Slide 1

10 JULY 1910 - 2010
100 YEARS ULM ACCIDENTS

Belgian ULM Federation – Safety
1
Conference 10/10/2010

The Air Safety Investigation
• As part of the global Aviation sphere, an investigation is
conducted for each accident and serious incident by an
independent enquiry body, aimed to;
– Determine the causes of the accident.
– Determine if all conditions that were defined by rules and
regulations to ensure flight safety were followed (such as risk
factors in design).
– Define recommendations in order to prevent future accidents.

• It is not the purpose of this investigation to apportion
blame or liability.

2

In Belgium; the Air Accident
Investigation Unit.
• All accidents and serious incidents occurring in Belgium,
on aircraft, helicopters, gliders, balloons, ULM, DPM,
regardless of their registration is investigated by a cell
functionnally independent from the BCAA, and all other
interrested parties.
• Independent doesn’t mean isolated; it is part of the world’s
network of the State’s Aviation Investigation Bodies.
• The cell reports to the President of the Board of the
SPF/FOD Mobility and Transport.
3

4

ULM
• First pendular (Delta Plane Motorized)
design in 1966
• First crossing of the Channel in 1978 by Mr
D. Cook.
• Commercial development from 1979.
• Evolution from 2-axis to 3-axis.
• In Belgium, first ULM registered (501) in
1982.

5

6

Evolution
• 1982: Weedhopper, Chickinox
– 80…100 km/h
– Basic – 2/3 axis
– Range: … 200 km…

• 2010: VL-3 Sprint, DynAero MCR01, WT9 Dynamic….
– 220….250 km/h,
– flaps, retractable gear, avionics,
– Range over 1000 km

• 550 OO- registered ULM;
• 571 ULM pilot licence (363 training licences)
• 300-400 foreign-registered ULM.
7

1000
900
800
700
600
500
400
300
200
100

Number of valid registration

8

Estimation of flying OO-regd ULM

20
10

20
08

20
06

20
04

20
02

20
00

19
98

19
96

19
94

19
92

19
90

19
88

19
86

19
84

19
82

0

Evolution in pilot’s / owner’s
expectations
• In 1982, ULM /DPM, a sporting way of flying,
outside the limits of parachuting, delta plane.

• In 2010, an efficient alternative to general
(certified) aviation. ULM becomes a means of
transport.
• Beyond 2010 ?? – The Need for Speed ?
9

Evolution
• From the user’s perspective, the difference between
General Aviation and ULM becomes very thin.
• However, ULMs are characterized by a huge variety of
different design types, with low production rate and
configuration variation between individual airplanes.
– Manufacturers come and go,
– Assembly of the same ULM type by different companies induce
differences in built configuration.

• The above makes it more and more difficult to speak about
ULMs in a general way; variation in quality is wider than
General (certified) Aviation.
10

EVOLUTION: MORE ULM FATAL ACCIDENTS ?

Fatalities: (up to now), In Belgium, on average 2 /year,
comparable to General (certified) Aviation.
Number of fatalities
12
10
8
6
4
2

Number of fatalities

11

20
10

20
08

20
06

20
04

20
02

20
00

19
98

19
96

19
94

19
92

19
90

19
88

19
86

19
84

0

19
82

FATALITIES:
Figures limited to
Belgium.
2009: + 2 in France.
2010: + 5 in France.

WHAT ARE THE EXPECTATIONS
FOR THE
ULM-ACCIDENTS CASUALITY
RATE ?
• On Belgian soil, 4 deads in 2010.
(casuality rate of U.S. Forces in Iraq 3.6 killed /1000
troop / year – 8 years – 152000 troops – 4424 killed).

• In France and Belgium in 2010, 9 Belgian
deads to-date.
12

Comparison with the road
• In Belgium, the road kills 1000 people on average per year
.
• Fleet of vehicles: 6 000 000 units (5 mio cars).
• For 1000 cars, the road kills on average 0.16 person per
year.
• If we combine these figures with the yearly utilization rate
of cars (1 h per day) versus ULM (40 h per year), we can
conclude that ULM / General Aviation flying is
considerably deadlier than the road.

13

What can we learn from accident
investigation ?

14

The investigation process
A long process (Months)
• Collect all factual elements,
–
–
–
–
–
–

The flow of events;
The pilot (training, experience, …)
The aircraft (contact w/manufacturer)
Meteo, Comm, Radar,
Flt recorders (GPS, ECU, camera, …)
Impact, aircraft damage,

• Analysis. (incl. simulation, testing,…)
• Define all possible causes.
• From the causes, define remedial action.
The depth of the investigation is somewhat influenced by the
expected ROI.
15

Accident analysis
• Accidents do not occur “by accident”; Accident are
caused by a series of events.
• There are no “isolated cases”; causes of accidents are often
recurrent.
• Out of the ULM accident data base, we can conclude;
– There are recurrent technical problems specific to ULM.
– The traditional causes of aviation accidents are also known to
ULM (fuel shortage)

– 80% of the causal factors are human-related.

16

Main causal factors (122 accidents –
fixed wing and ULM)
Loss of control Take-off
11%

Fuel Starvation
15%

Loss of control Flight & collision
12%

Technical
11%
Low piloting
experience
8%

Loss of control Landing
16%
Icing
3%

Low flying /
aerobatics obstacles - CFIT
24%

17

Specific problems with ULM
• Technical causes can be (easily) identified;
but fire can be devastating.
• There’s another problem for the
investigator, a lot of landmarks are missing.
– ULM requirements are national,
– Certification not applicable.
– Wide variety of products.
18

About certification.
• Everyone would agree that ULMs of to-day are as good,
even a lot better than the ‘certified’ airplane.
• ULMs are designed to fly.
ULM are quality products; they meet your expectations
(simple to handle, fly fast, cheap in usage, …)
• Certification means that a manufacturer must demonstrate
that his product meets a minimum level of safety, as
defined (ultimately) by the Aviation Community.
• The minimum level of safety is defined in the Certification
Specifications – For small aircraft, it is called CS23.
19

Technical.
• AAIU(be) is currently investigating on:
– Instrument Board lay-out design.
– Electrical System design.
– Emergency Parachute.
Why is it that (for the last cases) parachute did not save lifes ?
• Late decision ?
• Handle easy to grab ?
• Safety pin not removed before flight ?

20

Same ULM Type, instrument panel somewhat different.
Difference in Ergonomy.
Parachute handle – on pilot’s side, or on passenger’s side ?

21

Regulation: certification:
CS 23.671 General
(b) Controls must be arranged and identified
to provide for convenience in operation and
to prevent the possibility of confusion and
subsequent inadvertent operation.

For ULM, CS 23 is not applicable.
Each designer has his own solution, and
they will be challenged only by YOUR
experience.
22

Other example
The passenger door opens in
flight, causing the pilot to take
appropriate actions, that
eventually force him to an
emergency landing.

• Door lock (simple – crude).
Plexy flexible. Once opened in
flight, difficult to close.
CS 23.783
(1) There must be means to lock and safeguard the door against
inadvertent opening during flight by persons, by cargo, or as a
result of mechanical failure.
23

The problem
• Once we determine a technical problem, we
can define recommendations to improve the
product, but:
What do we do with the recommendation ?
– We can not improve the Standard, there’s no standard.
– We can not address more than one manufacturer,
– What about retrofit ?

24

ULM and Engine failures

25

Fly Synthesis Storch
Summer 2009
• After propeller replacement, and subsequent
engine ground tests, the pilot took off for a
flight test.
• He encountered heavy engine vibration, that
forced him to an emergency landing.
• Airplane was slightly damaged.
Cause was identified as Vapor Lock.
26

1/5/2010 – FK9
Emergency landing after in-flight engine failure.
• Lots of corrosion found in carburettor.
Corrosion comes from water condensation in
fuel system (tank, lines, pump,…- MOGAS)
during long immobilisation periods.
- how to prevent ? Filling up, draining ?

• Fuel system was modified in-service, by
addition of a pressure regulator.
27

France
20/5/2010 – Mistral
23/5/2010 – CT Short Wing
Mistral: Engine failure in flight.
Emergency landing in field; terrain was very soft, airplane
severely damaged.
CT Short Wing: In short final, the engine suddenly stops
The pilot attempts to land, but hit trees, and crashes – wings
ripped off.
RH wing tank empty, 15-25 l fuel remaining in LH tank.
During LH turn, fuel system unprimed, engine stopped by
fuel starvation.
28

4 /6/2010: SG Rally
Damaged during landing
• Due to engine problems (heavy vibrations), the
pilot performed emergency landing on EBHN.
Coming in too fast, the landing was brutal, and
Nose Landing Gear collapsed.

29

Conclusion
• Engine in-flight failure are not exceptional.
– Use of MOGAS (water content, flash point,..)
– Local modifications,
– Other specific to the configuration of the
specific airplane.
And..
– Traditional causes (engine starvation,..)
30

Solutions
• In this case, we can design some generic
recommendations:
– Human Factors; ULM pilots should be more
prepared to react to engine failures at any time
(awareness, briefing, training,…)
– Generic technical solutions; impact on the use
of MOGAS.
• Protection of the equipment during winter,
• Risk of Vapour lock.

31

• Designing stop-gaps, accident after accidents
may not be satisfactory;
What can we do we make sure ULM flying
improves up to an acceptable level and, more
important, remains at that level ?

• More Regulation ?

32

Aviation Regulation and the ULM
• No significant changes in Regulation.
– ULM defined by capacity, weight, structural and stall speed limitation.
– => Extensive use of carbon fiber, Flaps, etc

• CS-VLA.
– 750 kg.
– “light” CS-23.
– Expensive.

• Lower Requirements for licencing,
– What about competence ?
– Human Factors training

• National requirements in Europe.
– EASA Flight Permit per Part 21A.701.

33

Evolution: new EU Regulation on
Accident Investigation.
* Every civil aviation accident or serious incident involving
aircraft other than specified in Annex II to the Regulation (EC)
No 216/2008 of the European Parliament and of the Council
shall be the subject of a safety investigation

( = No obligation of enquiry for ULMs)
• Safety investigation authorities may decide to investigate
incidents other than those referred to in paragraph 1 as well as
accidents or serious incidents to other types of aircraft, in
accordance with the national legislation of the Member States,
when they expect to draw safety lessons from them.
34

• US. NTSB; no enquiry for ULM crashes.
• To-day already, in some EU countries, ULM
crash investigations are given a low priority,
unless the Public determines otherwise.
• Common sense dictates that the initiative
to improve safety must come from the
ULM community itself.

35

Reason Model
• aviation is a complex socio-technical
system, where safety is ensured by a
series of defense barriers.
• Each barrier may present flaws (latent
or active) whose combination can lead
to an accident.
• An usafe act (active failure) alone
would not cause an accident.
• Latent failures are more easily
detected and corrected that human
errors, which are (globally) inevitable.

36

• The ULM community should reinforce its
Defense Barriers.
• Organisation: Federation and Clubs.
Create a Safety Climate
- Norms and rules
- Safety Programs

- To define a Safety Climate, we need to
assess the potential risk, and for that we
need data: YOUR experience.
37

Pyramid of Heinrich
• If a fatal accident is caused by
a specific combination of
events, an uncomplete series
of events causes INCIDENTS.
• If we identify all potentially
dangerous events AND with
that information, build-up the
defenses, we can avoid
ACCIDENTS.
38

SHARING EXPERIENCE
• By informing the Federation of the small
events and incidents that spoiled one of
your flights, you allow the Community to
understand the potential dangers and act
upon. (and respect confidentiality)
“Learn from mistakes of others; you won’t
live long enough to make them all by
yourself”
39

Human Factors
• To err is human.
• Human life (and flying) is full of decisions.
• It is therefore more important to know yourself
than to know how to fly your aircraft.
– Get-home-itis, Distraction, Communication,..

• Understanding human factors is a very important
step in improving your defenses.
40

Competence and Readiness
• You hold a pilot licence; but are you a
competent flyer ?
• How will you react when faced with a
potential dangerous situation?
• Assessing your competences with an
instructor is an opportunity to improve.
• When flying, be ready.
41

What is the Authority doing for
you ?

42

A series of work groups
within EASA are thinking
about how to improve
flight safety.(ESSI)
One of them is about General
Aviation (EGAST).

Initiative includes a leaflet
On Collision Avoidance,
and has been relayed to you
by the Federation.
There are technical Work
Groups dealing with MOGAS
43

and

An initiative to develop
Posters with comic strips
On high risk topics.
The first goes about taking
The right decision when the
Weather is below minimum.
They are expected in the
Coming months.

44

For Belgium, Accident reports are made public on the SPF/FOD website.
Recent reports (from 1st May 2007) are directly available through
hyperlinks.
Reports are written in English.
Information Notes are also available in order to highlight specific danger
area: Nr 2010 is about engine cold start.
We would like to develop more Notes, for ULM in collaboration with
the Federation.
Historical reports: currently a list is posted.
The list is fairly complete from 1972.
2 ancient reports (1936 and 1965).
The reports (Fr /Nl) are desidentified and available on request.
The list will be completed as we go along in reviewing archives.

45

Thank you for your attention, and
AAIU (Belgium) wishes you
many happy landings

Photos credit:
MRA / KLM

46


Slide 2

10 JULY 1910 - 2010
100 YEARS ULM ACCIDENTS

Belgian ULM Federation – Safety
1
Conference 10/10/2010

The Air Safety Investigation
• As part of the global Aviation sphere, an investigation is
conducted for each accident and serious incident by an
independent enquiry body, aimed to;
– Determine the causes of the accident.
– Determine if all conditions that were defined by rules and
regulations to ensure flight safety were followed (such as risk
factors in design).
– Define recommendations in order to prevent future accidents.

• It is not the purpose of this investigation to apportion
blame or liability.

2

In Belgium; the Air Accident
Investigation Unit.
• All accidents and serious incidents occurring in Belgium,
on aircraft, helicopters, gliders, balloons, ULM, DPM,
regardless of their registration is investigated by a cell
functionnally independent from the BCAA, and all other
interrested parties.
• Independent doesn’t mean isolated; it is part of the world’s
network of the State’s Aviation Investigation Bodies.
• The cell reports to the President of the Board of the
SPF/FOD Mobility and Transport.
3

4

ULM
• First pendular (Delta Plane Motorized)
design in 1966
• First crossing of the Channel in 1978 by Mr
D. Cook.
• Commercial development from 1979.
• Evolution from 2-axis to 3-axis.
• In Belgium, first ULM registered (501) in
1982.

5

6

Evolution
• 1982: Weedhopper, Chickinox
– 80…100 km/h
– Basic – 2/3 axis
– Range: … 200 km…

• 2010: VL-3 Sprint, DynAero MCR01, WT9 Dynamic….
– 220….250 km/h,
– flaps, retractable gear, avionics,
– Range over 1000 km

• 550 OO- registered ULM;
• 571 ULM pilot licence (363 training licences)
• 300-400 foreign-registered ULM.
7

1000
900
800
700
600
500
400
300
200
100

Number of valid registration

8

Estimation of flying OO-regd ULM

20
10

20
08

20
06

20
04

20
02

20
00

19
98

19
96

19
94

19
92

19
90

19
88

19
86

19
84

19
82

0

Evolution in pilot’s / owner’s
expectations
• In 1982, ULM /DPM, a sporting way of flying,
outside the limits of parachuting, delta plane.

• In 2010, an efficient alternative to general
(certified) aviation. ULM becomes a means of
transport.
• Beyond 2010 ?? – The Need for Speed ?
9

Evolution
• From the user’s perspective, the difference between
General Aviation and ULM becomes very thin.
• However, ULMs are characterized by a huge variety of
different design types, with low production rate and
configuration variation between individual airplanes.
– Manufacturers come and go,
– Assembly of the same ULM type by different companies induce
differences in built configuration.

• The above makes it more and more difficult to speak about
ULMs in a general way; variation in quality is wider than
General (certified) Aviation.
10

EVOLUTION: MORE ULM FATAL ACCIDENTS ?

Fatalities: (up to now), In Belgium, on average 2 /year,
comparable to General (certified) Aviation.
Number of fatalities
12
10
8
6
4
2

Number of fatalities

11

20
10

20
08

20
06

20
04

20
02

20
00

19
98

19
96

19
94

19
92

19
90

19
88

19
86

19
84

0

19
82

FATALITIES:
Figures limited to
Belgium.
2009: + 2 in France.
2010: + 5 in France.

WHAT ARE THE EXPECTATIONS
FOR THE
ULM-ACCIDENTS CASUALITY
RATE ?
• On Belgian soil, 4 deads in 2010.
(casuality rate of U.S. Forces in Iraq 3.6 killed /1000
troop / year – 8 years – 152000 troops – 4424 killed).

• In France and Belgium in 2010, 9 Belgian
deads to-date.
12

Comparison with the road
• In Belgium, the road kills 1000 people on average per year
.
• Fleet of vehicles: 6 000 000 units (5 mio cars).
• For 1000 cars, the road kills on average 0.16 person per
year.
• If we combine these figures with the yearly utilization rate
of cars (1 h per day) versus ULM (40 h per year), we can
conclude that ULM / General Aviation flying is
considerably deadlier than the road.

13

What can we learn from accident
investigation ?

14

The investigation process
A long process (Months)
• Collect all factual elements,
–
–
–
–
–
–

The flow of events;
The pilot (training, experience, …)
The aircraft (contact w/manufacturer)
Meteo, Comm, Radar,
Flt recorders (GPS, ECU, camera, …)
Impact, aircraft damage,

• Analysis. (incl. simulation, testing,…)
• Define all possible causes.
• From the causes, define remedial action.
The depth of the investigation is somewhat influenced by the
expected ROI.
15

Accident analysis
• Accidents do not occur “by accident”; Accident are
caused by a series of events.
• There are no “isolated cases”; causes of accidents are often
recurrent.
• Out of the ULM accident data base, we can conclude;
– There are recurrent technical problems specific to ULM.
– The traditional causes of aviation accidents are also known to
ULM (fuel shortage)

– 80% of the causal factors are human-related.

16

Main causal factors (122 accidents –
fixed wing and ULM)
Loss of control Take-off
11%

Fuel Starvation
15%

Loss of control Flight & collision
12%

Technical
11%
Low piloting
experience
8%

Loss of control Landing
16%
Icing
3%

Low flying /
aerobatics obstacles - CFIT
24%

17

Specific problems with ULM
• Technical causes can be (easily) identified;
but fire can be devastating.
• There’s another problem for the
investigator, a lot of landmarks are missing.
– ULM requirements are national,
– Certification not applicable.
– Wide variety of products.
18

About certification.
• Everyone would agree that ULMs of to-day are as good,
even a lot better than the ‘certified’ airplane.
• ULMs are designed to fly.
ULM are quality products; they meet your expectations
(simple to handle, fly fast, cheap in usage, …)
• Certification means that a manufacturer must demonstrate
that his product meets a minimum level of safety, as
defined (ultimately) by the Aviation Community.
• The minimum level of safety is defined in the Certification
Specifications – For small aircraft, it is called CS23.
19

Technical.
• AAIU(be) is currently investigating on:
– Instrument Board lay-out design.
– Electrical System design.
– Emergency Parachute.
Why is it that (for the last cases) parachute did not save lifes ?
• Late decision ?
• Handle easy to grab ?
• Safety pin not removed before flight ?

20

Same ULM Type, instrument panel somewhat different.
Difference in Ergonomy.
Parachute handle – on pilot’s side, or on passenger’s side ?

21

Regulation: certification:
CS 23.671 General
(b) Controls must be arranged and identified
to provide for convenience in operation and
to prevent the possibility of confusion and
subsequent inadvertent operation.

For ULM, CS 23 is not applicable.
Each designer has his own solution, and
they will be challenged only by YOUR
experience.
22

Other example
The passenger door opens in
flight, causing the pilot to take
appropriate actions, that
eventually force him to an
emergency landing.

• Door lock (simple – crude).
Plexy flexible. Once opened in
flight, difficult to close.
CS 23.783
(1) There must be means to lock and safeguard the door against
inadvertent opening during flight by persons, by cargo, or as a
result of mechanical failure.
23

The problem
• Once we determine a technical problem, we
can define recommendations to improve the
product, but:
What do we do with the recommendation ?
– We can not improve the Standard, there’s no standard.
– We can not address more than one manufacturer,
– What about retrofit ?

24

ULM and Engine failures

25

Fly Synthesis Storch
Summer 2009
• After propeller replacement, and subsequent
engine ground tests, the pilot took off for a
flight test.
• He encountered heavy engine vibration, that
forced him to an emergency landing.
• Airplane was slightly damaged.
Cause was identified as Vapor Lock.
26

1/5/2010 – FK9
Emergency landing after in-flight engine failure.
• Lots of corrosion found in carburettor.
Corrosion comes from water condensation in
fuel system (tank, lines, pump,…- MOGAS)
during long immobilisation periods.
- how to prevent ? Filling up, draining ?

• Fuel system was modified in-service, by
addition of a pressure regulator.
27

France
20/5/2010 – Mistral
23/5/2010 – CT Short Wing
Mistral: Engine failure in flight.
Emergency landing in field; terrain was very soft, airplane
severely damaged.
CT Short Wing: In short final, the engine suddenly stops
The pilot attempts to land, but hit trees, and crashes – wings
ripped off.
RH wing tank empty, 15-25 l fuel remaining in LH tank.
During LH turn, fuel system unprimed, engine stopped by
fuel starvation.
28

4 /6/2010: SG Rally
Damaged during landing
• Due to engine problems (heavy vibrations), the
pilot performed emergency landing on EBHN.
Coming in too fast, the landing was brutal, and
Nose Landing Gear collapsed.

29

Conclusion
• Engine in-flight failure are not exceptional.
– Use of MOGAS (water content, flash point,..)
– Local modifications,
– Other specific to the configuration of the
specific airplane.
And..
– Traditional causes (engine starvation,..)
30

Solutions
• In this case, we can design some generic
recommendations:
– Human Factors; ULM pilots should be more
prepared to react to engine failures at any time
(awareness, briefing, training,…)
– Generic technical solutions; impact on the use
of MOGAS.
• Protection of the equipment during winter,
• Risk of Vapour lock.

31

• Designing stop-gaps, accident after accidents
may not be satisfactory;
What can we do we make sure ULM flying
improves up to an acceptable level and, more
important, remains at that level ?

• More Regulation ?

32

Aviation Regulation and the ULM
• No significant changes in Regulation.
– ULM defined by capacity, weight, structural and stall speed limitation.
– => Extensive use of carbon fiber, Flaps, etc

• CS-VLA.
– 750 kg.
– “light” CS-23.
– Expensive.

• Lower Requirements for licencing,
– What about competence ?
– Human Factors training

• National requirements in Europe.
– EASA Flight Permit per Part 21A.701.

33

Evolution: new EU Regulation on
Accident Investigation.
* Every civil aviation accident or serious incident involving
aircraft other than specified in Annex II to the Regulation (EC)
No 216/2008 of the European Parliament and of the Council
shall be the subject of a safety investigation

( = No obligation of enquiry for ULMs)
• Safety investigation authorities may decide to investigate
incidents other than those referred to in paragraph 1 as well as
accidents or serious incidents to other types of aircraft, in
accordance with the national legislation of the Member States,
when they expect to draw safety lessons from them.
34

• US. NTSB; no enquiry for ULM crashes.
• To-day already, in some EU countries, ULM
crash investigations are given a low priority,
unless the Public determines otherwise.
• Common sense dictates that the initiative
to improve safety must come from the
ULM community itself.

35

Reason Model
• aviation is a complex socio-technical
system, where safety is ensured by a
series of defense barriers.
• Each barrier may present flaws (latent
or active) whose combination can lead
to an accident.
• An usafe act (active failure) alone
would not cause an accident.
• Latent failures are more easily
detected and corrected that human
errors, which are (globally) inevitable.

36

• The ULM community should reinforce its
Defense Barriers.
• Organisation: Federation and Clubs.
Create a Safety Climate
- Norms and rules
- Safety Programs

- To define a Safety Climate, we need to
assess the potential risk, and for that we
need data: YOUR experience.
37

Pyramid of Heinrich
• If a fatal accident is caused by
a specific combination of
events, an uncomplete series
of events causes INCIDENTS.
• If we identify all potentially
dangerous events AND with
that information, build-up the
defenses, we can avoid
ACCIDENTS.
38

SHARING EXPERIENCE
• By informing the Federation of the small
events and incidents that spoiled one of
your flights, you allow the Community to
understand the potential dangers and act
upon. (and respect confidentiality)
“Learn from mistakes of others; you won’t
live long enough to make them all by
yourself”
39

Human Factors
• To err is human.
• Human life (and flying) is full of decisions.
• It is therefore more important to know yourself
than to know how to fly your aircraft.
– Get-home-itis, Distraction, Communication,..

• Understanding human factors is a very important
step in improving your defenses.
40

Competence and Readiness
• You hold a pilot licence; but are you a
competent flyer ?
• How will you react when faced with a
potential dangerous situation?
• Assessing your competences with an
instructor is an opportunity to improve.
• When flying, be ready.
41

What is the Authority doing for
you ?

42

A series of work groups
within EASA are thinking
about how to improve
flight safety.(ESSI)
One of them is about General
Aviation (EGAST).

Initiative includes a leaflet
On Collision Avoidance,
and has been relayed to you
by the Federation.
There are technical Work
Groups dealing with MOGAS
43

and

An initiative to develop
Posters with comic strips
On high risk topics.
The first goes about taking
The right decision when the
Weather is below minimum.
They are expected in the
Coming months.

44

For Belgium, Accident reports are made public on the SPF/FOD website.
Recent reports (from 1st May 2007) are directly available through
hyperlinks.
Reports are written in English.
Information Notes are also available in order to highlight specific danger
area: Nr 2010 is about engine cold start.
We would like to develop more Notes, for ULM in collaboration with
the Federation.
Historical reports: currently a list is posted.
The list is fairly complete from 1972.
2 ancient reports (1936 and 1965).
The reports (Fr /Nl) are desidentified and available on request.
The list will be completed as we go along in reviewing archives.

45

Thank you for your attention, and
AAIU (Belgium) wishes you
many happy landings

Photos credit:
MRA / KLM

46


Slide 3

10 JULY 1910 - 2010
100 YEARS ULM ACCIDENTS

Belgian ULM Federation – Safety
1
Conference 10/10/2010

The Air Safety Investigation
• As part of the global Aviation sphere, an investigation is
conducted for each accident and serious incident by an
independent enquiry body, aimed to;
– Determine the causes of the accident.
– Determine if all conditions that were defined by rules and
regulations to ensure flight safety were followed (such as risk
factors in design).
– Define recommendations in order to prevent future accidents.

• It is not the purpose of this investigation to apportion
blame or liability.

2

In Belgium; the Air Accident
Investigation Unit.
• All accidents and serious incidents occurring in Belgium,
on aircraft, helicopters, gliders, balloons, ULM, DPM,
regardless of their registration is investigated by a cell
functionnally independent from the BCAA, and all other
interrested parties.
• Independent doesn’t mean isolated; it is part of the world’s
network of the State’s Aviation Investigation Bodies.
• The cell reports to the President of the Board of the
SPF/FOD Mobility and Transport.
3

4

ULM
• First pendular (Delta Plane Motorized)
design in 1966
• First crossing of the Channel in 1978 by Mr
D. Cook.
• Commercial development from 1979.
• Evolution from 2-axis to 3-axis.
• In Belgium, first ULM registered (501) in
1982.

5

6

Evolution
• 1982: Weedhopper, Chickinox
– 80…100 km/h
– Basic – 2/3 axis
– Range: … 200 km…

• 2010: VL-3 Sprint, DynAero MCR01, WT9 Dynamic….
– 220….250 km/h,
– flaps, retractable gear, avionics,
– Range over 1000 km

• 550 OO- registered ULM;
• 571 ULM pilot licence (363 training licences)
• 300-400 foreign-registered ULM.
7

1000
900
800
700
600
500
400
300
200
100

Number of valid registration

8

Estimation of flying OO-regd ULM

20
10

20
08

20
06

20
04

20
02

20
00

19
98

19
96

19
94

19
92

19
90

19
88

19
86

19
84

19
82

0

Evolution in pilot’s / owner’s
expectations
• In 1982, ULM /DPM, a sporting way of flying,
outside the limits of parachuting, delta plane.

• In 2010, an efficient alternative to general
(certified) aviation. ULM becomes a means of
transport.
• Beyond 2010 ?? – The Need for Speed ?
9

Evolution
• From the user’s perspective, the difference between
General Aviation and ULM becomes very thin.
• However, ULMs are characterized by a huge variety of
different design types, with low production rate and
configuration variation between individual airplanes.
– Manufacturers come and go,
– Assembly of the same ULM type by different companies induce
differences in built configuration.

• The above makes it more and more difficult to speak about
ULMs in a general way; variation in quality is wider than
General (certified) Aviation.
10

EVOLUTION: MORE ULM FATAL ACCIDENTS ?

Fatalities: (up to now), In Belgium, on average 2 /year,
comparable to General (certified) Aviation.
Number of fatalities
12
10
8
6
4
2

Number of fatalities

11

20
10

20
08

20
06

20
04

20
02

20
00

19
98

19
96

19
94

19
92

19
90

19
88

19
86

19
84

0

19
82

FATALITIES:
Figures limited to
Belgium.
2009: + 2 in France.
2010: + 5 in France.

WHAT ARE THE EXPECTATIONS
FOR THE
ULM-ACCIDENTS CASUALITY
RATE ?
• On Belgian soil, 4 deads in 2010.
(casuality rate of U.S. Forces in Iraq 3.6 killed /1000
troop / year – 8 years – 152000 troops – 4424 killed).

• In France and Belgium in 2010, 9 Belgian
deads to-date.
12

Comparison with the road
• In Belgium, the road kills 1000 people on average per year
.
• Fleet of vehicles: 6 000 000 units (5 mio cars).
• For 1000 cars, the road kills on average 0.16 person per
year.
• If we combine these figures with the yearly utilization rate
of cars (1 h per day) versus ULM (40 h per year), we can
conclude that ULM / General Aviation flying is
considerably deadlier than the road.

13

What can we learn from accident
investigation ?

14

The investigation process
A long process (Months)
• Collect all factual elements,
–
–
–
–
–
–

The flow of events;
The pilot (training, experience, …)
The aircraft (contact w/manufacturer)
Meteo, Comm, Radar,
Flt recorders (GPS, ECU, camera, …)
Impact, aircraft damage,

• Analysis. (incl. simulation, testing,…)
• Define all possible causes.
• From the causes, define remedial action.
The depth of the investigation is somewhat influenced by the
expected ROI.
15

Accident analysis
• Accidents do not occur “by accident”; Accident are
caused by a series of events.
• There are no “isolated cases”; causes of accidents are often
recurrent.
• Out of the ULM accident data base, we can conclude;
– There are recurrent technical problems specific to ULM.
– The traditional causes of aviation accidents are also known to
ULM (fuel shortage)

– 80% of the causal factors are human-related.

16

Main causal factors (122 accidents –
fixed wing and ULM)
Loss of control Take-off
11%

Fuel Starvation
15%

Loss of control Flight & collision
12%

Technical
11%
Low piloting
experience
8%

Loss of control Landing
16%
Icing
3%

Low flying /
aerobatics obstacles - CFIT
24%

17

Specific problems with ULM
• Technical causes can be (easily) identified;
but fire can be devastating.
• There’s another problem for the
investigator, a lot of landmarks are missing.
– ULM requirements are national,
– Certification not applicable.
– Wide variety of products.
18

About certification.
• Everyone would agree that ULMs of to-day are as good,
even a lot better than the ‘certified’ airplane.
• ULMs are designed to fly.
ULM are quality products; they meet your expectations
(simple to handle, fly fast, cheap in usage, …)
• Certification means that a manufacturer must demonstrate
that his product meets a minimum level of safety, as
defined (ultimately) by the Aviation Community.
• The minimum level of safety is defined in the Certification
Specifications – For small aircraft, it is called CS23.
19

Technical.
• AAIU(be) is currently investigating on:
– Instrument Board lay-out design.
– Electrical System design.
– Emergency Parachute.
Why is it that (for the last cases) parachute did not save lifes ?
• Late decision ?
• Handle easy to grab ?
• Safety pin not removed before flight ?

20

Same ULM Type, instrument panel somewhat different.
Difference in Ergonomy.
Parachute handle – on pilot’s side, or on passenger’s side ?

21

Regulation: certification:
CS 23.671 General
(b) Controls must be arranged and identified
to provide for convenience in operation and
to prevent the possibility of confusion and
subsequent inadvertent operation.

For ULM, CS 23 is not applicable.
Each designer has his own solution, and
they will be challenged only by YOUR
experience.
22

Other example
The passenger door opens in
flight, causing the pilot to take
appropriate actions, that
eventually force him to an
emergency landing.

• Door lock (simple – crude).
Plexy flexible. Once opened in
flight, difficult to close.
CS 23.783
(1) There must be means to lock and safeguard the door against
inadvertent opening during flight by persons, by cargo, or as a
result of mechanical failure.
23

The problem
• Once we determine a technical problem, we
can define recommendations to improve the
product, but:
What do we do with the recommendation ?
– We can not improve the Standard, there’s no standard.
– We can not address more than one manufacturer,
– What about retrofit ?

24

ULM and Engine failures

25

Fly Synthesis Storch
Summer 2009
• After propeller replacement, and subsequent
engine ground tests, the pilot took off for a
flight test.
• He encountered heavy engine vibration, that
forced him to an emergency landing.
• Airplane was slightly damaged.
Cause was identified as Vapor Lock.
26

1/5/2010 – FK9
Emergency landing after in-flight engine failure.
• Lots of corrosion found in carburettor.
Corrosion comes from water condensation in
fuel system (tank, lines, pump,…- MOGAS)
during long immobilisation periods.
- how to prevent ? Filling up, draining ?

• Fuel system was modified in-service, by
addition of a pressure regulator.
27

France
20/5/2010 – Mistral
23/5/2010 – CT Short Wing
Mistral: Engine failure in flight.
Emergency landing in field; terrain was very soft, airplane
severely damaged.
CT Short Wing: In short final, the engine suddenly stops
The pilot attempts to land, but hit trees, and crashes – wings
ripped off.
RH wing tank empty, 15-25 l fuel remaining in LH tank.
During LH turn, fuel system unprimed, engine stopped by
fuel starvation.
28

4 /6/2010: SG Rally
Damaged during landing
• Due to engine problems (heavy vibrations), the
pilot performed emergency landing on EBHN.
Coming in too fast, the landing was brutal, and
Nose Landing Gear collapsed.

29

Conclusion
• Engine in-flight failure are not exceptional.
– Use of MOGAS (water content, flash point,..)
– Local modifications,
– Other specific to the configuration of the
specific airplane.
And..
– Traditional causes (engine starvation,..)
30

Solutions
• In this case, we can design some generic
recommendations:
– Human Factors; ULM pilots should be more
prepared to react to engine failures at any time
(awareness, briefing, training,…)
– Generic technical solutions; impact on the use
of MOGAS.
• Protection of the equipment during winter,
• Risk of Vapour lock.

31

• Designing stop-gaps, accident after accidents
may not be satisfactory;
What can we do we make sure ULM flying
improves up to an acceptable level and, more
important, remains at that level ?

• More Regulation ?

32

Aviation Regulation and the ULM
• No significant changes in Regulation.
– ULM defined by capacity, weight, structural and stall speed limitation.
– => Extensive use of carbon fiber, Flaps, etc

• CS-VLA.
– 750 kg.
– “light” CS-23.
– Expensive.

• Lower Requirements for licencing,
– What about competence ?
– Human Factors training

• National requirements in Europe.
– EASA Flight Permit per Part 21A.701.

33

Evolution: new EU Regulation on
Accident Investigation.
* Every civil aviation accident or serious incident involving
aircraft other than specified in Annex II to the Regulation (EC)
No 216/2008 of the European Parliament and of the Council
shall be the subject of a safety investigation

( = No obligation of enquiry for ULMs)
• Safety investigation authorities may decide to investigate
incidents other than those referred to in paragraph 1 as well as
accidents or serious incidents to other types of aircraft, in
accordance with the national legislation of the Member States,
when they expect to draw safety lessons from them.
34

• US. NTSB; no enquiry for ULM crashes.
• To-day already, in some EU countries, ULM
crash investigations are given a low priority,
unless the Public determines otherwise.
• Common sense dictates that the initiative
to improve safety must come from the
ULM community itself.

35

Reason Model
• aviation is a complex socio-technical
system, where safety is ensured by a
series of defense barriers.
• Each barrier may present flaws (latent
or active) whose combination can lead
to an accident.
• An usafe act (active failure) alone
would not cause an accident.
• Latent failures are more easily
detected and corrected that human
errors, which are (globally) inevitable.

36

• The ULM community should reinforce its
Defense Barriers.
• Organisation: Federation and Clubs.
Create a Safety Climate
- Norms and rules
- Safety Programs

- To define a Safety Climate, we need to
assess the potential risk, and for that we
need data: YOUR experience.
37

Pyramid of Heinrich
• If a fatal accident is caused by
a specific combination of
events, an uncomplete series
of events causes INCIDENTS.
• If we identify all potentially
dangerous events AND with
that information, build-up the
defenses, we can avoid
ACCIDENTS.
38

SHARING EXPERIENCE
• By informing the Federation of the small
events and incidents that spoiled one of
your flights, you allow the Community to
understand the potential dangers and act
upon. (and respect confidentiality)
“Learn from mistakes of others; you won’t
live long enough to make them all by
yourself”
39

Human Factors
• To err is human.
• Human life (and flying) is full of decisions.
• It is therefore more important to know yourself
than to know how to fly your aircraft.
– Get-home-itis, Distraction, Communication,..

• Understanding human factors is a very important
step in improving your defenses.
40

Competence and Readiness
• You hold a pilot licence; but are you a
competent flyer ?
• How will you react when faced with a
potential dangerous situation?
• Assessing your competences with an
instructor is an opportunity to improve.
• When flying, be ready.
41

What is the Authority doing for
you ?

42

A series of work groups
within EASA are thinking
about how to improve
flight safety.(ESSI)
One of them is about General
Aviation (EGAST).

Initiative includes a leaflet
On Collision Avoidance,
and has been relayed to you
by the Federation.
There are technical Work
Groups dealing with MOGAS
43

and

An initiative to develop
Posters with comic strips
On high risk topics.
The first goes about taking
The right decision when the
Weather is below minimum.
They are expected in the
Coming months.

44

For Belgium, Accident reports are made public on the SPF/FOD website.
Recent reports (from 1st May 2007) are directly available through
hyperlinks.
Reports are written in English.
Information Notes are also available in order to highlight specific danger
area: Nr 2010 is about engine cold start.
We would like to develop more Notes, for ULM in collaboration with
the Federation.
Historical reports: currently a list is posted.
The list is fairly complete from 1972.
2 ancient reports (1936 and 1965).
The reports (Fr /Nl) are desidentified and available on request.
The list will be completed as we go along in reviewing archives.

45

Thank you for your attention, and
AAIU (Belgium) wishes you
many happy landings

Photos credit:
MRA / KLM

46


Slide 4

10 JULY 1910 - 2010
100 YEARS ULM ACCIDENTS

Belgian ULM Federation – Safety
1
Conference 10/10/2010

The Air Safety Investigation
• As part of the global Aviation sphere, an investigation is
conducted for each accident and serious incident by an
independent enquiry body, aimed to;
– Determine the causes of the accident.
– Determine if all conditions that were defined by rules and
regulations to ensure flight safety were followed (such as risk
factors in design).
– Define recommendations in order to prevent future accidents.

• It is not the purpose of this investigation to apportion
blame or liability.

2

In Belgium; the Air Accident
Investigation Unit.
• All accidents and serious incidents occurring in Belgium,
on aircraft, helicopters, gliders, balloons, ULM, DPM,
regardless of their registration is investigated by a cell
functionnally independent from the BCAA, and all other
interrested parties.
• Independent doesn’t mean isolated; it is part of the world’s
network of the State’s Aviation Investigation Bodies.
• The cell reports to the President of the Board of the
SPF/FOD Mobility and Transport.
3

4

ULM
• First pendular (Delta Plane Motorized)
design in 1966
• First crossing of the Channel in 1978 by Mr
D. Cook.
• Commercial development from 1979.
• Evolution from 2-axis to 3-axis.
• In Belgium, first ULM registered (501) in
1982.

5

6

Evolution
• 1982: Weedhopper, Chickinox
– 80…100 km/h
– Basic – 2/3 axis
– Range: … 200 km…

• 2010: VL-3 Sprint, DynAero MCR01, WT9 Dynamic….
– 220….250 km/h,
– flaps, retractable gear, avionics,
– Range over 1000 km

• 550 OO- registered ULM;
• 571 ULM pilot licence (363 training licences)
• 300-400 foreign-registered ULM.
7

1000
900
800
700
600
500
400
300
200
100

Number of valid registration

8

Estimation of flying OO-regd ULM

20
10

20
08

20
06

20
04

20
02

20
00

19
98

19
96

19
94

19
92

19
90

19
88

19
86

19
84

19
82

0

Evolution in pilot’s / owner’s
expectations
• In 1982, ULM /DPM, a sporting way of flying,
outside the limits of parachuting, delta plane.

• In 2010, an efficient alternative to general
(certified) aviation. ULM becomes a means of
transport.
• Beyond 2010 ?? – The Need for Speed ?
9

Evolution
• From the user’s perspective, the difference between
General Aviation and ULM becomes very thin.
• However, ULMs are characterized by a huge variety of
different design types, with low production rate and
configuration variation between individual airplanes.
– Manufacturers come and go,
– Assembly of the same ULM type by different companies induce
differences in built configuration.

• The above makes it more and more difficult to speak about
ULMs in a general way; variation in quality is wider than
General (certified) Aviation.
10

EVOLUTION: MORE ULM FATAL ACCIDENTS ?

Fatalities: (up to now), In Belgium, on average 2 /year,
comparable to General (certified) Aviation.
Number of fatalities
12
10
8
6
4
2

Number of fatalities

11

20
10

20
08

20
06

20
04

20
02

20
00

19
98

19
96

19
94

19
92

19
90

19
88

19
86

19
84

0

19
82

FATALITIES:
Figures limited to
Belgium.
2009: + 2 in France.
2010: + 5 in France.

WHAT ARE THE EXPECTATIONS
FOR THE
ULM-ACCIDENTS CASUALITY
RATE ?
• On Belgian soil, 4 deads in 2010.
(casuality rate of U.S. Forces in Iraq 3.6 killed /1000
troop / year – 8 years – 152000 troops – 4424 killed).

• In France and Belgium in 2010, 9 Belgian
deads to-date.
12

Comparison with the road
• In Belgium, the road kills 1000 people on average per year
.
• Fleet of vehicles: 6 000 000 units (5 mio cars).
• For 1000 cars, the road kills on average 0.16 person per
year.
• If we combine these figures with the yearly utilization rate
of cars (1 h per day) versus ULM (40 h per year), we can
conclude that ULM / General Aviation flying is
considerably deadlier than the road.

13

What can we learn from accident
investigation ?

14

The investigation process
A long process (Months)
• Collect all factual elements,
–
–
–
–
–
–

The flow of events;
The pilot (training, experience, …)
The aircraft (contact w/manufacturer)
Meteo, Comm, Radar,
Flt recorders (GPS, ECU, camera, …)
Impact, aircraft damage,

• Analysis. (incl. simulation, testing,…)
• Define all possible causes.
• From the causes, define remedial action.
The depth of the investigation is somewhat influenced by the
expected ROI.
15

Accident analysis
• Accidents do not occur “by accident”; Accident are
caused by a series of events.
• There are no “isolated cases”; causes of accidents are often
recurrent.
• Out of the ULM accident data base, we can conclude;
– There are recurrent technical problems specific to ULM.
– The traditional causes of aviation accidents are also known to
ULM (fuel shortage)

– 80% of the causal factors are human-related.

16

Main causal factors (122 accidents –
fixed wing and ULM)
Loss of control Take-off
11%

Fuel Starvation
15%

Loss of control Flight & collision
12%

Technical
11%
Low piloting
experience
8%

Loss of control Landing
16%
Icing
3%

Low flying /
aerobatics obstacles - CFIT
24%

17

Specific problems with ULM
• Technical causes can be (easily) identified;
but fire can be devastating.
• There’s another problem for the
investigator, a lot of landmarks are missing.
– ULM requirements are national,
– Certification not applicable.
– Wide variety of products.
18

About certification.
• Everyone would agree that ULMs of to-day are as good,
even a lot better than the ‘certified’ airplane.
• ULMs are designed to fly.
ULM are quality products; they meet your expectations
(simple to handle, fly fast, cheap in usage, …)
• Certification means that a manufacturer must demonstrate
that his product meets a minimum level of safety, as
defined (ultimately) by the Aviation Community.
• The minimum level of safety is defined in the Certification
Specifications – For small aircraft, it is called CS23.
19

Technical.
• AAIU(be) is currently investigating on:
– Instrument Board lay-out design.
– Electrical System design.
– Emergency Parachute.
Why is it that (for the last cases) parachute did not save lifes ?
• Late decision ?
• Handle easy to grab ?
• Safety pin not removed before flight ?

