the organisation team, contractors, volunteers, and participants involved in the event were informed and aware of the risk management process.

On each flying day the organisers sent an email advisory to all major airspace users in the task area. The advisory provided details of the task area, operational altitudes expected for the day, the direction gliders would be heading, and estimated arrival times at nominated ‘choke points’ on the return to Benalla.

Rules and governance

The organisation, rules and governance arrangements for the 2017 World Gliding Championships (WGC) at Benalla are provided at the competition website.

The championships were conducted in accordance with Fédération Aéronautique Internationale (FAI) Rules, as managed by the International Gliding Commission (IGC).

These rules include task setting, starting, finishing, scoring and operational requirements.

The rules also mandated use of FLARM (FLARM is an EASA-approved electronic system used to selectively alert pilots to potential collisions between aircraft. It is not formally an implementation of ADS-B, as it is optimized for the specific needs of light aircraft, not for long-range communication or ATC interaction.) to aid in collision avoidance, and the wearing of parachutes in competition flights. Note that these rules did not exclude flying in gaggles in thermals, nor team flying practices to provide competitive advantage. The FAI Competition Rules were supplemented by Benalla Local Procedures. This document also summarises the competition organisation and names of officers in various roles.

Pilots also had access to the GFA Competition Safety Pack dated October 2013, which contained detailed operational safety guidance for competitors, including lookout and collision avoidance issues. This was a reference document for the Mandatory Pilots Safety Briefing conducted on Thursday 5th January.

The organising team

The WGC Contest Director was [Name 1], an experienced world competition pilot and GFA Executive member. While he had overall responsibility for the safe and effective conduct of a viable competition activity, he was assisted by a large team of officers and operational staff, each contributing to safety outcomes.

[Name 2], another experienced international competition pilot, was the competition Task Setter, responsible each day for designing and setting cross-country soaring tasks for three separate classes of gliders, cognizant of meteorological conditions and available soaring time.

[Name 3], an experienced pilot and instructor, was the appointed Safety Officer, representing the GFA Operations Department in the competition organisation. He conducted and arranged daily safety briefings during the competition.

[Name 3] also advised the Competition Director on safety issues, liaised with GFA Executive Manager Operations on accidents and incidents, and worked with both Team Captains and the Pilots Safety Committee on issues of concern. He assisted in investigation of the collision accidents. He also worked with the Contest Director and Task Setter on spatial and temporal aspects of task design to reduce the probability of large thermal gaggles and conflicts between gliders.

The pilots

Pilots are also responsible for managing their own risk and displaying sound airmanship.

Glider pilots are taught to lookout at all times, manage workload, mitigate risk, correct errors, and make good decisions. However, a single person can be more easily overwhelmed when faced with multiple decisions to make, and task management can quickly become difficult for even seasoned pilots when things go wrong. Consequently, errors can and will be made.

All pilots participating in the competition were competent, experienced and current. However, by its very nature competition flying has a number of threats that increase the likelihood of pilots making an error that could lead to reduced safety margins, or may contribute to an incident or accident. The type of threats that competition pilots need to manage include:

• environmental issues such as, flying with other gliders, flying from an unfamiliar airfield, weather changes, unpredictable lift, different terrain with changes in height above sea level, partly unlandable country, or flat but very small paddocks
• navigational challenges
• physiological factors, such as fatigue, dehydration, hunger, hypoxia, impatience, frustration, optimism bias and overconfidence
• time pressure on the ground (including Launch delays) and in flight
• pressure to get home
• risk of outlanding
• final glides.

All these threats increase the likelihood of pilots making an error that could lead to reduced safety margins, or may contribute to an incident or accident.

To quote from former World Gliding Champion Karol Staryszak, 8 May 2016:

‘It is often said that the organiser should do this or that… They should call a day, they should create an easier task, they should make sure there are outlanding fields along the task route, they should not launch so many gliders at the same time, etc. But the task is not an order, you do not have to fly it; the decision to fly is yours and yours only!

Whether I go over an area with no fields and no option to return, or my final glide is below the glide path, or I fly in a gaggle, or in the clouds—this decision is only MINE!’

