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In VMC within a GAAP CTR, the pilot in command was primarily responsible for ensuring separation from other aircraft. Consequently, despite the IFR category of the Duchess, the instructor and the pilot in that aircraft were required to maintain a lookout for other aircraft until leaving the CTR. The instructor in the Duchess was probably distracted by the coaching and assessing role such that he did not appreciate the potential for conflict and therefore did not look out, in the required direction, for the other aircraft.

The instructor in the Cherokee saw the Duchess on the runway but did not take action to maintain sight of that aircraft after it was obscured by the Cherokee's engine cowl. Had the instructor kept sight of the Duchess the occurrence was unlikely to have happened.

The inbound track adopted by the pilot of the Cherokee made it more likely that it would conflict with IFR aircraft departing the CTR on climb to an altitude above 2,000 ft. The radar information indicated that some pilots of inbound aircraft enter the circuit via early downwind instead of crosswind.

Pilots operating in GAAP CTRs need to understand that the practice of entering the CTR via wide or oblique crosswind reduces the safety benefit of GAAP entry procedures. Also, that maintenance of situational awareness is a precursor to being able to attend to areas of potential conflict adequately, when operating at GAAP aerodromes.

The Duchess pilot was cleared to operate in the CTR such that the procedural defences used to minimise the likelihood of conflict between arriving and departing aircraft were negated. The situation could have been assisted by the provision of traffic information by ATC to the pilot of the Duchess and/or the Cherokee pilot.

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