20

Same ULM Type, instrument panel somewhat different.
Difference in Ergonomy.
Parachute handle – on pilot’s side, or on passenger’s side ?

21

Regulation: certification:
CS 23.671 General
(b) Controls must be arranged and identified
to provide for convenience in operation and
to prevent the possibility of confusion and
subsequent inadvertent operation.

For ULM, CS 23 is not applicable.
Each designer has his own solution, and
they will be challenged only by YOUR
experience.
22

Other example
The passenger door opens in
flight, causing the pilot to take
appropriate actions, that
eventually force him to an
emergency landing.

• Door lock (simple – crude).
Plexy flexible. Once opened in
flight, difficult to close.
CS 23.783
(1) There must be means to lock and safeguard the door against
inadvertent opening during flight by persons, by cargo, or as a
result of mechanical failure.
23

The problem
• Once we determine a technical problem, we
can define recommendations to improve the
product, but:
What do we do with the recommendation ?
– We can not improve the Standard, there’s no standard.
– We can not address more than one manufacturer,
– What about retrofit ?

24

ULM and Engine failures

25

Fly Synthesis Storch
Summer 2009
• After propeller replacement, and subsequent
engine ground tests, the pilot took off for a
flight test.
• He encountered heavy engine vibration, that
forced him to an emergency landing.
• Airplane was slightly damaged.
Cause was identified as Vapor Lock.
26

1/5/2010 – FK9
Emergency landing after in-flight engine failure.
• Lots of corrosion found in carburettor.
Corrosion comes from water condensation in
fuel system (tank, lines, pump,…- MOGAS)
during long immobilisation periods.
- how to prevent ? Filling up, draining ?

• Fuel system was modified in-service, by
addition of a pressure regulator.
27

France
20/5/2010 – Mistral
23/5/2010 – CT Short Wing
Mistral: Engine failure in flight.
Emergency landing in field; terrain was very soft, airplane
severely damaged.
CT Short Wing: In short final, the engine suddenly stops
The pilot attempts to land, but hit trees, and crashes – wings
ripped off.
RH wing tank empty, 15-25 l fuel remaining in LH tank.
During LH turn, fuel system unprimed, engine stopped by
fuel starvation.
28

4 /6/2010: SG Rally
Damaged during landing
• Due to engine problems (heavy vibrations), the
pilot performed emergency landing on EBHN.
Coming in too fast, the landing was brutal, and
Nose Landing Gear collapsed.

29

Conclusion
• Engine in-flight failure are not exceptional.
– Use of MOGAS (water content, flash point,..)
– Local modifications,
– Other specific to the configuration of the
specific airplane.
And..
– Traditional causes (engine starvation,..)
30

Solutions
• In this case, we can design some generic
recommendations:
– Human Factors; ULM pilots should be more
prepared to react to engine failures at any time
(awareness, briefing, training,…)
– Generic technical solutions; impact on the use
of MOGAS.
• Protection of the equipment during winter,
• Risk of Vapour lock.

31

• Designing stop-gaps, accident after accidents
may not be satisfactory;
What can we do we make sure ULM flying
improves up to an acceptable level and, more
important, remains at that level ?

• More Regulation ?

32

Aviation Regulation and the ULM
• No significant changes in Regulation.
– ULM defined by capacity, weight, structural and stall speed limitation.
– => Extensive use of carbon fiber, Flaps, etc

• CS-VLA.
– 750 kg.
– “light” CS-23.
– Expensive.

• Lower Requirements for licencing,
– What about competence ?
– Human Factors training

• National requirements in Europe.
– EASA Flight Permit per Part 21A.701.

33

Evolution: new EU Regulation on
Accident Investigation.
* Every civil aviation accident or serious incident involving
aircraft other than specified in Annex II to the Regulation (EC)
No 216/2008 of the European Parliament and of the Council
shall be the subject of a safety investigation

( = No obligation of enquiry for ULMs)
• Safety investigation authorities may decide to investigate
incidents other than those referred to in paragraph 1 as well as
accidents or serious incidents to other types of aircraft, in
accordance with the national legislation of the Member States,
when they expect to draw safety lessons from them.
34

• US. NTSB; no enquiry for ULM crashes.
• To-day already, in some EU countries, ULM
crash investigations are given a low priority,
unless the Public determines otherwise.
• Common sense dictates that the initiative
to improve safety must come from the
ULM community itself.

35

Reason Model
• aviation is a complex socio-technical
system, where safety is ensured by a
series of defense barriers.
• Each barrier may present flaws (latent
or active) whose combination can lead
to an accident.
• An usafe act (active failure) alone
would not cause an accident.
• Latent failures are more easily
detected and corrected that human
errors, which are (globally) inevitable.

36

• The ULM community should reinforce its
Defense Barriers.
• Organisation: Federation and Clubs.
Create a Safety Climate
- Norms and rules
- Safety Programs

- To define a Safety Climate, we need to
assess the potential risk, and for that we
need data: YOUR experience.
37

Pyramid of Heinrich
• If a fatal accident is caused by
a specific combination of
events, an uncomplete series
of events causes INCIDENTS.
• If we identify all potentially
dangerous events AND with
that information, build-up the
defenses, we can avoid
ACCIDENTS.
38

SHARING EXPERIENCE
• By informing the Federation of the small
events and incidents that spoiled one of
your flights, you allow the Community to
understand the potential dangers and act
upon. (and respect confidentiality)
“Learn from mistakes of others; you won’t
live long enough to make them all by
yourself”
39

Human Factors
• To err is human.
• Human life (and flying) is full of decisions.
• It is therefore more important to know yourself
than to know how to fly your aircraft.
– Get-home-itis, Distraction, Communication,..

• Understanding human factors is a very important
step in improving your defenses.
40

Competence and Readiness
• You hold a pilot licence; but are you a
competent flyer ?
• How will you react when faced with a
potential dangerous situation?
• Assessing your competences with an
instructor is an opportunity to improve.
• When flying, be ready.
41

What is the Authority doing for
you ?

42

A series of work groups
within EASA are thinking
about how to improve
flight safety.(ESSI)
One of them is about General
Aviation (EGAST).

Initiative includes a leaflet
On Collision Avoidance,
and has been relayed to you
by the Federation.
There are technical Work
Groups dealing with MOGAS
43

and

An initiative to develop
Posters with comic strips
On high risk topics.
The first goes about taking
The right decision when the
Weather is below minimum.
They are expected in the
Coming months.

44

For Belgium, Accident reports are made public on the SPF/FOD website.
Recent reports (from 1st May 2007) are directly available through
hyperlinks.
Reports are written in English.
Information Notes are also available in order to highlight specific danger
area: Nr 2010 is about engine cold start.
We would like to develop more Notes, for ULM in collaboration with
the Federation.
Historical reports: currently a list is posted.
The list is fairly complete from 1972.
2 ancient reports (1936 and 1965).
The reports (Fr /Nl) are desidentified and available on request.
The list will be completed as we go along in reviewing archives.

45

Thank you for your attention, and
AAIU (Belgium) wishes you
many happy landings

Photos credit:
MRA / KLM

46


Slide 5

10 JULY 1910 - 2010
100 YEARS ULM ACCIDENTS

Belgian ULM Federation – Safety
1
Conference 10/10/2010

The Air Safety Investigation
• As part of the global Aviation sphere, an investigation is
conducted for each accident and serious incident by an
independent enquiry body, aimed to;
– Determine the causes of the accident.
– Determine if all conditions that were defined by rules and
regulations to ensure flight safety were followed (such as risk
factors in design).
– Define recommendations in order to prevent future accidents.

• It is not the purpose of this investigation to apportion
blame or liability.

2

In Belgium; the Air Accident
Investigation Unit.
• All accidents and serious incidents occurring in Belgium,
on aircraft, helicopters, gliders, balloons, ULM, DPM,
regardless of their registration is investigated by a cell
functionnally independent from the BCAA, and all other
interrested parties.
• Independent doesn’t mean isolated; it is part of the world’s
network of the State’s Aviation Investigation Bodies.
• The cell reports to the President of the Board of the
SPF/FOD Mobility and Transport.
3

4

ULM
• First pendular (Delta Plane Motorized)
design in 1966
• First crossing of the Channel in 1978 by Mr
D. Cook.
• Commercial development from 1979.
• Evolution from 2-axis to 3-axis.
• In Belgium, first ULM registered (501) in
1982.

5

6

Evolution
• 1982: Weedhopper, Chickinox
– 80…100 km/h
– Basic – 2/3 axis
– Range: … 200 km…

• 2010: VL-3 Sprint, DynAero MCR01, WT9 Dynamic….
– 220….250 km/h,
– flaps, retractable gear, avionics,
– Range over 1000 km

• 550 OO- registered ULM;
• 571 ULM pilot licence (363 training licences)
• 300-400 foreign-registered ULM.
7

1000
900
800
700
600
500
400
300
200
100

Number of valid registration

8

Estimation of flying OO-regd ULM

20
10

20
08

20
06

20
04

20
02

20
00

19
98

19
96

19
94

19
92

19
90

19
88

19
86

19
84

19
82

0

Evolution in pilot’s / owner’s
expectations
• In 1982, ULM /DPM, a sporting way of flying,
outside the limits of parachuting, delta plane.

• In 2010, an efficient alternative to general
(certified) aviation. ULM becomes a means of
transport.
• Beyond 2010 ?? – The Need for Speed ?
9

Evolution
• From the user’s perspective, the difference between
General Aviation and ULM becomes very thin.
• However, ULMs are characterized by a huge variety of
different design types, with low production rate and
configuration variation between individual airplanes.
– Manufacturers come and go,
– Assembly of the same ULM type by different companies induce
differences in built configuration.

• The above makes it more and more difficult to speak about
ULMs in a general way; variation in quality is wider than
General (certified) Aviation.
10

EVOLUTION: MORE ULM FATAL ACCIDENTS ?

Fatalities: (up to now), In Belgium, on average 2 /year,
comparable to General (certified) Aviation.
Number of fatalities
12
10
8
6
4
2

Number of fatalities

11

20
10

20
08

20
06

20
04

20
02

20
00

19
98

19
96

19
94

19
92

19
90

19
88

19
86

19
84

0

19
82

FATALITIES:
Figures limited to
Belgium.
2009: + 2 in France.
2010: + 5 in France.

WHAT ARE THE EXPECTATIONS
FOR THE
ULM-ACCIDENTS CASUALITY
RATE ?
• On Belgian soil, 4 deads in 2010.
(casuality rate of U.S. Forces in Iraq 3.6 killed /1000
troop / year – 8 years – 152000 troops – 4424 killed).

• In France and Belgium in 2010, 9 Belgian
deads to-date.
12

Comparison with the road
• In Belgium, the road kills 1000 people on average per year
.
• Fleet of vehicles: 6 000 000 units (5 mio cars).
• For 1000 cars, the road kills on average 0.16 person per
year.
• If we combine these figures with the yearly utilization rate
of cars (1 h per day) versus ULM (40 h per year), we can
conclude that ULM / General Aviation flying is
considerably deadlier than the road.

13

What can we learn from accident
investigation ?

14

The investigation process
A long process (Months)
• Collect all factual elements,
–
–
–
–
–
–

The flow of events;
The pilot (training, experience, …)
The aircraft (contact w/manufacturer)
Meteo, Comm, Radar,
Flt recorders (GPS, ECU, camera, …)
Impact, aircraft damage,

• Analysis. (incl. simulation, testing,…)
• Define all possible causes.
• From the causes, define remedial action.
The depth of the investigation is somewhat influenced by the
expected ROI.
15

Accident analysis
• Accidents do not occur “by accident”; Accident are
caused by a series of events.
• There are no “isolated cases”; causes of accidents are often
recurrent.
• Out of the ULM accident data base, we can conclude;
– There are recurrent technical problems specific to ULM.
– The traditional causes of aviation accidents are also known to
ULM (fuel shortage)

– 80% of the causal factors are human-related.

16

Main causal factors (122 accidents –
fixed wing and ULM)
Loss of control Take-off
11%

Fuel Starvation
15%

Loss of control Flight & collision
12%

Technical
11%
Low piloting
experience
8%

Loss of control Landing
16%
Icing
3%

Low flying /
aerobatics obstacles - CFIT
24%

17

Specific problems with ULM
• Technical causes can be (easily) identified;
but fire can be devastating.
• There’s another problem for the
investigator, a lot of landmarks are missing.
– ULM requirements are national,
– Certification not applicable.
– Wide variety of products.
18

About certification.
• Everyone would agree that ULMs of to-day are as good,
even a lot better than the ‘certified’ airplane.
• ULMs are designed to fly.
ULM are quality products; they meet your expectations
(simple to handle, fly fast, cheap in usage, …)
• Certification means that a manufacturer must demonstrate
that his product meets a minimum level of safety, as
defined (ultimately) by the Aviation Community.
• The minimum level of safety is defined in the Certification
Specifications – For small aircraft, it is called CS23.
19

Technical.
• AAIU(be) is currently investigating on:
– Instrument Board lay-out design.
– Electrical System design.
– Emergency Parachute.
Why is it that (for the last cases) parachute did not save lifes ?
• Late decision ?
• Handle easy to grab ?
• Safety pin not removed before flight ?

20

Same ULM Type, instrument panel somewhat different.
Difference in Ergonomy.
Parachute handle – on pilot’s side, or on passenger’s side ?

21

Regulation: certification:
CS 23.671 General
(b) Controls must be arranged and identified
to provide for convenience in operation and
to prevent the possibility of confusion and
subsequent inadvertent operation.

For ULM, CS 23 is not applicable.
Each designer has his own solution, and
they will be challenged only by YOUR
experience.
22

Other example
The passenger door opens in
flight, causing the pilot to take
appropriate actions, that
eventually force him to an
emergency landing.

• Door lock (simple – crude).
Plexy flexible. Once opened in
flight, difficult to close.
CS 23.783
(1) There must be means to lock and safeguard the door against
inadvertent opening during flight by persons, by cargo, or as a
result of mechanical failure.
23

The problem
• Once we determine a technical problem, we
can define recommendations to improve the
product, but:
What do we do with the recommendation ?
– We can not improve the Standard, there’s no standard.
– We can not address more than one manufacturer,
– What about retrofit ?

24

ULM and Engine failures

25

Fly Synthesis Storch
Summer 2009
• After propeller replacement, and subsequent
engine ground tests, the pilot took off for a
flight test.
• He encountered heavy engine vibration, that
forced him to an emergency landing.
• Airplane was slightly damaged.
Cause was identified as Vapor Lock.
26

1/5/2010 – FK9
Emergency landing after in-flight engine failure.
• Lots of corrosion found in carburettor.
Corrosion comes from water condensation in
fuel system (tank, lines, pump,…- MOGAS)
during long immobilisation periods.
- how to prevent ? Filling up, draining ?

• Fuel system was modified in-service, by
addition of a pressure regulator.
27

France
20/5/2010 – Mistral
23/5/2010 – CT Short Wing
Mistral: Engine failure in flight.
Emergency landing in field; terrain was very soft, airplane
severely damaged.
CT Short Wing: In short final, the engine suddenly stops
The pilot attempts to land, but hit trees, and crashes – wings
ripped off.
RH wing tank empty, 15-25 l fuel remaining in LH tank.
During LH turn, fuel system unprimed, engine stopped by
fuel starvation.
28

4 /6/2010: SG Rally
Damaged during landing
• Due to engine problems (heavy vibrations), the
pilot performed emergency landing on EBHN.
Coming in too fast, the landing was brutal, and
Nose Landing Gear collapsed.

29

Conclusion
• Engine in-flight failure are not exceptional.
– Use of MOGAS (water content, flash point,..)
– Local modifications,
– Other specific to the configuration of the
specific airplane.
And..
– Traditional causes (engine starvation,..)
30

Solutions
• In this case, we can design some generic
recommendations:
– Human Factors; ULM pilots should be more
prepared to react to engine failures at any time
(awareness, briefing, training,…)
– Generic technical solutions; impact on the use
of MOGAS.
• Protection of the equipment during winter,
• Risk of Vapour lock.

31

• Designing stop-gaps, accident after accidents
may not be satisfactory;
What can we do we make sure ULM flying
improves up to an acceptable level and, more
important, remains at that level ?

• More Regulation ?

32

Aviation Regulation and the ULM
• No significant changes in Regulation.
– ULM defined by capacity, weight, structural and stall speed limitation.
– => Extensive use of carbon fiber, Flaps, etc

• CS-VLA.
– 750 kg.
– “light” CS-23.
– Expensive.

• Lower Requirements for licencing,
– What about competence ?
– Human Factors training

• National requirements in Europe.
– EASA Flight Permit per Part 21A.701.

33

Evolution: new EU Regulation on
Accident Investigation.
* Every civil aviation accident or serious incident involving
aircraft other than specified in Annex II to the Regulation (EC)
No 216/2008 of the European Parliament and of the Council
shall be the subject of a safety investigation

( = No obligation of enquiry for ULMs)
• Safety investigation authorities may decide to investigate
incidents other than those referred to in paragraph 1 as well as
accidents or serious incidents to other types of aircraft, in
accordance with the national legislation of the Member States,
when they expect to draw safety lessons from them.
34

• US. NTSB; no enquiry for ULM crashes.
• To-day already, in some EU countries, ULM
crash investigations are given a low priority,
unless the Public determines otherwise.
• Common sense dictates that the initiative
to improve safety must come from the
ULM community itself.

35

Reason Model
• aviation is a complex socio-technical
system, where safety is ensured by a
series of defense barriers.
• Each barrier may present flaws (latent
or active) whose combination can lead
to an accident.
• An usafe act (active failure) alone
would not cause an accident.
• Latent failures are more easily
detected and corrected that human
errors, which are (globally) inevitable.

36

• The ULM community should reinforce its
Defense Barriers.
• Organisation: Federation and Clubs.
Create a Safety Climate
- Norms and rules
- Safety Programs

- To define a Safety Climate, we need to
assess the potential risk, and for that we
need data: YOUR experience.
37

Pyramid of Heinrich
• If a fatal accident is caused by
a specific combination of
events, an uncomplete series
of events causes INCIDENTS.
• If we identify all potentially
dangerous events AND with
that information, build-up the
defenses, we can avoid
ACCIDENTS.
38

SHARING EXPERIENCE
• By informing the Federation of the small
events and incidents that spoiled one of
your flights, you allow the Community to
understand the potential dangers and act
upon. (and respect confidentiality)
“Learn from mistakes of others; you won’t
live long enough to make them all by
yourself”
39

Human Factors
• To err is human.
• Human life (and flying) is full of decisions.
• It is therefore more important to know yourself
than to know how to fly your aircraft.
– Get-home-itis, Distraction, Communication,..

• Understanding human factors is a very important
step in improving your defenses.
40

Competence and Readiness
• You hold a pilot licence; but are you a
competent flyer ?
• How will you react when faced with a
potential dangerous situation?
• Assessing your competences with an
instructor is an opportunity to improve.
• When flying, be ready.
41

What is the Authority doing for
you ?

42

A series of work groups
within EASA are thinking
about how to improve
flight safety.(ESSI)
One of them is about General
Aviation (EGAST).

Initiative includes a leaflet
On Collision Avoidance,
and has been relayed to you
by the Federation.
There are technical Work
Groups dealing with MOGAS
43

and

An initiative to develop
Posters with comic strips
On high risk topics.
The first goes about taking
The right decision when the
Weather is below minimum.
They are expected in the
Coming months.

44

For Belgium, Accident reports are made public on the SPF/FOD website.
Recent reports (from 1st May 2007) are directly available through
hyperlinks.
Reports are written in English.
Information Notes are also available in order to highlight specific danger
area: Nr 2010 is about engine cold start.
We would like to develop more Notes, for ULM in collaboration with
the Federation.
Historical reports: currently a list is posted.
The list is fairly complete from 1972.
2 ancient reports (1936 and 1965).
The reports (Fr /Nl) are desidentified and available on request.
The list will be completed as we go along in reviewing archives.

45

Thank you for your attention, and
AAIU (Belgium) wishes you
many happy landings

Photos credit:
MRA / KLM

46


Slide 6

10 JULY 1910 - 2010
100 YEARS ULM ACCIDENTS

Belgian ULM Federation – Safety
1
Conference 10/10/2010

The Air Safety Investigation
• As part of the global Aviation sphere, an investigation is
conducted for each accident and serious incident by an
independent enquiry body, aimed to;
– Determine the causes of the accident.
– Determine if all conditions that were defined by rules and
regulations to ensure flight safety were followed (such as risk
factors in design).
– Define recommendations in order to prevent future accidents.

• It is not the purpose of this investigation to apportion
blame or liability.

2

In Belgium; the Air Accident
Investigation Unit.
• All accidents and serious incidents occurring in Belgium,
on aircraft, helicopters, gliders, balloons, ULM, DPM,
regardless of their registration is investigated by a cell
functionnally independent from the BCAA, and all other
interrested parties.
• Independent doesn’t mean isolated; it is part of the world’s
network of the State’s Aviation Investigation Bodies.
• The cell reports to the President of the Board of the
SPF/FOD Mobility and Transport.
3

4

ULM
• First pendular (Delta Plane Motorized)
design in 1966
• First crossing of the Channel in 1978 by Mr
D. Cook.
• Commercial development from 1979.
• Evolution from 2-axis to 3-axis.
• In Belgium, first ULM registered (501) in
1982.

5

6

Evolution
• 1982: Weedhopper, Chickinox
– 80…100 km/h
– Basic – 2/3 axis
– Range: … 200 km…

• 2010: VL-3 Sprint, DynAero MCR01, WT9 Dynamic….
– 220….250 km/h,
– flaps, retractable gear, avionics,
– Range over 1000 km

• 550 OO- registered ULM;
• 571 ULM pilot licence (363 training licences)
• 300-400 foreign-registered ULM.
7

1000
900
800
700
600
500
400
300
200
100

Number of valid registration

8

Estimation of flying OO-regd ULM

20
10

20
08

20
06

20
04

20
02

20
00

19
98

19
96

19
94

19
92

19
90

19
88

19
86

19
84

19
82

0

Evolution in pilot’s / owner’s
expectations
• In 1982, ULM /DPM, a sporting way of flying,
outside the limits of parachuting, delta plane.

• In 2010, an efficient alternative to general
(certified) aviation. ULM becomes a means of
transport.
• Beyond 2010 ?? – The Need for Speed ?
9

Evolution
• From the user’s perspective, the difference between
General Aviation and ULM becomes very thin.
• However, ULMs are characterized by a huge variety of
different design types, with low production rate and
configuration variation between individual airplanes.
– Manufacturers come and go,
– Assembly of the same ULM type by different companies induce
differences in built configuration.

• The above makes it more and more difficult to speak about
ULMs in a general way; variation in quality is wider than
General (certified) Aviation.
10

EVOLUTION: MORE ULM FATAL ACCIDENTS ?

Fatalities: (up to now), In Belgium, on average 2 /year,
comparable to General (certified) Aviation.
Number of fatalities
12
10
8
6
4
2

Number of fatalities

11

20
10

20
08

20
06

20
04

20
02

20
00

19
98

19
96

19
94

19
92

19
90

19
88

19
86

19
84

0

19
82

FATALITIES:
Figures limited to
Belgium.
2009: + 2 in France.
2010: + 5 in France.

WHAT ARE THE EXPECTATIONS
FOR THE
ULM-ACCIDENTS CASUALITY
RATE ?
• On Belgian soil, 4 deads in 2010.
(casuality rate of U.S. Forces in Iraq 3.6 killed /1000
troop / year – 8 years – 152000 troops – 4424 killed).

• In France and Belgium in 2010, 9 Belgian
deads to-date.
12

Comparison with the road
• In Belgium, the road kills 1000 people on average per year
.
• Fleet of vehicles: 6 000 000 units (5 mio cars).
• For 1000 cars, the road kills on average 0.16 person per
year.
• If we combine these figures with the yearly utilization rate
of cars (1 h per day) versus ULM (40 h per year), we can
conclude that ULM / General Aviation flying is
considerably deadlier than the road.

13

What can we learn from accident
investigation ?

14

The investigation process
A long process (Months)
• Collect all factual elements,
–
–
–
–
–
–

The flow of events;
The pilot (training, experience, …)
The aircraft (contact w/manufacturer)
Meteo, Comm, Radar,
Flt recorders (GPS, ECU, camera, …)
Impact, aircraft damage,

• Analysis. (incl. simulation, testing,…)
• Define all possible causes.
• From the causes, define remedial action.
The depth of the investigation is somewhat influenced by the
expected ROI.
15

Accident analysis
• Accidents do not occur “by accident”; Accident are
caused by a series of events.
• There are no “isolated cases”; causes of accidents are often
recurrent.
• Out of the ULM accident data base, we can conclude;
– There are recurrent technical problems specific to ULM.
– The traditional causes of aviation accidents are also known to
ULM (fuel shortage)

– 80% of the causal factors are human-related.

16

Main causal factors (122 accidents –
fixed wing and ULM)
Loss of control Take-off
11%

Fuel Starvation
15%

Loss of control Flight & collision
12%

Technical
11%
Low piloting
experience
8%

Loss of control Landing
16%
Icing
3%

Low flying /
aerobatics obstacles - CFIT
24%

17

Specific problems with ULM
• Technical causes can be (easily) identified;
but fire can be devastating.
• There’s another problem for the
investigator, a lot of landmarks are missing.
– ULM requirements are national,
– Certification not applicable.
– Wide variety of products.
18

About certification.
• Everyone would agree that ULMs of to-day are as good,
even a lot better than the ‘certified’ airplane.
• ULMs are designed to fly.
ULM are quality products; they meet your expectations
(simple to handle, fly fast, cheap in usage, …)
• Certification means that a manufacturer must demonstrate
that his product meets a minimum level of safety, as
defined (ultimately) by the Aviation Community.
• The minimum level of safety is defined in the Certification
Specifications – For small aircraft, it is called CS23.
19

Technical.
• AAIU(be) is currently investigating on:
– Instrument Board lay-out design.
– Electrical System design.
– Emergency Parachute.
Why is it that (for the last cases) parachute did not save lifes ?
• Late decision ?
• Handle easy to grab ?
• Safety pin not removed before flight ?

20

Same ULM Type, instrument panel somewhat different.
Difference in Ergonomy.
Parachute handle – on pilot’s side, or on passenger’s side ?

21

Regulation: certification:
CS 23.671 General
(b) Controls must be arranged and identified
to provide for convenience in operation and
to prevent the possibility of confusion and
subsequent inadvertent operation.

For ULM, CS 23 is not applicable.
Each designer has his own solution, and
they will be challenged only by YOUR
experience.
22

Other example
The passenger door opens in
flight, causing the pilot to take
appropriate actions, that
eventually force him to an
emergency landing.

• Door lock (simple – crude).
Plexy flexible. Once opened in
flight, difficult to close.
CS 23.783
(1) There must be means to lock and safeguard the door against
inadvertent opening during flight by persons, by cargo, or as a
result of mechanical failure.
23

The problem
• Once we determine a technical problem, we
can define recommendations to improve the
product, but:
What do we do with the recommendation ?
– We can not improve the Standard, there’s no standard.
– We can not address more than one manufacturer,
– What about retrofit ?

24

ULM and Engine failures

25

Fly Synthesis Storch
Summer 2009
• After propeller replacement, and subsequent
engine ground tests, the pilot took off for a
flight test.
• He encountered heavy engine vibration, that
forced him to an emergency landing.
• Airplane was slightly damaged.
Cause was identified as Vapor Lock.
26

1/5/2010 – FK9
Emergency landing after in-flight engine failure.
• Lots of corrosion found in carburettor.
Corrosion comes from water condensation in
fuel system (tank, lines, pump,…- MOGAS)
during long immobilisation periods.
- how to prevent ? Filling up, draining ?

• Fuel system was modified in-service, by
addition of a pressure regulator.
27

France
20/5/2010 – Mistral
23/5/2010 – CT Short Wing
Mistral: Engine failure in flight.
Emergency landing in field; terrain was very soft, airplane
severely damaged.
CT Short Wing: In short final, the engine suddenly stops
The pilot attempts to land, but hit trees, and crashes – wings
ripped off.
RH wing tank empty, 15-25 l fuel remaining in LH tank.
During LH turn, fuel system unprimed, engine stopped by
fuel starvation.
28

4 /6/2010: SG Rally
Damaged during landing
• Due to engine problems (heavy vibrations), the
pilot performed emergency landing on EBHN.
Coming in too fast, the landing was brutal, and
Nose Landing Gear collapsed.

29

Conclusion
• Engine in-flight failure are not exceptional.
– Use of MOGAS (water content, flash point,..)
– Local modifications,
– Other specific to the configuration of the
specific airplane.
And..
– Traditional causes (engine starvation,..)
30

Solutions
• In this case, we can design some generic
recommendations:
– Human Factors; ULM pilots should be more
prepared to react to engine failures at any time
(awareness, briefing, training,…)
– Generic technical solutions; impact on the use
of MOGAS.
• Protection of the equipment during winter,
• Risk of Vapour lock.

31

• Designing stop-gaps, accident after accidents
may not be satisfactory;
What can we do we make sure ULM flying
improves up to an acceptable level and, more
important, remains at that level ?

• More Regulation ?

32

Aviation Regulation and the ULM
• No significant changes in Regulation.
– ULM defined by capacity, weight, structural and stall speed limitation.
– => Extensive use of carbon fiber, Flaps, etc

• CS-VLA.
– 750 kg.
– “light” CS-23.
– Expensive.

• Lower Requirements for licencing,
– What about competence ?
– Human Factors training

• National requirements in Europe.
– EASA Flight Permit per Part 21A.701.

33

Evolution: new EU Regulation on
Accident Investigation.
* Every civil aviation accident or serious incident involving
aircraft other than specified in Annex II to the Regulation (EC)
No 216/2008 of the European Parliament and of the Council
shall be the subject of a safety investigation

( = No obligation of enquiry for ULMs)
• Safety investigation authorities may decide to investigate
incidents other than those referred to in paragraph 1 as well as
accidents or serious incidents to other types of aircraft, in
accordance with the national legislation of the Member States,
when they expect to draw safety lessons from them.
34

• US. NTSB; no enquiry for ULM crashes.
• To-day already, in some EU countries, ULM
crash investigations are given a low priority,
unless the Public determines otherwise.
• Common sense dictates that the initiative
to improve safety must come from the
ULM community itself.

35

Reason Model
• aviation is a complex socio-technical
system, where safety is ensured by a
series of defense barriers.
• Each barrier may present flaws (latent
or active) whose combination can lead
to an accident.
• An usafe act (active failure) alone
would not cause an accident.
• Latent failures are more easily
detected and corrected that human
errors, which are (globally) inevitable.

36

• The ULM community should reinforce its
Defense Barriers.
• Organisation: Federation and Clubs.
Create a Safety Climate
- Norms and rules
- Safety Programs

- To define a Safety Climate, we need to
assess the potential risk, and for that we
need data: YOUR experience.
37

Pyramid of Heinrich
• If a fatal accident is caused by
a specific combination of
events, an uncomplete series
of events causes INCIDENTS.
• If we identify all potentially
dangerous events AND with
that information, build-up the
defenses, we can avoid
ACCIDENTS.
38

SHARING EXPERIENCE
• By informing the Federation of the small
events and incidents that spoiled one of
your flights, you allow the Community to
understand the potential dangers and act
upon. (and respect confidentiality)
“Learn from mistakes of others; you won’t
live long enough to make them all by
yourself”
39

Human Factors
• To err is human.
• Human life (and flying) is full of decisions.
• It is therefore more important to know yourself
than to know how to fly your aircraft.
– Get-home-itis, Distraction, Communication,..

• Understanding human factors is a very important
step in improving your defenses.
40

Competence and Readiness
• You hold a pilot licence; but are you a
competent flyer ?
• How will you react when faced with a
potential dangerous situation?
• Assessing your competences with an
instructor is an opportunity to improve.
• When flying, be ready.
41

What is the Authority doing for
you ?

42

A series of work groups
within EASA are thinking
about how to improve
flight safety.(ESSI)
One of them is about General
Aviation (EGAST).

Initiative includes a leaflet
On Collision Avoidance,
and has been relayed to you
by the Federation.
There are technical Work
Groups dealing with MOGAS
43

and

An initiative to develop
Posters with comic strips
On high risk topics.
The first goes about taking
The right decision when the
Weather is below minimum.
They are expected in the
Coming months.

44

For Belgium, Accident reports are made public on the SPF/FOD website.
Recent reports (from 1st May 2007) are directly available through
hyperlinks.
Reports are written in English.
Information Notes are also available in order to highlight specific danger
area: Nr 2010 is about engine cold start.
We would like to develop more Notes, for ULM in collaboration with
the Federation.
Historical reports: currently a list is posted.
The list is fairly complete from 1972.
2 ancient reports (1936 and 1965).
The reports (Fr /Nl) are desidentified and available on request.
The list will be completed as we go along in reviewing archives.

45

Thank you for your attention, and
AAIU (Belgium) wishes you
many happy landings

Photos credit:
MRA / KLM

46


Slide 7

10 JULY 1910 - 2010
100 YEARS ULM ACCIDENTS

Belgian ULM Federation – Safety
1
Conference 10/10/2010

The Air Safety Investigation
• As part of the global Aviation sphere, an investigation is
conducted for each accident and serious incident by an
independent enquiry body, aimed to;
– Determine the causes of the accident.
– Determine if all conditions that were defined by rules and
regulations to ensure flight safety were followed (such as risk
factors in design).
– Define recommendations in order to prevent future accidents.

• It is not the purpose of this investigation to apportion
blame or liability.

2

In Belgium; the Air Accident
Investigation Unit.
• All accidents and serious incidents occurring in Belgium,
on aircraft, helicopters, gliders, balloons, ULM, DPM,
regardless of their registration is investigated by a cell
functionnally independent from the BCAA, and all other
interrested parties.
• Independent doesn’t mean isolated; it is part of the world’s
network of the State’s Aviation Investigation Bodies.
• The cell reports to the President of the Board of the
SPF/FOD Mobility and Transport.
3

4

ULM
• First pendular (Delta Plane Motorized)
design in 1966
• First crossing of the Channel in 1978 by Mr
D. Cook.
• Commercial development from 1979.
• Evolution from 2-axis to 3-axis.
• In Belgium, first ULM registered (501) in
1982.

5

6

Evolution
• 1982: Weedhopper, Chickinox
– 80…100 km/h
– Basic – 2/3 axis
– Range: … 200 km…

• 2010: VL-3 Sprint, DynAero MCR01, WT9 Dynamic….
– 220….250 km/h,
– flaps, retractable gear, avionics,
– Range over 1000 km

• 550 OO- registered ULM;
• 571 ULM pilot licence (363 training licences)
• 300-400 foreign-registered ULM.
7

1000
900
800
700
600
500
400
300
200
100

Number of valid registration

8

Estimation of flying OO-regd ULM

20
10

20
08

20
06

20
04

20
02

20
00

19
98

19
96

19
94

19
92

19
90

19
88

19
86

19
84

19
82

0

Evolution in pilot’s / owner’s
expectations
• In 1982, ULM /DPM, a sporting way of flying,
outside the limits of parachuting, delta plane.

• In 2010, an efficient alternative to general
(certified) aviation. ULM becomes a means of
transport.
• Beyond 2010 ?? – The Need for Speed ?
9

Evolution
• From the user’s perspective, the difference between
General Aviation and ULM becomes very thin.
• However, ULMs are characterized by a huge variety of
different design types, with low production rate and
configuration variation between individual airplanes.
– Manufacturers come and go,
– Assembly of the same ULM type by different companies induce
differences in built configuration.

• The above makes it more and more difficult to speak about
ULMs in a general way; variation in quality is wider than
General (certified) Aviation.
10

EVOLUTION: MORE ULM FATAL ACCIDENTS ?

Fatalities: (up to now), In Belgium, on average 2 /year,
comparable to General (certified) Aviation.
Number of fatalities
12
10
8
6
4
2

Number of fatalities

11

20
10

20
08

20
06

20
04

20
02

20
00

19
98

19
96

19
94

19
92

19
90

19
88

19
86

19
84

0

19
82

FATALITIES:
Figures limited to
Belgium.
2009: + 2 in France.
2010: + 5 in France.

WHAT ARE THE EXPECTATIONS
FOR THE
ULM-ACCIDENTS CASUALITY
RATE ?
• On Belgian soil, 4 deads in 2010.
(casuality rate of U.S. Forces in Iraq 3.6 killed /1000
troop / year – 8 years – 152000 troops – 4424 killed).

• In France and Belgium in 2010, 9 Belgian
deads to-date.
12

Comparison with the road
• In Belgium, the road kills 1000 people on average per year
.
• Fleet of vehicles: 6 000 000 units (5 mio cars).
• For 1000 cars, the road kills on average 0.16 person per
year.
• If we combine these figures with the yearly utilization rate
of cars (1 h per day) versus ULM (40 h per year), we can
conclude that ULM / General Aviation flying is
considerably deadlier than the road.

13

What can we learn from accident
investigation ?

14

The investigation process
A long process (Months)
• Collect all factual elements,
–
–
–
–
–
–

The flow of events;
The pilot (training, experience, …)
The aircraft (contact w/manufacturer)
Meteo, Comm, Radar,
Flt recorders (GPS, ECU, camera, …)
Impact, aircraft damage,

• Analysis. (incl. simulation, testing,…)
• Define all possible causes.
• From the causes, define remedial action.
The depth of the investigation is somewhat influenced by the
expected ROI.
15

Accident analysis
• Accidents do not occur “by accident”; Accident are
caused by a series of events.
• There are no “isolated cases”; causes of accidents are often
recurrent.
• Out of the ULM accident data base, we can conclude;
– There are recurrent technical problems specific to ULM.
– The traditional causes of aviation accidents are also known to
ULM (fuel shortage)

– 80% of the causal factors are human-related.

16

Main causal factors (122 accidents –
fixed wing and ULM)
Loss of control Take-off
11%

Fuel Starvation
15%

Loss of control Flight & collision
12%

Technical
11%
Low piloting
experience
8%

Loss of control Landing
16%
Icing
3%

Low flying /
aerobatics obstacles - CFIT
24%

17

Specific problems with ULM
• Technical causes can be (easily) identified;
but fire can be devastating.
• There’s another problem for the
investigator, a lot of landmarks are missing.
– ULM requirements are national,
– Certification not applicable.
– Wide variety of products.
18

About certification.
• Everyone would agree that ULMs of to-day are as good,
even a lot better than the ‘certified’ airplane.
• ULMs are designed to fly.
ULM are quality products; they meet your expectations
(simple to handle, fly fast, cheap in usage, …)
• Certification means that a manufacturer must demonstrate
that his product meets a minimum level of safety, as
defined (ultimately) by the Aviation Community.
• The minimum level of safety is defined in the Certification
Specifications – For small aircraft, it is called CS23.
19

Technical.
• AAIU(be) is currently investigating on:
– Instrument Board lay-out design.
– Electrical System design.
– Emergency Parachute.
Why is it that (for the last cases) parachute did not save lifes ?
• Late decision ?
• Handle easy to grab ?
• Safety pin not removed before flight ?

20

Same ULM Type, instrument panel somewhat different.
Difference in Ergonomy.
Parachute handle – on pilot’s side, or on passenger’s side ?

21

Regulation: certification:
CS 23.671 General
(b) Controls must be arranged and identified
to provide for convenience in operation and
to prevent the possibility of confusion and
subsequent inadvertent operation.

For ULM, CS 23 is not applicable.
Each designer has his own solution, and
they will be challenged only by YOUR
experience.
22

Other example
The passenger door opens in
flight, causing the pilot to take
appropriate actions, that
eventually force him to an
emergency landing.

• Door lock (simple – crude).
Plexy flexible. Once opened in
flight, difficult to close.
CS 23.783
(1) There must be means to lock and safeguard the door against
inadvertent opening during flight by persons, by cargo, or as a
result of mechanical failure.
23

The problem
• Once we determine a technical problem, we
can define recommendations to improve the
product, but:
What do we do with the recommendation ?
– We can not improve the Standard, there’s no standard.
– We can not address more than one manufacturer,
– What about retrofit ?

24

ULM and Engine failures

25

Fly Synthesis Storch
Summer 2009
• After propeller replacement, and subsequent
engine ground tests, the pilot took off for a
flight test.
• He encountered heavy engine vibration, that
forced him to an emergency landing.
• Airplane was slightly damaged.
Cause was identified as Vapor Lock.
26

1/5/2010 – FK9
Emergency landing after in-flight engine failure.
• Lots of corrosion found in carburettor.
Corrosion comes from water condensation in
fuel system (tank, lines, pump,…- MOGAS)
during long immobilisation periods.
- how to prevent ? Filling up, draining ?

• Fuel system was modified in-service, by
addition of a pressure regulator.
27

France
20/5/2010 – Mistral
23/5/2010 – CT Short Wing
Mistral: Engine failure in flight.
Emergency landing in field; terrain was very soft, airplane
severely damaged.
CT Short Wing: In short final, the engine suddenly stops
The pilot attempts to land, but hit trees, and crashes – wings
ripped off.
RH wing tank empty, 15-25 l fuel remaining in LH tank.
During LH turn, fuel system unprimed, engine stopped by
fuel starvation.
28

4 /6/2010: SG Rally
Damaged during landing
• Due to engine problems (heavy vibrations), the
pilot performed emergency landing on EBHN.
Coming in too fast, the landing was brutal, and
Nose Landing Gear collapsed.

29

Conclusion
• Engine in-flight failure are not exceptional.
– Use of MOGAS (water content, flash point,..)
– Local modifications,
– Other specific to the configuration of the
specific airplane.
And..
– Traditional causes (engine starvation,..)
30

Solutions
• In this case, we can design some generic
recommendations:
– Human Factors; ULM pilots should be more
prepared to react to engine failures at any time
(awareness, briefing, training,…)
– Generic technical solutions; impact on the use
of MOGAS.
• Protection of the equipment during winter,
• Risk of Vapour lock.

31

• Designing stop-gaps, accident after accidents
may not be satisfactory;
What can we do we make sure ULM flying
improves up to an acceptable level and, more
important, remains at that level ?

• More Regulation ?

32

Aviation Regulation and the ULM
• No significant changes in Regulation.
– ULM defined by capacity, weight, structural and stall speed limitation.
– => Extensive use of carbon fiber, Flaps, etc

• CS-VLA.
– 750 kg.
– “light” CS-23.
– Expensive.

• Lower Requirements for licencing,
– What about competence ?
– Human Factors training

• National requirements in Europe.
– EASA Flight Permit per Part 21A.701.

33

Evolution: new EU Regulation on
Accident Investigation.
* Every civil aviation accident or serious incident involving
aircraft other than specified in Annex II to the Regulation (EC)
No 216/2008 of the European Parliament and of the Council
shall be the subject of a safety investigation

( = No obligation of enquiry for ULMs)
• Safety investigation authorities may decide to investigate
incidents other than those referred to in paragraph 1 as well as
accidents or serious incidents to other types of aircraft, in
accordance with the national legislation of the Member States,
when they expect to draw safety lessons from them.
34

• US. NTSB; no enquiry for ULM crashes.
• To-day already, in some EU countries, ULM
crash investigations are given a low priority,
unless the Public determines otherwise.
• Common sense dictates that the initiative
to improve safety must come from the
ULM community itself.

35

Reason Model
• aviation is a complex socio-technical
system, where safety is ensured by a
series of defense barriers.
• Each barrier may present flaws (latent
or active) whose combination can lead
to an accident.
• An usafe act (active failure) alone
would not cause an accident.
• Latent failures are more easily
detected and corrected that human
errors, which are (globally) inevitable.

36

• The ULM community should reinforce its
Defense Barriers.
• Organisation: Federation and Clubs.
Create a Safety Climate
- Norms and rules
- Safety Programs

- To define a Safety Climate, we need to
assess the potential risk, and for that we
need data: YOUR experience.
37

Pyramid of Heinrich
• If a fatal accident is caused by
a specific combination of
events, an uncomplete series
of events causes INCIDENTS.
• If we identify all potentially
dangerous events AND with
that information, build-up the
defenses, we can avoid
ACCIDENTS.
38

SHARING EXPERIENCE
• By informing the Federation of the small
events and incidents that spoiled one of
your flights, you allow the Community to
understand the potential dangers and act
upon. (and respect confidentiality)
“Learn from mistakes of others; you won’t
live long enough to make them all by
yourself”
39

Human Factors
• To err is human.
• Human life (and flying) is full of decisions.
• It is therefore more important to know yourself
than to know how to fly your aircraft.
– Get-home-itis, Distraction, Communication,..