Task setting responses to reduce collision risk

The World Gliding Championships was a highly competitive event, with elite and experienced pilots flying very fast on long cross-country tasks, often in close company, often shadowing their competitors.

AS/NZS 31000 Risk Management highlights that risk (and opportunity) has dimensions of probability (likelihood) and consequence. The probability of mid-air collision in gliding events is increased when pilots fly in large gaggles in thermals, with large numbers of aircraft in the rising air mass in close relative proximity.

The probability of gaggle flying occurring is a function of:

• weather
• task design and
• pilot behaviour, competitiveness and risk appetite.

The probability of gaggle flying occurring is higher in ‘blue’ conditions, without cumulus clouds marking thermal position and cloud shape indicating thermal strength. During much of the competition period, blue days were experienced.

A number of measures were consciously addressed to discourage gaggle flying and reduce collision risk. These measures are based upon increasing spatial (distance) and temporal (time) separation of gliders in a competition. These included:

• setting different tasks for the three classes involved in the competition
• increasing spatial separation between the tasks, in particular on the first leg of the task, sending classes out in differing directions
• using dispersed start lines, SW, NW, NE and SE of Benalla AD, for the different classes, to reduce start gaggle size
• setting tasks of long duration relative to the projected soaring meteorological conditions, to encourage pilots to make rapid progress and not linger in groups or gaggles
• minimising overlaps between tasks for the three classes, and planning for temporal separation and minimum crossing angles where overlaps occurred
• planning Assigned Area Tasks, rather than fixed turnpoint tasks, to encourage pilot decisions to turn at dispersed locations and achieve greater separation.

All pilots were repeatedly warned about the risks of aggressive flying, sharp pullups, turning inside other gliders in thermals, joining thermals incorrectly, and poor lookout or situational awareness. They were specifically briefed on the limitations of FLARM for collision avoidance, and on the proximity data recorded. Mandatory data loggers were used and traces analysed, to assist in investigating allegations of dangerous flying, as well as instances where near misses had occurred. Some fixed video recordings assisted in capturing useful data on near misses. The Safety Officer used Pilot Briefings, meetings with pilots, meetings with Team Captains and video recordings to highlight risk and safety issues.

Inflight videos and social media

There are no rules governing the use of cameras and recording devices in aircraft and gliders. These are not prohibited by the competition rules applying to the WGC event.

GFA does not encourage the use of handheld cameras and devices for recoding inflight video, particularly in high workload situations, or where distraction may have adverse consequences. For this reason, GFA prefers that when cameras and recording technology are used, they should be either fixed mount or swivel on a fixed base, or else on headband or cap mount. They should not require constant viewfinder monitoring by the operator.

GFA has also found video footage to be beneficial to safety, training and instruction. A near miss between a climbing motor glider and a climbing glider/tow plane combination during the WGC event was recorded on video, which was in turn used to re-educate the pilots concerned and brief all pilots. Other accidents have seen video recording information used in accident investigation.

The decision to use a camera, data recorder, or other technology in the cockpit, at any given time, is primarily an issue for the Pilot In-Command. They are responsible for their own decisions and flight management. No amount of prescription or rule setting will change that.

Similarly, the decision to post still photos or video recordings of inflight situations on social media (Twitter, FaceBook, YouTube, Instagram etc.) is also an issue for the pilot-in-command and the owner of the social media account.

GFA does not accept that the organisers were encouraging risk taking and aggressive flying, rewarding pilots for unsafe behaviours in use of inflight video on social media. It is evident from much of the video on social media that pilots were trying to record and highlight the increased risk in gaggles, not glorify the practice. Many video clips used fixed mounts. Some handheld recordings were clearly made by gliders at the top of the thermal gaggle, not enmeshed in the higher risk environment lower down. Some recordings show the pilot stowing the camera in order to deal with higher priority airmanship tasks. Use of handheld cameras was a safety briefing topic on 19th January. Thermalling safety and lookout in gaggles were safety briefing topics on 13th January.