• Understanding human factors is a very important
step in improving your defenses.
40

Competence and Readiness
• You hold a pilot licence; but are you a
competent flyer ?
• How will you react when faced with a
potential dangerous situation?
• Assessing your competences with an
instructor is an opportunity to improve.
• When flying, be ready.
41

What is the Authority doing for
you ?

42

A series of work groups
within EASA are thinking
about how to improve
flight safety.(ESSI)
One of them is about General
Aviation (EGAST).

Initiative includes a leaflet
On Collision Avoidance,
and has been relayed to you
by the Federation.
There are technical Work
Groups dealing with MOGAS
43

and

An initiative to develop
Posters with comic strips
On high risk topics.
The first goes about taking
The right decision when the
Weather is below minimum.
They are expected in the
Coming months.

44

For Belgium, Accident reports are made public on the SPF/FOD website.
Recent reports (from 1st May 2007) are directly available through
hyperlinks.
Reports are written in English.
Information Notes are also available in order to highlight specific danger
area: Nr 2010 is about engine cold start.
We would like to develop more Notes, for ULM in collaboration with
the Federation.
Historical reports: currently a list is posted.
The list is fairly complete from 1972.
2 ancient reports (1936 and 1965).
The reports (Fr /Nl) are desidentified and available on request.
The list will be completed as we go along in reviewing archives.

45

Thank you for your attention, and
AAIU (Belgium) wishes you
many happy landings

Photos credit:
MRA / KLM

46


Slide 8

10 JULY 1910 - 2010
100 YEARS ULM ACCIDENTS

Belgian ULM Federation – Safety
1
Conference 10/10/2010

The Air Safety Investigation
• As part of the global Aviation sphere, an investigation is
conducted for each accident and serious incident by an
independent enquiry body, aimed to;
– Determine the causes of the accident.
– Determine if all conditions that were defined by rules and
regulations to ensure flight safety were followed (such as risk
factors in design).
– Define recommendations in order to prevent future accidents.

• It is not the purpose of this investigation to apportion
blame or liability.

2

In Belgium; the Air Accident
Investigation Unit.
• All accidents and serious incidents occurring in Belgium,
on aircraft, helicopters, gliders, balloons, ULM, DPM,
regardless of their registration is investigated by a cell
functionnally independent from the BCAA, and all other
interrested parties.
• Independent doesn’t mean isolated; it is part of the world’s
network of the State’s Aviation Investigation Bodies.
• The cell reports to the President of the Board of the
SPF/FOD Mobility and Transport.
3

4

ULM
• First pendular (Delta Plane Motorized)
design in 1966
• First crossing of the Channel in 1978 by Mr
D. Cook.
• Commercial development from 1979.
• Evolution from 2-axis to 3-axis.
• In Belgium, first ULM registered (501) in
1982.

5

6

Evolution
• 1982: Weedhopper, Chickinox
– 80…100 km/h
– Basic – 2/3 axis
– Range: … 200 km…

• 2010: VL-3 Sprint, DynAero MCR01, WT9 Dynamic….
– 220….250 km/h,
– flaps, retractable gear, avionics,
– Range over 1000 km

• 550 OO- registered ULM;
• 571 ULM pilot licence (363 training licences)
• 300-400 foreign-registered ULM.
7

1000
900
800
700
600
500
400
300
200
100

Number of valid registration

8

Estimation of flying OO-regd ULM

20
10

20
08

20
06

20
04

20
02

20
00

19
98

19
96

19
94

19
92

19
90

19
88

19
86

19
84

19
82

0

Evolution in pilot’s / owner’s
expectations
• In 1982, ULM /DPM, a sporting way of flying,
outside the limits of parachuting, delta plane.

• In 2010, an efficient alternative to general
(certified) aviation. ULM becomes a means of
transport.
• Beyond 2010 ?? – The Need for Speed ?
9

Evolution
• From the user’s perspective, the difference between
General Aviation and ULM becomes very thin.
• However, ULMs are characterized by a huge variety of
different design types, with low production rate and
configuration variation between individual airplanes.
– Manufacturers come and go,
– Assembly of the same ULM type by different companies induce
differences in built configuration.

• The above makes it more and more difficult to speak about
ULMs in a general way; variation in quality is wider than
General (certified) Aviation.
10

EVOLUTION: MORE ULM FATAL ACCIDENTS ?

Fatalities: (up to now), In Belgium, on average 2 /year,
comparable to General (certified) Aviation.
Number of fatalities
12
10
8
6
4
2

Number of fatalities

11

20
10

20
08

20
06

20
04

20
02

20
00

19
98

19
96

19
94

19
92

19
90

19
88

19
86

19
84

0

19
82

FATALITIES:
Figures limited to
Belgium.
2009: + 2 in France.
2010: + 5 in France.

WHAT ARE THE EXPECTATIONS
FOR THE
ULM-ACCIDENTS CASUALITY
RATE ?
• On Belgian soil, 4 deads in 2010.
(casuality rate of U.S. Forces in Iraq 3.6 killed /1000
troop / year – 8 years – 152000 troops – 4424 killed).

• In France and Belgium in 2010, 9 Belgian
deads to-date.
12

Comparison with the road
• In Belgium, the road kills 1000 people on average per year
.
• Fleet of vehicles: 6 000 000 units (5 mio cars).
• For 1000 cars, the road kills on average 0.16 person per
year.
• If we combine these figures with the yearly utilization rate
of cars (1 h per day) versus ULM (40 h per year), we can
conclude that ULM / General Aviation flying is
considerably deadlier than the road.

13

What can we learn from accident
investigation ?

14

The investigation process
A long process (Months)
• Collect all factual elements,
–
–
–
–
–
–

The flow of events;
The pilot (training, experience, …)
The aircraft (contact w/manufacturer)
Meteo, Comm, Radar,
Flt recorders (GPS, ECU, camera, …)
Impact, aircraft damage,

• Analysis. (incl. simulation, testing,…)
• Define all possible causes.
• From the causes, define remedial action.
The depth of the investigation is somewhat influenced by the
expected ROI.
15

Accident analysis
• Accidents do not occur “by accident”; Accident are
caused by a series of events.
• There are no “isolated cases”; causes of accidents are often
recurrent.
• Out of the ULM accident data base, we can conclude;
– There are recurrent technical problems specific to ULM.
– The traditional causes of aviation accidents are also known to
ULM (fuel shortage)

– 80% of the causal factors are human-related.

16

Main causal factors (122 accidents –
fixed wing and ULM)
Loss of control Take-off
11%

Fuel Starvation
15%

Loss of control Flight & collision
12%

Technical
11%
Low piloting
experience
8%

Loss of control Landing
16%
Icing
3%

Low flying /
aerobatics obstacles - CFIT
24%

17

Specific problems with ULM
• Technical causes can be (easily) identified;
but fire can be devastating.
• There’s another problem for the
investigator, a lot of landmarks are missing.
– ULM requirements are national,
– Certification not applicable.
– Wide variety of products.
18

About certification.
• Everyone would agree that ULMs of to-day are as good,
even a lot better than the ‘certified’ airplane.
• ULMs are designed to fly.
ULM are quality products; they meet your expectations
(simple to handle, fly fast, cheap in usage, …)
• Certification means that a manufacturer must demonstrate
that his product meets a minimum level of safety, as
defined (ultimately) by the Aviation Community.
• The minimum level of safety is defined in the Certification
Specifications – For small aircraft, it is called CS23.
19

Technical.
• AAIU(be) is currently investigating on:
– Instrument Board lay-out design.
– Electrical System design.
– Emergency Parachute.
Why is it that (for the last cases) parachute did not save lifes ?
• Late decision ?
• Handle easy to grab ?
• Safety pin not removed before flight ?

20

Same ULM Type, instrument panel somewhat different.
Difference in Ergonomy.
Parachute handle – on pilot’s side, or on passenger’s side ?

21

Regulation: certification:
CS 23.671 General
(b) Controls must be arranged and identified
to provide for convenience in operation and
to prevent the possibility of confusion and
subsequent inadvertent operation.

For ULM, CS 23 is not applicable.
Each designer has his own solution, and
they will be challenged only by YOUR
experience.
22

Other example
The passenger door opens in
flight, causing the pilot to take
appropriate actions, that
eventually force him to an
emergency landing.

• Door lock (simple – crude).
Plexy flexible. Once opened in
flight, difficult to close.
CS 23.783
(1) There must be means to lock and safeguard the door against
inadvertent opening during flight by persons, by cargo, or as a
result of mechanical failure.
23

The problem
• Once we determine a technical problem, we
can define recommendations to improve the
product, but:
What do we do with the recommendation ?
– We can not improve the Standard, there’s no standard.
– We can not address more than one manufacturer,
– What about retrofit ?

24

ULM and Engine failures

25

Fly Synthesis Storch
Summer 2009
• After propeller replacement, and subsequent
engine ground tests, the pilot took off for a
flight test.
• He encountered heavy engine vibration, that
forced him to an emergency landing.
• Airplane was slightly damaged.
Cause was identified as Vapor Lock.
26

1/5/2010 – FK9
Emergency landing after in-flight engine failure.
• Lots of corrosion found in carburettor.
Corrosion comes from water condensation in
fuel system (tank, lines, pump,…- MOGAS)
during long immobilisation periods.
- how to prevent ? Filling up, draining ?

• Fuel system was modified in-service, by
addition of a pressure regulator.
27

France
20/5/2010 – Mistral
23/5/2010 – CT Short Wing
Mistral: Engine failure in flight.
Emergency landing in field; terrain was very soft, airplane
severely damaged.
CT Short Wing: In short final, the engine suddenly stops
The pilot attempts to land, but hit trees, and crashes – wings
ripped off.
RH wing tank empty, 15-25 l fuel remaining in LH tank.
During LH turn, fuel system unprimed, engine stopped by
fuel starvation.
28

4 /6/2010: SG Rally
Damaged during landing
• Due to engine problems (heavy vibrations), the
pilot performed emergency landing on EBHN.
Coming in too fast, the landing was brutal, and
Nose Landing Gear collapsed.

29

Conclusion
• Engine in-flight failure are not exceptional.
– Use of MOGAS (water content, flash point,..)
– Local modifications,
– Other specific to the configuration of the
specific airplane.
And..
– Traditional causes (engine starvation,..)
30

Solutions
• In this case, we can design some generic
recommendations:
– Human Factors; ULM pilots should be more
prepared to react to engine failures at any time
(awareness, briefing, training,…)
– Generic technical solutions; impact on the use
of MOGAS.
• Protection of the equipment during winter,
• Risk of Vapour lock.

31

• Designing stop-gaps, accident after accidents
may not be satisfactory;
What can we do we make sure ULM flying
improves up to an acceptable level and, more
important, remains at that level ?

• More Regulation ?

32

Aviation Regulation and the ULM
• No significant changes in Regulation.
– ULM defined by capacity, weight, structural and stall speed limitation.
– => Extensive use of carbon fiber, Flaps, etc

• CS-VLA.
– 750 kg.
– “light” CS-23.
– Expensive.

• Lower Requirements for licencing,
– What about competence ?
– Human Factors training

• National requirements in Europe.
– EASA Flight Permit per Part 21A.701.

33

Evolution: new EU Regulation on
Accident Investigation.
* Every civil aviation accident or serious incident involving
aircraft other than specified in Annex II to the Regulation (EC)
No 216/2008 of the European Parliament and of the Council
shall be the subject of a safety investigation

( = No obligation of enquiry for ULMs)
• Safety investigation authorities may decide to investigate
incidents other than those referred to in paragraph 1 as well as
accidents or serious incidents to other types of aircraft, in
accordance with the national legislation of the Member States,
when they expect to draw safety lessons from them.
34

• US. NTSB; no enquiry for ULM crashes.
• To-day already, in some EU countries, ULM
crash investigations are given a low priority,
unless the Public determines otherwise.
• Common sense dictates that the initiative
to improve safety must come from the
ULM community itself.

35

Reason Model
• aviation is a complex socio-technical
system, where safety is ensured by a
series of defense barriers.
• Each barrier may present flaws (latent
or active) whose combination can lead
to an accident.
• An usafe act (active failure) alone
would not cause an accident.
• Latent failures are more easily
detected and corrected that human
errors, which are (globally) inevitable.

36

• The ULM community should reinforce its
Defense Barriers.
• Organisation: Federation and Clubs.
Create a Safety Climate
- Norms and rules
- Safety Programs

- To define a Safety Climate, we need to
assess the potential risk, and for that we
need data: YOUR experience.
37

Pyramid of Heinrich
• If a fatal accident is caused by
a specific combination of
events, an uncomplete series
of events causes INCIDENTS.
• If we identify all potentially
dangerous events AND with
that information, build-up the
defenses, we can avoid
ACCIDENTS.
38

SHARING EXPERIENCE
• By informing the Federation of the small
events and incidents that spoiled one of
your flights, you allow the Community to
understand the potential dangers and act
upon. (and respect confidentiality)
“Learn from mistakes of others; you won’t
live long enough to make them all by
yourself”
39

Human Factors
• To err is human.
• Human life (and flying) is full of decisions.
• It is therefore more important to know yourself
than to know how to fly your aircraft.
– Get-home-itis, Distraction, Communication,..

• Understanding human factors is a very important
step in improving your defenses.
40

Competence and Readiness
• You hold a pilot licence; but are you a
competent flyer ?
• How will you react when faced with a
potential dangerous situation?
• Assessing your competences with an
instructor is an opportunity to improve.
• When flying, be ready.
41

What is the Authority doing for
you ?

42

A series of work groups
within EASA are thinking
about how to improve
flight safety.(ESSI)
One of them is about General
Aviation (EGAST).

Initiative includes a leaflet
On Collision Avoidance,
and has been relayed to you
by the Federation.
There are technical Work
Groups dealing with MOGAS
43

and

An initiative to develop
Posters with comic strips
On high risk topics.
The first goes about taking
The right decision when the
Weather is below minimum.
They are expected in the
Coming months.

44

For Belgium, Accident reports are made public on the SPF/FOD website.
Recent reports (from 1st May 2007) are directly available through
hyperlinks.
Reports are written in English.
Information Notes are also available in order to highlight specific danger
area: Nr 2010 is about engine cold start.
We would like to develop more Notes, for ULM in collaboration with
the Federation.
Historical reports: currently a list is posted.
The list is fairly complete from 1972.
2 ancient reports (1936 and 1965).
The reports (Fr /Nl) are desidentified and available on request.
The list will be completed as we go along in reviewing archives.

45

Thank you for your attention, and
AAIU (Belgium) wishes you
many happy landings

Photos credit:
MRA / KLM

46


Slide 9

10 JULY 1910 - 2010
100 YEARS ULM ACCIDENTS

Belgian ULM Federation – Safety
1
Conference 10/10/2010

The Air Safety Investigation
• As part of the global Aviation sphere, an investigation is
conducted for each accident and serious incident by an
independent enquiry body, aimed to;
– Determine the causes of the accident.
– Determine if all conditions that were defined by rules and
regulations to ensure flight safety were followed (such as risk
factors in design).
– Define recommendations in order to prevent future accidents.

• It is not the purpose of this investigation to apportion
blame or liability.

2

In Belgium; the Air Accident
Investigation Unit.
• All accidents and serious incidents occurring in Belgium,
on aircraft, helicopters, gliders, balloons, ULM, DPM,
regardless of their registration is investigated by a cell
functionnally independent from the BCAA, and all other
interrested parties.
• Independent doesn’t mean isolated; it is part of the world’s
network of the State’s Aviation Investigation Bodies.
• The cell reports to the President of the Board of the
SPF/FOD Mobility and Transport.
3

4

ULM
• First pendular (Delta Plane Motorized)
design in 1966
• First crossing of the Channel in 1978 by Mr
D. Cook.
• Commercial development from 1979.
• Evolution from 2-axis to 3-axis.
• In Belgium, first ULM registered (501) in
1982.

5

6

Evolution
• 1982: Weedhopper, Chickinox
– 80…100 km/h
– Basic – 2/3 axis
– Range: … 200 km…

• 2010: VL-3 Sprint, DynAero MCR01, WT9 Dynamic….
– 220….250 km/h,
– flaps, retractable gear, avionics,
– Range over 1000 km

• 550 OO- registered ULM;
• 571 ULM pilot licence (363 training licences)
• 300-400 foreign-registered ULM.
7

1000
900
800
700
600
500
400
300
200
100

Number of valid registration

8

Estimation of flying OO-regd ULM

20
10

20
08

20
06

20
04

20
02

20
00

19
98

19
96

19
94

19
92

19
90

19
88

19
86

19
84

19
82

0

Evolution in pilot’s / owner’s
expectations
• In 1982, ULM /DPM, a sporting way of flying,
outside the limits of parachuting, delta plane.

• In 2010, an efficient alternative to general
(certified) aviation. ULM becomes a means of
transport.
• Beyond 2010 ?? – The Need for Speed ?
9

Evolution
• From the user’s perspective, the difference between
General Aviation and ULM becomes very thin.
• However, ULMs are characterized by a huge variety of
different design types, with low production rate and
configuration variation between individual airplanes.
– Manufacturers come and go,
– Assembly of the same ULM type by different companies induce
differences in built configuration.

• The above makes it more and more difficult to speak about
ULMs in a general way; variation in quality is wider than
General (certified) Aviation.
10

EVOLUTION: MORE ULM FATAL ACCIDENTS ?

Fatalities: (up to now), In Belgium, on average 2 /year,
comparable to General (certified) Aviation.
Number of fatalities
12
10
8
6
4
2

Number of fatalities

11

20
10

20
08

20
06

20
04

20
02

20
00

19
98

19
96

19
94

19
92

19
90

19
88

19
86

19
84

0

19
82

FATALITIES:
Figures limited to
Belgium.
2009: + 2 in France.
2010: + 5 in France.

WHAT ARE THE EXPECTATIONS
FOR THE
ULM-ACCIDENTS CASUALITY
RATE ?
• On Belgian soil, 4 deads in 2010.
(casuality rate of U.S. Forces in Iraq 3.6 killed /1000
troop / year – 8 years – 152000 troops – 4424 killed).

• In France and Belgium in 2010, 9 Belgian
deads to-date.
12

Comparison with the road
• In Belgium, the road kills 1000 people on average per year
.
• Fleet of vehicles: 6 000 000 units (5 mio cars).
• For 1000 cars, the road kills on average 0.16 person per
year.
• If we combine these figures with the yearly utilization rate
of cars (1 h per day) versus ULM (40 h per year), we can
conclude that ULM / General Aviation flying is
considerably deadlier than the road.

13

What can we learn from accident
investigation ?

14

The investigation process
A long process (Months)
• Collect all factual elements,
–
–
–
–
–
–

The flow of events;
The pilot (training, experience, …)
The aircraft (contact w/manufacturer)
Meteo, Comm, Radar,
Flt recorders (GPS, ECU, camera, …)
Impact, aircraft damage,

• Analysis. (incl. simulation, testing,…)
• Define all possible causes.
• From the causes, define remedial action.
The depth of the investigation is somewhat influenced by the
expected ROI.
15

Accident analysis
• Accidents do not occur “by accident”; Accident are
caused by a series of events.
• There are no “isolated cases”; causes of accidents are often
recurrent.
• Out of the ULM accident data base, we can conclude;
– There are recurrent technical problems specific to ULM.
– The traditional causes of aviation accidents are also known to
ULM (fuel shortage)

– 80% of the causal factors are human-related.

16

Main causal factors (122 accidents –
fixed wing and ULM)
Loss of control Take-off
11%

Fuel Starvation
15%

Loss of control Flight & collision
12%

Technical
11%
Low piloting
experience
8%

Loss of control Landing
16%
Icing
3%

Low flying /
aerobatics obstacles - CFIT
24%

17

Specific problems with ULM
• Technical causes can be (easily) identified;
but fire can be devastating.
• There’s another problem for the
investigator, a lot of landmarks are missing.
– ULM requirements are national,
– Certification not applicable.
– Wide variety of products.
18

About certification.
• Everyone would agree that ULMs of to-day are as good,
even a lot better than the ‘certified’ airplane.
• ULMs are designed to fly.
ULM are quality products; they meet your expectations
(simple to handle, fly fast, cheap in usage, …)
• Certification means that a manufacturer must demonstrate
that his product meets a minimum level of safety, as
defined (ultimately) by the Aviation Community.
• The minimum level of safety is defined in the Certification
Specifications – For small aircraft, it is called CS23.
19

Technical.
• AAIU(be) is currently investigating on:
– Instrument Board lay-out design.
– Electrical System design.
– Emergency Parachute.
Why is it that (for the last cases) parachute did not save lifes ?
• Late decision ?
• Handle easy to grab ?
• Safety pin not removed before flight ?

20

Same ULM Type, instrument panel somewhat different.
Difference in Ergonomy.
Parachute handle – on pilot’s side, or on passenger’s side ?

21

Regulation: certification:
CS 23.671 General
(b) Controls must be arranged and identified
to provide for convenience in operation and
to prevent the possibility of confusion and
subsequent inadvertent operation.

For ULM, CS 23 is not applicable.
Each designer has his own solution, and
they will be challenged only by YOUR
experience.
22

Other example
The passenger door opens in
flight, causing the pilot to take
appropriate actions, that
eventually force him to an
emergency landing.

• Door lock (simple – crude).
Plexy flexible. Once opened in
flight, difficult to close.
CS 23.783
(1) There must be means to lock and safeguard the door against
inadvertent opening during flight by persons, by cargo, or as a
result of mechanical failure.
23

The problem
• Once we determine a technical problem, we
can define recommendations to improve the
product, but:
What do we do with the recommendation ?
– We can not improve the Standard, there’s no standard.
– We can not address more than one manufacturer,
– What about retrofit ?

24

ULM and Engine failures

25

Fly Synthesis Storch
Summer 2009
• After propeller replacement, and subsequent
engine ground tests, the pilot took off for a
flight test.
• He encountered heavy engine vibration, that
forced him to an emergency landing.
• Airplane was slightly damaged.
Cause was identified as Vapor Lock.
26

1/5/2010 – FK9
Emergency landing after in-flight engine failure.
• Lots of corrosion found in carburettor.
Corrosion comes from water condensation in
fuel system (tank, lines, pump,…- MOGAS)
during long immobilisation periods.
- how to prevent ? Filling up, draining ?

• Fuel system was modified in-service, by
addition of a pressure regulator.
27

France
20/5/2010 – Mistral
23/5/2010 – CT Short Wing
Mistral: Engine failure in flight.
Emergency landing in field; terrain was very soft, airplane
severely damaged.
CT Short Wing: In short final, the engine suddenly stops
The pilot attempts to land, but hit trees, and crashes – wings
ripped off.
RH wing tank empty, 15-25 l fuel remaining in LH tank.
During LH turn, fuel system unprimed, engine stopped by
fuel starvation.
28

4 /6/2010: SG Rally
Damaged during landing
• Due to engine problems (heavy vibrations), the
pilot performed emergency landing on EBHN.
Coming in too fast, the landing was brutal, and
Nose Landing Gear collapsed.

29

Conclusion
• Engine in-flight failure are not exceptional.
– Use of MOGAS (water content, flash point,..)
– Local modifications,
– Other specific to the configuration of the
specific airplane.
And..
– Traditional causes (engine starvation,..)
30

Solutions
• In this case, we can design some generic
recommendations:
– Human Factors; ULM pilots should be more
prepared to react to engine failures at any time
(awareness, briefing, training,…)
– Generic technical solutions; impact on the use
of MOGAS.
• Protection of the equipment during winter,
• Risk of Vapour lock.

31

• Designing stop-gaps, accident after accidents
may not be satisfactory;
What can we do we make sure ULM flying
improves up to an acceptable level and, more
important, remains at that level ?

• More Regulation ?

32

Aviation Regulation and the ULM
• No significant changes in Regulation.
– ULM defined by capacity, weight, structural and stall speed limitation.
– => Extensive use of carbon fiber, Flaps, etc

• CS-VLA.
– 750 kg.
– “light” CS-23.
– Expensive.

• Lower Requirements for licencing,
– What about competence ?
– Human Factors training

• National requirements in Europe.
– EASA Flight Permit per Part 21A.701.

33

Evolution: new EU Regulation on
Accident Investigation.
* Every civil aviation accident or serious incident involving
aircraft other than specified in Annex II to the Regulation (EC)
No 216/2008 of the European Parliament and of the Council
shall be the subject of a safety investigation

( = No obligation of enquiry for ULMs)
• Safety investigation authorities may decide to investigate
incidents other than those referred to in paragraph 1 as well as
accidents or serious incidents to other types of aircraft, in
accordance with the national legislation of the Member States,
when they expect to draw safety lessons from them.
34

• US. NTSB; no enquiry for ULM crashes.
• To-day already, in some EU countries, ULM
crash investigations are given a low priority,
unless the Public determines otherwise.
• Common sense dictates that the initiative
to improve safety must come from the
ULM community itself.

35

Reason Model
• aviation is a complex socio-technical
system, where safety is ensured by a
series of defense barriers.
• Each barrier may present flaws (latent
or active) whose combination can lead
to an accident.
• An usafe act (active failure) alone
would not cause an accident.
• Latent failures are more easily
detected and corrected that human
errors, which are (globally) inevitable.

36

• The ULM community should reinforce its
Defense Barriers.
• Organisation: Federation and Clubs.
Create a Safety Climate
- Norms and rules
- Safety Programs

- To define a Safety Climate, we need to
assess the potential risk, and for that we
need data: YOUR experience.
37

Pyramid of Heinrich
• If a fatal accident is caused by
a specific combination of
events, an uncomplete series
of events causes INCIDENTS.
• If we identify all potentially
dangerous events AND with
that information, build-up the
defenses, we can avoid
ACCIDENTS.
38

SHARING EXPERIENCE
• By informing the Federation of the small
events and incidents that spoiled one of
your flights, you allow the Community to
understand the potential dangers and act
upon. (and respect confidentiality)
“Learn from mistakes of others; you won’t
live long enough to make them all by
yourself”
39

Human Factors
• To err is human.
• Human life (and flying) is full of decisions.
• It is therefore more important to know yourself
than to know how to fly your aircraft.
– Get-home-itis, Distraction, Communication,..

• Understanding human factors is a very important
step in improving your defenses.
40

Competence and Readiness
• You hold a pilot licence; but are you a
competent flyer ?
• How will you react when faced with a
potential dangerous situation?
• Assessing your competences with an
instructor is an opportunity to improve.
• When flying, be ready.
41

What is the Authority doing for
you ?

42

A series of work groups
within EASA are thinking
about how to improve
flight safety.(ESSI)
One of them is about General
Aviation (EGAST).

Initiative includes a leaflet
On Collision Avoidance,
and has been relayed to you
by the Federation.
There are technical Work
Groups dealing with MOGAS
43

and

An initiative to develop
Posters with comic strips
On high risk topics.
The first goes about taking
The right decision when the
Weather is below minimum.
They are expected in the
Coming months.

44

For Belgium, Accident reports are made public on the SPF/FOD website.
Recent reports (from 1st May 2007) are directly available through
hyperlinks.
Reports are written in English.
Information Notes are also available in order to highlight specific danger
area: Nr 2010 is about engine cold start.
We would like to develop more Notes, for ULM in collaboration with
the Federation.
Historical reports: currently a list is posted.
The list is fairly complete from 1972.
2 ancient reports (1936 and 1965).
The reports (Fr /Nl) are desidentified and available on request.
The list will be completed as we go along in reviewing archives.

45

Thank you for your attention, and
AAIU (Belgium) wishes you
many happy landings

Photos credit:
MRA / KLM

46


Slide 10

10 JULY 1910 - 2010
100 YEARS ULM ACCIDENTS

Belgian ULM Federation – Safety
1
Conference 10/10/2010

The Air Safety Investigation
• As part of the global Aviation sphere, an investigation is
conducted for each accident and serious incident by an
independent enquiry body, aimed to;
– Determine the causes of the accident.
– Determine if all conditions that were defined by rules and
regulations to ensure flight safety were followed (such as risk
factors in design).
– Define recommendations in order to prevent future accidents.

• It is not the purpose of this investigation to apportion
blame or liability.

2

In Belgium; the Air Accident
Investigation Unit.
• All accidents and serious incidents occurring in Belgium,
on aircraft, helicopters, gliders, balloons, ULM, DPM,
regardless of their registration is investigated by a cell
functionnally independent from the BCAA, and all other
interrested parties.
• Independent doesn’t mean isolated; it is part of the world’s
network of the State’s Aviation Investigation Bodies.
• The cell reports to the President of the Board of the
SPF/FOD Mobility and Transport.
3

4

ULM
• First pendular (Delta Plane Motorized)
design in 1966
• First crossing of the Channel in 1978 by Mr
D. Cook.
• Commercial development from 1979.
• Evolution from 2-axis to 3-axis.
• In Belgium, first ULM registered (501) in
1982.

5

6

Evolution
• 1982: Weedhopper, Chickinox
– 80…100 km/h
– Basic – 2/3 axis
– Range: … 200 km…

• 2010: VL-3 Sprint, DynAero MCR01, WT9 Dynamic….
– 220….250 km/h,
– flaps, retractable gear, avionics,
– Range over 1000 km

• 550 OO- registered ULM;
• 571 ULM pilot licence (363 training licences)
• 300-400 foreign-registered ULM.
7

1000
900
800
700
600
500
400
300
200
100

Number of valid registration

8

Estimation of flying OO-regd ULM

20
10

20
08

20
06

20
04

20
02

20
00

19
98

19
96

19
94

19
92

19
90

19
88

19
86

19
84

19
82

0

Evolution in pilot’s / owner’s
expectations
• In 1982, ULM /DPM, a sporting way of flying,
outside the limits of parachuting, delta plane.

• In 2010, an efficient alternative to general
(certified) aviation. ULM becomes a means of
transport.
• Beyond 2010 ?? – The Need for Speed ?
9

Evolution
• From the user’s perspective, the difference between
General Aviation and ULM becomes very thin.
• However, ULMs are characterized by a huge variety of
different design types, with low production rate and
configuration variation between individual airplanes.
– Manufacturers come and go,
– Assembly of the same ULM type by different companies induce
differences in built configuration.

• The above makes it more and more difficult to speak about
ULMs in a general way; variation in quality is wider than
General (certified) Aviation.
10

EVOLUTION: MORE ULM FATAL ACCIDENTS ?

Fatalities: (up to now), In Belgium, on average 2 /year,
comparable to General (certified) Aviation.
Number of fatalities
12
10
8
6
4
2

Number of fatalities

11

20
10

20
08

20
06

20
04

20
02

20
00

19
98

19
96

19
94

19
92

19
90

19
88

19
86

19
84

0

19
82

FATALITIES:
Figures limited to
Belgium.
2009: + 2 in France.
2010: + 5 in France.

WHAT ARE THE EXPECTATIONS
FOR THE
ULM-ACCIDENTS CASUALITY
RATE ?
• On Belgian soil, 4 deads in 2010.
(casuality rate of U.S. Forces in Iraq 3.6 killed /1000
troop / year – 8 years – 152000 troops – 4424 killed).

• In France and Belgium in 2010, 9 Belgian
deads to-date.
12

Comparison with the road
• In Belgium, the road kills 1000 people on average per year
.
• Fleet of vehicles: 6 000 000 units (5 mio cars).
• For 1000 cars, the road kills on average 0.16 person per
year.
• If we combine these figures with the yearly utilization rate
of cars (1 h per day) versus ULM (40 h per year), we can
conclude that ULM / General Aviation flying is
considerably deadlier than the road.

13

What can we learn from accident
investigation ?

14

The investigation process
A long process (Months)
• Collect all factual elements,
–
–
–
–
–
–

The flow of events;
The pilot (training, experience, …)
The aircraft (contact w/manufacturer)
Meteo, Comm, Radar,
Flt recorders (GPS, ECU, camera, …)
Impact, aircraft damage,

• Analysis. (incl. simulation, testing,…)
• Define all possible causes.
• From the causes, define remedial action.
The depth of the investigation is somewhat influenced by the
expected ROI.
15

Accident analysis
• Accidents do not occur “by accident”; Accident are
caused by a series of events.
• There are no “isolated cases”; causes of accidents are often
recurrent.
• Out of the ULM accident data base, we can conclude;
– There are recurrent technical problems specific to ULM.
– The traditional causes of aviation accidents are also known to
ULM (fuel shortage)

– 80% of the causal factors are human-related.

16

Main causal factors (122 accidents –
fixed wing and ULM)
Loss of control Take-off
11%

Fuel Starvation
15%

Loss of control Flight & collision
12%

Technical
11%
Low piloting
experience
8%

Loss of control Landing
16%
Icing
3%

Low flying /
aerobatics obstacles - CFIT
24%

17

Specific problems with ULM
• Technical causes can be (easily) identified;
but fire can be devastating.
• There’s another problem for the
investigator, a lot of landmarks are missing.
– ULM requirements are national,
– Certification not applicable.
– Wide variety of products.
18

About certification.
• Everyone would agree that ULMs of to-day are as good,
even a lot better than the ‘certified’ airplane.
• ULMs are designed to fly.
ULM are quality products; they meet your expectations
(simple to handle, fly fast, cheap in usage, …)
• Certification means that a manufacturer must demonstrate
that his product meets a minimum level of safety, as
defined (ultimately) by the Aviation Community.
• The minimum level of safety is defined in the Certification
Specifications – For small aircraft, it is called CS23.
19

Technical.
• AAIU(be) is currently investigating on:
– Instrument Board lay-out design.
– Electrical System design.
– Emergency Parachute.
Why is it that (for the last cases) parachute did not save lifes ?
• Late decision ?
• Handle easy to grab ?
• Safety pin not removed before flight ?

20

Same ULM Type, instrument panel somewhat different.
Difference in Ergonomy.
Parachute handle – on pilot’s side, or on passenger’s side ?

21

Regulation: certification:
CS 23.671 General
(b) Controls must be arranged and identified
to provide for convenience in operation and
to prevent the possibility of confusion and
subsequent inadvertent operation.

For ULM, CS 23 is not applicable.
Each designer has his own solution, and
they will be challenged only by YOUR
experience.
22

Other example
The passenger door opens in
flight, causing the pilot to take
appropriate actions, that
eventually force him to an
emergency landing.

• Door lock (simple – crude).
Plexy flexible. Once opened in
flight, difficult to close.
CS 23.783
(1) There must be means to lock and safeguard the door against
inadvertent opening during flight by persons, by cargo, or as a
result of mechanical failure.
23

The problem
• Once we determine a technical problem, we
can define recommendations to improve the
product, but:
What do we do with the recommendation ?
– We can not improve the Standard, there’s no standard.
– We can not address more than one manufacturer,
– What about retrofit ?

24

ULM and Engine failures

25

Fly Synthesis Storch
Summer 2009
• After propeller replacement, and subsequent
engine ground tests, the pilot took off for a
flight test.
• He encountered heavy engine vibration, that
forced him to an emergency landing.
• Airplane was slightly damaged.
Cause was identified as Vapor Lock.
26

1/5/2010 – FK9
Emergency landing after in-flight engine failure.
• Lots of corrosion found in carburettor.
Corrosion comes from water condensation in
fuel system (tank, lines, pump,…- MOGAS)
during long immobilisation periods.
- how to prevent ? Filling up, draining ?

• Fuel system was modified in-service, by
addition of a pressure regulator.
27

France
20/5/2010 – Mistral
23/5/2010 – CT Short Wing
Mistral: Engine failure in flight.
Emergency landing in field; terrain was very soft, airplane
severely damaged.
CT Short Wing: In short final, the engine suddenly stops
The pilot attempts to land, but hit trees, and crashes – wings
ripped off.
RH wing tank empty, 15-25 l fuel remaining in LH tank.
During LH turn, fuel system unprimed, engine stopped by
fuel starvation.
28

4 /6/2010: SG Rally
Damaged during landing
• Due to engine problems (heavy vibrations), the
pilot performed emergency landing on EBHN.
Coming in too fast, the landing was brutal, and
Nose Landing Gear collapsed.

29

Conclusion
• Engine in-flight failure are not exceptional.
– Use of MOGAS (water content, flash point,..)
– Local modifications,
– Other specific to the configuration of the
specific airplane.
And..
– Traditional causes (engine starvation,..)
30

Solutions
• In this case, we can design some generic
recommendations:
– Human Factors; ULM pilots should be more
prepared to react to engine failures at any time
(awareness, briefing, training,…)
– Generic technical solutions; impact on the use
of MOGAS.
• Protection of the equipment during winter,
• Risk of Vapour lock.

31

• Designing stop-gaps, accident after accidents
may not be satisfactory;
What can we do we make sure ULM flying
improves up to an acceptable level and, more
important, remains at that level ?

• More Regulation ?

32

Aviation Regulation and the ULM
• No significant changes in Regulation.
– ULM defined by capacity, weight, structural and stall speed limitation.
– => Extensive use of carbon fiber, Flaps, etc

• CS-VLA.
– 750 kg.
– “light” CS-23.
– Expensive.

• Lower Requirements for licencing,
– What about competence ?
– Human Factors training

• National requirements in Europe.
– EASA Flight Permit per Part 21A.701.

33

Evolution: new EU Regulation on
Accident Investigation.
* Every civil aviation accident or serious incident involving
aircraft other than specified in Annex II to the Regulation (EC)
No 216/2008 of the European Parliament and of the Council
shall be the subject of a safety investigation

( = No obligation of enquiry for ULMs)
• Safety investigation authorities may decide to investigate
incidents other than those referred to in paragraph 1 as well as
accidents or serious incidents to other types of aircraft, in
accordance with the national legislation of the Member States,
when they expect to draw safety lessons from them.
34

• US. NTSB; no enquiry for ULM crashes.
• To-day already, in some EU countries, ULM
crash investigations are given a low priority,
unless the Public determines otherwise.
• Common sense dictates that the initiative
to improve safety must come from the
ULM community itself.

35

Reason Model
• aviation is a complex socio-technical
system, where safety is ensured by a
series of defense barriers.
• Each barrier may present flaws (latent
or active) whose combination can lead
to an accident.
• An usafe act (active failure) alone
would not cause an accident.
• Latent failures are more easily
detected and corrected that human
errors, which are (globally) inevitable.

36

• The ULM community should reinforce its
Defense Barriers.
• Organisation: Federation and Clubs.
Create a Safety Climate
- Norms and rules
- Safety Programs

- To define a Safety Climate, we need to
assess the potential risk, and for that we
need data: YOUR experience.
37

Pyramid of Heinrich
• If a fatal accident is caused by
a specific combination of
events, an uncomplete series
of events causes INCIDENTS.
• If we identify all potentially
dangerous events AND with
that information, build-up the
defenses, we can avoid
ACCIDENTS.
38

SHARING EXPERIENCE
• By informing the Federation of the small
events and incidents that spoiled one of
your flights, you allow the Community to
understand the potential dangers and act
upon. (and respect confidentiality)
“Learn from mistakes of others; you won’t
live long enough to make them all by
yourself”
39

Human Factors
• To err is human.
• Human life (and flying) is full of decisions.
• It is therefore more important to know yourself
than to know how to fly your aircraft.
– Get-home-itis, Distraction, Communication,..

• Understanding human factors is a very important
step in improving your defenses.
40

Competence and Readiness
• You hold a pilot licence; but are you a
competent flyer ?
• How will you react when faced with a
potential dangerous situation?
• Assessing your competences with an
instructor is an opportunity to improve.
• When flying, be ready.
41

What is the Authority doing for
you ?

42

A series of work groups
within EASA are thinking
about how to improve
flight safety.(ESSI)
One of them is about General
Aviation (EGAST).

Initiative includes a leaflet
On Collision Avoidance,
and has been relayed to you
by the Federation.
There are technical Work
Groups dealing with MOGAS
43

and

An initiative to develop
Posters with comic strips
On high risk topics.
The first goes about taking
The right decision when the
Weather is below minimum.
They are expected in the
Coming months.

44

For Belgium, Accident reports are made public on the SPF/FOD website.
Recent reports (from 1st May 2007) are directly available through
hyperlinks.
Reports are written in English.
Information Notes are also available in order to highlight specific danger
area: Nr 2010 is about engine cold start.
We would like to develop more Notes, for ULM in collaboration with
the Federation.
Historical reports: currently a list is posted.
The list is fairly complete from 1972.
2 ancient reports (1936 and 1965).
The reports (Fr /Nl) are desidentified and available on request.
The list will be completed as we go along in reviewing archives.

45

Thank you for your attention, and
AAIU (Belgium) wishes you
many happy landings

Photos credit:
MRA / KLM

46


Slide 11

10 JULY 1910 - 2010
100 YEARS ULM ACCIDENTS

Belgian ULM Federation – Safety
1
Conference 10/10/2010

The Air Safety Investigation
• As part of the global Aviation sphere, an investigation is
conducted for each accident and serious incident by an
independent enquiry body, aimed to;
– Determine the causes of the accident.
– Determine if all conditions that were defined by rules and
regulations to ensure flight safety were followed (such as risk
factors in design).
– Define recommendations in order to prevent future accidents.

• It is not the purpose of this investigation to apportion
blame or liability.

2

In Belgium; the Air Accident
Investigation Unit.
• All accidents and serious incidents occurring in Belgium,
on aircraft, helicopters, gliders, balloons, ULM, DPM,
regardless of their registration is investigated by a cell
functionnally independent from the BCAA, and all other
interrested parties.
• Independent doesn’t mean isolated; it is part of the world’s
network of the State’s Aviation Investigation Bodies.
• The cell reports to the President of the Board of the
SPF/FOD Mobility and Transport.
3

4

ULM
• First pendular (Delta Plane Motorized)
design in 1966
• First crossing of the Channel in 1978 by Mr
D. Cook.
• Commercial development from 1979.
• Evolution from 2-axis to 3-axis.
• In Belgium, first ULM registered (501) in
1982.

5

6

Evolution
• 1982: Weedhopper, Chickinox
– 80…100 km/h
– Basic – 2/3 axis
– Range: … 200 km…

• 2010: VL-3 Sprint, DynAero MCR01, WT9 Dynamic….
– 220….250 km/h,
– flaps, retractable gear, avionics,
– Range over 1000 km

• 550 OO- registered ULM;
• 571 ULM pilot licence (363 training licences)
• 300-400 foreign-registered ULM.
7

1000
900
800
700
600
500
400
300
200
100

Number of valid registration

8

Estimation of flying OO-regd ULM

20
10

20
08

20
06

20
04

20
02

20
00

19
98

19
96

19
94

19
92

19
90

19
88

19
86

19
84

19
82

0

Evolution in pilot’s / owner’s
expectations
• In 1982, ULM /DPM, a sporting way of flying,
outside the limits of parachuting, delta plane.

• In 2010, an efficient alternative to general
(certified) aviation. ULM becomes a means of
transport.
• Beyond 2010 ?? – The Need for Speed ?
9

Evolution
• From the user’s perspective, the difference between
General Aviation and ULM becomes very thin.
• However, ULMs are characterized by a huge variety of
different design types, with low production rate and
configuration variation between individual airplanes.
– Manufacturers come and go,
– Assembly of the same ULM type by different companies induce
differences in built configuration.

• The above makes it more and more difficult to speak about
ULMs in a general way; variation in quality is wider than
General (certified) Aviation.
10

EVOLUTION: MORE ULM FATAL ACCIDENTS ?

Fatalities: (up to now), In Belgium, on average 2 /year,
comparable to General (certified) Aviation.
Number of fatalities
12
10
8
6
4
2

Number of fatalities

11

20
10

20
08

20
06

20
04

20
02

20
00

19
98

19
96

19
94

19
92

19
90

19
88

19
86

19
84

0

19
82

FATALITIES:
Figures limited to
Belgium.
2009: + 2 in France.
2010: + 5 in France.

WHAT ARE THE EXPECTATIONS
FOR THE
ULM-ACCIDENTS CASUALITY
RATE ?
• On Belgian soil, 4 deads in 2010.
(casuality rate of U.S. Forces in Iraq 3.6 killed /1000
troop / year – 8 years – 152000 troops – 4424 killed).

• In France and Belgium in 2010, 9 Belgian
deads to-date.
12

Comparison with the road
• In Belgium, the road kills 1000 people on average per year
.
• Fleet of vehicles: 6 000 000 units (5 mio cars).
• For 1000 cars, the road kills on average 0.16 person per
year.
• If we combine these figures with the yearly utilization rate
of cars (1 h per day) versus ULM (40 h per year), we can
conclude that ULM / General Aviation flying is
considerably deadlier than the road.

13

What can we learn from accident
investigation ?

14

The investigation process
A long process (Months)
• Collect all factual elements,
–
–
–
–
–
–

The flow of events;
The pilot (training, experience, …)
The aircraft (contact w/manufacturer)
Meteo, Comm, Radar,
Flt recorders (GPS, ECU, camera, …)
Impact, aircraft damage,

• Analysis. (incl. simulation, testing,…)
• Define all possible causes.
• From the causes, define remedial action.
The depth of the investigation is somewhat influenced by the
expected ROI.
15

Accident analysis
• Accidents do not occur “by accident”; Accident are
caused by a series of events.
• There are no “isolated cases”; causes of accidents are often
recurrent.
• Out of the ULM accident data base, we can conclude;
– There are recurrent technical problems specific to ULM.
– The traditional causes of aviation accidents are also known to
ULM (fuel shortage)

– 80% of the causal factors are human-related.

16

Main causal factors (122 accidents –
fixed wing and ULM)
Loss of control Take-off
11%

Fuel Starvation
15%

Loss of control Flight & collision
12%

Technical
11%
Low piloting
experience
8%

Loss of control Landing
16%
Icing
3%

Low flying /
aerobatics obstacles - CFIT
24%

17

Specific problems with ULM
• Technical causes can be (easily) identified;
but fire can be devastating.
• There’s another problem for the
investigator, a lot of landmarks are missing.
– ULM requirements are national,
– Certification not applicable.
– Wide variety of products.
18

About certification.
• Everyone would agree that ULMs of to-day are as good,
even a lot better than the ‘certified’ airplane.
• ULMs are designed to fly.
ULM are quality products; they meet your expectations
(simple to handle, fly fast, cheap in usage, …)
• Certification means that a manufacturer must demonstrate
that his product meets a minimum level of safety, as
defined (ultimately) by the Aviation Community.
• The minimum level of safety is defined in the Certification
Specifications – For small aircraft, it is called CS23.
19

Technical.
• AAIU(be) is currently investigating on:
– Instrument Board lay-out design.
– Electrical System design.
– Emergency Parachute.
Why is it that (for the last cases) parachute did not save lifes ?
• Late decision ?
• Handle easy to grab ?
• Safety pin not removed before flight ?

20

Same ULM Type, instrument panel somewhat different.
Difference in Ergonomy.
Parachute handle – on pilot’s side, or on passenger’s side ?

21

Regulation: certification:
CS 23.671 General
(b) Controls must be arranged and identified
to provide for convenience in operation and
to prevent the possibility of confusion and
subsequent inadvertent operation.

For ULM, CS 23 is not applicable.
Each designer has his own solution, and
they will be challenged only by YOUR
experience.
22

Other example
The passenger door opens in
flight, causing the pilot to take
appropriate actions, that
eventually force him to an
emergency landing.

• Door lock (simple – crude).
Plexy flexible. Once opened in
flight, difficult to close.
CS 23.783
(1) There must be means to lock and safeguard the door against
inadvertent opening during flight by persons, by cargo, or as a
result of mechanical failure.
23

The problem
• Once we determine a technical problem, we
can define recommendations to improve the
product, but:
What do we do with the recommendation ?
– We can not improve the Standard, there’s no standard.
– We can not address more than one manufacturer,
– What about retrofit ?

24

ULM and Engine failures

25

Fly Synthesis Storch
Summer 2009
• After propeller replacement, and subsequent
engine ground tests, the pilot took off for a
flight test.
• He encountered heavy engine vibration, that
forced him to an emergency landing.
• Airplane was slightly damaged.
Cause was identified as Vapor Lock.
26

1/5/2010 – FK9
Emergency landing after in-flight engine failure.
• Lots of corrosion found in carburettor.
Corrosion comes from water condensation in
fuel system (tank, lines, pump,…- MOGAS)
during long immobilisation periods.
- how to prevent ? Filling up, draining ?

• Fuel system was modified in-service, by
addition of a pressure regulator.
27

France
20/5/2010 – Mistral
23/5/2010 – CT Short Wing
Mistral: Engine failure in flight.
Emergency landing in field; terrain was very soft, airplane
severely damaged.
CT Short Wing: In short final, the engine suddenly stops
The pilot attempts to land, but hit trees, and crashes – wings
ripped off.
RH wing tank empty, 15-25 l fuel remaining in LH tank.
During LH turn, fuel system unprimed, engine stopped by
fuel starvation.
28

4 /6/2010: SG Rally
Damaged during landing
• Due to engine problems (heavy vibrations), the
pilot performed emergency landing on EBHN.
Coming in too fast, the landing was brutal, and
Nose Landing Gear collapsed.

29

Conclusion
• Engine in-flight failure are not exceptional.
– Use of MOGAS (water content, flash point,..)
– Local modifications,
– Other specific to the configuration of the
specific airplane.
And..
– Traditional causes (engine starvation,..)
30

Solutions
• In this case, we can design some generic
recommendations:
– Human Factors; ULM pilots should be more
prepared to react to engine failures at any time
(awareness, briefing, training,…)
– Generic technical solutions; impact on the use
of MOGAS.
• Protection of the equipment during winter,
• Risk of Vapour lock.

31

• Designing stop-gaps, accident after accidents
may not be satisfactory;
What can we do we make sure ULM flying
improves up to an acceptable level and, more
important, remains at that level ?

• More Regulation ?

32

Aviation Regulation and the ULM
• No significant changes in Regulation.
– ULM defined by capacity, weight, structural and stall speed limitation.
– => Extensive use of carbon fiber, Flaps, etc

• CS-VLA.
– 750 kg.
– “light” CS-23.
– Expensive.

• Lower Requirements for licencing,
– What about competence ?
– Human Factors training

• National requirements in Europe.
– EASA Flight Permit per Part 21A.701.

33

Evolution: new EU Regulation on
Accident Investigation.
* Every civil aviation accident or serious incident involving
aircraft other than specified in Annex II to the Regulation (EC)
No 216/2008 of the European Parliament and of the Council
shall be the subject of a safety investigation

( = No obligation of enquiry for ULMs)
• Safety investigation authorities may decide to investigate
incidents other than those referred to in paragraph 1 as well as
accidents or serious incidents to other types of aircraft, in
accordance with the national legislation of the Member States,
when they expect to draw safety lessons from them.
34

• US. NTSB; no enquiry for ULM crashes.
• To-day already, in some EU countries, ULM
crash investigations are given a low priority,
unless the Public determines otherwise.
• Common sense dictates that the initiative
to improve safety must come from the
ULM community itself.

35

Reason Model
• aviation is a complex socio-technical
system, where safety is ensured by a
series of defense barriers.
• Each barrier may present flaws (latent
or active) whose combination can lead
to an accident.
• An usafe act (active failure) alone
would not cause an accident.
• Latent failures are more easily
detected and corrected that human
errors, which are (globally) inevitable.

36

• The ULM community should reinforce its
Defense Barriers.
• Organisation: Federation and Clubs.
Create a Safety Climate
- Norms and rules
- Safety Programs

- To define a Safety Climate, we need to
assess the potential risk, and for that we
need data: YOUR experience.
37

Pyramid of Heinrich
• If a fatal accident is caused by
a specific combination of
events, an uncomplete series
of events causes INCIDENTS.
• If we identify all potentially
dangerous events AND with
that information, build-up the
defenses, we can avoid
ACCIDENTS.
38

SHARING EXPERIENCE
• By informing the Federation of the small
events and incidents that spoiled one of
your flights, you allow the Community to
understand the potential dangers and act
upon. (and respect confidentiality)
“Learn from mistakes of others; you won’t
live long enough to make them all by
yourself”
39

Human Factors
• To err is human.
• Human life (and flying) is full of decisions.
• It is therefore more important to know yourself
than to know how to fly your aircraft.
– Get-home-itis, Distraction, Communication,..

• Understanding human factors is a very important
step in improving your defenses.
40

Competence and Readiness
• You hold a pilot licence; but are you a
competent flyer ?
• How will you react when faced with a
potential dangerous situation?
• Assessing your competences with an
instructor is an opportunity to improve.
• When flying, be ready.
41

What is the Authority doing for
you ?

42

A series of work groups
within EASA are thinking
about how to improve
flight safety.(ESSI)
One of them is about General
Aviation (EGAST).

Initiative includes a leaflet
On Collision Avoidance,
and has been relayed to you
by the Federation.
There are technical Work
Groups dealing with MOGAS
43

and

An initiative to develop
Posters with comic strips
On high risk topics.
The first goes about taking
The right decision when the
Weather is below minimum.
They are expected in the
Coming months.

44

For Belgium, Accident reports are made public on the SPF/FOD website.
Recent reports (from 1st May 2007) are directly available through
hyperlinks.
Reports are written in English.
Information Notes are also available in order to highlight specific danger
area: Nr 2010 is about engine cold start.
We would like to develop more Notes, for ULM in collaboration with
the Federation.
Historical reports: currently a list is posted.
The list is fairly complete from 1972.
2 ancient reports (1936 and 1965).
The reports (Fr /Nl) are desidentified and available on request.
The list will be completed as we go along in reviewing archives.

45

Thank you for your attention, and
AAIU (Belgium) wishes you
many happy landings

Photos credit:
MRA / KLM

46


Slide 12

10 JULY 1910 - 2010
100 YEARS ULM ACCIDENTS

Belgian ULM Federation – Safety
1
Conference 10/10/2010

The Air Safety Investigation
• As part of the global Aviation sphere, an investigation is
conducted for each accident and serious incident by an
independent enquiry body, aimed to;
– Determine the causes of the accident.
– Determine if all conditions that were defined by rules and
regulations to ensure flight safety were followed (such as risk
factors in design).
– Define recommendations in order to prevent future accidents.

• It is not the purpose of this investigation to apportion
blame or liability.

2

In Belgium; the Air Accident
Investigation Unit.
• All accidents and serious incidents occurring in Belgium,
on aircraft, helicopters, gliders, balloons, ULM, DPM,
regardless of their registration is investigated by a cell
functionnally independent from the BCAA, and all other
interrested parties.
• Independent doesn’t mean isolated; it is part of the world’s
network of the State’s Aviation Investigation Bodies.
• The cell reports to the President of the Board of the
SPF/FOD Mobility and Transport.
3

4

ULM
• First pendular (Delta Plane Motorized)
design in 1966
• First crossing of the Channel in 1978 by Mr
D. Cook.
• Commercial development from 1979.
• Evolution from 2-axis to 3-axis.
• In Belgium, first ULM registered (501) in
1982.

5

6

Evolution
• 1982: Weedhopper, Chickinox
– 80…100 km/h
– Basic – 2/3 axis
– Range: … 200 km…

• 2010: VL-3 Sprint, DynAero MCR01, WT9 Dynamic….
– 220….250 km/h,
– flaps, retractable gear, avionics,
– Range over 1000 km

• 550 OO- registered ULM;
• 571 ULM pilot licence (363 training licences)
• 300-400 foreign-registered ULM.
7

1000
900
800
700
600
500
400
300
200
100

Number of valid registration

8

Estimation of flying OO-regd ULM

20
10

20
08

20
06

20
04

20
02

20
00

19
98

19
96

19
94

19
92

19
90

19
88

19
86

19
84

19
82

0

Evolution in pilot’s / owner’s
expectations
• In 1982, ULM /DPM, a sporting way of flying,
outside the limits of parachuting, delta plane.

• In 2010, an efficient alternative to general
(certified) aviation. ULM becomes a means of
transport.
• Beyond 2010 ?? – The Need for Speed ?
9

Evolution
• From the user’s perspective, the difference between
General Aviation and ULM becomes very thin.
• However, ULMs are characterized by a huge variety of
different design types, with low production rate and
configuration variation between individual airplanes.
– Manufacturers come and go,
– Assembly of the same ULM type by different companies induce
differences in built configuration.

• The above makes it more and more difficult to speak about
ULMs in a general way; variation in quality is wider than
General (certified) Aviation.
10

EVOLUTION: MORE ULM FATAL ACCIDENTS ?

Fatalities: (up to now), In Belgium, on average 2 /year,
comparable to General (certified) Aviation.
Number of fatalities
12
10
8
6
4
2

Number of fatalities

11

20
10

20
08

20
06

20
04

20
02

20
00

19
98

19
96

19
94

19
92

19
90

19
88

19
86

19
84

0

19
82

FATALITIES:
Figures limited to
Belgium.
2009: + 2 in France.
2010: + 5 in France.

WHAT ARE THE EXPECTATIONS
FOR THE
ULM-ACCIDENTS CASUALITY
RATE ?
• On Belgian soil, 4 deads in 2010.
(casuality rate of U.S. Forces in Iraq 3.6 killed /1000
troop / year – 8 years – 152000 troops – 4424 killed).

• In France and Belgium in 2010, 9 Belgian
deads to-date.
12

Comparison with the road
• In Belgium, the road kills 1000 people on average per year
.
• Fleet of vehicles: 6 000 000 units (5 mio cars).
• For 1000 cars, the road kills on average 0.16 person per
year.
• If we combine these figures with the yearly utilization rate
of cars (1 h per day) versus ULM (40 h per year), we can
conclude that ULM / General Aviation flying is
considerably deadlier than the road.

13

What can we learn from accident
investigation ?

14

The investigation process
A long process (Months)
• Collect all factual elements,
–
–
–
–
–
–

The flow of events;
The pilot (training, experience, …)
The aircraft (contact w/manufacturer)
Meteo, Comm, Radar,
Flt recorders (GPS, ECU, camera, …)
Impact, aircraft damage,

• Analysis. (incl. simulation, testing,…)
• Define all possible causes.
• From the causes, define remedial action.
The depth of the investigation is somewhat influenced by the
expected ROI.
15

Accident analysis
• Accidents do not occur “by accident”; Accident are
caused by a series of events.
• There are no “isolated cases”; causes of accidents are often
recurrent.
• Out of the ULM accident data base, we can conclude;
– There are recurrent technical problems specific to ULM.
– The traditional causes of aviation accidents are also known to
ULM (fuel shortage)

– 80% of the causal factors are human-related.

16

Main causal factors (122 accidents –
fixed wing and ULM)
Loss of control Take-off
11%

Fuel Starvation
15%

Loss of control Flight & collision
12%

Technical
11%
Low piloting
experience
8%

Loss of control Landing
16%
Icing
3%

Low flying /
aerobatics obstacles - CFIT
24%

17

Specific problems with ULM
• Technical causes can be (easily) identified;
but fire can be devastating.
• There’s another problem for the
investigator, a lot of landmarks are missing.
– ULM requirements are national,
– Certification not applicable.
– Wide variety of products.
18

About certification.
• Everyone would agree that ULMs of to-day are as good,
even a lot better than the ‘certified’ airplane.
• ULMs are designed to fly.
ULM are quality products; they meet your expectations
(simple to handle, fly fast, cheap in usage, …)
• Certification means that a manufacturer must demonstrate
that his product meets a minimum level of safety, as
defined (ultimately) by the Aviation Community.
• The minimum level of safety is defined in the Certification
Specifications – For small aircraft, it is called CS23.
19

Technical.
• AAIU(be) is currently investigating on:
– Instrument Board lay-out design.
– Electrical System design.
– Emergency Parachute.
Why is it that (for the last cases) parachute did not save lifes ?
• Late decision ?
• Handle easy to grab ?
• Safety pin not removed before flight ?

20

Same ULM Type, instrument panel somewhat different.
Difference in Ergonomy.
Parachute handle – on pilot’s side, or on passenger’s side ?

21

Regulation: certification:
CS 23.671 General
(b) Controls must be arranged and identified
to provide for convenience in operation and
to prevent the possibility of confusion and
subsequent inadvertent operation.

For ULM, CS 23 is not applicable.
Each designer has his own solution, and
they will be challenged only by YOUR
experience.
22

Other example
The passenger door opens in
flight, causing the pilot to take
appropriate actions, that
eventually force him to an
emergency landing.

• Door lock (simple – crude).
Plexy flexible. Once opened in
flight, difficult to close.
CS 23.783
(1) There must be means to lock and safeguard the door against
inadvertent opening during flight by persons, by cargo, or as a
result of mechanical failure.
23

The problem
• Once we determine a technical problem, we
can define recommendations to improve the
product, but:
What do we do with the recommendation ?
– We can not improve the Standard, there’s no standard.
– We can not address more than one manufacturer,
– What about retrofit ?

24

ULM and Engine failures

25

Fly Synthesis Storch
Summer 2009
• After propeller replacement, and subsequent
engine ground tests, the pilot took off for a
flight test.
• He encountered heavy engine vibration, that
forced him to an emergency landing.
• Airplane was slightly damaged.
Cause was identified as Vapor Lock.
26

1/5/2010 – FK9
Emergency landing after in-flight engine failure.
• Lots of corrosion found in carburettor.
Corrosion comes from water condensation in
fuel system (tank, lines, pump,…- MOGAS)
during long immobilisation periods.
- how to prevent ? Filling up, draining ?

• Fuel system was modified in-service, by
addition of a pressure regulator.
27

France
20/5/2010 – Mistral
23/5/2010 – CT Short Wing
Mistral: Engine failure in flight.
Emergency landing in field; terrain was very soft, airplane
severely damaged.
CT Short Wing: In short final, the engine suddenly stops
The pilot attempts to land, but hit trees, and crashes – wings
ripped off.
RH wing tank empty, 15-25 l fuel remaining in LH tank.
During LH turn, fuel system unprimed, engine stopped by
fuel starvation.
28

4 /6/2010: SG Rally
Damaged during landing
• Due to engine problems (heavy vibrations), the
pilot performed emergency landing on EBHN.
Coming in too fast, the landing was brutal, and
Nose Landing Gear collapsed.

29

Conclusion
• Engine in-flight failure are not exceptional.
– Use of MOGAS (water content, flash point,..)
– Local modifications,
– Other specific to the configuration of the
specific airplane.
And..
– Traditional causes (engine starvation,..)
30

Solutions
• In this case, we can design some generic
recommendations:
– Human Factors; ULM pilots should be more
prepared to react to engine failures at any time
(awareness, briefing, training,…)
– Generic technical solutions; impact on the use
of MOGAS.
• Protection of the equipment during winter,
• Risk of Vapour lock.

31

• Designing stop-gaps, accident after accidents
may not be satisfactory;
What can we do we make sure ULM flying
improves up to an acceptable level and, more
important, remains at that level ?

• More Regulation ?

32

Aviation Regulation and the ULM
• No significant changes in Regulation.
– ULM defined by capacity, weight, structural and stall speed limitation.
– => Extensive use of carbon fiber, Flaps, etc

• CS-VLA.
– 750 kg.
– “light” CS-23.
– Expensive.

• Lower Requirements for licencing,
– What about competence ?
– Human Factors training

• National requirements in Europe.
– EASA Flight Permit per Part 21A.701.

33

Evolution: new EU Regulation on
Accident Investigation.
* Every civil aviation accident or serious incident involving
aircraft other than specified in Annex II to the Regulation (EC)
No 216/2008 of the European Parliament and of the Council
shall be the subject of a safety investigation

( = No obligation of enquiry for ULMs)
• Safety investigation authorities may decide to investigate
incidents other than those referred to in paragraph 1 as well as
accidents or serious incidents to other types of aircraft, in
accordance with the national legislation of the Member States,
when they expect to draw safety lessons from them.
34

• US. NTSB; no enquiry for ULM crashes.
• To-day already, in some EU countries, ULM
crash investigations are given a low priority,
unless the Public determines otherwise.
• Common sense dictates that the initiative
to improve safety must come from the
ULM community itself.

35

Reason Model
• aviation is a complex socio-technical
system, where safety is ensured by a
series of defense barriers.
• Each barrier may present flaws (latent
or active) whose combination can lead
to an accident.
• An usafe act (active failure) alone
would not cause an accident.
• Latent failures are more easily
detected and corrected that human
errors, which are (globally) inevitable.

36

• The ULM community should reinforce its
Defense Barriers.
• Organisation: Federation and Clubs.
Create a Safety Climate
- Norms and rules
- Safety Programs

- To define a Safety Climate, we need to
assess the potential risk, and for that we
need data: YOUR experience.
37

Pyramid of Heinrich
• If a fatal accident is caused by
a specific combination of
events, an uncomplete series
of events causes INCIDENTS.
• If we identify all potentially
dangerous events AND with
that information, build-up the
defenses, we can avoid
ACCIDENTS.
38

SHARING EXPERIENCE
• By informing the Federation of the small
events and incidents that spoiled one of
your flights, you allow the Community to
understand the potential dangers and act
upon. (and respect confidentiality)
“Learn from mistakes of others; you won’t
live long enough to make them all by
yourself”
39

Human Factors
• To err is human.
• Human life (and flying) is full of decisions.
• It is therefore more important to know yourself
than to know how to fly your aircraft.
– Get-home-itis, Distraction, Communication,..

• Understanding human factors is a very important
step in improving your defenses.
40

Competence and Readiness
• You hold a pilot licence; but are you a
competent flyer ?
• How will you react when faced with a
potential dangerous situation?
• Assessing your competences with an
instructor is an opportunity to improve.
• When flying, be ready.
41

What is the Authority doing for
you ?

42

A series of work groups
within EASA are thinking
about how to improve
flight safety.(ESSI)
One of them is about General
Aviation (EGAST).

Initiative includes a leaflet
On Collision Avoidance,
and has been relayed to you
by the Federation.
There are technical Work
Groups dealing with MOGAS
43

and

An initiative to develop
Posters with comic strips
On high risk topics.
The first goes about taking
The right decision when the
Weather is below minimum.
They are expected in the
Coming months.

44

For Belgium, Accident reports are made public on the SPF/FOD website.
Recent reports (from 1st May 2007) are directly available through
hyperlinks.
Reports are written in English.
Information Notes are also available in order to highlight specific danger
area: Nr 2010 is about engine cold start.
We would like to develop more Notes, for ULM in collaboration with
the Federation.
Historical reports: currently a list is posted.
The list is fairly complete from 1972.
2 ancient reports (1936 and 1965).
The reports (Fr /Nl) are desidentified and available on request.
The list will be completed as we go along in reviewing archives.

45

Thank you for your attention, and
AAIU (Belgium) wishes you
many happy landings

Photos credit:
MRA / KLM

46


Slide 13

10 JULY 1910 - 2010
100 YEARS ULM ACCIDENTS

Belgian ULM Federation – Safety
1
Conference 10/10/2010

The Air Safety Investigation
• As part of the global Aviation sphere, an investigation is
conducted for each accident and serious incident by an
independent enquiry body, aimed to;
– Determine the causes of the accident.
– Determine if all conditions that were defined by rules and
regulations to ensure flight safety were followed (such as risk
factors in design).
– Define recommendations in order to prevent future accidents.

• It is not the purpose of this investigation to apportion
blame or liability.

2

In Belgium; the Air Accident
Investigation Unit.
• All accidents and serious incidents occurring in Belgium,
on aircraft, helicopters, gliders, balloons, ULM, DPM,
regardless of their registration is investigated by a cell
functionnally independent from the BCAA, and all other
interrested parties.
• Independent doesn’t mean isolated; it is part of the world’s
network of the State’s Aviation Investigation Bodies.
• The cell reports to the President of the Board of the
SPF/FOD Mobility and Transport.
3

4

ULM
• First pendular (Delta Plane Motorized)
design in 1966
• First crossing of the Channel in 1978 by Mr
D. Cook.
• Commercial development from 1979.
• Evolution from 2-axis to 3-axis.
• In Belgium, first ULM registered (501) in
1982.

5

6

Evolution
• 1982: Weedhopper, Chickinox
– 80…100 km/h
– Basic – 2/3 axis
– Range: … 200 km…

• 2010: VL-3 Sprint, DynAero MCR01, WT9 Dynamic….
– 220….250 km/h,
– flaps, retractable gear, avionics,
– Range over 1000 km

• 550 OO- registered ULM;
• 571 ULM pilot licence (363 training licences)
• 300-400 foreign-registered ULM.
7

1000
900
800
700
600
500
400
300
200
100

Number of valid registration

8

Estimation of flying OO-regd ULM

20
10

20
08

20
06

20
04

20
02

20
00

19
98

19
96

19
94

19
92

19
90

19
88

19
86

19
84

19
82

0

Evolution in pilot’s / owner’s
expectations
• In 1982, ULM /DPM, a sporting way of flying,
outside the limits of parachuting, delta plane.

• In 2010, an efficient alternative to general
(certified) aviation. ULM becomes a means of
transport.
• Beyond 2010 ?? – The Need for Speed ?
9

Evolution
• From the user’s perspective, the difference between
General Aviation and ULM becomes very thin.
• However, ULMs are characterized by a huge variety of
different design types, with low production rate and
configuration variation between individual airplanes.
– Manufacturers come and go,
– Assembly of the same ULM type by different companies induce
differences in built configuration.

• The above makes it more and more difficult to speak about
ULMs in a general way; variation in quality is wider than
General (certified) Aviation.
10

EVOLUTION: MORE ULM FATAL ACCIDENTS ?

Fatalities: (up to now), In Belgium, on average 2 /year,
comparable to General (certified) Aviation.
Number of fatalities
12
10
8
6
4
2

Number of fatalities

11

20
10

20
08

20
06

20
04

20
02

20
00

19
98

19
96

19
94

19
92

19
90

19
88

19
86

19
84

0

19
82

FATALITIES:
Figures limited to
Belgium.
2009: + 2 in France.
2010: + 5 in France.

WHAT ARE THE EXPECTATIONS
FOR THE
ULM-ACCIDENTS CASUALITY
RATE ?
• On Belgian soil, 4 deads in 2010.
(casuality rate of U.S. Forces in Iraq 3.6 killed /1000
troop / year – 8 years – 152000 troops – 4424 killed).

• In France and Belgium in 2010, 9 Belgian
deads to-date.
12

Comparison with the road
• In Belgium, the road kills 1000 people on average per year
.
• Fleet of vehicles: 6 000 000 units (5 mio cars).
• For 1000 cars, the road kills on average 0.16 person per
year.
• If we combine these figures with the yearly utilization rate
of cars (1 h per day) versus ULM (40 h per year), we can
conclude that ULM / General Aviation flying is
considerably deadlier than the road.

13

What can we learn from accident
investigation ?

14

The investigation process
A long process (Months)
• Collect all factual elements,
–
–
–
–
–
–

The flow of events;
The pilot (training, experience, …)
The aircraft (contact w/manufacturer)
Meteo, Comm, Radar,
Flt recorders (GPS, ECU, camera, …)
Impact, aircraft damage,

• Analysis. (incl. simulation, testing,…)
• Define all possible causes.
• From the causes, define remedial action.
The depth of the investigation is somewhat influenced by the
expected ROI.
15

Accident analysis
• Accidents do not occur “by accident”; Accident are
caused by a series of events.
• There are no “isolated cases”; causes of accidents are often
recurrent.
• Out of the ULM accident data base, we can conclude;
– There are recurrent technical problems specific to ULM.
– The traditional causes of aviation accidents are also known to
ULM (fuel shortage)

– 80% of the causal factors are human-related.

16

Main causal factors (122 accidents –
fixed wing and ULM)
Loss of control Take-off
11%

Fuel Starvation
15%

Loss of control Flight & collision
12%

Technical
11%
Low piloting
experience
8%

Loss of control Landing
16%
Icing
3%

Low flying /
aerobatics obstacles - CFIT
24%

17

Specific problems with ULM
• Technical causes can be (easily) identified;
but fire can be devastating.
• There’s another problem for the
investigator, a lot of landmarks are missing.
– ULM requirements are national,
– Certification not applicable.
– Wide variety of products.
18

About certification.
• Everyone would agree that ULMs of to-day are as good,
even a lot better than the ‘certified’ airplane.
• ULMs are designed to fly.
ULM are quality products; they meet your expectations
(simple to handle, fly fast, cheap in usage, …)
• Certification means that a manufacturer must demonstrate
that his product meets a minimum level of safety, as
defined (ultimately) by the Aviation Community.
• The minimum level of safety is defined in the Certification
Specifications – For small aircraft, it is called CS23.
19

Technical.
• AAIU(be) is currently investigating on:
– Instrument Board lay-out design.
– Electrical System design.
– Emergency Parachute.
Why is it that (for the last cases) parachute did not save lifes ?
• Late decision ?
• Handle easy to grab ?
• Safety pin not removed before flight ?

20

Same ULM Type, instrument panel somewhat different.
Difference in Ergonomy.
Parachute handle – on pilot’s side, or on passenger’s side ?

21

Regulation: certification:
CS 23.671 General
(b) Controls must be arranged and identified
to provide for convenience in operation and
to prevent the possibility of confusion and
subsequent inadvertent operation.

For ULM, CS 23 is not applicable.
Each designer has his own solution, and
they will be challenged only by YOUR
experience.
22

Other example
The passenger door opens in
flight, causing the pilot to take
appropriate actions, that
eventually force him to an
emergency landing.

• Door lock (simple – crude).
Plexy flexible. Once opened in
flight, difficult to close.
CS 23.783
(1) There must be means to lock and safeguard the door against
inadvertent opening during flight by persons, by cargo, or as a
result of mechanical failure.
23

The problem
• Once we determine a technical problem, we
can define recommendations to improve the
product, but:
What do we do with the recommendation ?
– We can not improve the Standard, there’s no standard.
– We can not address more than one manufacturer,
– What about retrofit ?

24

ULM and Engine failures

25

Fly Synthesis Storch
Summer 2009
• After propeller replacement, and subsequent
engine ground tests, the pilot took off for a
flight test.
• He encountered heavy engine vibration, that
forced him to an emergency landing.
• Airplane was slightly damaged.
Cause was identified as Vapor Lock.
26

1/5/2010 – FK9
Emergency landing after in-flight engine failure.
• Lots of corrosion found in carburettor.
Corrosion comes from water condensation in
fuel system (tank, lines, pump,…- MOGAS)
during long immobilisation periods.
- how to prevent ? Filling up, draining ?

• Fuel system was modified in-service, by
addition of a pressure regulator.
27

France
20/5/2010 – Mistral
23/5/2010 – CT Short Wing
Mistral: Engine failure in flight.
Emergency landing in field; terrain was very soft, airplane
severely damaged.
CT Short Wing: In short final, the engine suddenly stops
The pilot attempts to land, but hit trees, and crashes – wings
ripped off.
RH wing tank empty, 15-25 l fuel remaining in LH tank.
During LH turn, fuel system unprimed, engine stopped by
fuel starvation.
28

4 /6/2010: SG Rally
Damaged during landing
• Due to engine problems (heavy vibrations), the
pilot performed emergency landing on EBHN.
Coming in too fast, the landing was brutal, and
Nose Landing Gear collapsed.

29

Conclusion
• Engine in-flight failure are not exceptional.
– Use of MOGAS (water content, flash point,..)
– Local modifications,
– Other specific to the configuration of the
specific airplane.
And..
– Traditional causes (engine starvation,..)
30

Solutions
• In this case, we can design some generic
recommendations:
– Human Factors; ULM pilots should be more
prepared to react to engine failures at any time
(awareness, briefing, training,…)
– Generic technical solutions; impact on the use
of MOGAS.
• Protection of the equipment during winter,
• Risk of Vapour lock.

31

• Designing stop-gaps, accident after accidents
may not be satisfactory;
What can we do we make sure ULM flying
improves up to an acceptable level and, more
important, remains at that level ?

• More Regulation ?

32

Aviation Regulation and the ULM
• No significant changes in Regulation.
– ULM defined by capacity, weight, structural and stall speed limitation.
– => Extensive use of carbon fiber, Flaps, etc

• CS-VLA.
– 750 kg.
– “light” CS-23.
– Expensive.

• Lower Requirements for licencing,
– What about competence ?
– Human Factors training

• National requirements in Europe.
– EASA Flight Permit per Part 21A.701.

33

Evolution: new EU Regulation on
Accident Investigation.
* Every civil aviation accident or serious incident involving
aircraft other than specified in Annex II to the Regulation (EC)
No 216/2008 of the European Parliament and of the Council
shall be the subject of a safety investigation

( = No obligation of enquiry for ULMs)
• Safety investigation authorities may decide to investigate
incidents other than those referred to in paragraph 1 as well as
accidents or serious incidents to other types of aircraft, in
accordance with the national legislation of the Member States,
when they expect to draw safety lessons from them.
34

• US. NTSB; no enquiry for ULM crashes.
• To-day already, in some EU countries, ULM
crash investigations are given a low priority,
unless the Public determines otherwise.
• Common sense dictates that the initiative
to improve safety must come from the
ULM community itself.

35

Reason Model
• aviation is a complex socio-technical
system, where safety is ensured by a
series of defense barriers.
• Each barrier may present flaws (latent
or active) whose combination can lead
to an accident.
• An usafe act (active failure) alone
would not cause an accident.
• Latent failures are more easily
detected and corrected that human
errors, which are (globally) inevitable.

36

• The ULM community should reinforce its
Defense Barriers.
• Organisation: Federation and Clubs.
Create a Safety Climate
- Norms and rules
- Safety Programs

- To define a Safety Climate, we need to
assess the potential risk, and for that we
need data: YOUR experience.
37

Pyramid of Heinrich
• If a fatal accident is caused by
a specific combination of
events, an uncomplete series
of events causes INCIDENTS.
• If we identify all potentially
dangerous events AND with
that information, build-up the
defenses, we can avoid
ACCIDENTS.
38

SHARING EXPERIENCE
• By informing the Federation of the small
events and incidents that spoiled one of
your flights, you allow the Community to
understand the potential dangers and act
upon. (and respect confidentiality)
“Learn from mistakes of others; you won’t
live long enough to make them all by
yourself”
39

Human Factors
• To err is human.
• Human life (and flying) is full of decisions.
• It is therefore more important to know yourself
than to know how to fly your aircraft.
– Get-home-itis, Distraction, Communication,..

• Understanding human factors is a very important
step in improving your defenses.
40

Competence and Readiness
• You hold a pilot licence; but are you a
competent flyer ?
• How will you react when faced with a
potential dangerous situation?
• Assessing your competences with an
instructor is an opportunity to improve.
• When flying, be ready.
41

What is the Authority doing for
you ?

42

A series of work groups
within EASA are thinking
about how to improve
flight safety.(ESSI)
One of them is about General
Aviation (EGAST).

Initiative includes a leaflet
On Collision Avoidance,
and has been relayed to you
by the Federation.
There are technical Work
Groups dealing with MOGAS
43

and

An initiative to develop
Posters with comic strips
On high risk topics.
The first goes about taking
The right decision when the
Weather is below minimum.
They are expected in the
Coming months.

44

For Belgium, Accident reports are made public on the SPF/FOD website.
Recent reports (from 1st May 2007) are directly available through
hyperlinks.
Reports are written in English.
Information Notes are also available in order to highlight specific danger
area: Nr 2010 is about engine cold start.
We would like to develop more Notes, for ULM in collaboration with
the Federation.
Historical reports: currently a list is posted.
The list is fairly complete from 1972.
2 ancient reports (1936 and 1965).
The reports (Fr /Nl) are desidentified and available on request.
The list will be completed as we go along in reviewing archives.

45

Thank you for your attention, and
AAIU (Belgium) wishes you
many happy landings

Photos credit:
MRA / KLM

46


Slide 14

10 JULY 1910 - 2010
100 YEARS ULM ACCIDENTS

Belgian ULM Federation – Safety
1
Conference 10/10/2010

The Air Safety Investigation
• As part of the global Aviation sphere, an investigation is
conducted for each accident and serious incident by an
independent enquiry body, aimed to;
– Determine the causes of the accident.
– Determine if all conditions that were defined by rules and
regulations to ensure flight safety were followed (such as risk
factors in design).
– Define recommendations in order to prevent future accidents.

• It is not the purpose of this investigation to apportion
blame or liability.

2

In Belgium; the Air Accident
Investigation Unit.
• All accidents and serious incidents occurring in Belgium,
on aircraft, helicopters, gliders, balloons, ULM, DPM,
regardless of their registration is investigated by a cell
functionnally independent from the BCAA, and all other
interrested parties.
• Independent doesn’t mean isolated; it is part of the world’s
network of the State’s Aviation Investigation Bodies.
• The cell reports to the President of the Board of the
SPF/FOD Mobility and Transport.
3

4

ULM
• First pendular (Delta Plane Motorized)
design in 1966
• First crossing of the Channel in 1978 by Mr
D. Cook.
• Commercial development from 1979.
• Evolution from 2-axis to 3-axis.
• In Belgium, first ULM registered (501) in
1982.

5

6

Evolution
• 1982: Weedhopper, Chickinox
– 80…100 km/h
– Basic – 2/3 axis
– Range: … 200 km…

• 2010: VL-3 Sprint, DynAero MCR01, WT9 Dynamic….
– 220….250 km/h,
– flaps, retractable gear, avionics,
– Range over 1000 km

• 550 OO- registered ULM;
• 571 ULM pilot licence (363 training licences)
• 300-400 foreign-registered ULM.
7

1000
900
800
700
600
500
400
300
200
100

Number of valid registration

8

Estimation of flying OO-regd ULM

20
10

20
08

20
06

20
04

20
02

20
00

19
98

19
96

19
94

19
92

19
90

19
88

19
86

19
84

19
82

0

Evolution in pilot’s / owner’s
expectations
• In 1982, ULM /DPM, a sporting way of flying,
outside the limits of parachuting, delta plane.

• In 2010, an efficient alternative to general
(certified) aviation. ULM becomes a means of
transport.
• Beyond 2010 ?? – The Need for Speed ?
9

Evolution
• From the user’s perspective, the difference between
General Aviation and ULM becomes very thin.
• However, ULMs are characterized by a huge variety of
different design types, with low production rate and
configuration variation between individual airplanes.
– Manufacturers come and go,
– Assembly of the same ULM type by different companies induce
differences in built configuration.

• The above makes it more and more difficult to speak about
ULMs in a general way; variation in quality is wider than
General (certified) Aviation.
10

EVOLUTION: MORE ULM FATAL ACCIDENTS ?

Fatalities: (up to now), In Belgium, on average 2 /year,
comparable to General (certified) Aviation.
Number of fatalities
12
10
8
6
4
2

Number of fatalities

11

20
10

20
08

20
06

20
04

20
02

20
00

19
98

19
96

19
94

19
92

19
90

19
88

19
86

19
84

0

19
82

FATALITIES:
Figures limited to
Belgium.
2009: + 2 in France.
2010: + 5 in France.

WHAT ARE THE EXPECTATIONS
FOR THE
ULM-ACCIDENTS CASUALITY
RATE ?
• On Belgian soil, 4 deads in 2010.
(casuality rate of U.S. Forces in Iraq 3.6 killed /1000
troop / year – 8 years – 152000 troops – 4424 killed).

• In France and Belgium in 2010, 9 Belgian
deads to-date.
12

Comparison with the road
• In Belgium, the road kills 1000 people on average per year
.
• Fleet of vehicles: 6 000 000 units (5 mio cars).
• For 1000 cars, the road kills on average 0.16 person per
year.
• If we combine these figures with the yearly utilization rate
of cars (1 h per day) versus ULM (40 h per year), we can
conclude that ULM / General Aviation flying is
considerably deadlier than the road.

13

What can we learn from accident
investigation ?

14

The investigation process
A long process (Months)
• Collect all factual elements,
–
–
–
–
–
–

The flow of events;
The pilot (training, experience, …)
The aircraft (contact w/manufacturer)
Meteo, Comm, Radar,
Flt recorders (GPS, ECU, camera, …)
Impact, aircraft damage,

• Analysis. (incl. simulation, testing,…)
• Define all possible causes.
• From the causes, define remedial action.
The depth of the investigation is somewhat influenced by the
expected ROI.
15

Accident analysis
• Accidents do not occur “by accident”; Accident are
caused by a series of events.
• There are no “isolated cases”; causes of accidents are often
recurrent.
• Out of the ULM accident data base, we can conclude;
– There are recurrent technical problems specific to ULM.
– The traditional causes of aviation accidents are also known to
ULM (fuel shortage)

– 80% of the causal factors are human-related.

16

Main causal factors (122 accidents –
fixed wing and ULM)
Loss of control Take-off
11%

Fuel Starvation
15%

Loss of control Flight & collision
12%

Technical
11%
Low piloting
experience
8%

Loss of control Landing
16%
Icing
3%

Low flying /
aerobatics obstacles - CFIT
24%

17

Specific problems with ULM
• Technical causes can be (easily) identified;
but fire can be devastating.
• There’s another problem for the
investigator, a lot of landmarks are missing.
– ULM requirements are national,
– Certification not applicable.
– Wide variety of products.
18

About certification.
• Everyone would agree that ULMs of to-day are as good,
even a lot better than the ‘certified’ airplane.
• ULMs are designed to fly.
ULM are quality products; they meet your expectations
(simple to handle, fly fast, cheap in usage, …)
• Certification means that a manufacturer must demonstrate
that his product meets a minimum level of safety, as
defined (ultimately) by the Aviation Community.
• The minimum level of safety is defined in the Certification
Specifications – For small aircraft, it is called CS23.
19

Technical.
• AAIU(be) is currently investigating on:
– Instrument Board lay-out design.
– Electrical System design.
– Emergency Parachute.
Why is it that (for the last cases) parachute did not save lifes ?
• Late decision ?
• Handle easy to grab ?
• Safety pin not removed before flight ?

20

Same ULM Type, instrument panel somewhat different.
Difference in Ergonomy.
Parachute handle – on pilot’s side, or on passenger’s side ?

21

Regulation: certification:
CS 23.671 General
(b) Controls must be arranged and identified
to provide for convenience in operation and
to prevent the possibility of confusion and
subsequent inadvertent operation.

For ULM, CS 23 is not applicable.
Each designer has his own solution, and
they will be challenged only by YOUR
experience.
22

Other example
The passenger door opens in
flight, causing the pilot to take
appropriate actions, that
eventually force him to an
emergency landing.

• Door lock (simple – crude).
Plexy flexible. Once opened in
flight, difficult to close.
CS 23.783
(1) There must be means to lock and safeguard the door against
inadvertent opening during flight by persons, by cargo, or as a
result of mechanical failure.
23

The problem
• Once we determine a technical problem, we
can define recommendations to improve the
product, but:
What do we do with the recommendation ?
– We can not improve the Standard, there’s no standard.
– We can not address more than one manufacturer,
– What about retrofit ?

24

ULM and Engine failures

25

Fly Synthesis Storch
Summer 2009
• After propeller replacement, and subsequent
engine ground tests, the pilot took off for a
flight test.
• He encountered heavy engine vibration, that
forced him to an emergency landing.
• Airplane was slightly damaged.
Cause was identified as Vapor Lock.
26

1/5/2010 – FK9
Emergency landing after in-flight engine failure.
• Lots of corrosion found in carburettor.
Corrosion comes from water condensation in
fuel system (tank, lines, pump,…- MOGAS)
during long immobilisation periods.
- how to prevent ? Filling up, draining ?

• Fuel system was modified in-service, by
addition of a pressure regulator.
27

France
20/5/2010 – Mistral
23/5/2010 – CT Short Wing
Mistral: Engine failure in flight.
Emergency landing in field; terrain was very soft, airplane
severely damaged.
CT Short Wing: In short final, the engine suddenly stops
The pilot attempts to land, but hit trees, and crashes – wings
ripped off.
RH wing tank empty, 15-25 l fuel remaining in LH tank.
During LH turn, fuel system unprimed, engine stopped by
fuel starvation.
28

4 /6/2010: SG Rally
Damaged during landing
• Due to engine problems (heavy vibrations), the
pilot performed emergency landing on EBHN.
Coming in too fast, the landing was brutal, and
Nose Landing Gear collapsed.

29

Conclusion
• Engine in-flight failure are not exceptional.
– Use of MOGAS (water content, flash point,..)
– Local modifications,
– Other specific to the configuration of the
specific airplane.
And..
– Traditional causes (engine starvation,..)
30

Solutions
• In this case, we can design some generic
recommendations:
– Human Factors; ULM pilots should be more
prepared to react to engine failures at any time
(awareness, briefing, training,…)
– Generic technical solutions; impact on the use
of MOGAS.
• Protection of the equipment during winter,
• Risk of Vapour lock.

31

• Designing stop-gaps, accident after accidents
may not be satisfactory;
What can we do we make sure ULM flying
improves up to an acceptable level and, more
important, remains at that level ?

• More Regulation ?

32

Aviation Regulation and the ULM
• No significant changes in Regulation.
– ULM defined by capacity, weight, structural and stall speed limitation.
– => Extensive use of carbon fiber, Flaps, etc

• CS-VLA.
– 750 kg.
– “light” CS-23.
– Expensive.

• Lower Requirements for licencing,
– What about competence ?
– Human Factors training

• National requirements in Europe.
– EASA Flight Permit per Part 21A.701.

33

Evolution: new EU Regulation on
Accident Investigation.
* Every civil aviation accident or serious incident involving
aircraft other than specified in Annex II to the Regulation (EC)
No 216/2008 of the European Parliament and of the Council
shall be the subject of a safety investigation

( = No obligation of enquiry for ULMs)
• Safety investigation authorities may decide to investigate
incidents other than those referred to in paragraph 1 as well as
accidents or serious incidents to other types of aircraft, in
accordance with the national legislation of the Member States,
when they expect to draw safety lessons from them.
34

• US. NTSB; no enquiry for ULM crashes.
• To-day already, in some EU countries, ULM
crash investigations are given a low priority,
unless the Public determines otherwise.
• Common sense dictates that the initiative
to improve safety must come from the
ULM community itself.