Safety culture

The safety culture of the event was positive and was supported by the organisers, the team captains from the 27 competing nations, the internationally appointed stewards and the jury members. A safety committee was convened, comprising one competitor from each of the three classes and the competition safety officer. The safety committee dealt with concerns raised by pilots about the flying conduct of other pilots.

The competition rules required a compulsory safety briefing at the beginning of the competition and regular safety communication throughout. At the start of the competition on 5 January 2017, a general safety briefing was delivered, and further safety briefings were delivered as issues became apparent.

All reported safety concerns were investigated using GPS records of the flights that enabled a reasonably accurate assessment of the actions of each pilot. In most cases, the complaint was found to be not sustained, and often involved less than ideal decision making by the pilots involved or unfortunate coincidences. In cases where poor behaviour by a pilot was evident, that pilot was interviewed, together with their team captain, and presented with the evidence so they could see how their behaviour had created a hazardous situation. The pilots and team captains were then placed on notice that a repeat of such behaviours would result in significant penalties. In all cases, the pilots did not re-offend. The process of self-awareness and the use of peer feedback, made pilots aware of their vulnerability to different types of errors, decision styles and biases.

Risk mitigation strategies

There is considerable evidence of actions by WGC officers to brief, educate, oversee and intervene where necessary to promote the required safety first culture.

A Fly-Tool Safety Reporting process was specifically introduced to facilitate reporting of issues by international pilots, supplementing the GFA accident and incident reporting system which many of them were unfamiliar with. Pilot Safety Reports were also introduced to allow pilots to advise who was causing concerns re safety.

Rules and Competition Safety Guide documents were provided for reference by teams and pilots.

A pilot safety committee was formed, to assist the safety officer and contest director. A mandatory safety briefing was held before the competition, and each then morning during the competition. These briefings included:

• close call re climbing motor-glider and tow plane-glider combination, recorded on video camera
• changes to procedures to improve separation between tow planes and motor gliders
• role of pilot safety committee, nominations and election of pilot representatives
• safety advice re gaggle flying, flying in close company, techniques for joining thermals, clearance, lookout, leaving         
• dangers in gaggle flying
• analysis of first collision, gaggle safety and lookout when flying straight, flight trace analysis video
• analysis of complaint, flight trace regarding overtaking in straight flight
• use of pilot safety reports, nomination of pilots causing concerns to other pilots
• presentation by pilot involved in second collision and bail-out
• flying too close in cruise
• winning versus safety, relative priorities
• use of cameras in flight.

Task design measures described above were used to reduce the probability of gaggle flying in thermals and between thermals.

Summary

Overall GFA found the safety culture was positive and steps were taken to reduce safety hazards as they were identified. The Organisers actively worked to reduce risk, which resulted in some significant improvement and reduction in reported incidents.

A report is being prepared for the international Gliding Commission to encourage some rule changes that would reduce the risk faced by pilots. Many of these changes have already been implemented in Australia with proven benefit.

The organisers also identified methods to extract meaningful data from the GPS flight records to help identify pilots with a higher risk profile, and can also be used to issue penalties to the worst offenders.

CASA has reviewed the REPCON and the information contained in the report and has the following comments:

There appears to be little evidence to support the claim that the organisers encouraged aggressive flying practices, increased risk taking and rewarded unsafe behaviour.

The GFA response provided to the REPCON did not suggest that adverse safety outcomes were as a result of the use of handheld cameras and highlighted the safety measures taken by the organisers when this issue was identified during the competition.

CASA attended the event also during this time and witnessed the competition mass briefing prior to operations, observed the departures and return of all glider classes on 16th of January 2017 and it was clearly evident that the organisers consciously attempted to address close proximity operations by de-confliction of routes and briefed pilots on the priorities of safe flight rather than winning.

It is CASA’s opinion that while some persons may have used handheld devices to capture video, there does not appear to be any suggestion that unsafe operations or behaviours were actively encouraged by the WGC organisers, in fact tangible evidence exists that the organisers addressed known and emerging safety risks at the time of the high tempo operations.

CASA considers the steps, investigations and mitigators that the GFA have provided in response to the REPCON as appropriate under the circumstances of the World Gliding Competition at Benalla.