35

Reason Model
• aviation is a complex socio-technical
system, where safety is ensured by a
series of defense barriers.
• Each barrier may present flaws (latent
or active) whose combination can lead
to an accident.
• An usafe act (active failure) alone
would not cause an accident.
• Latent failures are more easily
detected and corrected that human
errors, which are (globally) inevitable.

36

• The ULM community should reinforce its
Defense Barriers.
• Organisation: Federation and Clubs.
Create a Safety Climate
- Norms and rules
- Safety Programs

- To define a Safety Climate, we need to
assess the potential risk, and for that we
need data: YOUR experience.
37

Pyramid of Heinrich
• If a fatal accident is caused by
a specific combination of
events, an uncomplete series
of events causes INCIDENTS.
• If we identify all potentially
dangerous events AND with
that information, build-up the
defenses, we can avoid
ACCIDENTS.
38

SHARING EXPERIENCE
• By informing the Federation of the small
events and incidents that spoiled one of
your flights, you allow the Community to
understand the potential dangers and act
upon. (and respect confidentiality)
“Learn from mistakes of others; you won’t
live long enough to make them all by
yourself”
39

Human Factors
• To err is human.
• Human life (and flying) is full of decisions.
• It is therefore more important to know yourself
than to know how to fly your aircraft.
– Get-home-itis, Distraction, Communication,..

• Understanding human factors is a very important
step in improving your defenses.
40

Competence and Readiness
• You hold a pilot licence; but are you a
competent flyer ?
• How will you react when faced with a
potential dangerous situation?
• Assessing your competences with an
instructor is an opportunity to improve.
• When flying, be ready.
41

What is the Authority doing for
you ?

42

A series of work groups
within EASA are thinking
about how to improve
flight safety.(ESSI)
One of them is about General
Aviation (EGAST).

Initiative includes a leaflet
On Collision Avoidance,
and has been relayed to you
by the Federation.
There are technical Work
Groups dealing with MOGAS
43

and

An initiative to develop
Posters with comic strips
On high risk topics.
The first goes about taking
The right decision when the
Weather is below minimum.
They are expected in the
Coming months.

44

For Belgium, Accident reports are made public on the SPF/FOD website.
Recent reports (from 1st May 2007) are directly available through
hyperlinks.
Reports are written in English.
Information Notes are also available in order to highlight specific danger
area: Nr 2010 is about engine cold start.
We would like to develop more Notes, for ULM in collaboration with
the Federation.
Historical reports: currently a list is posted.
The list is fairly complete from 1972.
2 ancient reports (1936 and 1965).
The reports (Fr /Nl) are desidentified and available on request.
The list will be completed as we go along in reviewing archives.

45

Thank you for your attention, and
AAIU (Belgium) wishes you
many happy landings

Photos credit:
MRA / KLM

46


Slide 15

10 JULY 1910 - 2010
100 YEARS ULM ACCIDENTS

Belgian ULM Federation – Safety
1
Conference 10/10/2010

The Air Safety Investigation
• As part of the global Aviation sphere, an investigation is
conducted for each accident and serious incident by an
independent enquiry body, aimed to;
– Determine the causes of the accident.
– Determine if all conditions that were defined by rules and
regulations to ensure flight safety were followed (such as risk
factors in design).
– Define recommendations in order to prevent future accidents.

• It is not the purpose of this investigation to apportion
blame or liability.

2

In Belgium; the Air Accident
Investigation Unit.
• All accidents and serious incidents occurring in Belgium,
on aircraft, helicopters, gliders, balloons, ULM, DPM,
regardless of their registration is investigated by a cell
functionnally independent from the BCAA, and all other
interrested parties.
• Independent doesn’t mean isolated; it is part of the world’s
network of the State’s Aviation Investigation Bodies.
• The cell reports to the President of the Board of the
SPF/FOD Mobility and Transport.
3

4

ULM
• First pendular (Delta Plane Motorized)
design in 1966
• First crossing of the Channel in 1978 by Mr
D. Cook.
• Commercial development from 1979.
• Evolution from 2-axis to 3-axis.
• In Belgium, first ULM registered (501) in
1982.

5

6

Evolution
• 1982: Weedhopper, Chickinox
– 80…100 km/h
– Basic – 2/3 axis
– Range: … 200 km…

• 2010: VL-3 Sprint, DynAero MCR01, WT9 Dynamic….
– 220….250 km/h,
– flaps, retractable gear, avionics,
– Range over 1000 km

• 550 OO- registered ULM;
• 571 ULM pilot licence (363 training licences)
• 300-400 foreign-registered ULM.
7

1000
900
800
700
600
500
400
300
200
100

Number of valid registration

8

Estimation of flying OO-regd ULM

20
10

20
08

20
06

20
04

20
02

20
00

19
98

19
96

19
94

19
92

19
90

19
88

19
86

19
84

19
82

0

Evolution in pilot’s / owner’s
expectations
• In 1982, ULM /DPM, a sporting way of flying,
outside the limits of parachuting, delta plane.

• In 2010, an efficient alternative to general
(certified) aviation. ULM becomes a means of
transport.
• Beyond 2010 ?? – The Need for Speed ?
9

Evolution
• From the user’s perspective, the difference between
General Aviation and ULM becomes very thin.
• However, ULMs are characterized by a huge variety of
different design types, with low production rate and
configuration variation between individual airplanes.
– Manufacturers come and go,
– Assembly of the same ULM type by different companies induce
differences in built configuration.

• The above makes it more and more difficult to speak about
ULMs in a general way; variation in quality is wider than
General (certified) Aviation.
10

EVOLUTION: MORE ULM FATAL ACCIDENTS ?

Fatalities: (up to now), In Belgium, on average 2 /year,
comparable to General (certified) Aviation.
Number of fatalities
12
10
8
6
4
2

Number of fatalities

11

20
10

20
08

20
06

20
04

20
02

20
00

19
98

19
96

19
94

19
92

19
90

19
88

19
86

19
84

0

19
82

FATALITIES:
Figures limited to
Belgium.
2009: + 2 in France.
2010: + 5 in France.

WHAT ARE THE EXPECTATIONS
FOR THE
ULM-ACCIDENTS CASUALITY
RATE ?
• On Belgian soil, 4 deads in 2010.
(casuality rate of U.S. Forces in Iraq 3.6 killed /1000
troop / year – 8 years – 152000 troops – 4424 killed).

• In France and Belgium in 2010, 9 Belgian
deads to-date.
12

Comparison with the road
• In Belgium, the road kills 1000 people on average per year
.
• Fleet of vehicles: 6 000 000 units (5 mio cars).
• For 1000 cars, the road kills on average 0.16 person per
year.
• If we combine these figures with the yearly utilization rate
of cars (1 h per day) versus ULM (40 h per year), we can
conclude that ULM / General Aviation flying is
considerably deadlier than the road.

13

What can we learn from accident
investigation ?

14

The investigation process
A long process (Months)
• Collect all factual elements,
–
–
–
–
–
–

The flow of events;
The pilot (training, experience, …)
The aircraft (contact w/manufacturer)
Meteo, Comm, Radar,
Flt recorders (GPS, ECU, camera, …)
Impact, aircraft damage,

• Analysis. (incl. simulation, testing,…)
• Define all possible causes.
• From the causes, define remedial action.
The depth of the investigation is somewhat influenced by the
expected ROI.
15

Accident analysis
• Accidents do not occur “by accident”; Accident are
caused by a series of events.
• There are no “isolated cases”; causes of accidents are often
recurrent.
• Out of the ULM accident data base, we can conclude;
– There are recurrent technical problems specific to ULM.
– The traditional causes of aviation accidents are also known to
ULM (fuel shortage)

– 80% of the causal factors are human-related.

16

Main causal factors (122 accidents –
fixed wing and ULM)
Loss of control Take-off
11%

Fuel Starvation
15%

Loss of control Flight & collision
12%

Technical
11%
Low piloting
experience
8%

Loss of control Landing
16%
Icing
3%

Low flying /
aerobatics obstacles - CFIT
24%

17

Specific problems with ULM
• Technical causes can be (easily) identified;
but fire can be devastating.
• There’s another problem for the
investigator, a lot of landmarks are missing.
– ULM requirements are national,
– Certification not applicable.
– Wide variety of products.
18

About certification.
• Everyone would agree that ULMs of to-day are as good,
even a lot better than the ‘certified’ airplane.
• ULMs are designed to fly.
ULM are quality products; they meet your expectations
(simple to handle, fly fast, cheap in usage, …)
• Certification means that a manufacturer must demonstrate
that his product meets a minimum level of safety, as
defined (ultimately) by the Aviation Community.
• The minimum level of safety is defined in the Certification
Specifications – For small aircraft, it is called CS23.
19

Technical.
• AAIU(be) is currently investigating on:
– Instrument Board lay-out design.
– Electrical System design.
– Emergency Parachute.
Why is it that (for the last cases) parachute did not save lifes ?
• Late decision ?
• Handle easy to grab ?
• Safety pin not removed before flight ?

20

Same ULM Type, instrument panel somewhat different.
Difference in Ergonomy.
Parachute handle – on pilot’s side, or on passenger’s side ?

21

Regulation: certification:
CS 23.671 General
(b) Controls must be arranged and identified
to provide for convenience in operation and
to prevent the possibility of confusion and
subsequent inadvertent operation.

For ULM, CS 23 is not applicable.
Each designer has his own solution, and
they will be challenged only by YOUR
experience.
22

Other example
The passenger door opens in
flight, causing the pilot to take
appropriate actions, that
eventually force him to an
emergency landing.

• Door lock (simple – crude).
Plexy flexible. Once opened in
flight, difficult to close.
CS 23.783
(1) There must be means to lock and safeguard the door against
inadvertent opening during flight by persons, by cargo, or as a
result of mechanical failure.
23

The problem
• Once we determine a technical problem, we
can define recommendations to improve the
product, but:
What do we do with the recommendation ?
– We can not improve the Standard, there’s no standard.
– We can not address more than one manufacturer,
– What about retrofit ?

24

ULM and Engine failures

25

Fly Synthesis Storch
Summer 2009
• After propeller replacement, and subsequent
engine ground tests, the pilot took off for a
flight test.
• He encountered heavy engine vibration, that
forced him to an emergency landing.
• Airplane was slightly damaged.
Cause was identified as Vapor Lock.
26

1/5/2010 – FK9
Emergency landing after in-flight engine failure.
• Lots of corrosion found in carburettor.
Corrosion comes from water condensation in
fuel system (tank, lines, pump,…- MOGAS)
during long immobilisation periods.
- how to prevent ? Filling up, draining ?

• Fuel system was modified in-service, by
addition of a pressure regulator.
27

France
20/5/2010 – Mistral
23/5/2010 – CT Short Wing
Mistral: Engine failure in flight.
Emergency landing in field; terrain was very soft, airplane
severely damaged.
CT Short Wing: In short final, the engine suddenly stops
The pilot attempts to land, but hit trees, and crashes – wings
ripped off.
RH wing tank empty, 15-25 l fuel remaining in LH tank.
During LH turn, fuel system unprimed, engine stopped by
fuel starvation.
28

4 /6/2010: SG Rally
Damaged during landing
• Due to engine problems (heavy vibrations), the
pilot performed emergency landing on EBHN.
Coming in too fast, the landing was brutal, and
Nose Landing Gear collapsed.

29

Conclusion
• Engine in-flight failure are not exceptional.
– Use of MOGAS (water content, flash point,..)
– Local modifications,
– Other specific to the configuration of the
specific airplane.
And..
– Traditional causes (engine starvation,..)
30

Solutions
• In this case, we can design some generic
recommendations:
– Human Factors; ULM pilots should be more
prepared to react to engine failures at any time
(awareness, briefing, training,…)
– Generic technical solutions; impact on the use
of MOGAS.
• Protection of the equipment during winter,
• Risk of Vapour lock.

31

• Designing stop-gaps, accident after accidents
may not be satisfactory;
What can we do we make sure ULM flying
improves up to an acceptable level and, more
important, remains at that level ?

• More Regulation ?

32

Aviation Regulation and the ULM
• No significant changes in Regulation.
– ULM defined by capacity, weight, structural and stall speed limitation.
– => Extensive use of carbon fiber, Flaps, etc

• CS-VLA.
– 750 kg.
– “light” CS-23.
– Expensive.

• Lower Requirements for licencing,
– What about competence ?
– Human Factors training

• National requirements in Europe.
– EASA Flight Permit per Part 21A.701.

33

Evolution: new EU Regulation on
Accident Investigation.
* Every civil aviation accident or serious incident involving
aircraft other than specified in Annex II to the Regulation (EC)
No 216/2008 of the European Parliament and of the Council
shall be the subject of a safety investigation

( = No obligation of enquiry for ULMs)
• Safety investigation authorities may decide to investigate
incidents other than those referred to in paragraph 1 as well as
accidents or serious incidents to other types of aircraft, in
accordance with the national legislation of the Member States,
when they expect to draw safety lessons from them.
34

• US. NTSB; no enquiry for ULM crashes.
• To-day already, in some EU countries, ULM
crash investigations are given a low priority,
unless the Public determines otherwise.
• Common sense dictates that the initiative
to improve safety must come from the
ULM community itself.

35

Reason Model
• aviation is a complex socio-technical
system, where safety is ensured by a
series of defense barriers.
• Each barrier may present flaws (latent
or active) whose combination can lead
to an accident.
• An usafe act (active failure) alone
would not cause an accident.
• Latent failures are more easily
detected and corrected that human
errors, which are (globally) inevitable.

36

• The ULM community should reinforce its
Defense Barriers.
• Organisation: Federation and Clubs.
Create a Safety Climate
- Norms and rules
- Safety Programs

- To define a Safety Climate, we need to
assess the potential risk, and for that we
need data: YOUR experience.
37

Pyramid of Heinrich
• If a fatal accident is caused by
a specific combination of
events, an uncomplete series
of events causes INCIDENTS.
• If we identify all potentially
dangerous events AND with
that information, build-up the
defenses, we can avoid
ACCIDENTS.
38

SHARING EXPERIENCE
• By informing the Federation of the small
events and incidents that spoiled one of
your flights, you allow the Community to
understand the potential dangers and act
upon. (and respect confidentiality)
“Learn from mistakes of others; you won’t
live long enough to make them all by
yourself”
39

Human Factors
• To err is human.
• Human life (and flying) is full of decisions.
• It is therefore more important to know yourself
than to know how to fly your aircraft.
– Get-home-itis, Distraction, Communication,..

• Understanding human factors is a very important
step in improving your defenses.
40

Competence and Readiness
• You hold a pilot licence; but are you a
competent flyer ?
• How will you react when faced with a
potential dangerous situation?
• Assessing your competences with an
instructor is an opportunity to improve.
• When flying, be ready.
41

What is the Authority doing for
you ?

42

A series of work groups
within EASA are thinking
about how to improve
flight safety.(ESSI)
One of them is about General
Aviation (EGAST).

Initiative includes a leaflet
On Collision Avoidance,
and has been relayed to you
by the Federation.
There are technical Work
Groups dealing with MOGAS
43

and

An initiative to develop
Posters with comic strips
On high risk topics.
The first goes about taking
The right decision when the
Weather is below minimum.
They are expected in the
Coming months.

44

For Belgium, Accident reports are made public on the SPF/FOD website.
Recent reports (from 1st May 2007) are directly available through
hyperlinks.
Reports are written in English.
Information Notes are also available in order to highlight specific danger
area: Nr 2010 is about engine cold start.
We would like to develop more Notes, for ULM in collaboration with
the Federation.
Historical reports: currently a list is posted.
The list is fairly complete from 1972.
2 ancient reports (1936 and 1965).
The reports (Fr /Nl) are desidentified and available on request.
The list will be completed as we go along in reviewing archives.

45

Thank you for your attention, and
AAIU (Belgium) wishes you
many happy landings

Photos credit:
MRA / KLM

46


Slide 16

10 JULY 1910 - 2010
100 YEARS ULM ACCIDENTS

Belgian ULM Federation – Safety
1
Conference 10/10/2010

The Air Safety Investigation
• As part of the global Aviation sphere, an investigation is
conducted for each accident and serious incident by an
independent enquiry body, aimed to;
– Determine the causes of the accident.
– Determine if all conditions that were defined by rules and
regulations to ensure flight safety were followed (such as risk
factors in design).
– Define recommendations in order to prevent future accidents.

• It is not the purpose of this investigation to apportion
blame or liability.

2

In Belgium; the Air Accident
Investigation Unit.
• All accidents and serious incidents occurring in Belgium,
on aircraft, helicopters, gliders, balloons, ULM, DPM,
regardless of their registration is investigated by a cell
functionnally independent from the BCAA, and all other
interrested parties.
• Independent doesn’t mean isolated; it is part of the world’s
network of the State’s Aviation Investigation Bodies.
• The cell reports to the President of the Board of the
SPF/FOD Mobility and Transport.
3

4

ULM
• First pendular (Delta Plane Motorized)
design in 1966
• First crossing of the Channel in 1978 by Mr
D. Cook.
• Commercial development from 1979.
• Evolution from 2-axis to 3-axis.
• In Belgium, first ULM registered (501) in
1982.

5

6

Evolution
• 1982: Weedhopper, Chickinox
– 80…100 km/h
– Basic – 2/3 axis
– Range: … 200 km…

• 2010: VL-3 Sprint, DynAero MCR01, WT9 Dynamic….
– 220….250 km/h,
– flaps, retractable gear, avionics,
– Range over 1000 km

• 550 OO- registered ULM;
• 571 ULM pilot licence (363 training licences)
• 300-400 foreign-registered ULM.
7

1000
900
800
700
600
500
400
300
200
100

Number of valid registration

8

Estimation of flying OO-regd ULM

20
10

20
08

20
06

20
04

20
02

20
00

19
98

19
96

19
94

19
92

19
90

19
88

19
86

19
84

19
82

0

Evolution in pilot’s / owner’s
expectations
• In 1982, ULM /DPM, a sporting way of flying,
outside the limits of parachuting, delta plane.

• In 2010, an efficient alternative to general
(certified) aviation. ULM becomes a means of
transport.
• Beyond 2010 ?? – The Need for Speed ?
9

Evolution
• From the user’s perspective, the difference between
General Aviation and ULM becomes very thin.
• However, ULMs are characterized by a huge variety of
different design types, with low production rate and
configuration variation between individual airplanes.
– Manufacturers come and go,
– Assembly of the same ULM type by different companies induce
differences in built configuration.

• The above makes it more and more difficult to speak about
ULMs in a general way; variation in quality is wider than
General (certified) Aviation.
10

EVOLUTION: MORE ULM FATAL ACCIDENTS ?

Fatalities: (up to now), In Belgium, on average 2 /year,
comparable to General (certified) Aviation.
Number of fatalities
12
10
8
6
4
2

Number of fatalities

11

20
10

20
08

20
06

20
04

20
02

20
00

19
98

19
96

19
94

19
92

19
90

19
88

19
86

19
84

0

19
82

FATALITIES:
Figures limited to
Belgium.
2009: + 2 in France.
2010: + 5 in France.

WHAT ARE THE EXPECTATIONS
FOR THE
ULM-ACCIDENTS CASUALITY
RATE ?
• On Belgian soil, 4 deads in 2010.
(casuality rate of U.S. Forces in Iraq 3.6 killed /1000
troop / year – 8 years – 152000 troops – 4424 killed).

• In France and Belgium in 2010, 9 Belgian
deads to-date.
12

Comparison with the road
• In Belgium, the road kills 1000 people on average per year
.
• Fleet of vehicles: 6 000 000 units (5 mio cars).
• For 1000 cars, the road kills on average 0.16 person per
year.
• If we combine these figures with the yearly utilization rate
of cars (1 h per day) versus ULM (40 h per year), we can
conclude that ULM / General Aviation flying is
considerably deadlier than the road.

13

What can we learn from accident
investigation ?

14

The investigation process
A long process (Months)
• Collect all factual elements,
–
–
–
–
–
–

The flow of events;
The pilot (training, experience, …)
The aircraft (contact w/manufacturer)
Meteo, Comm, Radar,
Flt recorders (GPS, ECU, camera, …)
Impact, aircraft damage,

• Analysis. (incl. simulation, testing,…)
• Define all possible causes.
• From the causes, define remedial action.
The depth of the investigation is somewhat influenced by the
expected ROI.
15

Accident analysis
• Accidents do not occur “by accident”; Accident are
caused by a series of events.
• There are no “isolated cases”; causes of accidents are often
recurrent.
• Out of the ULM accident data base, we can conclude;
– There are recurrent technical problems specific to ULM.
– The traditional causes of aviation accidents are also known to
ULM (fuel shortage)

– 80% of the causal factors are human-related.

16

Main causal factors (122 accidents –
fixed wing and ULM)
Loss of control Take-off
11%

Fuel Starvation
15%

Loss of control Flight & collision
12%

Technical
11%
Low piloting
experience
8%

Loss of control Landing
16%
Icing
3%

Low flying /
aerobatics obstacles - CFIT
24%

17

Specific problems with ULM
• Technical causes can be (easily) identified;
but fire can be devastating.
• There’s another problem for the
investigator, a lot of landmarks are missing.
– ULM requirements are national,
– Certification not applicable.
– Wide variety of products.
18

About certification.
• Everyone would agree that ULMs of to-day are as good,
even a lot better than the ‘certified’ airplane.
• ULMs are designed to fly.
ULM are quality products; they meet your expectations
(simple to handle, fly fast, cheap in usage, …)
• Certification means that a manufacturer must demonstrate
that his product meets a minimum level of safety, as
defined (ultimately) by the Aviation Community.
• The minimum level of safety is defined in the Certification
Specifications – For small aircraft, it is called CS23.
19

Technical.
• AAIU(be) is currently investigating on:
– Instrument Board lay-out design.
– Electrical System design.
– Emergency Parachute.
Why is it that (for the last cases) parachute did not save lifes ?
• Late decision ?
• Handle easy to grab ?
• Safety pin not removed before flight ?

20

Same ULM Type, instrument panel somewhat different.
Difference in Ergonomy.
Parachute handle – on pilot’s side, or on passenger’s side ?

21

Regulation: certification:
CS 23.671 General
(b) Controls must be arranged and identified
to provide for convenience in operation and
to prevent the possibility of confusion and
subsequent inadvertent operation.

For ULM, CS 23 is not applicable.
Each designer has his own solution, and
they will be challenged only by YOUR
experience.
22

Other example
The passenger door opens in
flight, causing the pilot to take
appropriate actions, that
eventually force him to an
emergency landing.

• Door lock (simple – crude).
Plexy flexible. Once opened in
flight, difficult to close.
CS 23.783
(1) There must be means to lock and safeguard the door against
inadvertent opening during flight by persons, by cargo, or as a
result of mechanical failure.
23

The problem
• Once we determine a technical problem, we
can define recommendations to improve the
product, but:
What do we do with the recommendation ?
– We can not improve the Standard, there’s no standard.
– We can not address more than one manufacturer,
– What about retrofit ?

24

ULM and Engine failures

25

Fly Synthesis Storch
Summer 2009
• After propeller replacement, and subsequent
engine ground tests, the pilot took off for a
flight test.
• He encountered heavy engine vibration, that
forced him to an emergency landing.
• Airplane was slightly damaged.
Cause was identified as Vapor Lock.
26

1/5/2010 – FK9
Emergency landing after in-flight engine failure.
• Lots of corrosion found in carburettor.
Corrosion comes from water condensation in
fuel system (tank, lines, pump,…- MOGAS)
during long immobilisation periods.
- how to prevent ? Filling up, draining ?

• Fuel system was modified in-service, by
addition of a pressure regulator.
27

France
20/5/2010 – Mistral
23/5/2010 – CT Short Wing
Mistral: Engine failure in flight.
Emergency landing in field; terrain was very soft, airplane
severely damaged.
CT Short Wing: In short final, the engine suddenly stops
The pilot attempts to land, but hit trees, and crashes – wings
ripped off.
RH wing tank empty, 15-25 l fuel remaining in LH tank.
During LH turn, fuel system unprimed, engine stopped by
fuel starvation.
28

4 /6/2010: SG Rally
Damaged during landing
• Due to engine problems (heavy vibrations), the
pilot performed emergency landing on EBHN.
Coming in too fast, the landing was brutal, and
Nose Landing Gear collapsed.

29

Conclusion
• Engine in-flight failure are not exceptional.
– Use of MOGAS (water content, flash point,..)
– Local modifications,
– Other specific to the configuration of the
specific airplane.
And..
– Traditional causes (engine starvation,..)
30

Solutions
• In this case, we can design some generic
recommendations:
– Human Factors; ULM pilots should be more
prepared to react to engine failures at any time
(awareness, briefing, training,…)
– Generic technical solutions; impact on the use
of MOGAS.
• Protection of the equipment during winter,
• Risk of Vapour lock.

31

• Designing stop-gaps, accident after accidents
may not be satisfactory;
What can we do we make sure ULM flying
improves up to an acceptable level and, more
important, remains at that level ?

• More Regulation ?

32

Aviation Regulation and the ULM
• No significant changes in Regulation.
– ULM defined by capacity, weight, structural and stall speed limitation.
– => Extensive use of carbon fiber, Flaps, etc

• CS-VLA.
– 750 kg.
– “light” CS-23.
– Expensive.

• Lower Requirements for licencing,
– What about competence ?
– Human Factors training

• National requirements in Europe.
– EASA Flight Permit per Part 21A.701.

33

Evolution: new EU Regulation on
Accident Investigation.
* Every civil aviation accident or serious incident involving
aircraft other than specified in Annex II to the Regulation (EC)
No 216/2008 of the European Parliament and of the Council
shall be the subject of a safety investigation

( = No obligation of enquiry for ULMs)
• Safety investigation authorities may decide to investigate
incidents other than those referred to in paragraph 1 as well as
accidents or serious incidents to other types of aircraft, in
accordance with the national legislation of the Member States,
when they expect to draw safety lessons from them.
34

• US. NTSB; no enquiry for ULM crashes.
• To-day already, in some EU countries, ULM
crash investigations are given a low priority,
unless the Public determines otherwise.
• Common sense dictates that the initiative
to improve safety must come from the
ULM community itself.

35

Reason Model
• aviation is a complex socio-technical
system, where safety is ensured by a
series of defense barriers.
• Each barrier may present flaws (latent
or active) whose combination can lead
to an accident.
• An usafe act (active failure) alone
would not cause an accident.
• Latent failures are more easily
detected and corrected that human
errors, which are (globally) inevitable.

36

• The ULM community should reinforce its
Defense Barriers.
• Organisation: Federation and Clubs.
Create a Safety Climate
- Norms and rules
- Safety Programs

- To define a Safety Climate, we need to
assess the potential risk, and for that we
need data: YOUR experience.
37

Pyramid of Heinrich
• If a fatal accident is caused by
a specific combination of
events, an uncomplete series
of events causes INCIDENTS.
• If we identify all potentially
dangerous events AND with
that information, build-up the
defenses, we can avoid
ACCIDENTS.
38

SHARING EXPERIENCE
• By informing the Federation of the small
events and incidents that spoiled one of
your flights, you allow the Community to
understand the potential dangers and act
upon. (and respect confidentiality)
“Learn from mistakes of others; you won’t
live long enough to make them all by
yourself”
39

Human Factors
• To err is human.
• Human life (and flying) is full of decisions.
• It is therefore more important to know yourself
than to know how to fly your aircraft.
– Get-home-itis, Distraction, Communication,..

• Understanding human factors is a very important
step in improving your defenses.
40

Competence and Readiness
• You hold a pilot licence; but are you a
competent flyer ?
• How will you react when faced with a
potential dangerous situation?
• Assessing your competences with an
instructor is an opportunity to improve.
• When flying, be ready.
41

What is the Authority doing for
you ?

42

A series of work groups
within EASA are thinking
about how to improve
flight safety.(ESSI)
One of them is about General
Aviation (EGAST).

Initiative includes a leaflet
On Collision Avoidance,
and has been relayed to you
by the Federation.
There are technical Work
Groups dealing with MOGAS
43

and

An initiative to develop
Posters with comic strips
On high risk topics.
The first goes about taking
The right decision when the
Weather is below minimum.
They are expected in the
Coming months.

44

For Belgium, Accident reports are made public on the SPF/FOD website.
Recent reports (from 1st May 2007) are directly available through
hyperlinks.
Reports are written in English.
Information Notes are also available in order to highlight specific danger
area: Nr 2010 is about engine cold start.
We would like to develop more Notes, for ULM in collaboration with
the Federation.
Historical reports: currently a list is posted.
The list is fairly complete from 1972.
2 ancient reports (1936 and 1965).
The reports (Fr /Nl) are desidentified and available on request.
The list will be completed as we go along in reviewing archives.

45

Thank you for your attention, and
AAIU (Belgium) wishes you
many happy landings

Photos credit:
MRA / KLM

46


Slide 17

10 JULY 1910 - 2010
100 YEARS ULM ACCIDENTS

Belgian ULM Federation – Safety
1
Conference 10/10/2010

The Air Safety Investigation
• As part of the global Aviation sphere, an investigation is
conducted for each accident and serious incident by an
independent enquiry body, aimed to;
– Determine the causes of the accident.
– Determine if all conditions that were defined by rules and
regulations to ensure flight safety were followed (such as risk
factors in design).
– Define recommendations in order to prevent future accidents.

• It is not the purpose of this investigation to apportion
blame or liability.

2

In Belgium; the Air Accident
Investigation Unit.
• All accidents and serious incidents occurring in Belgium,
on aircraft, helicopters, gliders, balloons, ULM, DPM,
regardless of their registration is investigated by a cell
functionnally independent from the BCAA, and all other
interrested parties.
• Independent doesn’t mean isolated; it is part of the world’s
network of the State’s Aviation Investigation Bodies.
• The cell reports to the President of the Board of the
SPF/FOD Mobility and Transport.
3

4

ULM
• First pendular (Delta Plane Motorized)
design in 1966
• First crossing of the Channel in 1978 by Mr
D. Cook.
• Commercial development from 1979.
• Evolution from 2-axis to 3-axis.
• In Belgium, first ULM registered (501) in
1982.

5

6

Evolution
• 1982: Weedhopper, Chickinox
– 80…100 km/h
– Basic – 2/3 axis
– Range: … 200 km…

• 2010: VL-3 Sprint, DynAero MCR01, WT9 Dynamic….
– 220….250 km/h,
– flaps, retractable gear, avionics,
– Range over 1000 km

• 550 OO- registered ULM;
• 571 ULM pilot licence (363 training licences)
• 300-400 foreign-registered ULM.
7

1000
900
800
700
600
500
400
300
200
100

Number of valid registration

8

Estimation of flying OO-regd ULM

20
10

20
08

20
06

20
04

20
02

20
00

19
98

19
96

19
94

19
92

19
90

19
88

19
86

19
84

19
82

0

Evolution in pilot’s / owner’s
expectations
• In 1982, ULM /DPM, a sporting way of flying,
outside the limits of parachuting, delta plane.

• In 2010, an efficient alternative to general
(certified) aviation. ULM becomes a means of
transport.
• Beyond 2010 ?? – The Need for Speed ?
9

Evolution
• From the user’s perspective, the difference between
General Aviation and ULM becomes very thin.
• However, ULMs are characterized by a huge variety of
different design types, with low production rate and
configuration variation between individual airplanes.
– Manufacturers come and go,
– Assembly of the same ULM type by different companies induce
differences in built configuration.

• The above makes it more and more difficult to speak about
ULMs in a general way; variation in quality is wider than
General (certified) Aviation.
10

EVOLUTION: MORE ULM FATAL ACCIDENTS ?

Fatalities: (up to now), In Belgium, on average 2 /year,
comparable to General (certified) Aviation.
Number of fatalities
12
10
8
6
4
2

Number of fatalities

11

20
10

20
08

20
06

20
04

20
02

20
00

19
98

19
96

19
94

19
92

19
90

19
88

19
86

19
84

0

19
82

FATALITIES:
Figures limited to
Belgium.
2009: + 2 in France.
2010: + 5 in France.

WHAT ARE THE EXPECTATIONS
FOR THE
ULM-ACCIDENTS CASUALITY
RATE ?
• On Belgian soil, 4 deads in 2010.
(casuality rate of U.S. Forces in Iraq 3.6 killed /1000
troop / year – 8 years – 152000 troops – 4424 killed).

• In France and Belgium in 2010, 9 Belgian
deads to-date.
12

Comparison with the road
• In Belgium, the road kills 1000 people on average per year
.
• Fleet of vehicles: 6 000 000 units (5 mio cars).
• For 1000 cars, the road kills on average 0.16 person per
year.
• If we combine these figures with the yearly utilization rate
of cars (1 h per day) versus ULM (40 h per year), we can
conclude that ULM / General Aviation flying is
considerably deadlier than the road.

13

What can we learn from accident
investigation ?

14

The investigation process
A long process (Months)
• Collect all factual elements,
–
–
–
–
–
–

The flow of events;
The pilot (training, experience, …)
The aircraft (contact w/manufacturer)
Meteo, Comm, Radar,
Flt recorders (GPS, ECU, camera, …)
Impact, aircraft damage,

• Analysis. (incl. simulation, testing,…)
• Define all possible causes.
• From the causes, define remedial action.
The depth of the investigation is somewhat influenced by the
expected ROI.
15

Accident analysis
• Accidents do not occur “by accident”; Accident are
caused by a series of events.
• There are no “isolated cases”; causes of accidents are often
recurrent.
• Out of the ULM accident data base, we can conclude;
– There are recurrent technical problems specific to ULM.
– The traditional causes of aviation accidents are also known to
ULM (fuel shortage)

– 80% of the causal factors are human-related.

16

Main causal factors (122 accidents –
fixed wing and ULM)
Loss of control Take-off
11%

Fuel Starvation
15%

Loss of control Flight & collision
12%

Technical
11%
Low piloting
experience
8%

Loss of control Landing
16%
Icing
3%

Low flying /
aerobatics obstacles - CFIT
24%

17

Specific problems with ULM
• Technical causes can be (easily) identified;
but fire can be devastating.
• There’s another problem for the
investigator, a lot of landmarks are missing.
– ULM requirements are national,
– Certification not applicable.
– Wide variety of products.
18

About certification.
• Everyone would agree that ULMs of to-day are as good,
even a lot better than the ‘certified’ airplane.
• ULMs are designed to fly.
ULM are quality products; they meet your expectations
(simple to handle, fly fast, cheap in usage, …)
• Certification means that a manufacturer must demonstrate
that his product meets a minimum level of safety, as
defined (ultimately) by the Aviation Community.
• The minimum level of safety is defined in the Certification
Specifications – For small aircraft, it is called CS23.
19

Technical.
• AAIU(be) is currently investigating on:
– Instrument Board lay-out design.
– Electrical System design.
– Emergency Parachute.
Why is it that (for the last cases) parachute did not save lifes ?
• Late decision ?
• Handle easy to grab ?
• Safety pin not removed before flight ?

20

Same ULM Type, instrument panel somewhat different.
Difference in Ergonomy.
Parachute handle – on pilot’s side, or on passenger’s side ?

21

Regulation: certification:
CS 23.671 General
(b) Controls must be arranged and identified
to provide for convenience in operation and
to prevent the possibility of confusion and
subsequent inadvertent operation.

For ULM, CS 23 is not applicable.
Each designer has his own solution, and
they will be challenged only by YOUR
experience.
22

Other example
The passenger door opens in
flight, causing the pilot to take
appropriate actions, that
eventually force him to an
emergency landing.

• Door lock (simple – crude).
Plexy flexible. Once opened in
flight, difficult to close.
CS 23.783
(1) There must be means to lock and safeguard the door against
inadvertent opening during flight by persons, by cargo, or as a
result of mechanical failure.
23

The problem
• Once we determine a technical problem, we
can define recommendations to improve the
product, but:
What do we do with the recommendation ?
– We can not improve the Standard, there’s no standard.
– We can not address more than one manufacturer,
– What about retrofit ?

24

ULM and Engine failures

25

Fly Synthesis Storch
Summer 2009
• After propeller replacement, and subsequent
engine ground tests, the pilot took off for a
flight test.
• He encountered heavy engine vibration, that
forced him to an emergency landing.
• Airplane was slightly damaged.
Cause was identified as Vapor Lock.
26

1/5/2010 – FK9
Emergency landing after in-flight engine failure.
• Lots of corrosion found in carburettor.
Corrosion comes from water condensation in
fuel system (tank, lines, pump,…- MOGAS)
during long immobilisation periods.
- how to prevent ? Filling up, draining ?

• Fuel system was modified in-service, by
addition of a pressure regulator.
27

France
20/5/2010 – Mistral
23/5/2010 – CT Short Wing
Mistral: Engine failure in flight.
Emergency landing in field; terrain was very soft, airplane
severely damaged.
CT Short Wing: In short final, the engine suddenly stops
The pilot attempts to land, but hit trees, and crashes – wings
ripped off.
RH wing tank empty, 15-25 l fuel remaining in LH tank.
During LH turn, fuel system unprimed, engine stopped by
fuel starvation.
28

4 /6/2010: SG Rally
Damaged during landing
• Due to engine problems (heavy vibrations), the
pilot performed emergency landing on EBHN.
Coming in too fast, the landing was brutal, and
Nose Landing Gear collapsed.

29

Conclusion
• Engine in-flight failure are not exceptional.
– Use of MOGAS (water content, flash point,..)
– Local modifications,
– Other specific to the configuration of the
specific airplane.
And..
– Traditional causes (engine starvation,..)
30

Solutions
• In this case, we can design some generic
recommendations:
– Human Factors; ULM pilots should be more
prepared to react to engine failures at any time
(awareness, briefing, training,…)
– Generic technical solutions; impact on the use
of MOGAS.
• Protection of the equipment during winter,
• Risk of Vapour lock.

31

• Designing stop-gaps, accident after accidents
may not be satisfactory;
What can we do we make sure ULM flying
improves up to an acceptable level and, more
important, remains at that level ?

• More Regulation ?

32

Aviation Regulation and the ULM
• No significant changes in Regulation.
– ULM defined by capacity, weight, structural and stall speed limitation.
– => Extensive use of carbon fiber, Flaps, etc

• CS-VLA.
– 750 kg.
– “light” CS-23.
– Expensive.

• Lower Requirements for licencing,
– What about competence ?
– Human Factors training

• National requirements in Europe.
– EASA Flight Permit per Part 21A.701.

33

Evolution: new EU Regulation on
Accident Investigation.
* Every civil aviation accident or serious incident involving
aircraft other than specified in Annex II to the Regulation (EC)
No 216/2008 of the European Parliament and of the Council
shall be the subject of a safety investigation

( = No obligation of enquiry for ULMs)
• Safety investigation authorities may decide to investigate
incidents other than those referred to in paragraph 1 as well as
accidents or serious incidents to other types of aircraft, in
accordance with the national legislation of the Member States,
when they expect to draw safety lessons from them.
34

• US. NTSB; no enquiry for ULM crashes.
• To-day already, in some EU countries, ULM
crash investigations are given a low priority,
unless the Public determines otherwise.
• Common sense dictates that the initiative
to improve safety must come from the
ULM community itself.

35

Reason Model
• aviation is a complex socio-technical
system, where safety is ensured by a
series of defense barriers.
• Each barrier may present flaws (latent
or active) whose combination can lead
to an accident.
• An usafe act (active failure) alone
would not cause an accident.
• Latent failures are more easily
detected and corrected that human
errors, which are (globally) inevitable.

36

• The ULM community should reinforce its
Defense Barriers.
• Organisation: Federation and Clubs.
Create a Safety Climate
- Norms and rules
- Safety Programs

- To define a Safety Climate, we need to
assess the potential risk, and for that we
need data: YOUR experience.
37

Pyramid of Heinrich
• If a fatal accident is caused by
a specific combination of
events, an uncomplete series
of events causes INCIDENTS.
• If we identify all potentially
dangerous events AND with
that information, build-up the
defenses, we can avoid
ACCIDENTS.
38

SHARING EXPERIENCE
• By informing the Federation of the small
events and incidents that spoiled one of
your flights, you allow the Community to
understand the potential dangers and act
upon. (and respect confidentiality)
“Learn from mistakes of others; you won’t
live long enough to make them all by
yourself”
39

Human Factors
• To err is human.
• Human life (and flying) is full of decisions.
• It is therefore more important to know yourself
than to know how to fly your aircraft.
– Get-home-itis, Distraction, Communication,..

• Understanding human factors is a very important
step in improving your defenses.
40

Competence and Readiness
• You hold a pilot licence; but are you a
competent flyer ?
• How will you react when faced with a
potential dangerous situation?
• Assessing your competences with an
instructor is an opportunity to improve.
• When flying, be ready.
41

What is the Authority doing for
you ?

42

A series of work groups
within EASA are thinking
about how to improve
flight safety.(ESSI)
One of them is about General
Aviation (EGAST).

Initiative includes a leaflet
On Collision Avoidance,
and has been relayed to you
by the Federation.
There are technical Work
Groups dealing with MOGAS
43

and

An initiative to develop
Posters with comic strips
On high risk topics.
The first goes about taking
The right decision when the
Weather is below minimum.
They are expected in the
Coming months.

44

For Belgium, Accident reports are made public on the SPF/FOD website.
Recent reports (from 1st May 2007) are directly available through
hyperlinks.
Reports are written in English.
Information Notes are also available in order to highlight specific danger
area: Nr 2010 is about engine cold start.
We would like to develop more Notes, for ULM in collaboration with
the Federation.
Historical reports: currently a list is posted.
The list is fairly complete from 1972.
2 ancient reports (1936 and 1965).
The reports (Fr /Nl) are desidentified and available on request.
The list will be completed as we go along in reviewing archives.

45

Thank you for your attention, and
AAIU (Belgium) wishes you
many happy landings

Photos credit:
MRA / KLM

46


Slide 18

10 JULY 1910 - 2010
100 YEARS ULM ACCIDENTS

Belgian ULM Federation – Safety
1
Conference 10/10/2010

The Air Safety Investigation
• As part of the global Aviation sphere, an investigation is
conducted for each accident and serious incident by an
independent enquiry body, aimed to;
– Determine the causes of the accident.
– Determine if all conditions that were defined by rules and
regulations to ensure flight safety were followed (such as risk
factors in design).
– Define recommendations in order to prevent future accidents.

• It is not the purpose of this investigation to apportion
blame or liability.

2

In Belgium; the Air Accident
Investigation Unit.
• All accidents and serious incidents occurring in Belgium,
on aircraft, helicopters, gliders, balloons, ULM, DPM,
regardless of their registration is investigated by a cell
functionnally independent from the BCAA, and all other
interrested parties.
• Independent doesn’t mean isolated; it is part of the world’s
network of the State’s Aviation Investigation Bodies.
• The cell reports to the President of the Board of the
SPF/FOD Mobility and Transport.
3

4

ULM
• First pendular (Delta Plane Motorized)
design in 1966
• First crossing of the Channel in 1978 by Mr
D. Cook.
• Commercial development from 1979.
• Evolution from 2-axis to 3-axis.
• In Belgium, first ULM registered (501) in
1982.

5

6

Evolution
• 1982: Weedhopper, Chickinox
– 80…100 km/h
– Basic – 2/3 axis
– Range: … 200 km…

• 2010: VL-3 Sprint, DynAero MCR01, WT9 Dynamic….
– 220….250 km/h,
– flaps, retractable gear, avionics,
– Range over 1000 km

• 550 OO- registered ULM;
• 571 ULM pilot licence (363 training licences)
• 300-400 foreign-registered ULM.
7

1000
900
800
700
600
500
400
300
200
100

Number of valid registration

8

Estimation of flying OO-regd ULM

20
10

20
08

20
06

20
04

20
02

20
00

19
98

19
96

19
94

19
92

19
90

19
88

19
86

19
84

19
82

0

Evolution in pilot’s / owner’s
expectations
• In 1982, ULM /DPM, a sporting way of flying,
outside the limits of parachuting, delta plane.

• In 2010, an efficient alternative to general
(certified) aviation. ULM becomes a means of
transport.
• Beyond 2010 ?? – The Need for Speed ?
9

Evolution
• From the user’s perspective, the difference between
General Aviation and ULM becomes very thin.
• However, ULMs are characterized by a huge variety of
different design types, with low production rate and
configuration variation between individual airplanes.
– Manufacturers come and go,
– Assembly of the same ULM type by different companies induce
differences in built configuration.

• The above makes it more and more difficult to speak about
ULMs in a general way; variation in quality is wider than
General (certified) Aviation.
10

EVOLUTION: MORE ULM FATAL ACCIDENTS ?

Fatalities: (up to now), In Belgium, on average 2 /year,
comparable to General (certified) Aviation.
Number of fatalities
12
10
8
6
4
2

Number of fatalities

11

20
10

20
08

20
06

20
04

20
02

20
00

19
98

19
96

19
94

19
92

19
90

19
88

19
86

19
84

0

19
82

FATALITIES:
Figures limited to
Belgium.
2009: + 2 in France.
2010: + 5 in France.

WHAT ARE THE EXPECTATIONS
FOR THE
ULM-ACCIDENTS CASUALITY
RATE ?
• On Belgian soil, 4 deads in 2010.
(casuality rate of U.S. Forces in Iraq 3.6 killed /1000
troop / year – 8 years – 152000 troops – 4424 killed).

• In France and Belgium in 2010, 9 Belgian
deads to-date.
12

Comparison with the road
• In Belgium, the road kills 1000 people on average per year
.
• Fleet of vehicles: 6 000 000 units (5 mio cars).
• For 1000 cars, the road kills on average 0.16 person per
year.
• If we combine these figures with the yearly utilization rate
of cars (1 h per day) versus ULM (40 h per year), we can
conclude that ULM / General Aviation flying is
considerably deadlier than the road.

13

What can we learn from accident
investigation ?

14

The investigation process
A long process (Months)
• Collect all factual elements,
–
–
–
–
–
–

The flow of events;
The pilot (training, experience, …)
The aircraft (contact w/manufacturer)
Meteo, Comm, Radar,
Flt recorders (GPS, ECU, camera, …)
Impact, aircraft damage,

• Analysis. (incl. simulation, testing,…)
• Define all possible causes.
• From the causes, define remedial action.
The depth of the investigation is somewhat influenced by the
expected ROI.
15

Accident analysis
• Accidents do not occur “by accident”; Accident are
caused by a series of events.
• There are no “isolated cases”; causes of accidents are often
recurrent.
• Out of the ULM accident data base, we can conclude;
– There are recurrent technical problems specific to ULM.
– The traditional causes of aviation accidents are also known to
ULM (fuel shortage)

– 80% of the causal factors are human-related.

16

Main causal factors (122 accidents –
fixed wing and ULM)
Loss of control Take-off
11%

Fuel Starvation
15%

Loss of control Flight & collision
12%

Technical
11%
Low piloting
experience
8%

Loss of control Landing
16%
Icing
3%

Low flying /
aerobatics obstacles - CFIT
24%

17

Specific problems with ULM
• Technical causes can be (easily) identified;
but fire can be devastating.
• There’s another problem for the
investigator, a lot of landmarks are missing.
– ULM requirements are national,
– Certification not applicable.
– Wide variety of products.
18

About certification.
• Everyone would agree that ULMs of to-day are as good,
even a lot better than the ‘certified’ airplane.
• ULMs are designed to fly.
ULM are quality products; they meet your expectations
(simple to handle, fly fast, cheap in usage, …)
• Certification means that a manufacturer must demonstrate
that his product meets a minimum level of safety, as
defined (ultimately) by the Aviation Community.
• The minimum level of safety is defined in the Certification
Specifications – For small aircraft, it is called CS23.
19

Technical.
• AAIU(be) is currently investigating on:
– Instrument Board lay-out design.
– Electrical System design.
– Emergency Parachute.
Why is it that (for the last cases) parachute did not save lifes ?
• Late decision ?
• Handle easy to grab ?
• Safety pin not removed before flight ?

20

Same ULM Type, instrument panel somewhat different.
Difference in Ergonomy.
Parachute handle – on pilot’s side, or on passenger’s side ?

21

Regulation: certification:
CS 23.671 General
(b) Controls must be arranged and identified
to provide for convenience in operation and
to prevent the possibility of confusion and
subsequent inadvertent operation.

For ULM, CS 23 is not applicable.
Each designer has his own solution, and
they will be challenged only by YOUR
experience.
22

Other example
The passenger door opens in
flight, causing the pilot to take
appropriate actions, that
eventually force him to an
emergency landing.

• Door lock (simple – crude).
Plexy flexible. Once opened in
flight, difficult to close.
CS 23.783
(1) There must be means to lock and safeguard the door against
inadvertent opening during flight by persons, by cargo, or as a
result of mechanical failure.
23

The problem
• Once we determine a technical problem, we
can define recommendations to improve the
product, but:
What do we do with the recommendation ?
– We can not improve the Standard, there’s no standard.
– We can not address more than one manufacturer,
– What about retrofit ?

24

ULM and Engine failures

25

Fly Synthesis Storch
Summer 2009
• After propeller replacement, and subsequent
engine ground tests, the pilot took off for a
flight test.
• He encountered heavy engine vibration, that
forced him to an emergency landing.
• Airplane was slightly damaged.
Cause was identified as Vapor Lock.
26

1/5/2010 – FK9
Emergency landing after in-flight engine failure.
• Lots of corrosion found in carburettor.
Corrosion comes from water condensation in
fuel system (tank, lines, pump,…- MOGAS)
during long immobilisation periods.
- how to prevent ? Filling up, draining ?

• Fuel system was modified in-service, by
addition of a pressure regulator.
27

France
20/5/2010 – Mistral
23/5/2010 – CT Short Wing
Mistral: Engine failure in flight.
Emergency landing in field; terrain was very soft, airplane
severely damaged.
CT Short Wing: In short final, the engine suddenly stops
The pilot attempts to land, but hit trees, and crashes – wings
ripped off.
RH wing tank empty, 15-25 l fuel remaining in LH tank.
During LH turn, fuel system unprimed, engine stopped by
fuel starvation.
28

4 /6/2010: SG Rally
Damaged during landing
• Due to engine problems (heavy vibrations), the
pilot performed emergency landing on EBHN.
Coming in too fast, the landing was brutal, and
Nose Landing Gear collapsed.

29

Conclusion
• Engine in-flight failure are not exceptional.
– Use of MOGAS (water content, flash point,..)
– Local modifications,
– Other specific to the configuration of the
specific airplane.
And..
– Traditional causes (engine starvation,..)
30

Solutions
• In this case, we can design some generic
recommendations:
– Human Factors; ULM pilots should be more
prepared to react to engine failures at any time
(awareness, briefing, training,…)
– Generic technical solutions; impact on the use
of MOGAS.
• Protection of the equipment during winter,
• Risk of Vapour lock.

31

• Designing stop-gaps, accident after accidents
may not be satisfactory;
What can we do we make sure ULM flying
improves up to an acceptable level and, more
important, remains at that level ?

• More Regulation ?

32

Aviation Regulation and the ULM
• No significant changes in Regulation.
– ULM defined by capacity, weight, structural and stall speed limitation.
– => Extensive use of carbon fiber, Flaps, etc

• CS-VLA.
– 750 kg.
– “light” CS-23.
– Expensive.

• Lower Requirements for licencing,
– What about competence ?
– Human Factors training

• National requirements in Europe.
– EASA Flight Permit per Part 21A.701.

33

Evolution: new EU Regulation on
Accident Investigation.
* Every civil aviation accident or serious incident involving
aircraft other than specified in Annex II to the Regulation (EC)
No 216/2008 of the European Parliament and of the Council
shall be the subject of a safety investigation

( = No obligation of enquiry for ULMs)
• Safety investigation authorities may decide to investigate
incidents other than those referred to in paragraph 1 as well as
accidents or serious incidents to other types of aircraft, in
accordance with the national legislation of the Member States,
when they expect to draw safety lessons from them.
34

• US. NTSB; no enquiry for ULM crashes.
• To-day already, in some EU countries, ULM
crash investigations are given a low priority,
unless the Public determines otherwise.
• Common sense dictates that the initiative
to improve safety must come from the
ULM community itself.

35

Reason Model
• aviation is a complex socio-technical
system, where safety is ensured by a
series of defense barriers.
• Each barrier may present flaws (latent
or active) whose combination can lead
to an accident.
• An usafe act (active failure) alone
would not cause an accident.
• Latent failures are more easily
detected and corrected that human
errors, which are (globally) inevitable.

36

• The ULM community should reinforce its
Defense Barriers.
• Organisation: Federation and Clubs.
Create a Safety Climate
- Norms and rules
- Safety Programs

- To define a Safety Climate, we need to
assess the potential risk, and for that we
need data: YOUR experience.
37

Pyramid of Heinrich
• If a fatal accident is caused by
a specific combination of
events, an uncomplete series
of events causes INCIDENTS.
• If we identify all potentially
dangerous events AND with
that information, build-up the
defenses, we can avoid
ACCIDENTS.
38

SHARING EXPERIENCE
• By informing the Federation of the small
events and incidents that spoiled one of
your flights, you allow the Community to
understand the potential dangers and act
upon. (and respect confidentiality)
“Learn from mistakes of others; you won’t
live long enough to make them all by
yourself”
39

Human Factors
• To err is human.
• Human life (and flying) is full of decisions.
• It is therefore more important to know yourself
than to know how to fly your aircraft.
– Get-home-itis, Distraction, Communication,..

• Understanding human factors is a very important
step in improving your defenses.
40

Competence and Readiness
• You hold a pilot licence; but are you a
competent flyer ?
• How will you react when faced with a
potential dangerous situation?
• Assessing your competences with an
instructor is an opportunity to improve.
• When flying, be ready.
41

What is the Authority doing for
you ?

42

A series of work groups
within EASA are thinking
about how to improve
flight safety.(ESSI)
One of them is about General
Aviation (EGAST).

Initiative includes a leaflet
On Collision Avoidance,
and has been relayed to you
by the Federation.
There are technical Work
Groups dealing with MOGAS
43

and

An initiative to develop
Posters with comic strips
On high risk topics.
The first goes about taking
The right decision when the
Weather is below minimum.
They are expected in the
Coming months.

44

For Belgium, Accident reports are made public on the SPF/FOD website.
Recent reports (from 1st May 2007) are directly available through
hyperlinks.
Reports are written in English.
Information Notes are also available in order to highlight specific danger
area: Nr 2010 is about engine cold start.
We would like to develop more Notes, for ULM in collaboration with
the Federation.
Historical reports: currently a list is posted.
The list is fairly complete from 1972.
2 ancient reports (1936 and 1965).
The reports (Fr /Nl) are desidentified and available on request.
The list will be completed as we go along in reviewing archives.

45

Thank you for your attention, and
AAIU (Belgium) wishes you
many happy landings

Photos credit:
MRA / KLM

46


Slide 19

10 JULY 1910 - 2010
100 YEARS ULM ACCIDENTS

Belgian ULM Federation – Safety
1
Conference 10/10/2010

The Air Safety Investigation
• As part of the global Aviation sphere, an investigation is
conducted for each accident and serious incident by an
independent enquiry body, aimed to;
– Determine the causes of the accident.
– Determine if all conditions that were defined by rules and
regulations to ensure flight safety were followed (such as risk
factors in design).
– Define recommendations in order to prevent future accidents.

• It is not the purpose of this investigation to apportion
blame or liability.

2

In Belgium; the Air Accident
Investigation Unit.
• All accidents and serious incidents occurring in Belgium,
on aircraft, helicopters, gliders, balloons, ULM, DPM,
regardless of their registration is investigated by a cell
functionnally independent from the BCAA, and all other
interrested parties.
• Independent doesn’t mean isolated; it is part of the world’s
network of the State’s Aviation Investigation Bodies.
• The cell reports to the President of the Board of the
SPF/FOD Mobility and Transport.
3

4

ULM
• First pendular (Delta Plane Motorized)
design in 1966
• First crossing of the Channel in 1978 by Mr
D. Cook.
• Commercial development from 1979.
• Evolution from 2-axis to 3-axis.
• In Belgium, first ULM registered (501) in
1982.

5

6

Evolution
• 1982: Weedhopper, Chickinox
– 80…100 km/h
– Basic – 2/3 axis
– Range: … 200 km…

• 2010: VL-3 Sprint, DynAero MCR01, WT9 Dynamic….
– 220….250 km/h,
– flaps, retractable gear, avionics,
– Range over 1000 km

• 550 OO- registered ULM;
• 571 ULM pilot licence (363 training licences)
• 300-400 foreign-registered ULM.
7

1000
900
800
700
600
500
400
300
200
100

Number of valid registration

8

Estimation of flying OO-regd ULM

20
10

20
08

20
06

20
04

20
02

20
00

19
98

19
96

19
94

19
92

19
90

19
88

19
86

19
84

19
82

0

Evolution in pilot’s / owner’s
expectations
• In 1982, ULM /DPM, a sporting way of flying,
outside the limits of parachuting, delta plane.

• In 2010, an efficient alternative to general
(certified) aviation. ULM becomes a means of
transport.
• Beyond 2010 ?? – The Need for Speed ?
9

Evolution
• From the user’s perspective, the difference between
General Aviation and ULM becomes very thin.
• However, ULMs are characterized by a huge variety of
different design types, with low production rate and
configuration variation between individual airplanes.
– Manufacturers come and go,
– Assembly of the same ULM type by different companies induce
differences in built configuration.

• The above makes it more and more difficult to speak about
ULMs in a general way; variation in quality is wider than
General (certified) Aviation.
10

EVOLUTION: MORE ULM FATAL ACCIDENTS ?

Fatalities: (up to now), In Belgium, on average 2 /year,
comparable to General (certified) Aviation.
Number of fatalities
12
10
8
6
4
2

Number of fatalities

11

20
10

20
08

20
06

20
04

20
02

20
00

19
98

19
96

19
94

19
92

19
90

19
88

19
86

19
84

0

19
82

FATALITIES:
Figures limited to
Belgium.
2009: + 2 in France.
2010: + 5 in France.

WHAT ARE THE EXPECTATIONS
FOR THE
ULM-ACCIDENTS CASUALITY
RATE ?
• On Belgian soil, 4 deads in 2010.
(casuality rate of U.S. Forces in Iraq 3.6 killed /1000
troop / year – 8 years – 152000 troops – 4424 killed).

• In France and Belgium in 2010, 9 Belgian
deads to-date.
12

Comparison with the road
• In Belgium, the road kills 1000 people on average per year
.
• Fleet of vehicles: 6 000 000 units (5 mio cars).
• For 1000 cars, the road kills on average 0.16 person per
year.
• If we combine these figures with the yearly utilization rate
of cars (1 h per day) versus ULM (40 h per year), we can
conclude that ULM / General Aviation flying is
considerably deadlier than the road.

13

What can we learn from accident
investigation ?

14

The investigation process
A long process (Months)
• Collect all factual elements,
–
–
–
–
–
–

The flow of events;
The pilot (training, experience, …)
The aircraft (contact w/manufacturer)
Meteo, Comm, Radar,
Flt recorders (GPS, ECU, camera, …)
Impact, aircraft damage,

• Analysis. (incl. simulation, testing,…)
• Define all possible causes.
• From the causes, define remedial action.
The depth of the investigation is somewhat influenced by the
expected ROI.
15

Accident analysis
• Accidents do not occur “by accident”; Accident are
caused by a series of events.
• There are no “isolated cases”; causes of accidents are often
recurrent.
• Out of the ULM accident data base, we can conclude;
– There are recurrent technical problems specific to ULM.
– The traditional causes of aviation accidents are also known to
ULM (fuel shortage)

– 80% of the causal factors are human-related.

16

Main causal factors (122 accidents –
fixed wing and ULM)
Loss of control Take-off
11%

Fuel Starvation
15%

Loss of control Flight & collision
12%

Technical
11%
Low piloting
experience
8%

Loss of control Landing
16%
Icing
3%

Low flying /
aerobatics obstacles - CFIT
24%

17

Specific problems with ULM
• Technical causes can be (easily) identified;
but fire can be devastating.
• There’s another problem for the
investigator, a lot of landmarks are missing.
– ULM requirements are national,
– Certification not applicable.
– Wide variety of products.
18

About certification.
• Everyone would agree that ULMs of to-day are as good,
even a lot better than the ‘certified’ airplane.
• ULMs are designed to fly.
ULM are quality products; they meet your expectations
(simple to handle, fly fast, cheap in usage, …)
• Certification means that a manufacturer must demonstrate
that his product meets a minimum level of safety, as
defined (ultimately) by the Aviation Community.
• The minimum level of safety is defined in the Certification
Specifications – For small aircraft, it is called CS23.
19

Technical.
• AAIU(be) is currently investigating on:
– Instrument Board lay-out design.
– Electrical System design.
– Emergency Parachute.
Why is it that (for the last cases) parachute did not save lifes ?
• Late decision ?
• Handle easy to grab ?
• Safety pin not removed before flight ?

20

Same ULM Type, instrument panel somewhat different.
Difference in Ergonomy.
Parachute handle – on pilot’s side, or on passenger’s side ?

21

Regulation: certification:
CS 23.671 General
(b) Controls must be arranged and identified
to provide for convenience in operation and
to prevent the possibility of confusion and
subsequent inadvertent operation.

For ULM, CS 23 is not applicable.
Each designer has his own solution, and
they will be challenged only by YOUR
experience.
22

Other example
The passenger door opens in
flight, causing the pilot to take
appropriate actions, that
eventually force him to an
emergency landing.

• Door lock (simple – crude).
Plexy flexible. Once opened in
flight, difficult to close.
CS 23.783
(1) There must be means to lock and safeguard the door against
inadvertent opening during flight by persons, by cargo, or as a
result of mechanical failure.
23

The problem
• Once we determine a technical problem, we
can define recommendations to improve the
product, but:
What do we do with the recommendation ?
– We can not improve the Standard, there’s no standard.
– We can not address more than one manufacturer,
– What about retrofit ?

24

ULM and Engine failures

25

Fly Synthesis Storch
Summer 2009
• After propeller replacement, and subsequent
engine ground tests, the pilot took off for a
flight test.
• He encountered heavy engine vibration, that
forced him to an emergency landing.
• Airplane was slightly damaged.
Cause was identified as Vapor Lock.
26

1/5/2010 – FK9
Emergency landing after in-flight engine failure.
• Lots of corrosion found in carburettor.
Corrosion comes from water condensation in
fuel system (tank, lines, pump,…- MOGAS)
during long immobilisation periods.
- how to prevent ? Filling up, draining ?

• Fuel system was modified in-service, by
addition of a pressure regulator.
27

France
20/5/2010 – Mistral
23/5/2010 – CT Short Wing
Mistral: Engine failure in flight.
Emergency landing in field; terrain was very soft, airplane
severely damaged.
CT Short Wing: In short final, the engine suddenly stops
The pilot attempts to land, but hit trees, and crashes – wings
ripped off.
RH wing tank empty, 15-25 l fuel remaining in LH tank.
During LH turn, fuel system unprimed, engine stopped by
fuel starvation.
28

4 /6/2010: SG Rally
Damaged during landing
• Due to engine problems (heavy vibrations), the
pilot performed emergency landing on EBHN.
Coming in too fast, the landing was brutal, and
Nose Landing Gear collapsed.

29

Conclusion
• Engine in-flight failure are not exceptional.
– Use of MOGAS (water content, flash point,..)
– Local modifications,
– Other specific to the configuration of the
specific airplane.
And..
– Traditional causes (engine starvation,..)
30

Solutions
• In this case, we can design some generic
recommendations:
– Human Factors; ULM pilots should be more
prepared to react to engine failures at any time
(awareness, briefing, training,…)
– Generic technical solutions; impact on the use
of MOGAS.
• Protection of the equipment during winter,
• Risk of Vapour lock.

31

• Designing stop-gaps, accident after accidents
may not be satisfactory;
What can we do we make sure ULM flying
improves up to an acceptable level and, more
important, remains at that level ?

• More Regulation ?

32

Aviation Regulation and the ULM
• No significant changes in Regulation.
– ULM defined by capacity, weight, structural and stall speed limitation.
– => Extensive use of carbon fiber, Flaps, etc

• CS-VLA.
– 750 kg.
– “light” CS-23.
– Expensive.

• Lower Requirements for licencing,
– What about competence ?
– Human Factors training

• National requirements in Europe.
– EASA Flight Permit per Part 21A.701.

33

Evolution: new EU Regulation on
Accident Investigation.
* Every civil aviation accident or serious incident involving
aircraft other than specified in Annex II to the Regulation (EC)
No 216/2008 of the European Parliament and of the Council
shall be the subject of a safety investigation

( = No obligation of enquiry for ULMs)
• Safety investigation authorities may decide to investigate
incidents other than those referred to in paragraph 1 as well as
accidents or serious incidents to other types of aircraft, in
accordance with the national legislation of the Member States,
when they expect to draw safety lessons from them.
34

• US. NTSB; no enquiry for ULM crashes.
• To-day already, in some EU countries, ULM
crash investigations are given a low priority,
unless the Public determines otherwise.
• Common sense dictates that the initiative
to improve safety must come from the
ULM community itself.

35

Reason Model
• aviation is a complex socio-technical
system, where safety is ensured by a
series of defense barriers.
• Each barrier may present flaws (latent
or active) whose combination can lead
to an accident.
• An usafe act (active failure) alone
would not cause an accident.
• Latent failures are more easily
detected and corrected that human
errors, which are (globally) inevitable.

36

• The ULM community should reinforce its
Defense Barriers.
• Organisation: Federation and Clubs.
Create a Safety Climate
- Norms and rules
- Safety Programs

- To define a Safety Climate, we need to
assess the potential risk, and for that we
need data: YOUR experience.
37

Pyramid of Heinrich
• If a fatal accident is caused by
a specific combination of
events, an uncomplete series
of events causes INCIDENTS.
• If we identify all potentially
dangerous events AND with
that information, build-up the
defenses, we can avoid
ACCIDENTS.
38

SHARING EXPERIENCE
• By informing the Federation of the small
events and incidents that spoiled one of
your flights, you allow the Community to
understand the potential dangers and act
upon. (and respect confidentiality)
“Learn from mistakes of others; you won’t
live long enough to make them all by
yourself”
39

Human Factors
• To err is human.
• Human life (and flying) is full of decisions.
• It is therefore more important to know yourself
than to know how to fly your aircraft.
– Get-home-itis, Distraction, Communication,..

• Understanding human factors is a very important
step in improving your defenses.
40

Competence and Readiness
• You hold a pilot licence; but are you a
competent flyer ?
• How will you react when faced with a
potential dangerous situation?
• Assessing your competences with an
instructor is an opportunity to improve.
• When flying, be ready.
41

What is the Authority doing for
you ?

42

A series of work groups
within EASA are thinking
about how to improve
flight safety.(ESSI)
One of them is about General
Aviation (EGAST).

Initiative includes a leaflet
On Collision Avoidance,
and has been relayed to you
by the Federation.
There are technical Work
Groups dealing with MOGAS
43

and

An initiative to develop
Posters with comic strips
On high risk topics.
The first goes about taking
The right decision when the
Weather is below minimum.
They are expected in the
Coming months.

44

For Belgium, Accident reports are made public on the SPF/FOD website.
Recent reports (from 1st May 2007) are directly available through
hyperlinks.
Reports are written in English.
Information Notes are also available in order to highlight specific danger
area: Nr 2010 is about engine cold start.
We would like to develop more Notes, for ULM in collaboration with
the Federation.
Historical reports: currently a list is posted.
The list is fairly complete from 1972.
2 ancient reports (1936 and 1965).
The reports (Fr /Nl) are desidentified and available on request.
The list will be completed as we go along in reviewing archives.

45

Thank you for your attention, and
AAIU (Belgium) wishes you
many happy landings

Photos credit:
MRA / KLM

46


Slide 20

10 JULY 1910 - 2010
100 YEARS ULM ACCIDENTS

Belgian ULM Federation – Safety
1
Conference 10/10/2010

The Air Safety Investigation
• As part of the global Aviation sphere, an investigation is
conducted for each accident and serious incident by an
independent enquiry body, aimed to;
– Determine the causes of the accident.
– Determine if all conditions that were defined by rules and
regulations to ensure flight safety were followed (such as risk
factors in design).
– Define recommendations in order to prevent future accidents.

• It is not the purpose of this investigation to apportion
blame or liability.

2

In Belgium; the Air Accident
Investigation Unit.
• All accidents and serious incidents occurring in Belgium,
on aircraft, helicopters, gliders, balloons, ULM, DPM,
regardless of their registration is investigated by a cell
functionnally independent from the BCAA, and all other
interrested parties.
• Independent doesn’t mean isolated; it is part of the world’s
network of the State’s Aviation Investigation Bodies.
• The cell reports to the President of the Board of the
SPF/FOD Mobility and Transport.
3

4

ULM
• First pendular (Delta Plane Motorized)
design in 1966
• First crossing of the Channel in 1978 by Mr
D. Cook.
• Commercial development from 1979.
• Evolution from 2-axis to 3-axis.
• In Belgium, first ULM registered (501) in
1982.

5

6

Evolution
• 1982: Weedhopper, Chickinox
– 80…100 km/h
– Basic – 2/3 axis
– Range: … 200 km…

• 2010: VL-3 Sprint, DynAero MCR01, WT9 Dynamic….
– 220….250 km/h,
– flaps, retractable gear, avionics,
– Range over 1000 km

• 550 OO- registered ULM;
• 571 ULM pilot licence (363 training licences)
• 300-400 foreign-registered ULM.
7

1000
900
800
700
600
500
400
300
200
100

Number of valid registration

8

Estimation of flying OO-regd ULM

20
10

20
08

20
06

20
04

20
02

20
00

19
98

19
96

19
94

19
92

19
90

19
88

19
86

19
84

19
82

0

Evolution in pilot’s / owner’s
expectations
• In 1982, ULM /DPM, a sporting way of flying,
outside the limits of parachuting, delta plane.

• In 2010, an efficient alternative to general
(certified) aviation. ULM becomes a means of
transport.
• Beyond 2010 ?? – The Need for Speed ?
9

Evolution
• From the user’s perspective, the difference between
General Aviation and ULM becomes very thin.
• However, ULMs are characterized by a huge variety of
different design types, with low production rate and
configuration variation between individual airplanes.
– Manufacturers come and go,
– Assembly of the same ULM type by different companies induce
differences in built configuration.

• The above makes it more and more difficult to speak about
ULMs in a general way; variation in quality is wider than
General (certified) Aviation.
10

EVOLUTION: MORE ULM FATAL ACCIDENTS ?

Fatalities: (up to now), In Belgium, on average 2 /year,
comparable to General (certified) Aviation.
Number of fatalities
12
10
8
6
4
2

Number of fatalities

11

20
10

20
08

20
06

20
04

20
02

20
00

19
98

19
96

19
94

19
92

19
90

19
88

19
86

19
84

0

19
82

FATALITIES:
Figures limited to
Belgium.
2009: + 2 in France.
2010: + 5 in France.

WHAT ARE THE EXPECTATIONS
FOR THE
ULM-ACCIDENTS CASUALITY
RATE ?
• On Belgian soil, 4 deads in 2010.
(casuality rate of U.S. Forces in Iraq 3.6 killed /1000
troop / year – 8 years – 152000 troops – 4424 killed).

• In France and Belgium in 2010, 9 Belgian
deads to-date.
12

Comparison with the road
• In Belgium, the road kills 1000 people on average per year
.
• Fleet of vehicles: 6 000 000 units (5 mio cars).
• For 1000 cars, the road kills on average 0.16 person per
year.
• If we combine these figures with the yearly utilization rate
of cars (1 h per day) versus ULM (40 h per year), we can
conclude that ULM / General Aviation flying is
considerably deadlier than the road.

13

What can we learn from accident
investigation ?

14

The investigation process
A long process (Months)
• Collect all factual elements,
–
–
–
–
–
–

The flow of events;
The pilot (training, experience, …)
The aircraft (contact w/manufacturer)
Meteo, Comm, Radar,
Flt recorders (GPS, ECU, camera, …)
Impact, aircraft damage,

• Analysis. (incl. simulation, testing,…)
• Define all possible causes.
• From the causes, define remedial action.
The depth of the investigation is somewhat influenced by the
expected ROI.
15

Accident analysis
• Accidents do not occur “by accident”; Accident are
caused by a series of events.
• There are no “isolated cases”; causes of accidents are often
recurrent.
• Out of the ULM accident data base, we can conclude;
– There are recurrent technical problems specific to ULM.
– The traditional causes of aviation accidents are also known to
ULM (fuel shortage)

– 80% of the causal factors are human-related.

16

Main causal factors (122 accidents –
fixed wing and ULM)
Loss of control Take-off
11%

Fuel Starvation
15%

Loss of control Flight & collision
12%

Technical
11%
Low piloting
experience
8%

Loss of control Landing
16%
Icing
3%

Low flying /
aerobatics obstacles - CFIT
24%

17

Specific problems with ULM
• Technical causes can be (easily) identified;
but fire can be devastating.
• There’s another problem for the
investigator, a lot of landmarks are missing.
– ULM requirements are national,
– Certification not applicable.
– Wide variety of products.
18

About certification.
• Everyone would agree that ULMs of to-day are as good,
even a lot better than the ‘certified’ airplane.
• ULMs are designed to fly.
ULM are quality products; they meet your expectations
(simple to handle, fly fast, cheap in usage, …)
• Certification means that a manufacturer must demonstrate
that his product meets a minimum level of safety, as
defined (ultimately) by the Aviation Community.
• The minimum level of safety is defined in the Certification
Specifications – For small aircraft, it is called CS23.
19

Technical.
• AAIU(be) is currently investigating on:
– Instrument Board lay-out design.
– Electrical System design.
– Emergency Parachute.
Why is it that (for the last cases) parachute did not save lifes ?
• Late decision ?
• Handle easy to grab ?
• Safety pin not removed before flight ?

20

Same ULM Type, instrument panel somewhat different.
Difference in Ergonomy.
Parachute handle – on pilot’s side, or on passenger’s side ?

21

Regulation: certification:
CS 23.671 General
(b) Controls must be arranged and identified
to provide for convenience in operation and
to prevent the possibility of confusion and
subsequent inadvertent operation.

For ULM, CS 23 is not applicable.
Each designer has his own solution, and
they will be challenged only by YOUR
experience.
22

Other example
The passenger door opens in
flight, causing the pilot to take
appropriate actions, that
eventually force him to an
emergency landing.

• Door lock (simple – crude).
Plexy flexible. Once opened in
flight, difficult to close.
CS 23.783
(1) There must be means to lock and safeguard the door against
inadvertent opening during flight by persons, by cargo, or as a
result of mechanical failure.
23

The problem
• Once we determine a technical problem, we
can define recommendations to improve the
product, but:
What do we do with the recommendation ?
– We can not improve the Standard, there’s no standard.
– We can not address more than one manufacturer,
– What about retrofit ?

24

ULM and Engine failures

25

Fly Synthesis Storch
Summer 2009
• After propeller replacement, and subsequent
engine ground tests, the pilot took off for a
flight test.
• He encountered heavy engine vibration, that
forced him to an emergency landing.
• Airplane was slightly damaged.
Cause was identified as Vapor Lock.
26

1/5/2010 – FK9
Emergency landing after in-flight engine failure.
• Lots of corrosion found in carburettor.
Corrosion comes from water condensation in
fuel system (tank, lines, pump,…- MOGAS)
during long immobilisation periods.
- how to prevent ? Filling up, draining ?

• Fuel system was modified in-service, by
addition of a pressure regulator.
27

France
20/5/2010 – Mistral
23/5/2010 – CT Short Wing
Mistral: Engine failure in flight.
Emergency landing in field; terrain was very soft, airplane
severely damaged.
CT Short Wing: In short final, the engine suddenly stops
The pilot attempts to land, but hit trees, and crashes – wings
ripped off.
RH wing tank empty, 15-25 l fuel remaining in LH tank.
During LH turn, fuel system unprimed, engine stopped by
fuel starvation.
28

4 /6/2010: SG Rally
Damaged during landing
• Due to engine problems (heavy vibrations), the
pilot performed emergency landing on EBHN.
Coming in too fast, the landing was brutal, and
Nose Landing Gear collapsed.

29

Conclusion
• Engine in-flight failure are not exceptional.
– Use of MOGAS (water content, flash point,..)
– Local modifications,
– Other specific to the configuration of the
specific airplane.
And..
– Traditional causes (engine starvation,..)
30

Solutions
• In this case, we can design some generic
recommendations:
– Human Factors; ULM pilots should be more
prepared to react to engine failures at any time
(awareness, briefing, training,…)
– Generic technical solutions; impact on the use
of MOGAS.
• Protection of the equipment during winter,
• Risk of Vapour lock.

31

• Designing stop-gaps, accident after accidents
may not be satisfactory;
What can we do we make sure ULM flying
improves up to an acceptable level and, more
important, remains at that level ?

• More Regulation ?

32

Aviation Regulation and the ULM
• No significant changes in Regulation.
– ULM defined by capacity, weight, structural and stall speed limitation.
– => Extensive use of carbon fiber, Flaps, etc

• CS-VLA.
– 750 kg.
– “light” CS-23.
– Expensive.

• Lower Requirements for licencing,
– What about competence ?
– Human Factors training

• National requirements in Europe.
– EASA Flight Permit per Part 21A.701.

33

Evolution: new EU Regulation on
Accident Investigation.
* Every civil aviation accident or serious incident involving
aircraft other than specified in Annex II to the Regulation (EC)
No 216/2008 of the European Parliament and of the Council
shall be the subject of a safety investigation

( = No obligation of enquiry for ULMs)
• Safety investigation authorities may decide to investigate
incidents other than those referred to in paragraph 1 as well as
accidents or serious incidents to other types of aircraft, in
accordance with the national legislation of the Member States,
when they expect to draw safety lessons from them.
34

• US. NTSB; no enquiry for ULM crashes.
• To-day already, in some EU countries, ULM
crash investigations are given a low priority,
unless the Public determines otherwise.
• Common sense dictates that the initiative
to improve safety must come from the
ULM community itself.

35

Reason Model
• aviation is a complex socio-technical
system, where safety is ensured by a
series of defense barriers.
• Each barrier may present flaws (latent
or active) whose combination can lead
to an accident.
• An usafe act (active failure) alone
would not cause an accident.
• Latent failures are more easily
detected and corrected that human
errors, which are (globally) inevitable.

36

• The ULM community should reinforce its
Defense Barriers.
• Organisation: Federation and Clubs.
Create a Safety Climate
- Norms and rules
- Safety Programs

- To define a Safety Climate, we need to
assess the potential risk, and for that we
need data: YOUR experience.
37

Pyramid of Heinrich
• If a fatal accident is caused by
a specific combination of
events, an uncomplete series
of events causes INCIDENTS.
• If we identify all potentially
dangerous events AND with
that information, build-up the
defenses, we can avoid
ACCIDENTS.
38

SHARING EXPERIENCE
• By informing the Federation of the small
events and incidents that spoiled one of
your flights, you allow the Community to
understand the potential dangers and act
upon. (and respect confidentiality)
“Learn from mistakes of others; you won’t
live long enough to make them all by
yourself”
39

Human Factors
• To err is human.
• Human life (and flying) is full of decisions.
• It is therefore more important to know yourself
than to know how to fly your aircraft.
– Get-home-itis, Distraction, Communication,..

• Understanding human factors is a very important
step in improving your defenses.
40

Competence and Readiness
• You hold a pilot licence; but are you a
competent flyer ?
• How will you react when faced with a
potential dangerous situation?
• Assessing your competences with an
instructor is an opportunity to improve.
• When flying, be ready.
41

What is the Authority doing for
you ?

42

A series of work groups
within EASA are thinking
about how to improve
flight safety.(ESSI)
One of them is about General
Aviation (EGAST).

Initiative includes a leaflet
On Collision Avoidance,
and has been relayed to you
by the Federation.
There are technical Work
Groups dealing with MOGAS
43

and

An initiative to develop
Posters with comic strips
On high risk topics.
The first goes about taking
The right decision when the
Weather is below minimum.
They are expected in the
Coming months.

44

For Belgium, Accident reports are made public on the SPF/FOD website.
Recent reports (from 1st May 2007) are directly available through
hyperlinks.
Reports are written in English.
Information Notes are also available in order to highlight specific danger
area: Nr 2010 is about engine cold start.
We would like to develop more Notes, for ULM in collaboration with
the Federation.
Historical reports: currently a list is posted.
The list is fairly complete from 1972.
2 ancient reports (1936 and 1965).
The reports (Fr /Nl) are desidentified and available on request.
The list will be completed as we go along in reviewing archives.

45

Thank you for your attention, and
AAIU (Belgium) wishes you
many happy landings

Photos credit:
MRA / KLM

46


Slide 21

10 JULY 1910 - 2010
100 YEARS ULM ACCIDENTS

Belgian ULM Federation – Safety
1
Conference 10/10/2010

The Air Safety Investigation
• As part of the global Aviation sphere, an investigation is
conducted for each accident and serious incident by an
independent enquiry body, aimed to;
– Determine the causes of the accident.
– Determine if all conditions that were defined by rules and
regulations to ensure flight safety were followed (such as risk
factors in design).
– Define recommendations in order to prevent future accidents.

• It is not the purpose of this investigation to apportion
blame or liability.

2

In Belgium; the Air Accident
Investigation Unit.
• All accidents and serious incidents occurring in Belgium,
on aircraft, helicopters, gliders, balloons, ULM, DPM,
regardless of their registration is investigated by a cell
functionnally independent from the BCAA, and all other
interrested parties.
• Independent doesn’t mean isolated; it is part of the world’s
network of the State’s Aviation Investigation Bodies.
• The cell reports to the President of the Board of the
SPF/FOD Mobility and Transport.
3

4

ULM
• First pendular (Delta Plane Motorized)
design in 1966
• First crossing of the Channel in 1978 by Mr
D. Cook.
• Commercial development from 1979.
• Evolution from 2-axis to 3-axis.
• In Belgium, first ULM registered (501) in
1982.

5

6

Evolution
• 1982: Weedhopper, Chickinox
– 80…100 km/h
– Basic – 2/3 axis
– Range: … 200 km…

• 2010: VL-3 Sprint, DynAero MCR01, WT9 Dynamic….
– 220….250 km/h,
– flaps, retractable gear, avionics,
– Range over 1000 km

• 550 OO- registered ULM;
• 571 ULM pilot licence (363 training licences)
• 300-400 foreign-registered ULM.
7

1000
900
800
700
600
500
400
300
200
100

Number of valid registration

8

Estimation of flying OO-regd ULM

20
10

20
08

20
06

20
04

20
02

20
00

19
98

19
96

19
94

19
92

19
90

19
88

19
86

19
84

19
82

0

Evolution in pilot’s / owner’s
expectations
• In 1982, ULM /DPM, a sporting way of flying,
outside the limits of parachuting, delta plane.

• In 2010, an efficient alternative to general
(certified) aviation. ULM becomes a means of
transport.
• Beyond 2010 ?? – The Need for Speed ?
9

Evolution
• From the user’s perspective, the difference between
General Aviation and ULM becomes very thin.
• However, ULMs are characterized by a huge variety of
different design types, with low production rate and
configuration variation between individual airplanes.
– Manufacturers come and go,
– Assembly of the same ULM type by different companies induce
differences in built configuration.

• The above makes it more and more difficult to speak about
ULMs in a general way; variation in quality is wider than
General (certified) Aviation.
10

EVOLUTION: MORE ULM FATAL ACCIDENTS ?

Fatalities: (up to now), In Belgium, on average 2 /year,
comparable to General (certified) Aviation.
Number of fatalities
12
10
8
6
4
2

Number of fatalities

11

20
10

20
08

20
06

20
04

20
02

20
00

19
98

19
96

19
94

19
92

19
90

19
88

19
86

19
84

0

19
82

FATALITIES:
Figures limited to
Belgium.
2009: + 2 in France.
2010: + 5 in France.

WHAT ARE THE EXPECTATIONS
FOR THE
ULM-ACCIDENTS CASUALITY
RATE ?
• On Belgian soil, 4 deads in 2010.
(casuality rate of U.S. Forces in Iraq 3.6 killed /1000
troop / year – 8 years – 152000 troops – 4424 killed).

• In France and Belgium in 2010, 9 Belgian
deads to-date.
12

Comparison with the road
• In Belgium, the road kills 1000 people on average per year
.
• Fleet of vehicles: 6 000 000 units (5 mio cars).
• For 1000 cars, the road kills on average 0.16 person per
year.
• If we combine these figures with the yearly utilization rate
of cars (1 h per day) versus ULM (40 h per year), we can
conclude that ULM / General Aviation flying is
considerably deadlier than the road.

13

What can we learn from accident
investigation ?

14

The investigation process
A long process (Months)
• Collect all factual elements,
–
–
–
–
–
–

The flow of events;
The pilot (training, experience, …)
The aircraft (contact w/manufacturer)
Meteo, Comm, Radar,
Flt recorders (GPS, ECU, camera, …)
Impact, aircraft damage,

• Analysis. (incl. simulation, testing,…)
• Define all possible causes.
• From the causes, define remedial action.
The depth of the investigation is somewhat influenced by the
expected ROI.
15

Accident analysis
• Accidents do not occur “by accident”; Accident are
caused by a series of events.
• There are no “isolated cases”; causes of accidents are often
recurrent.
• Out of the ULM accident data base, we can conclude;
– There are recurrent technical problems specific to ULM.
– The traditional causes of aviation accidents are also known to
ULM (fuel shortage)

– 80% of the causal factors are human-related.

16

Main causal factors (122 accidents –
fixed wing and ULM)
Loss of control Take-off
11%

Fuel Starvation
15%

Loss of control Flight & collision
12%

Technical
11%
Low piloting
experience
8%

Loss of control Landing
16%
Icing
3%

Low flying /
aerobatics obstacles - CFIT
24%

17

Specific problems with ULM
• Technical causes can be (easily) identified;
but fire can be devastating.
• There’s another problem for the
investigator, a lot of landmarks are missing.
– ULM requirements are national,
– Certification not applicable.
– Wide variety of products.
18

About certification.
• Everyone would agree that ULMs of to-day are as good,
even a lot better than the ‘certified’ airplane.
• ULMs are designed to fly.
ULM are quality products; they meet your expectations
(simple to handle, fly fast, cheap in usage, …)
• Certification means that a manufacturer must demonstrate
that his product meets a minimum level of safety, as
defined (ultimately) by the Aviation Community.
• The minimum level of safety is defined in the Certification
Specifications – For small aircraft, it is called CS23.
19

Technical.
• AAIU(be) is currently investigating on:
– Instrument Board lay-out design.
– Electrical System design.
– Emergency Parachute.
Why is it that (for the last cases) parachute did not save lifes ?
• Late decision ?
• Handle easy to grab ?
• Safety pin not removed before flight ?

20

Same ULM Type, instrument panel somewhat different.
Difference in Ergonomy.
Parachute handle – on pilot’s side, or on passenger’s side ?

21

Regulation: certification:
CS 23.671 General
(b) Controls must be arranged and identified
to provide for convenience in operation and
to prevent the possibility of confusion and
subsequent inadvertent operation.

For ULM, CS 23 is not applicable.
Each designer has his own solution, and
they will be challenged only by YOUR
experience.
22

Other example
The passenger door opens in
flight, causing the pilot to take
appropriate actions, that
eventually force him to an
emergency landing.

• Door lock (simple – crude).
Plexy flexible. Once opened in
flight, difficult to close.
CS 23.783
(1) There must be means to lock and safeguard the door against
inadvertent opening during flight by persons, by cargo, or as a
result of mechanical failure.
23

The problem
• Once we determine a technical problem, we
can define recommendations to improve the
product, but:
What do we do with the recommendation ?
– We can not improve the Standard, there’s no standard.
– We can not address more than one manufacturer,
– What about retrofit ?

24

ULM and Engine failures

25

Fly Synthesis Storch
Summer 2009
• After propeller replacement, and subsequent
engine ground tests, the pilot took off for a
flight test.
• He encountered heavy engine vibration, that
forced him to an emergency landing.
• Airplane was slightly damaged.
Cause was identified as Vapor Lock.
26

1/5/2010 – FK9
Emergency landing after in-flight engine failure.
• Lots of corrosion found in carburettor.
Corrosion comes from water condensation in
fuel system (tank, lines, pump,…- MOGAS)
during long immobilisation periods.
- how to prevent ? Filling up, draining ?

• Fuel system was modified in-service, by
addition of a pressure regulator.
27

France
20/5/2010 – Mistral
23/5/2010 – CT Short Wing
Mistral: Engine failure in flight.
Emergency landing in field; terrain was very soft, airplane
severely damaged.
CT Short Wing: In short final, the engine suddenly stops
The pilot attempts to land, but hit trees, and crashes – wings
ripped off.
RH wing tank empty, 15-25 l fuel remaining in LH tank.
During LH turn, fuel system unprimed, engine stopped by
fuel starvation.
28

4 /6/2010: SG Rally
Damaged during landing
• Due to engine problems (heavy vibrations), the
pilot performed emergency landing on EBHN.
Coming in too fast, the landing was brutal, and
Nose Landing Gear collapsed.

29

Conclusion
• Engine in-flight failure are not exceptional.
– Use of MOGAS (water content, flash point,..)
– Local modifications,
– Other specific to the configuration of the
specific airplane.
And..
– Traditional causes (engine starvation,..)
30

Solutions
• In this case, we can design some generic
recommendations:
– Human Factors; ULM pilots should be more
prepared to react to engine failures at any time
(awareness, briefing, training,…)
– Generic technical solutions; impact on the use
of MOGAS.
• Protection of the equipment during winter,
• Risk of Vapour lock.

31

• Designing stop-gaps, accident after accidents
may not be satisfactory;
What can we do we make sure ULM flying
improves up to an acceptable level and, more
important, remains at that level ?

• More Regulation ?

32

Aviation Regulation and the ULM
• No significant changes in Regulation.
– ULM defined by capacity, weight, structural and stall speed limitation.
– => Extensive use of carbon fiber, Flaps, etc

• CS-VLA.
– 750 kg.
– “light” CS-23.
– Expensive.

• Lower Requirements for licencing,
– What about competence ?
– Human Factors training

• National requirements in Europe.
– EASA Flight Permit per Part 21A.701.

33

Evolution: new EU Regulation on
Accident Investigation.
* Every civil aviation accident or serious incident involving
aircraft other than specified in Annex II to the Regulation (EC)
No 216/2008 of the European Parliament and of the Council
shall be the subject of a safety investigation

( = No obligation of enquiry for ULMs)
• Safety investigation authorities may decide to investigate
incidents other than those referred to in paragraph 1 as well as
accidents or serious incidents to other types of aircraft, in
accordance with the national legislation of the Member States,
when they expect to draw safety lessons from them.
34

• US. NTSB; no enquiry for ULM crashes.
• To-day already, in some EU countries, ULM
crash investigations are given a low priority,
unless the Public determines otherwise.
• Common sense dictates that the initiative
to improve safety must come from the
ULM community itself.

35

Reason Model
• aviation is a complex socio-technical
system, where safety is ensured by a
series of defense barriers.
• Each barrier may present flaws (latent
or active) whose combination can lead
to an accident.
• An usafe act (active failure) alone
would not cause an accident.
• Latent failures are more easily
detected and corrected that human
errors, which are (globally) inevitable.

36

• The ULM community should reinforce its
Defense Barriers.
• Organisation: Federation and Clubs.
Create a Safety Climate
- Norms and rules
- Safety Programs

- To define a Safety Climate, we need to
assess the potential risk, and for that we
need data: YOUR experience.
37

Pyramid of Heinrich
• If a fatal accident is caused by
a specific combination of
events, an uncomplete series
of events causes INCIDENTS.
• If we identify all potentially
dangerous events AND with
that information, build-up the
defenses, we can avoid
ACCIDENTS.
38

SHARING EXPERIENCE
• By informing the Federation of the small
events and incidents that spoiled one of
your flights, you allow the Community to
understand the potential dangers and act
upon. (and respect confidentiality)
“Learn from mistakes of others; you won’t
live long enough to make them all by
yourself”
39

Human Factors
• To err is human.
• Human life (and flying) is full of decisions.
• It is therefore more important to know yourself
than to know how to fly your aircraft.
– Get-home-itis, Distraction, Communication,..

• Understanding human factors is a very important
step in improving your defenses.
40

Competence and Readiness
• You hold a pilot licence; but are you a
competent flyer ?
• How will you react when faced with a
potential dangerous situation?
• Assessing your competences with an
instructor is an opportunity to improve.
• When flying, be ready.
41

What is the Authority doing for
you ?

42

A series of work groups
within EASA are thinking
about how to improve
flight safety.(ESSI)
One of them is about General
Aviation (EGAST).

Initiative includes a leaflet
On Collision Avoidance,
and has been relayed to you
by the Federation.
There are technical Work
Groups dealing with MOGAS
43

and

An initiative to develop
Posters with comic strips
On high risk topics.
The first goes about taking
The right decision when the
Weather is below minimum.
They are expected in the
Coming months.

44

For Belgium, Accident reports are made public on the SPF/FOD website.
Recent reports (from 1st May 2007) are directly available through
hyperlinks.
Reports are written in English.
Information Notes are also available in order to highlight specific danger
area: Nr 2010 is about engine cold start.
We would like to develop more Notes, for ULM in collaboration with
the Federation.
Historical reports: currently a list is posted.
The list is fairly complete from 1972.
2 ancient reports (1936 and 1965).
The reports (Fr /Nl) are desidentified and available on request.
The list will be completed as we go along in reviewing archives.

45

Thank you for your attention, and
AAIU (Belgium) wishes you
many happy landings

Photos credit:
MRA / KLM

46


Slide 22

10 JULY 1910 - 2010
100 YEARS ULM ACCIDENTS

Belgian ULM Federation – Safety
1
Conference 10/10/2010

The Air Safety Investigation
• As part of the global Aviation sphere, an investigation is
conducted for each accident and serious incident by an
independent enquiry body, aimed to;
– Determine the causes of the accident.
– Determine if all conditions that were defined by rules and
regulations to ensure flight safety were followed (such as risk
factors in design).
– Define recommendations in order to prevent future accidents.

• It is not the purpose of this investigation to apportion
blame or liability.

2

In Belgium; the Air Accident
Investigation Unit.
• All accidents and serious incidents occurring in Belgium,
on aircraft, helicopters, gliders, balloons, ULM, DPM,
regardless of their registration is investigated by a cell
functionnally independent from the BCAA, and all other
interrested parties.
• Independent doesn’t mean isolated; it is part of the world’s
network of the State’s Aviation Investigation Bodies.
• The cell reports to the President of the Board of the
SPF/FOD Mobility and Transport.
3

4

ULM
• First pendular (Delta Plane Motorized)
design in 1966
• First crossing of the Channel in 1978 by Mr
D. Cook.
• Commercial development from 1979.
• Evolution from 2-axis to 3-axis.
• In Belgium, first ULM registered (501) in
1982.

5

6

Evolution
• 1982: Weedhopper, Chickinox
– 80…100 km/h
– Basic – 2/3 axis
– Range: … 200 km…

• 2010: VL-3 Sprint, DynAero MCR01, WT9 Dynamic….
– 220….250 km/h,
– flaps, retractable gear, avionics,
– Range over 1000 km

• 550 OO- registered ULM;
• 571 ULM pilot licence (363 training licences)
• 300-400 foreign-registered ULM.
7

1000
900
800
700
600
500
400
300
200
100

Number of valid registration

8

Estimation of flying OO-regd ULM

20
10

20
08

20
06

20
04

20
02

20
00

19
98

19
96

19
94

19
92

19
90

19
88

19
86

19
84

19
82

0

Evolution in pilot’s / owner’s
expectations
• In 1982, ULM /DPM, a sporting way of flying,
outside the limits of parachuting, delta plane.

• In 2010, an efficient alternative to general
(certified) aviation. ULM becomes a means of
transport.
• Beyond 2010 ?? – The Need for Speed ?
9

Evolution
• From the user’s perspective, the difference between
General Aviation and ULM becomes very thin.
• However, ULMs are characterized by a huge variety of
different design types, with low production rate and
configuration variation between individual airplanes.
– Manufacturers come and go,
– Assembly of the same ULM type by different companies induce
differences in built configuration.

• The above makes it more and more difficult to speak about
ULMs in a general way; variation in quality is wider than
General (certified) Aviation.
10

EVOLUTION: MORE ULM FATAL ACCIDENTS ?

Fatalities: (up to now), In Belgium, on average 2 /year,
comparable to General (certified) Aviation.
Number of fatalities
12
10
8
6
4
2

Number of fatalities

11

20
10

20
08

20
06

20
04

20
02

20
00

19
98

19
96

19
94

19
92

19
90

19
88

19
86

19
84

0

19
82

FATALITIES:
Figures limited to
Belgium.
2009: + 2 in France.
2010: + 5 in France.

WHAT ARE THE EXPECTATIONS
FOR THE
ULM-ACCIDENTS CASUALITY
RATE ?
• On Belgian soil, 4 deads in 2010.
(casuality rate of U.S. Forces in Iraq 3.6 killed /1000
troop / year – 8 years – 152000 troops – 4424 killed).

• In France and Belgium in 2010, 9 Belgian
deads to-date.
12

Comparison with the road
• In Belgium, the road kills 1000 people on average per year
.
• Fleet of vehicles: 6 000 000 units (5 mio cars).
• For 1000 cars, the road kills on average 0.16 person per
year.
• If we combine these figures with the yearly utilization rate
of cars (1 h per day) versus ULM (40 h per year), we can
conclude that ULM / General Aviation flying is
considerably deadlier than the road.

13

What can we learn from accident
investigation ?

14

The investigation process
A long process (Months)
• Collect all factual elements,
–
–
–
–
–
–

The flow of events;
The pilot (training, experience, …)
The aircraft (contact w/manufacturer)
Meteo, Comm, Radar,
Flt recorders (GPS, ECU, camera, …)
Impact, aircraft damage,

• Analysis. (incl. simulation, testing,…)
• Define all possible causes.
• From the causes, define remedial action.
The depth of the investigation is somewhat influenced by the
expected ROI.
15

Accident analysis
• Accidents do not occur “by accident”; Accident are
caused by a series of events.
• There are no “isolated cases”; causes of accidents are often
recurrent.
• Out of the ULM accident data base, we can conclude;
– There are recurrent technical problems specific to ULM.
– The traditional causes of aviation accidents are also known to
ULM (fuel shortage)

– 80% of the causal factors are human-related.

16

Main causal factors (122 accidents –
fixed wing and ULM)
Loss of control Take-off
11%

Fuel Starvation
15%

Loss of control Flight & collision
12%

Technical
11%
Low piloting
experience
8%

Loss of control Landing
16%
Icing
3%

Low flying /
aerobatics obstacles - CFIT
24%

17

Specific problems with ULM
• Technical causes can be (easily) identified;
but fire can be devastating.
• There’s another problem for the
investigator, a lot of landmarks are missing.
– ULM requirements are national,
– Certification not applicable.
– Wide variety of products.
18

About certification.
• Everyone would agree that ULMs of to-day are as good,
even a lot better than the ‘certified’ airplane.
• ULMs are designed to fly.
ULM are quality products; they meet your expectations
(simple to handle, fly fast, cheap in usage, …)
• Certification means that a manufacturer must demonstrate
that his product meets a minimum level of safety, as
defined (ultimately) by the Aviation Community.
• The minimum level of safety is defined in the Certification
Specifications – For small aircraft, it is called CS23.
19

Technical.
• AAIU(be) is currently investigating on:
– Instrument Board lay-out design.
– Electrical System design.
– Emergency Parachute.
Why is it that (for the last cases) parachute did not save lifes ?
• Late decision ?
• Handle easy to grab ?
• Safety pin not removed before flight ?

20

Same ULM Type, instrument panel somewhat different.
Difference in Ergonomy.
Parachute handle – on pilot’s side, or on passenger’s side ?

21

Regulation: certification:
CS 23.671 General
(b) Controls must be arranged and identified
to provide for convenience in operation and
to prevent the possibility of confusion and
subsequent inadvertent operation.

For ULM, CS 23 is not applicable.
Each designer has his own solution, and
they will be challenged only by YOUR
experience.
22

Other example
The passenger door opens in
flight, causing the pilot to take
appropriate actions, that
eventually force him to an
emergency landing.

• Door lock (simple – crude).
Plexy flexible. Once opened in
flight, difficult to close.
CS 23.783
(1) There must be means to lock and safeguard the door against
inadvertent opening during flight by persons, by cargo, or as a
result of mechanical failure.
23

The problem
• Once we determine a technical problem, we
can define recommendations to improve the
product, but:
What do we do with the recommendation ?
– We can not improve the Standard, there’s no standard.
– We can not address more than one manufacturer,
– What about retrofit ?

24

ULM and Engine failures

25

Fly Synthesis Storch
Summer 2009
• After propeller replacement, and subsequent
engine ground tests, the pilot took off for a
flight test.
• He encountered heavy engine vibration, that
forced him to an emergency landing.
• Airplane was slightly damaged.
Cause was identified as Vapor Lock.
26

1/5/2010 – FK9
Emergency landing after in-flight engine failure.
• Lots of corrosion found in carburettor.
Corrosion comes from water condensation in
fuel system (tank, lines, pump,…- MOGAS)
during long immobilisation periods.
- how to prevent ? Filling up, draining ?

• Fuel system was modified in-service, by
addition of a pressure regulator.
27

France
20/5/2010 – Mistral
23/5/2010 – CT Short Wing
Mistral: Engine failure in flight.
Emergency landing in field; terrain was very soft, airplane
severely damaged.
CT Short Wing: In short final, the engine suddenly stops
The pilot attempts to land, but hit trees, and crashes – wings
ripped off.
RH wing tank empty, 15-25 l fuel remaining in LH tank.
During LH turn, fuel system unprimed, engine stopped by
fuel starvation.
28

4 /6/2010: SG Rally
Damaged during landing
• Due to engine problems (heavy vibrations), the
pilot performed emergency landing on EBHN.
Coming in too fast, the landing was brutal, and
Nose Landing Gear collapsed.

29

Conclusion
• Engine in-flight failure are not exceptional.
– Use of MOGAS (water content, flash point,..)
– Local modifications,
– Other specific to the configuration of the
specific airplane.
And..
– Traditional causes (engine starvation,..)
30

Solutions
• In this case, we can design some generic
recommendations:
– Human Factors; ULM pilots should be more
prepared to react to engine failures at any time
(awareness, briefing, training,…)
– Generic technical solutions; impact on the use
of MOGAS.
• Protection of the equipment during winter,
• Risk of Vapour lock.

31

• Designing stop-gaps, accident after accidents
may not be satisfactory;
What can we do we make sure ULM flying
improves up to an acceptable level and, more
important, remains at that level ?

• More Regulation ?

32

Aviation Regulation and the ULM
• No significant changes in Regulation.
– ULM defined by capacity, weight, structural and stall speed limitation.
– => Extensive use of carbon fiber, Flaps, etc

• CS-VLA.
– 750 kg.
– “light” CS-23.
– Expensive.

• Lower Requirements for licencing,
– What about competence ?
– Human Factors training

• National requirements in Europe.
– EASA Flight Permit per Part 21A.701.

33

Evolution: new EU Regulation on
Accident Investigation.
* Every civil aviation accident or serious incident involving
aircraft other than specified in Annex II to the Regulation (EC)
No 216/2008 of the European Parliament and of the Council
shall be the subject of a safety investigation

( = No obligation of enquiry for ULMs)
• Safety investigation authorities may decide to investigate
incidents other than those referred to in paragraph 1 as well as
accidents or serious incidents to other types of aircraft, in
accordance with the national legislation of the Member States,
when they expect to draw safety lessons from them.
34

• US. NTSB; no enquiry for ULM crashes.
• To-day already, in some EU countries, ULM
crash investigations are given a low priority,
unless the Public determines otherwise.
• Common sense dictates that the initiative
to improve safety must come from the
ULM community itself.

35

Reason Model
• aviation is a complex socio-technical
system, where safety is ensured by a
series of defense barriers.
• Each barrier may present flaws (latent
or active) whose combination can lead
to an accident.
• An usafe act (active failure) alone
would not cause an accident.
• Latent failures are more easily
detected and corrected that human
errors, which are (globally) inevitable.

36

• The ULM community should reinforce its
Defense Barriers.
• Organisation: Federation and Clubs.
Create a Safety Climate
- Norms and rules
- Safety Programs

- To define a Safety Climate, we need to
assess the potential risk, and for that we
need data: YOUR experience.
37

Pyramid of Heinrich
• If a fatal accident is caused by
a specific combination of
events, an uncomplete series
of events causes INCIDENTS.
• If we identify all potentially
dangerous events AND with
that information, build-up the
defenses, we can avoid
ACCIDENTS.
38

SHARING EXPERIENCE
• By informing the Federation of the small
events and incidents that spoiled one of
your flights, you allow the Community to
understand the potential dangers and act
upon. (and respect confidentiality)
“Learn from mistakes of others; you won’t
live long enough to make them all by
yourself”
39

Human Factors
• To err is human.
• Human life (and flying) is full of decisions.
• It is therefore more important to know yourself
than to know how to fly your aircraft.
– Get-home-itis, Distraction, Communication,..

• Understanding human factors is a very important
step in improving your defenses.
40

Competence and Readiness
• You hold a pilot licence; but are you a
competent flyer ?
• How will you react when faced with a
potential dangerous situation?
• Assessing your competences with an
instructor is an opportunity to improve.
• When flying, be ready.
41

What is the Authority doing for
you ?

42

A series of work groups
within EASA are thinking
about how to improve
flight safety.(ESSI)
One of them is about General
Aviation (EGAST).

Initiative includes a leaflet
On Collision Avoidance,
and has been relayed to you
by the Federation.
There are technical Work
Groups dealing with MOGAS
43

and

An initiative to develop
Posters with comic strips
On high risk topics.
The first goes about taking
The right decision when the
Weather is below minimum.
They are expected in the
Coming months.

44

For Belgium, Accident reports are made public on the SPF/FOD website.
Recent reports (from 1st May 2007) are directly available through
hyperlinks.
Reports are written in English.
Information Notes are also available in order to highlight specific danger
area: Nr 2010 is about engine cold start.
We would like to develop more Notes, for ULM in collaboration with
the Federation.
Historical reports: currently a list is posted.
The list is fairly complete from 1972.
2 ancient reports (1936 and 1965).
The reports (Fr /Nl) are desidentified and available on request.
The list will be completed as we go along in reviewing archives.

45

Thank you for your attention, and
AAIU (Belgium) wishes you
many happy landings

Photos credit:
MRA / KLM

46


Slide 23

10 JULY 1910 - 2010
100 YEARS ULM ACCIDENTS

Belgian ULM Federation – Safety
1
Conference 10/10/2010

The Air Safety Investigation
• As part of the global Aviation sphere, an investigation is
conducted for each accident and serious incident by an
independent enquiry body, aimed to;
– Determine the causes of the accident.
– Determine if all conditions that were defined by rules and
regulations to ensure flight safety were followed (such as risk
factors in design).
– Define recommendations in order to prevent future accidents.

• It is not the purpose of this investigation to apportion
blame or liability.

2

In Belgium; the Air Accident
Investigation Unit.
• All accidents and serious incidents occurring in Belgium,
on aircraft, helicopters, gliders, balloons, ULM, DPM,
regardless of their registration is investigated by a cell
functionnally independent from the BCAA, and all other
interrested parties.
• Independent doesn’t mean isolated; it is part of the world’s
network of the State’s Aviation Investigation Bodies.
• The cell reports to the President of the Board of the
SPF/FOD Mobility and Transport.
3

4

ULM
• First pendular (Delta Plane Motorized)
design in 1966
• First crossing of the Channel in 1978 by Mr
D. Cook.
• Commercial development from 1979.
• Evolution from 2-axis to 3-axis.
• In Belgium, first ULM registered (501) in
1982.

5

6

Evolution
• 1982: Weedhopper, Chickinox
– 80…100 km/h
– Basic – 2/3 axis
– Range: … 200 km…

• 2010: VL-3 Sprint, DynAero MCR01, WT9 Dynamic….
– 220….250 km/h,
– flaps, retractable gear, avionics,
– Range over 1000 km

• 550 OO- registered ULM;
• 571 ULM pilot licence (363 training licences)
• 300-400 foreign-registered ULM.
7

1000
900
800
700
600
500
400
300
200
100

Number of valid registration

8

Estimation of flying OO-regd ULM

20
10

20
08

20
06

20
04

20
02

20
00

19
98

19
96

19
94

19
92

19
90

19
88

19
86

19
84

19
82

0

Evolution in pilot’s / owner’s
expectations
• In 1982, ULM /DPM, a sporting way of flying,
outside the limits of parachuting, delta plane.

• In 2010, an efficient alternative to general
(certified) aviation. ULM becomes a means of
transport.
• Beyond 2010 ?? – The Need for Speed ?
9

Evolution
• From the user’s perspective, the difference between
General Aviation and ULM becomes very thin.
• However, ULMs are characterized by a huge variety of
different design types, with low production rate and
configuration variation between individual airplanes.
– Manufacturers come and go,
– Assembly of the same ULM type by different companies induce
differences in built configuration.

• The above makes it more and more difficult to speak about
ULMs in a general way; variation in quality is wider than
General (certified) Aviation.
10

EVOLUTION: MORE ULM FATAL ACCIDENTS ?

Fatalities: (up to now), In Belgium, on average 2 /year,
comparable to General (certified) Aviation.
Number of fatalities
12
10
8
6
4
2

Number of fatalities

11

20
10

20
08

20
06

20
04

20
02

20
00

19
98

19
96

19
94

19
92

19
90

19
88

19
86

19
84

0

19
82

FATALITIES:
Figures limited to
Belgium.
2009: + 2 in France.
2010: + 5 in France.

WHAT ARE THE EXPECTATIONS
FOR THE
ULM-ACCIDENTS CASUALITY
RATE ?
• On Belgian soil, 4 deads in 2010.
(casuality rate of U.S. Forces in Iraq 3.6 killed /1000
troop / year – 8 years – 152000 troops – 4424 killed).

• In France and Belgium in 2010, 9 Belgian
deads to-date.
12

Comparison with the road
• In Belgium, the road kills 1000 people on average per year
.
• Fleet of vehicles: 6 000 000 units (5 mio cars).
• For 1000 cars, the road kills on average 0.16 person per
year.
• If we combine these figures with the yearly utilization rate
of cars (1 h per day) versus ULM (40 h per year), we can
conclude that ULM / General Aviation flying is
considerably deadlier than the road.

13

What can we learn from accident
investigation ?

14

The investigation process
A long process (Months)
• Collect all factual elements,
–
–
–
–
–
–

The flow of events;
The pilot (training, experience, …)
The aircraft (contact w/manufacturer)
Meteo, Comm, Radar,
Flt recorders (GPS, ECU, camera, …)
Impact, aircraft damage,

• Analysis. (incl. simulation, testing,…)
• Define all possible causes.
• From the causes, define remedial action.
The depth of the investigation is somewhat influenced by the
expected ROI.
15

Accident analysis
• Accidents do not occur “by accident”; Accident are
caused by a series of events.
• There are no “isolated cases”; causes of accidents are often
recurrent.
• Out of the ULM accident data base, we can conclude;
– There are recurrent technical problems specific to ULM.
– The traditional causes of aviation accidents are also known to
ULM (fuel shortage)

– 80% of the causal factors are human-related.

16

Main causal factors (122 accidents –
fixed wing and ULM)
Loss of control Take-off
11%

Fuel Starvation
15%

Loss of control Flight & collision
12%

Technical
11%
Low piloting
experience
8%

Loss of control Landing
16%
Icing
3%

Low flying /
aerobatics obstacles - CFIT
24%

17

Specific problems with ULM
• Technical causes can be (easily) identified;
but fire can be devastating.
• There’s another problem for the
investigator, a lot of landmarks are missing.
– ULM requirements are national,
– Certification not applicable.
– Wide variety of products.
18

About certification.
• Everyone would agree that ULMs of to-day are as good,
even a lot better than the ‘certified’ airplane.
• ULMs are designed to fly.
ULM are quality products; they meet your expectations
(simple to handle, fly fast, cheap in usage, …)
• Certification means that a manufacturer must demonstrate
that his product meets a minimum level of safety, as
defined (ultimately) by the Aviation Community.
• The minimum level of safety is defined in the Certification
Specifications – For small aircraft, it is called CS23.
19

Technical.
• AAIU(be) is currently investigating on:
– Instrument Board lay-out design.
– Electrical System design.
– Emergency Parachute.
Why is it that (for the last cases) parachute did not save lifes ?
• Late decision ?
• Handle easy to grab ?
• Safety pin not removed before flight ?

20

Same ULM Type, instrument panel somewhat different.
Difference in Ergonomy.
Parachute handle – on pilot’s side, or on passenger’s side ?

21

Regulation: certification:
CS 23.671 General
(b) Controls must be arranged and identified
to provide for convenience in operation and
to prevent the possibility of confusion and
subsequent inadvertent operation.

For ULM, CS 23 is not applicable.
Each designer has his own solution, and
they will be challenged only by YOUR
experience.
22

Other example
The passenger door opens in
flight, causing the pilot to take
appropriate actions, that
eventually force him to an
emergency landing.

• Door lock (simple – crude).
Plexy flexible. Once opened in
flight, difficult to close.
CS 23.783
(1) There must be means to lock and safeguard the door against
inadvertent opening during flight by persons, by cargo, or as a
result of mechanical failure.
23

The problem
• Once we determine a technical problem, we
can define recommendations to improve the
product, but:
What do we do with the recommendation ?
– We can not improve the Standard, there’s no standard.
– We can not address more than one manufacturer,
– What about retrofit ?

24

ULM and Engine failures

25

Fly Synthesis Storch
Summer 2009
• After propeller replacement, and subsequent
engine ground tests, the pilot took off for a
flight test.
• He encountered heavy engine vibration, that
forced him to an emergency landing.
• Airplane was slightly damaged.
Cause was identified as Vapor Lock.
26

1/5/2010 – FK9
Emergency landing after in-flight engine failure.
• Lots of corrosion found in carburettor.
Corrosion comes from water condensation in
fuel system (tank, lines, pump,…- MOGAS)
during long immobilisation periods.
- how to prevent ? Filling up, draining ?

• Fuel system was modified in-service, by
addition of a pressure regulator.
27

France
20/5/2010 – Mistral
23/5/2010 – CT Short Wing
Mistral: Engine failure in flight.
Emergency landing in field; terrain was very soft, airplane
severely damaged.
CT Short Wing: In short final, the engine suddenly stops
The pilot attempts to land, but hit trees, and crashes – wings
ripped off.
RH wing tank empty, 15-25 l fuel remaining in LH tank.
During LH turn, fuel system unprimed, engine stopped by
fuel starvation.
28

4 /6/2010: SG Rally
Damaged during landing
• Due to engine problems (heavy vibrations), the
pilot performed emergency landing on EBHN.
Coming in too fast, the landing was brutal, and
Nose Landing Gear collapsed.

29

Conclusion
• Engine in-flight failure are not exceptional.
– Use of MOGAS (water content, flash point,..)
– Local modifications,
– Other specific to the configuration of the
specific airplane.
And..
– Traditional causes (engine starvation,..)
30

Solutions
• In this case, we can design some generic
recommendations:
– Human Factors; ULM pilots should be more
prepared to react to engine failures at any time
(awareness, briefing, training,…)
– Generic technical solutions; impact on the use
of MOGAS.
• Protection of the equipment during winter,
• Risk of Vapour lock.

31

• Designing stop-gaps, accident after accidents
may not be satisfactory;
What can we do we make sure ULM flying
improves up to an acceptable level and, more
important, remains at that level ?

• More Regulation ?

32

Aviation Regulation and the ULM
• No significant changes in Regulation.
– ULM defined by capacity, weight, structural and stall speed limitation.
– => Extensive use of carbon fiber, Flaps, etc

• CS-VLA.
– 750 kg.
– “light” CS-23.
– Expensive.

• Lower Requirements for licencing,
– What about competence ?
– Human Factors training

• National requirements in Europe.
– EASA Flight Permit per Part 21A.701.

33

Evolution: new EU Regulation on
Accident Investigation.
* Every civil aviation accident or serious incident involving
aircraft other than specified in Annex II to the Regulation (EC)
No 216/2008 of the European Parliament and of the Council
shall be the subject of a safety investigation

( = No obligation of enquiry for ULMs)
• Safety investigation authorities may decide to investigate
incidents other than those referred to in paragraph 1 as well as
accidents or serious incidents to other types of aircraft, in
accordance with the national legislation of the Member States,
when they expect to draw safety lessons from them.
34

• US. NTSB; no enquiry for ULM crashes.
• To-day already, in some EU countries, ULM
crash investigations are given a low priority,
unless the Public determines otherwise.
• Common sense dictates that the initiative
to improve safety must come from the
ULM community itself.

35

Reason Model
• aviation is a complex socio-technical
system, where safety is ensured by a
series of defense barriers.
• Each barrier may present flaws (latent
or active) whose combination can lead
to an accident.
• An usafe act (active failure) alone
would not cause an accident.
• Latent failures are more easily
detected and corrected that human
errors, which are (globally) inevitable.

36

• The ULM community should reinforce its
Defense Barriers.
• Organisation: Federation and Clubs.
Create a Safety Climate
- Norms and rules
- Safety Programs

- To define a Safety Climate, we need to
assess the potential risk, and for that we
need data: YOUR experience.
37

Pyramid of Heinrich
• If a fatal accident is caused by
a specific combination of
events, an uncomplete series
of events causes INCIDENTS.
• If we identify all potentially
dangerous events AND with
that information, build-up the
defenses, we can avoid
ACCIDENTS.
38

SHARING EXPERIENCE
• By informing the Federation of the small
events and incidents that spoiled one of
your flights, you allow the Community to
understand the potential dangers and act
upon. (and respect confidentiality)
“Learn from mistakes of others; you won’t
live long enough to make them all by
yourself”
39

Human Factors
• To err is human.
• Human life (and flying) is full of decisions.
• It is therefore more important to know yourself
than to know how to fly your aircraft.
– Get-home-itis, Distraction, Communication,..

• Understanding human factors is a very important
step in improving your defenses.
40

Competence and Readiness
• You hold a pilot licence; but are you a
competent flyer ?
• How will you react when faced with a
potential dangerous situation?
• Assessing your competences with an
instructor is an opportunity to improve.
• When flying, be ready.
41

What is the Authority doing for
you ?

42

A series of work groups
within EASA are thinking
about how to improve
flight safety.(ESSI)
One of them is about General
Aviation (EGAST).

Initiative includes a leaflet
On Collision Avoidance,
and has been relayed to you
by the Federation.
There are technical Work
Groups dealing with MOGAS
43

and

An initiative to develop
Posters with comic strips
On high risk topics.
The first goes about taking
The right decision when the
Weather is below minimum.
They are expected in the
Coming months.

44

For Belgium, Accident reports are made public on the SPF/FOD website.
Recent reports (from 1st May 2007) are directly available through
hyperlinks.
Reports are written in English.
Information Notes are also available in order to highlight specific danger
area: Nr 2010 is about engine cold start.
We would like to develop more Notes, for ULM in collaboration with
the Federation.
Historical reports: currently a list is posted.
The list is fairly complete from 1972.
2 ancient reports (1936 and 1965).
The reports (Fr /Nl) are desidentified and available on request.
The list will be completed as we go along in reviewing archives.

45

Thank you for your attention, and
AAIU (Belgium) wishes you
many happy landings

Photos credit:
MRA / KLM

46


Slide 24

10 JULY 1910 - 2010
100 YEARS ULM ACCIDENTS

Belgian ULM Federation – Safety
1
Conference 10/10/2010

The Air Safety Investigation
• As part of the global Aviation sphere, an investigation is
conducted for each accident and serious incident by an
independent enquiry body, aimed to;
– Determine the causes of the accident.
– Determine if all conditions that were defined by rules and
regulations to ensure flight safety were followed (such as risk
factors in design).
– Define recommendations in order to prevent future accidents.

• It is not the purpose of this investigation to apportion
blame or liability.

2

In Belgium; the Air Accident
Investigation Unit.
• All accidents and serious incidents occurring in Belgium,
on aircraft, helicopters, gliders, balloons, ULM, DPM,
regardless of their registration is investigated by a cell
functionnally independent from the BCAA, and all other
interrested parties.
• Independent doesn’t mean isolated; it is part of the world’s
network of the State’s Aviation Investigation Bodies.
• The cell reports to the President of the Board of the
SPF/FOD Mobility and Transport.
3

4

ULM
• First pendular (Delta Plane Motorized)
design in 1966
• First crossing of the Channel in 1978 by Mr
D. Cook.
• Commercial development from 1979.
• Evolution from 2-axis to 3-axis.
• In Belgium, first ULM registered (501) in
1982.

5

6

Evolution
• 1982: Weedhopper, Chickinox
– 80…100 km/h
– Basic – 2/3 axis
– Range: … 200 km…

• 2010: VL-3 Sprint, DynAero MCR01, WT9 Dynamic….
– 220….250 km/h,
– flaps, retractable gear, avionics,
– Range over 1000 km

• 550 OO- registered ULM;
• 571 ULM pilot licence (363 training licences)
• 300-400 foreign-registered ULM.
7

1000
900
800
700
600
500
400
300
200
100

Number of valid registration

8

Estimation of flying OO-regd ULM

20
10

20
08

20
06

20
04

20
02

20
00

19
98

19
96

19
94

19
92

19
90

19
88

19
86

19
84

19
82

0

Evolution in pilot’s / owner’s
expectations
• In 1982, ULM /DPM, a sporting way of flying,
outside the limits of parachuting, delta plane.

• In 2010, an efficient alternative to general
(certified) aviation. ULM becomes a means of
transport.
• Beyond 2010 ?? – The Need for Speed ?
9

Evolution
• From the user’s perspective, the difference between
General Aviation and ULM becomes very thin.
• However, ULMs are characterized by a huge variety of
different design types, with low production rate and
configuration variation between individual airplanes.
– Manufacturers come and go,
– Assembly of the same ULM type by different companies induce
differences in built configuration.

• The above makes it more and more difficult to speak about
ULMs in a general way; variation in quality is wider than
General (certified) Aviation.
10

EVOLUTION: MORE ULM FATAL ACCIDENTS ?

Fatalities: (up to now), In Belgium, on average 2 /year,
comparable to General (certified) Aviation.
Number of fatalities
12
10
8
6
4
2

Number of fatalities

11

20
10

20
08

20
06

20
04

20
02

20
00

19
98

19
96

19
94

19
92

19
90

19
88

19
86

19
84

0

19
82

FATALITIES:
Figures limited to
Belgium.
2009: + 2 in France.
2010: + 5 in France.

WHAT ARE THE EXPECTATIONS
FOR THE
ULM-ACCIDENTS CASUALITY
RATE ?
• On Belgian soil, 4 deads in 2010.
(casuality rate of U.S. Forces in Iraq 3.6 killed /1000
troop / year – 8 years – 152000 troops – 4424 killed).

• In France and Belgium in 2010, 9 Belgian
deads to-date.
12

Comparison with the road
• In Belgium, the road kills 1000 people on average per year
.
• Fleet of vehicles: 6 000 000 units (5 mio cars).
• For 1000 cars, the road kills on average 0.16 person per
year.
• If we combine these figures with the yearly utilization rate
of cars (1 h per day) versus ULM (40 h per year), we can
conclude that ULM / General Aviation flying is
considerably deadlier than the road.

13

What can we learn from accident
investigation ?

14

The investigation process
A long process (Months)
• Collect all factual elements,
–
–
–
–
–
–

The flow of events;
The pilot (training, experience, …)
The aircraft (contact w/manufacturer)
Meteo, Comm, Radar,
Flt recorders (GPS, ECU, camera, …)
Impact, aircraft damage,

• Analysis. (incl. simulation, testing,…)
• Define all possible causes.
• From the causes, define remedial action.
The depth of the investigation is somewhat influenced by the
expected ROI.
15

Accident analysis
• Accidents do not occur “by accident”; Accident are
caused by a series of events.
• There are no “isolated cases”; causes of accidents are often
recurrent.
• Out of the ULM accident data base, we can conclude;
– There are recurrent technical problems specific to ULM.
– The traditional causes of aviation accidents are also known to
ULM (fuel shortage)

– 80% of the causal factors are human-related.

16

Main causal factors (122 accidents –
fixed wing and ULM)
Loss of control Take-off
11%

Fuel Starvation
15%

Loss of control Flight & collision
12%

Technical
11%
Low piloting
experience
8%

Loss of control Landing
16%
Icing
3%

Low flying /
aerobatics obstacles - CFIT
24%

17

Specific problems with ULM
• Technical causes can be (easily) identified;
but fire can be devastating.
• There’s another problem for the
investigator, a lot of landmarks are missing.
– ULM requirements are national,
– Certification not applicable.
– Wide variety of products.
18

About certification.
• Everyone would agree that ULMs of to-day are as good,
even a lot better than the ‘certified’ airplane.
• ULMs are designed to fly.
ULM are quality products; they meet your expectations
(simple to handle, fly fast, cheap in usage, …)
• Certification means that a manufacturer must demonstrate
that his product meets a minimum level of safety, as
defined (ultimately) by the Aviation Community.
• The minimum level of safety is defined in the Certification
Specifications – For small aircraft, it is called CS23.
19

Technical.
• AAIU(be) is currently investigating on:
– Instrument Board lay-out design.
– Electrical System design.
– Emergency Parachute.
Why is it that (for the last cases) parachute did not save lifes ?
• Late decision ?
• Handle easy to grab ?
• Safety pin not removed before flight ?

20

Same ULM Type, instrument panel somewhat different.
Difference in Ergonomy.
Parachute handle – on pilot’s side, or on passenger’s side ?

21

Regulation: certification:
CS 23.671 General
(b) Controls must be arranged and identified
to provide for convenience in operation and
to prevent the possibility of confusion and
subsequent inadvertent operation.

For ULM, CS 23 is not applicable.
Each designer has his own solution, and
they will be challenged only by YOUR
experience.
22

Other example
The passenger door opens in
flight, causing the pilot to take
appropriate actions, that
eventually force him to an
emergency landing.

• Door lock (simple – crude).
Plexy flexible. Once opened in
flight, difficult to close.
CS 23.783
(1) There must be means to lock and safeguard the door against
inadvertent opening during flight by persons, by cargo, or as a
result of mechanical failure.
23

The problem
• Once we determine a technical problem, we
can define recommendations to improve the
product, but:
What do we do with the recommendation ?
– We can not improve the Standard, there’s no standard.
– We can not address more than one manufacturer,
– What about retrofit ?

24

ULM and Engine failures

25

Fly Synthesis Storch
Summer 2009
• After propeller replacement, and subsequent
engine ground tests, the pilot took off for a
flight test.
• He encountered heavy engine vibration, that
forced him to an emergency landing.
• Airplane was slightly damaged.
Cause was identified as Vapor Lock.
26

1/5/2010 – FK9
Emergency landing after in-flight engine failure.
• Lots of corrosion found in carburettor.
Corrosion comes from water condensation in
fuel system (tank, lines, pump,…- MOGAS)
during long immobilisation periods.
- how to prevent ? Filling up, draining ?

• Fuel system was modified in-service, by
addition of a pressure regulator.
27

France
20/5/2010 – Mistral
23/5/2010 – CT Short Wing
Mistral: Engine failure in flight.
Emergency landing in field; terrain was very soft, airplane
severely damaged.
CT Short Wing: In short final, the engine suddenly stops
The pilot attempts to land, but hit trees, and crashes – wings
ripped off.
RH wing tank empty, 15-25 l fuel remaining in LH tank.
During LH turn, fuel system unprimed, engine stopped by
fuel starvation.
28

4 /6/2010: SG Rally
Damaged during landing
• Due to engine problems (heavy vibrations), the
pilot performed emergency landing on EBHN.
Coming in too fast, the landing was brutal, and
Nose Landing Gear collapsed.

29

Conclusion
• Engine in-flight failure are not exceptional.
– Use of MOGAS (water content, flash point,..)
– Local modifications,
– Other specific to the configuration of the
specific airplane.
And..
– Traditional causes (engine starvation,..)
30

Solutions
• In this case, we can design some generic
recommendations:
– Human Factors; ULM pilots should be more
prepared to react to engine failures at any time
(awareness, briefing, training,…)
– Generic technical solutions; impact on the use
of MOGAS.
• Protection of the equipment during winter,
• Risk of Vapour lock.

31

• Designing stop-gaps, accident after accidents
may not be satisfactory;
What can we do we make sure ULM flying
improves up to an acceptable level and, more
important, remains at that level ?

• More Regulation ?

32

Aviation Regulation and the ULM
• No significant changes in Regulation.
– ULM defined by capacity, weight, structural and stall speed limitation.
– => Extensive use of carbon fiber, Flaps, etc

• CS-VLA.
– 750 kg.
– “light” CS-23.
– Expensive.

• Lower Requirements for licencing,
– What about competence ?
– Human Factors training

• National requirements in Europe.
– EASA Flight Permit per Part 21A.701.

33

Evolution: new EU Regulation on
Accident Investigation.
* Every civil aviation accident or serious incident involving
aircraft other than specified in Annex II to the Regulation (EC)
No 216/2008 of the European Parliament and of the Council
shall be the subject of a safety investigation

( = No obligation of enquiry for ULMs)
• Safety investigation authorities may decide to investigate
incidents other than those referred to in paragraph 1 as well as
accidents or serious incidents to other types of aircraft, in
accordance with the national legislation of the Member States,
when they expect to draw safety lessons from them.
34

• US. NTSB; no enquiry for ULM crashes.
• To-day already, in some EU countries, ULM
crash investigations are given a low priority,
unless the Public determines otherwise.
• Common sense dictates that the initiative
to improve safety must come from the
ULM community itself.

35

Reason Model
• aviation is a complex socio-technical
system, where safety is ensured by a
series of defense barriers.
• Each barrier may present flaws (latent
or active) whose combination can lead
to an accident.
• An usafe act (active failure) alone
would not cause an accident.
• Latent failures are more easily
detected and corrected that human
errors, which are (globally) inevitable.

36

• The ULM community should reinforce its
Defense Barriers.
• Organisation: Federation and Clubs.
Create a Safety Climate
- Norms and rules
- Safety Programs

- To define a Safety Climate, we need to
assess the potential risk, and for that we
need data: YOUR experience.
37

Pyramid of Heinrich
• If a fatal accident is caused by
a specific combination of
events, an uncomplete series
of events causes INCIDENTS.
• If we identify all potentially
dangerous events AND with
that information, build-up the
defenses, we can avoid
ACCIDENTS.
38

SHARING EXPERIENCE
• By informing the Federation of the small
events and incidents that spoiled one of
your flights, you allow the Community to
understand the potential dangers and act
upon. (and respect confidentiality)
“Learn from mistakes of others; you won’t
live long enough to make them all by
yourself”
39

Human Factors
• To err is human.
• Human life (and flying) is full of decisions.
• It is therefore more important to know yourself
than to know how to fly your aircraft.
– Get-home-itis, Distraction, Communication,..

• Understanding human factors is a very important
step in improving your defenses.
40

Competence and Readiness
• You hold a pilot licence; but are you a
competent flyer ?
• How will you react when faced with a
potential dangerous situation?
• Assessing your competences with an
instructor is an opportunity to improve.
• When flying, be ready.
41

What is the Authority doing for
you ?

42

A series of work groups
within EASA are thinking
about how to improve
flight safety.(ESSI)
One of them is about General
Aviation (EGAST).

Initiative includes a leaflet
On Collision Avoidance,
and has been relayed to you
by the Federation.
There are technical Work
Groups dealing with MOGAS
43

and

An initiative to develop
Posters with comic strips
On high risk topics.
The first goes about taking
The right decision when the
Weather is below minimum.
They are expected in the
Coming months.

44

For Belgium, Accident reports are made public on the SPF/FOD website.
Recent reports (from 1st May 2007) are directly available through
hyperlinks.
Reports are written in English.
Information Notes are also available in order to highlight specific danger
area: Nr 2010 is about engine cold start.
We would like to develop more Notes, for ULM in collaboration with
the Federation.
Historical reports: currently a list is posted.
The list is fairly complete from 1972.
2 ancient reports (1936 and 1965).
The reports (Fr /Nl) are desidentified and available on request.
The list will be completed as we go along in reviewing archives.

45

Thank you for your attention, and
AAIU (Belgium) wishes you
many happy landings

Photos credit:
MRA / KLM

46


Slide 25

10 JULY 1910 - 2010
100 YEARS ULM ACCIDENTS

Belgian ULM Federation – Safety
1
Conference 10/10/2010

The Air Safety Investigation
• As part of the global Aviation sphere, an investigation is
conducted for each accident and serious incident by an
independent enquiry body, aimed to;
– Determine the causes of the accident.
– Determine if all conditions that were defined by rules and
regulations to ensure flight safety were followed (such as risk
factors in design).
– Define recommendations in order to prevent future accidents.

• It is not the purpose of this investigation to apportion
blame or liability.

2

In Belgium; the Air Accident
Investigation Unit.
• All accidents and serious incidents occurring in Belgium,
on aircraft, helicopters, gliders, balloons, ULM, DPM,
regardless of their registration is investigated by a cell
functionnally independent from the BCAA, and all other
interrested parties.
• Independent doesn’t mean isolated; it is part of the world’s
network of the State’s Aviation Investigation Bodies.
• The cell reports to the President of the Board of the
SPF/FOD Mobility and Transport.
3

4

ULM
• First pendular (Delta Plane Motorized)
design in 1966
• First crossing of the Channel in 1978 by Mr
D. Cook.
• Commercial development from 1979.
• Evolution from 2-axis to 3-axis.
• In Belgium, first ULM registered (501) in
1982.

5

6

Evolution
• 1982: Weedhopper, Chickinox
– 80…100 km/h
– Basic – 2/3 axis
– Range: … 200 km…

• 2010: VL-3 Sprint, DynAero MCR01, WT9 Dynamic….
– 220….250 km/h,
– flaps, retractable gear, avionics,
– Range over 1000 km

• 550 OO- registered ULM;
• 571 ULM pilot licence (363 training licences)
• 300-400 foreign-registered ULM.
7

1000
900
800
700
600
500
400
300
200
100

Number of valid registration

8

Estimation of flying OO-regd ULM

20
10

20
08

20
06

20
04

20
02

20
00

19
98

19
96

19
94

19
92

19
90

19
88

19
86

19
84

19
82

0

Evolution in pilot’s / owner’s
expectations
• In 1982, ULM /DPM, a sporting way of flying,
outside the limits of parachuting, delta plane.

• In 2010, an efficient alternative to general
(certified) aviation. ULM becomes a means of
transport.
• Beyond 2010 ?? – The Need for Speed ?
9

Evolution
• From the user’s perspective, the difference between
General Aviation and ULM becomes very thin.
• However, ULMs are characterized by a huge variety of
different design types, with low production rate and
configuration variation between individual airplanes.
– Manufacturers come and go,
– Assembly of the same ULM type by different companies induce
differences in built configuration.

• The above makes it more and more difficult to speak about
ULMs in a general way; variation in quality is wider than
General (certified) Aviation.
10

EVOLUTION: MORE ULM FATAL ACCIDENTS ?

Fatalities: (up to now), In Belgium, on average 2 /year,
comparable to General (certified) Aviation.
Number of fatalities
12
10
8
6
4
2

Number of fatalities

11

20
10

20
08

20
06

20
04

20
02

20
00

19
98

19
96

19
94

19
92

19
90

19
88

19
86

19
84

0

19
82

FATALITIES:
Figures limited to
Belgium.
2009: + 2 in France.
2010: + 5 in France.

WHAT ARE THE EXPECTATIONS
FOR THE
ULM-ACCIDENTS CASUALITY
RATE ?
• On Belgian soil, 4 deads in 2010.
(casuality rate of U.S. Forces in Iraq 3.6 killed /1000
troop / year – 8 years – 152000 troops – 4424 killed).

• In France and Belgium in 2010, 9 Belgian
deads to-date.
12

Comparison with the road
• In Belgium, the road kills 1000 people on average per year
.
• Fleet of vehicles: 6 000 000 units (5 mio cars).
• For 1000 cars, the road kills on average 0.16 person per
year.
• If we combine these figures with the yearly utilization rate
of cars (1 h per day) versus ULM (40 h per year), we can
conclude that ULM / General Aviation flying is
considerably deadlier than the road.

13

What can we learn from accident
investigation ?

14

The investigation process
A long process (Months)
• Collect all factual elements,
–
–
–
–
–
–

The flow of events;
The pilot (training, experience, …)
The aircraft (contact w/manufacturer)
Meteo, Comm, Radar,
Flt recorders (GPS, ECU, camera, …)
Impact, aircraft damage,

• Analysis. (incl. simulation, testing,…)
• Define all possible causes.
• From the causes, define remedial action.
The depth of the investigation is somewhat influenced by the
expected ROI.
15

Accident analysis
• Accidents do not occur “by accident”; Accident are
caused by a series of events.
• There are no “isolated cases”; causes of accidents are often
recurrent.
• Out of the ULM accident data base, we can conclude;
– There are recurrent technical problems specific to ULM.
– The traditional causes of aviation accidents are also known to
ULM (fuel shortage)

– 80% of the causal factors are human-related.

16

Main causal factors (122 accidents –
fixed wing and ULM)
Loss of control Take-off
11%

Fuel Starvation
15%

Loss of control Flight & collision
12%

Technical
11%
Low piloting
experience
8%

Loss of control Landing
16%
Icing
3%

Low flying /
aerobatics obstacles - CFIT
24%

17

Specific problems with ULM
• Technical causes can be (easily) identified;
but fire can be devastating.
• There’s another problem for the
investigator, a lot of landmarks are missing.
– ULM requirements are national,
– Certification not applicable.
– Wide variety of products.
18

About certification.
• Everyone would agree that ULMs of to-day are as good,
even a lot better than the ‘certified’ airplane.
• ULMs are designed to fly.
ULM are quality products; they meet your expectations
(simple to handle, fly fast, cheap in usage, …)
• Certification means that a manufacturer must demonstrate
that his product meets a minimum level of safety, as
defined (ultimately) by the Aviation Community.
• The minimum level of safety is defined in the Certification
Specifications – For small aircraft, it is called CS23.
19

Technical.
• AAIU(be) is currently investigating on:
– Instrument Board lay-out design.
– Electrical System design.
– Emergency Parachute.
Why is it that (for the last cases) parachute did not save lifes ?
• Late decision ?
• Handle easy to grab ?
• Safety pin not removed before flight ?

20

Same ULM Type, instrument panel somewhat different.
Difference in Ergonomy.
Parachute handle – on pilot’s side, or on passenger’s side ?

21

Regulation: certification:
CS 23.671 General
(b) Controls must be arranged and identified
to provide for convenience in operation and
to prevent the possibility of confusion and
subsequent inadvertent operation.

For ULM, CS 23 is not applicable.
Each designer has his own solution, and
they will be challenged only by YOUR
experience.
22

Other example
The passenger door opens in
flight, causing the pilot to take
appropriate actions, that
eventually force him to an
emergency landing.

• Door lock (simple – crude).
Plexy flexible. Once opened in
flight, difficult to close.
CS 23.783
(1) There must be means to lock and safeguard the door against
inadvertent opening during flight by persons, by cargo, or as a
result of mechanical failure.
23

The problem
• Once we determine a technical problem, we
can define recommendations to improve the
product, but:
What do we do with the recommendation ?
– We can not improve the Standard, there’s no standard.
– We can not address more than one manufacturer,
– What about retrofit ?

24

ULM and Engine failures

25

Fly Synthesis Storch
Summer 2009
• After propeller replacement, and subsequent
engine ground tests, the pilot took off for a
flight test.
• He encountered heavy engine vibration, that
forced him to an emergency landing.
• Airplane was slightly damaged.
Cause was identified as Vapor Lock.
26

1/5/2010 – FK9
Emergency landing after in-flight engine failure.
• Lots of corrosion found in carburettor.
Corrosion comes from water condensation in
fuel system (tank, lines, pump,…- MOGAS)
during long immobilisation periods.
- how to prevent ? Filling up, draining ?

• Fuel system was modified in-service, by
addition of a pressure regulator.
27

France
20/5/2010 – Mistral
23/5/2010 – CT Short Wing
Mistral: Engine failure in flight.
Emergency landing in field; terrain was very soft, airplane
severely damaged.
CT Short Wing: In short final, the engine suddenly stops
The pilot attempts to land, but hit trees, and crashes – wings
ripped off.
RH wing tank empty, 15-25 l fuel remaining in LH tank.
During LH turn, fuel system unprimed, engine stopped by
fuel starvation.
28

4 /6/2010: SG Rally
Damaged during landing
• Due to engine problems (heavy vibrations), the
pilot performed emergency landing on EBHN.
Coming in too fast, the landing was brutal, and
Nose Landing Gear collapsed.

29

Conclusion
• Engine in-flight failure are not exceptional.
– Use of MOGAS (water content, flash point,..)
– Local modifications,
– Other specific to the configuration of the
specific airplane.
And..
– Traditional causes (engine starvation,..)
30

Solutions
• In this case, we can design some generic
recommendations:
– Human Factors; ULM pilots should be more
prepared to react to engine failures at any time
(awareness, briefing, training,…)
– Generic technical solutions; impact on the use
of MOGAS.
• Protection of the equipment during winter,
• Risk of Vapour lock.

31

• Designing stop-gaps, accident after accidents
may not be satisfactory;
What can we do we make sure ULM flying
improves up to an acceptable level and, more
important, remains at that level ?

• More Regulation ?

32

Aviation Regulation and the ULM
• No significant changes in Regulation.
– ULM defined by capacity, weight, structural and stall speed limitation.
– => Extensive use of carbon fiber, Flaps, etc

• CS-VLA.
– 750 kg.
– “light” CS-23.
– Expensive.

• Lower Requirements for licencing,
– What about competence ?
– Human Factors training

• National requirements in Europe.
– EASA Flight Permit per Part 21A.701.

33

Evolution: new EU Regulation on
Accident Investigation.
* Every civil aviation accident or serious incident involving
aircraft other than specified in Annex II to the Regulation (EC)
No 216/2008 of the European Parliament and of the Council
shall be the subject of a safety investigation

( = No obligation of enquiry for ULMs)
• Safety investigation authorities may decide to investigate
incidents other than those referred to in paragraph 1 as well as
accidents or serious incidents to other types of aircraft, in
accordance with the national legislation of the Member States,
when they expect to draw safety lessons from them.
34

• US. NTSB; no enquiry for ULM crashes.
• To-day already, in some EU countries, ULM
crash investigations are given a low priority,
unless the Public determines otherwise.
• Common sense dictates that the initiative
to improve safety must come from the
ULM community itself.

35

Reason Model
• aviation is a complex socio-technical
system, where safety is ensured by a
series of defense barriers.
• Each barrier may present flaws (latent
or active) whose combination can lead
to an accident.
• An usafe act (active failure) alone
would not cause an accident.
• Latent failures are more easily
detected and corrected that human
errors, which are (globally) inevitable.

36

• The ULM community should reinforce its
Defense Barriers.
• Organisation: Federation and Clubs.
Create a Safety Climate
- Norms and rules
- Safety Programs

- To define a Safety Climate, we need to
assess the potential risk, and for that we
need data: YOUR experience.
37

Pyramid of Heinrich
• If a fatal accident is caused by
a specific combination of
events, an uncomplete series
of events causes INCIDENTS.
• If we identify all potentially
dangerous events AND with
that information, build-up the
defenses, we can avoid
ACCIDENTS.
38

SHARING EXPERIENCE
• By informing the Federation of the small
events and incidents that spoiled one of
your flights, you allow the Community to
understand the potential dangers and act
upon. (and respect confidentiality)
“Learn from mistakes of others; you won’t
live long enough to make them all by
yourself”
39

Human Factors
• To err is human.
• Human life (and flying) is full of decisions.
• It is therefore more important to know yourself
than to know how to fly your aircraft.
– Get-home-itis, Distraction, Communication,..

• Understanding human factors is a very important
step in improving your defenses.
40

Competence and Readiness
• You hold a pilot licence; but are you a
competent flyer ?
• How will you react when faced with a
potential dangerous situation?
• Assessing your competences with an
instructor is an opportunity to improve.
• When flying, be ready.
41

What is the Authority doing for
you ?

42

A series of work groups
within EASA are thinking
about how to improve
flight safety.(ESSI)
One of them is about General
Aviation (EGAST).

Initiative includes a leaflet
On Collision Avoidance,
and has been relayed to you
by the Federation.
There are technical Work
Groups dealing with MOGAS
43

and

An initiative to develop
Posters with comic strips
On high risk topics.
The first goes about taking
The right decision when the
Weather is below minimum.
They are expected in the
Coming months.

44

For Belgium, Accident reports are made public on the SPF/FOD website.
Recent reports (from 1st May 2007) are directly available through
hyperlinks.
Reports are written in English.
Information Notes are also available in order to highlight specific danger
area: Nr 2010 is about engine cold start.
We would like to develop more Notes, for ULM in collaboration with
the Federation.
Historical reports: currently a list is posted.
The list is fairly complete from 1972.
2 ancient reports (1936 and 1965).
The reports (Fr /Nl) are desidentified and available on request.
The list will be completed as we go along in reviewing archives.

45

Thank you for your attention, and
AAIU (Belgium) wishes you
many happy landings

Photos credit:
MRA / KLM

46


Slide 26

10 JULY 1910 - 2010
100 YEARS ULM ACCIDENTS

Belgian ULM Federation – Safety
1
Conference 10/10/2010

The Air Safety Investigation
• As part of the global Aviation sphere, an investigation is
conducted for each accident and serious incident by an
independent enquiry body, aimed to;
– Determine the causes of the accident.
– Determine if all conditions that were defined by rules and
regulations to ensure flight safety were followed (such as risk
factors in design).
– Define recommendations in order to prevent future accidents.

• It is not the purpose of this investigation to apportion
blame or liability.

2

In Belgium; the Air Accident
Investigation Unit.
• All accidents and serious incidents occurring in Belgium,
on aircraft, helicopters, gliders, balloons, ULM, DPM,
regardless of their registration is investigated by a cell
functionnally independent from the BCAA, and all other
interrested parties.
• Independent doesn’t mean isolated; it is part of the world’s
network of the State’s Aviation Investigation Bodies.
• The cell reports to the President of the Board of the
SPF/FOD Mobility and Transport.
3

4

ULM
• First pendular (Delta Plane Motorized)
design in 1966
• First crossing of the Channel in 1978 by Mr
D. Cook.
• Commercial development from 1979.
• Evolution from 2-axis to 3-axis.
• In Belgium, first ULM registered (501) in
1982.

5

6

Evolution
• 1982: Weedhopper, Chickinox
– 80…100 km/h
– Basic – 2/3 axis
– Range: … 200 km…

• 2010: VL-3 Sprint, DynAero MCR01, WT9 Dynamic….
– 220….250 km/h,
– flaps, retractable gear, avionics,
– Range over 1000 km

• 550 OO- registered ULM;
• 571 ULM pilot licence (363 training licences)
• 300-400 foreign-registered ULM.
7

1000
900
800
700
600
500
400
300
200
100

Number of valid registration

8

Estimation of flying OO-regd ULM

20
10

20
08

20
06

20
04

20
02

20
00

19
98

19
96

19
94

19
92

19
90

19
88

19
86

19
84

19
82

0

Evolution in pilot’s / owner’s
expectations
• In 1982, ULM /DPM, a sporting way of flying,
outside the limits of parachuting, delta plane.

• In 2010, an efficient alternative to general
(certified) aviation. ULM becomes a means of
transport.
• Beyond 2010 ?? – The Need for Speed ?
9

Evolution
• From the user’s perspective, the difference between
General Aviation and ULM becomes very thin.
• However, ULMs are characterized by a huge variety of
different design types, with low production rate and
configuration variation between individual airplanes.
– Manufacturers come and go,
– Assembly of the same ULM type by different companies induce
differences in built configuration.

• The above makes it more and more difficult to speak about
ULMs in a general way; variation in quality is wider than
General (certified) Aviation.
10

EVOLUTION: MORE ULM FATAL ACCIDENTS ?

Fatalities: (up to now), In Belgium, on average 2 /year,
comparable to General (certified) Aviation.
Number of fatalities
12
10
8
6
4
2

Number of fatalities

11

20
10

20
08

20
06

20
04

20
02

20
00

19
98

19
96

19
94

19
92

19
90

19
88

19
86

19
84

0

19
82

FATALITIES:
Figures limited to
Belgium.
2009: + 2 in France.
2010: + 5 in France.

WHAT ARE THE EXPECTATIONS
FOR THE
ULM-ACCIDENTS CASUALITY
RATE ?
• On Belgian soil, 4 deads in 2010.
(casuality rate of U.S. Forces in Iraq 3.6 killed /1000
troop / year – 8 years – 152000 troops – 4424 killed).

• In France and Belgium in 2010, 9 Belgian
deads to-date.
12

Comparison with the road
• In Belgium, the road kills 1000 people on average per year
.
• Fleet of vehicles: 6 000 000 units (5 mio cars).
• For 1000 cars, the road kills on average 0.16 person per
year.
• If we combine these figures with the yearly utilization rate
of cars (1 h per day) versus ULM (40 h per year), we can
conclude that ULM / General Aviation flying is
considerably deadlier than the road.

13

What can we learn from accident
investigation ?

14

The investigation process
A long process (Months)
• Collect all factual elements,
–
–
–
–
–
–

The flow of events;
The pilot (training, experience, …)
The aircraft (contact w/manufacturer)
Meteo, Comm, Radar,
Flt recorders (GPS, ECU, camera, …)
Impact, aircraft damage,

• Analysis. (incl. simulation, testing,…)
• Define all possible causes.
• From the causes, define remedial action.
The depth of the investigation is somewhat influenced by the
expected ROI.
15

Accident analysis
• Accidents do not occur “by accident”; Accident are
caused by a series of events.
• There are no “isolated cases”; causes of accidents are often
recurrent.
• Out of the ULM accident data base, we can conclude;
– There are recurrent technical problems specific to ULM.
– The traditional causes of aviation accidents are also known to
ULM (fuel shortage)

– 80% of the causal factors are human-related.

16

Main causal factors (122 accidents –
fixed wing and ULM)
Loss of control Take-off
11%

Fuel Starvation
15%

Loss of control Flight & collision
12%

Technical
11%
Low piloting
experience
8%

Loss of control Landing
16%
Icing
3%

Low flying /
aerobatics obstacles - CFIT
24%

17

Specific problems with ULM
• Technical causes can be (easily) identified;
but fire can be devastating.
• There’s another problem for the
investigator, a lot of landmarks are missing.
– ULM requirements are national,
– Certification not applicable.
– Wide variety of products.
18

About certification.
• Everyone would agree that ULMs of to-day are as good,
even a lot better than the ‘certified’ airplane.
• ULMs are designed to fly.
ULM are quality products; they meet your expectations
(simple to handle, fly fast, cheap in usage, …)
• Certification means that a manufacturer must demonstrate
that his product meets a minimum level of safety, as
defined (ultimately) by the Aviation Community.
• The minimum level of safety is defined in the Certification
Specifications – For small aircraft, it is called CS23.
19

Technical.
• AAIU(be) is currently investigating on:
– Instrument Board lay-out design.
– Electrical System design.
– Emergency Parachute.
Why is it that (for the last cases) parachute did not save lifes ?
• Late decision ?
• Handle easy to grab ?
• Safety pin not removed before flight ?

20

Same ULM Type, instrument panel somewhat different.
Difference in Ergonomy.
Parachute handle – on pilot’s side, or on passenger’s side ?

21

Regulation: certification:
CS 23.671 General
(b) Controls must be arranged and identified
to provide for convenience in operation and
to prevent the possibility of confusion and
subsequent inadvertent operation.

For ULM, CS 23 is not applicable.
Each designer has his own solution, and
they will be challenged only by YOUR
experience.
22

Other example
The passenger door opens in
flight, causing the pilot to take
appropriate actions, that
eventually force him to an
emergency landing.

• Door lock (simple – crude).
Plexy flexible. Once opened in
flight, difficult to close.
CS 23.783
(1) There must be means to lock and safeguard the door against
inadvertent opening during flight by persons, by cargo, or as a
result of mechanical failure.
23

The problem
• Once we determine a technical problem, we
can define recommendations to improve the
product, but:
What do we do with the recommendation ?
– We can not improve the Standard, there’s no standard.
– We can not address more than one manufacturer,
– What about retrofit ?

24

ULM and Engine failures

25

Fly Synthesis Storch
Summer 2009
• After propeller replacement, and subsequent
engine ground tests, the pilot took off for a
flight test.
• He encountered heavy engine vibration, that
forced him to an emergency landing.
• Airplane was slightly damaged.
Cause was identified as Vapor Lock.
26

1/5/2010 – FK9
Emergency landing after in-flight engine failure.
• Lots of corrosion found in carburettor.
Corrosion comes from water condensation in
fuel system (tank, lines, pump,…- MOGAS)
during long immobilisation periods.
- how to prevent ? Filling up, draining ?

• Fuel system was modified in-service, by
addition of a pressure regulator.
27

France
20/5/2010 – Mistral
23/5/2010 – CT Short Wing
Mistral: Engine failure in flight.
Emergency landing in field; terrain was very soft, airplane
severely damaged.
CT Short Wing: In short final, the engine suddenly stops
The pilot attempts to land, but hit trees, and crashes – wings
ripped off.
RH wing tank empty, 15-25 l fuel remaining in LH tank.
During LH turn, fuel system unprimed, engine stopped by
fuel starvation.
28

4 /6/2010: SG Rally
Damaged during landing
• Due to engine problems (heavy vibrations), the
pilot performed emergency landing on EBHN.
Coming in too fast, the landing was brutal, and
Nose Landing Gear collapsed.

29

Conclusion
• Engine in-flight failure are not exceptional.
– Use of MOGAS (water content, flash point,..)
– Local modifications,
– Other specific to the configuration of the
specific airplane.
And..
– Traditional causes (engine starvation,..)
30

Solutions
• In this case, we can design some generic
recommendations:
– Human Factors; ULM pilots should be more
prepared to react to engine failures at any time
(awareness, briefing, training,…)
– Generic technical solutions; impact on the use
of MOGAS.
• Protection of the equipment during winter,
• Risk of Vapour lock.

31

• Designing stop-gaps, accident after accidents
may not be satisfactory;
What can we do we make sure ULM flying
improves up to an acceptable level and, more
important, remains at that level ?

• More Regulation ?

32

Aviation Regulation and the ULM
• No significant changes in Regulation.
– ULM defined by capacity, weight, structural and stall speed limitation.
– => Extensive use of carbon fiber, Flaps, etc

• CS-VLA.
– 750 kg.
– “light” CS-23.
– Expensive.

• Lower Requirements for licencing,
– What about competence ?
– Human Factors training

• National requirements in Europe.
– EASA Flight Permit per Part 21A.701.

33

Evolution: new EU Regulation on
Accident Investigation.
* Every civil aviation accident or serious incident involving
aircraft other than specified in Annex II to the Regulation (EC)
No 216/2008 of the European Parliament and of the Council
shall be the subject of a safety investigation

( = No obligation of enquiry for ULMs)
• Safety investigation authorities may decide to investigate
incidents other than those referred to in paragraph 1 as well as
accidents or serious incidents to other types of aircraft, in
accordance with the national legislation of the Member States,
when they expect to draw safety lessons from them.
34

• US. NTSB; no enquiry for ULM crashes.
• To-day already, in some EU countries, ULM
crash investigations are given a low priority,
unless the Public determines otherwise.
• Common sense dictates that the initiative
to improve safety must come from the
ULM community itself.

35

Reason Model
• aviation is a complex socio-technical
system, where safety is ensured by a
series of defense barriers.
• Each barrier may present flaws (latent
or active) whose combination can lead
to an accident.
• An usafe act (active failure) alone
would not cause an accident.
• Latent failures are more easily
detected and corrected that human
errors, which are (globally) inevitable.

36

• The ULM community should reinforce its
Defense Barriers.
• Organisation: Federation and Clubs.
Create a Safety Climate
- Norms and rules
- Safety Programs

- To define a Safety Climate, we need to
assess the potential risk, and for that we
need data: YOUR experience.
37

Pyramid of Heinrich
• If a fatal accident is caused by
a specific combination of
events, an uncomplete series
of events causes INCIDENTS.
• If we identify all potentially
dangerous events AND with
that information, build-up the
defenses, we can avoid
ACCIDENTS.
38

SHARING EXPERIENCE
• By informing the Federation of the small
events and incidents that spoiled one of
your flights, you allow the Community to
understand the potential dangers and act
upon. (and respect confidentiality)
“Learn from mistakes of others; you won’t
live long enough to make them all by
yourself”
39

Human Factors
• To err is human.
• Human life (and flying) is full of decisions.
• It is therefore more important to know yourself
than to know how to fly your aircraft.
– Get-home-itis, Distraction, Communication,..

• Understanding human factors is a very important
step in improving your defenses.
40

Competence and Readiness
• You hold a pilot licence; but are you a
competent flyer ?
• How will you react when faced with a
potential dangerous situation?
• Assessing your competences with an
instructor is an opportunity to improve.
• When flying, be ready.
41

What is the Authority doing for
you ?

42

A series of work groups
within EASA are thinking
about how to improve
flight safety.(ESSI)
One of them is about General
Aviation (EGAST).

Initiative includes a leaflet
On Collision Avoidance,
and has been relayed to you
by the Federation.
There are technical Work
Groups dealing with MOGAS
43

and

An initiative to develop
Posters with comic strips
On high risk topics.
The first goes about taking
The right decision when the
Weather is below minimum.
They are expected in the
Coming months.

44

For Belgium, Accident reports are made public on the SPF/FOD website.
Recent reports (from 1st May 2007) are directly available through
hyperlinks.
Reports are written in English.
Information Notes are also available in order to highlight specific danger
area: Nr 2010 is about engine cold start.
We would like to develop more Notes, for ULM in collaboration with
the Federation.
Historical reports: currently a list is posted.
The list is fairly complete from 1972.
2 ancient reports (1936 and 1965).
The reports (Fr /Nl) are desidentified and available on request.
The list will be completed as we go along in reviewing archives.

45

Thank you for your attention, and
AAIU (Belgium) wishes you
many happy landings

Photos credit:
MRA / KLM

46


Slide 27

10 JULY 1910 - 2010
100 YEARS ULM ACCIDENTS

Belgian ULM Federation – Safety
1
Conference 10/10/2010

The Air Safety Investigation
• As part of the global Aviation sphere, an investigation is
conducted for each accident and serious incident by an
independent enquiry body, aimed to;
– Determine the causes of the accident.
– Determine if all conditions that were defined by rules and
regulations to ensure flight safety were followed (such as risk
factors in design).
– Define recommendations in order to prevent future accidents.

• It is not the purpose of this investigation to apportion
blame or liability.

2

In Belgium; the Air Accident
Investigation Unit.
• All accidents and serious incidents occurring in Belgium,
on aircraft, helicopters, gliders, balloons, ULM, DPM,
regardless of their registration is investigated by a cell
functionnally independent from the BCAA, and all other
interrested parties.
• Independent doesn’t mean isolated; it is part of the world’s
network of the State’s Aviation Investigation Bodies.
• The cell reports to the President of the Board of the
SPF/FOD Mobility and Transport.
3

4

ULM
• First pendular (Delta Plane Motorized)
design in 1966
• First crossing of the Channel in 1978 by Mr
D. Cook.
• Commercial development from 1979.
• Evolution from 2-axis to 3-axis.
• In Belgium, first ULM registered (501) in
1982.

5

6

Evolution
• 1982: Weedhopper, Chickinox
– 80…100 km/h
– Basic – 2/3 axis
– Range: … 200 km…

• 2010: VL-3 Sprint, DynAero MCR01, WT9 Dynamic….
– 220….250 km/h,
– flaps, retractable gear, avionics,
– Range over 1000 km

• 550 OO- registered ULM;
• 571 ULM pilot licence (363 training licences)
• 300-400 foreign-registered ULM.
7

1000
900
800
700
600
500
400
300
200
100

Number of valid registration

8

Estimation of flying OO-regd ULM

20
10

20
08

20
06

20
04

20
02

20
00

19
98

19
96

19
94

19
92

19
90

19
88

19
86

19
84

19
82

0

Evolution in pilot’s / owner’s
expectations
• In 1982, ULM /DPM, a sporting way of flying,
outside the limits of parachuting, delta plane.

• In 2010, an efficient alternative to general
(certified) aviation. ULM becomes a means of
transport.
• Beyond 2010 ?? – The Need for Speed ?
9

Evolution
• From the user’s perspective, the difference between
General Aviation and ULM becomes very thin.
• However, ULMs are characterized by a huge variety of
different design types, with low production rate and
configuration variation between individual airplanes.
– Manufacturers come and go,
– Assembly of the same ULM type by different companies induce
differences in built configuration.

• The above makes it more and more difficult to speak about
ULMs in a general way; variation in quality is wider than
General (certified) Aviation.
10

EVOLUTION: MORE ULM FATAL ACCIDENTS ?

Fatalities: (up to now), In Belgium, on average 2 /year,
comparable to General (certified) Aviation.
Number of fatalities
12
10
8
6
4
2

Number of fatalities

11

20
10

20
08

20
06

20
04

20
02

20
00

19
98

19
96

19
94

19
92

19
90

19
88

19
86

19
84

0

19
82

FATALITIES:
Figures limited to
Belgium.
2009: + 2 in France.
2010: + 5 in France.

WHAT ARE THE EXPECTATIONS
FOR THE
ULM-ACCIDENTS CASUALITY
RATE ?
• On Belgian soil, 4 deads in 2010.
(casuality rate of U.S. Forces in Iraq 3.6 killed /1000
troop / year – 8 years – 152000 troops – 4424 killed).

• In France and Belgium in 2010, 9 Belgian
deads to-date.
12

Comparison with the road
• In Belgium, the road kills 1000 people on average per year
.
• Fleet of vehicles: 6 000 000 units (5 mio cars).
• For 1000 cars, the road kills on average 0.16 person per
year.
• If we combine these figures with the yearly utilization rate
of cars (1 h per day) versus ULM (40 h per year), we can
conclude that ULM / General Aviation flying is
considerably deadlier than the road.

13

What can we learn from accident
investigation ?

14

The investigation process
A long process (Months)
• Collect all factual elements,
–
–
–
–
–
–

The flow of events;
The pilot (training, experience, …)
The aircraft (contact w/manufacturer)
Meteo, Comm, Radar,
Flt recorders (GPS, ECU, camera, …)
Impact, aircraft damage,

• Analysis. (incl. simulation, testing,…)
• Define all possible causes.
• From the causes, define remedial action.
The depth of the investigation is somewhat influenced by the
expected ROI.
15

Accident analysis
• Accidents do not occur “by accident”; Accident are
caused by a series of events.
• There are no “isolated cases”; causes of accidents are often
recurrent.
• Out of the ULM accident data base, we can conclude;
– There are recurrent technical problems specific to ULM.
– The traditional causes of aviation accidents are also known to
ULM (fuel shortage)

– 80% of the causal factors are human-related.

16

Main causal factors (122 accidents –
fixed wing and ULM)
Loss of control Take-off
11%

Fuel Starvation
15%

Loss of control Flight & collision
12%

Technical
11%
Low piloting
experience
8%

Loss of control Landing
16%
Icing
3%

Low flying /
aerobatics obstacles - CFIT
24%

17

Specific problems with ULM
• Technical causes can be (easily) identified;
but fire can be devastating.
• There’s another problem for the
investigator, a lot of landmarks are missing.
– ULM requirements are national,
– Certification not applicable.
– Wide variety of products.
18

About certification.
• Everyone would agree that ULMs of to-day are as good,
even a lot better than the ‘certified’ airplane.
• ULMs are designed to fly.
ULM are quality products; they meet your expectations
(simple to handle, fly fast, cheap in usage, …)
• Certification means that a manufacturer must demonstrate
that his product meets a minimum level of safety, as
defined (ultimately) by the Aviation Community.
• The minimum level of safety is defined in the Certification
Specifications – For small aircraft, it is called CS23.
19

Technical.
• AAIU(be) is currently investigating on:
– Instrument Board lay-out design.
– Electrical System design.
– Emergency Parachute.
Why is it that (for the last cases) parachute did not save lifes ?
• Late decision ?
• Handle easy to grab ?
• Safety pin not removed before flight ?

20

Same ULM Type, instrument panel somewhat different.
Difference in Ergonomy.
Parachute handle – on pilot’s side, or on passenger’s side ?

21

Regulation: certification:
CS 23.671 General
(b) Controls must be arranged and identified
to provide for convenience in operation and
to prevent the possibility of confusion and
subsequent inadvertent operation.

For ULM, CS 23 is not applicable.
Each designer has his own solution, and
they will be challenged only by YOUR
experience.
22

Other example
The passenger door opens in
flight, causing the pilot to take
appropriate actions, that
eventually force him to an
emergency landing.

• Door lock (simple – crude).
Plexy flexible. Once opened in
flight, difficult to close.
CS 23.783
(1) There must be means to lock and safeguard the door against
inadvertent opening during flight by persons, by cargo, or as a
result of mechanical failure.
23

The problem
• Once we determine a technical problem, we
can define recommendations to improve the
product, but:
What do we do with the recommendation ?
– We can not improve the Standard, there’s no standard.
– We can not address more than one manufacturer,
– What about retrofit ?

24

ULM and Engine failures

25

Fly Synthesis Storch
Summer 2009
• After propeller replacement, and subsequent
engine ground tests, the pilot took off for a
flight test.
• He encountered heavy engine vibration, that
forced him to an emergency landing.
• Airplane was slightly damaged.
Cause was identified as Vapor Lock.
26

1/5/2010 – FK9
Emergency landing after in-flight engine failure.
• Lots of corrosion found in carburettor.
Corrosion comes from water condensation in
fuel system (tank, lines, pump,…- MOGAS)
during long immobilisation periods.
- how to prevent ? Filling up, draining ?

• Fuel system was modified in-service, by
addition of a pressure regulator.
27

France
20/5/2010 – Mistral
23/5/2010 – CT Short Wing
Mistral: Engine failure in flight.
Emergency landing in field; terrain was very soft, airplane
severely damaged.
CT Short Wing: In short final, the engine suddenly stops
The pilot attempts to land, but hit trees, and crashes – wings
ripped off.
RH wing tank empty, 15-25 l fuel remaining in LH tank.
During LH turn, fuel system unprimed, engine stopped by
fuel starvation.
28

4 /6/2010: SG Rally
Damaged during landing
• Due to engine problems (heavy vibrations), the
pilot performed emergency landing on EBHN.
Coming in too fast, the landing was brutal, and
Nose Landing Gear collapsed.

29

Conclusion
• Engine in-flight failure are not exceptional.
– Use of MOGAS (water content, flash point,..)
– Local modifications,
– Other specific to the configuration of the
specific airplane.
And..
– Traditional causes (engine starvation,..)
30

Solutions
• In this case, we can design some generic
recommendations:
– Human Factors; ULM pilots should be more
prepared to react to engine failures at any time
(awareness, briefing, training,…)
– Generic technical solutions; impact on the use
of MOGAS.
• Protection of the equipment during winter,
• Risk of Vapour lock.

31

• Designing stop-gaps, accident after accidents
may not be satisfactory;
What can we do we make sure ULM flying
improves up to an acceptable level and, more
important, remains at that level ?

• More Regulation ?

32

Aviation Regulation and the ULM
• No significant changes in Regulation.
– ULM defined by capacity, weight, structural and stall speed limitation.
– => Extensive use of carbon fiber, Flaps, etc

• CS-VLA.
– 750 kg.
– “light” CS-23.
– Expensive.

• Lower Requirements for licencing,
– What about competence ?
– Human Factors training

• National requirements in Europe.
– EASA Flight Permit per Part 21A.701.

33

Evolution: new EU Regulation on
Accident Investigation.
* Every civil aviation accident or serious incident involving
aircraft other than specified in Annex II to the Regulation (EC)
No 216/2008 of the European Parliament and of the Council
shall be the subject of a safety investigation

( = No obligation of enquiry for ULMs)
• Safety investigation authorities may decide to investigate
incidents other than those referred to in paragraph 1 as well as
accidents or serious incidents to other types of aircraft, in
accordance with the national legislation of the Member States,
when they expect to draw safety lessons from them.
34

• US. NTSB; no enquiry for ULM crashes.
• To-day already, in some EU countries, ULM
crash investigations are given a low priority,
unless the Public determines otherwise.
• Common sense dictates that the initiative
to improve safety must come from the
ULM community itself.

35

Reason Model
• aviation is a complex socio-technical
system, where safety is ensured by a
series of defense barriers.
• Each barrier may present flaws (latent
or active) whose combination can lead
to an accident.
• An usafe act (active failure) alone
would not cause an accident.
• Latent failures are more easily
detected and corrected that human
errors, which are (globally) inevitable.

36

• The ULM community should reinforce its
Defense Barriers.
• Organisation: Federation and Clubs.
Create a Safety Climate
- Norms and rules
- Safety Programs

- To define a Safety Climate, we need to
assess the potential risk, and for that we
need data: YOUR experience.
37

Pyramid of Heinrich
• If a fatal accident is caused by
a specific combination of
events, an uncomplete series
of events causes INCIDENTS.
• If we identify all potentially
dangerous events AND with
that information, build-up the
defenses, we can avoid
ACCIDENTS.
38

SHARING EXPERIENCE
• By informing the Federation of the small
events and incidents that spoiled one of
your flights, you allow the Community to
understand the potential dangers and act
upon. (and respect confidentiality)
“Learn from mistakes of others; you won’t
live long enough to make them all by
yourself”
39

Human Factors
• To err is human.
• Human life (and flying) is full of decisions.
• It is therefore more important to know yourself
than to know how to fly your aircraft.
– Get-home-itis, Distraction, Communication,..

• Understanding human factors is a very important
step in improving your defenses.
40

Competence and Readiness
• You hold a pilot licence; but are you a
competent flyer ?
• How will you react when faced with a
potential dangerous situation?
• Assessing your competences with an
instructor is an opportunity to improve.
• When flying, be ready.
41

What is the Authority doing for
you ?

42

A series of work groups
within EASA are thinking
about how to improve
flight safety.(ESSI)
One of them is about General
Aviation (EGAST).

Initiative includes a leaflet
On Collision Avoidance,
and has been relayed to you
by the Federation.
There are technical Work
Groups dealing with MOGAS
43

and

An initiative to develop
Posters with comic strips
On high risk topics.
The first goes about taking
The right decision when the
Weather is below minimum.
They are expected in the
Coming months.

44

For Belgium, Accident reports are made public on the SPF/FOD website.
Recent reports (from 1st May 2007) are directly available through
hyperlinks.
Reports are written in English.
Information Notes are also available in order to highlight specific danger
area: Nr 2010 is about engine cold start.
We would like to develop more Notes, for ULM in collaboration with
the Federation.
Historical reports: currently a list is posted.
The list is fairly complete from 1972.
2 ancient reports (1936 and 1965).
The reports (Fr /Nl) are desidentified and available on request.
The list will be completed as we go along in reviewing archives.

45

Thank you for your attention, and
AAIU (Belgium) wishes you
many happy landings

Photos credit:
MRA / KLM

46


Slide 28

10 JULY 1910 - 2010
100 YEARS ULM ACCIDENTS

Belgian ULM Federation – Safety
1
Conference 10/10/2010

The Air Safety Investigation
• As part of the global Aviation sphere, an investigation is
conducted for each accident and serious incident by an
independent enquiry body, aimed to;
– Determine the causes of the accident.
– Determine if all conditions that were defined by rules and
regulations to ensure flight safety were followed (such as risk
factors in design).
– Define recommendations in order to prevent future accidents.

• It is not the purpose of this investigation to apportion
blame or liability.

2

In Belgium; the Air Accident
Investigation Unit.
• All accidents and serious incidents occurring in Belgium,
on aircraft, helicopters, gliders, balloons, ULM, DPM,
regardless of their registration is investigated by a cell
functionnally independent from the BCAA, and all other
interrested parties.
• Independent doesn’t mean isolated; it is part of the world’s
network of the State’s Aviation Investigation Bodies.
• The cell reports to the President of the Board of the
SPF/FOD Mobility and Transport.
3

4

ULM
• First pendular (Delta Plane Motorized)
design in 1966
• First crossing of the Channel in 1978 by Mr
D. Cook.
• Commercial development from 1979.
• Evolution from 2-axis to 3-axis.
• In Belgium, first ULM registered (501) in
1982.

5

6

Evolution
• 1982: Weedhopper, Chickinox
– 80…100 km/h
– Basic – 2/3 axis
– Range: … 200 km…

• 2010: VL-3 Sprint, DynAero MCR01, WT9 Dynamic….
– 220….250 km/h,
– flaps, retractable gear, avionics,
– Range over 1000 km

• 550 OO- registered ULM;
• 571 ULM pilot licence (363 training licences)
• 300-400 foreign-registered ULM.
7

1000
900
800
700
600
500
400
300
200
100

Number of valid registration

8

Estimation of flying OO-regd ULM

20
10

20
08

20
06

20
04

20
02

20
00

19
98

19
96

19
94

19
92

19
90

19
88

19
86

19
84

19
82

0

Evolution in pilot’s / owner’s
expectations
• In 1982, ULM /DPM, a sporting way of flying,
outside the limits of parachuting, delta plane.

• In 2010, an efficient alternative to general
(certified) aviation. ULM becomes a means of
transport.
• Beyond 2010 ?? – The Need for Speed ?
9

Evolution
• From the user’s perspective, the difference between
General Aviation and ULM becomes very thin.
• However, ULMs are characterized by a huge variety of
different design types, with low production rate and
configuration variation between individual airplanes.
– Manufacturers come and go,
– Assembly of the same ULM type by different companies induce
differences in built configuration.

• The above makes it more and more difficult to speak about
ULMs in a general way; variation in quality is wider than
General (certified) Aviation.
10

EVOLUTION: MORE ULM FATAL ACCIDENTS ?

Fatalities: (up to now), In Belgium, on average 2 /year,
comparable to General (certified) Aviation.
Number of fatalities
12
10
8
6
4
2

Number of fatalities

11

20
10

20
08

20
06

20
04

20
02

20
00

19
98

19
96

19
94

19
92

19
90

19
88

19
86

19
84

0

19
82

FATALITIES:
Figures limited to
Belgium.
2009: + 2 in France.
2010: + 5 in France.

WHAT ARE THE EXPECTATIONS
FOR THE
ULM-ACCIDENTS CASUALITY
RATE ?
• On Belgian soil, 4 deads in 2010.
(casuality rate of U.S. Forces in Iraq 3.6 killed /1000
troop / year – 8 years – 152000 troops – 4424 killed).

• In France and Belgium in 2010, 9 Belgian
deads to-date.
12

Comparison with the road
• In Belgium, the road kills 1000 people on average per year
.
• Fleet of vehicles: 6 000 000 units (5 mio cars).
• For 1000 cars, the road kills on average 0.16 person per
year.
• If we combine these figures with the yearly utilization rate
of cars (1 h per day) versus ULM (40 h per year), we can
conclude that ULM / General Aviation flying is
considerably deadlier than the road.

13

What can we learn from accident
investigation ?

14

The investigation process
A long process (Months)
• Collect all factual elements,
–
–
–
–
–
–

The flow of events;
The pilot (training, experience, …)
The aircraft (contact w/manufacturer)
Meteo, Comm, Radar,
Flt recorders (GPS, ECU, camera, …)
Impact, aircraft damage,

• Analysis. (incl. simulation, testing,…)
• Define all possible causes.
• From the causes, define remedial action.
The depth of the investigation is somewhat influenced by the
expected ROI.
15

Accident analysis
• Accidents do not occur “by accident”; Accident are
caused by a series of events.
• There are no “isolated cases”; causes of accidents are often
recurrent.
• Out of the ULM accident data base, we can conclude;
– There are recurrent technical problems specific to ULM.
– The traditional causes of aviation accidents are also known to
ULM (fuel shortage)

– 80% of the causal factors are human-related.

16

Main causal factors (122 accidents –
fixed wing and ULM)
Loss of control Take-off
11%

Fuel Starvation
15%

Loss of control Flight & collision
12%

Technical
11%
Low piloting
experience
8%

Loss of control Landing
16%
Icing
3%

Low flying /
aerobatics obstacles - CFIT
24%

17

Specific problems with ULM
• Technical causes can be (easily) identified;
but fire can be devastating.
• There’s another problem for the
investigator, a lot of landmarks are missing.
– ULM requirements are national,
– Certification not applicable.
– Wide variety of products.
18

About certification.
• Everyone would agree that ULMs of to-day are as good,
even a lot better than the ‘certified’ airplane.
• ULMs are designed to fly.
ULM are quality products; they meet your expectations
(simple to handle, fly fast, cheap in usage, …)
• Certification means that a manufacturer must demonstrate
that his product meets a minimum level of safety, as
defined (ultimately) by the Aviation Community.
• The minimum level of safety is defined in the Certification
Specifications – For small aircraft, it is called CS23.
19

Technical.
• AAIU(be) is currently investigating on:
– Instrument Board lay-out design.
– Electrical System design.
– Emergency Parachute.
Why is it that (for the last cases) parachute did not save lifes ?
• Late decision ?
• Handle easy to grab ?
• Safety pin not removed before flight ?

20

Same ULM Type, instrument panel somewhat different.
Difference in Ergonomy.
Parachute handle – on pilot’s side, or on passenger’s side ?

21

Regulation: certification:
CS 23.671 General
(b) Controls must be arranged and identified
to provide for convenience in operation and
to prevent the possibility of confusion and
subsequent inadvertent operation.

For ULM, CS 23 is not applicable.
Each designer has his own solution, and
they will be challenged only by YOUR
experience.
22

Other example
The passenger door opens in
flight, causing the pilot to take
appropriate actions, that
eventually force him to an
emergency landing.

• Door lock (simple – crude).
Plexy flexible. Once opened in
flight, difficult to close.
CS 23.783
(1) There must be means to lock and safeguard the door against
inadvertent opening during flight by persons, by cargo, or as a
result of mechanical failure.
23

The problem
• Once we determine a technical problem, we
can define recommendations to improve the
product, but:
What do we do with the recommendation ?
– We can not improve the Standard, there’s no standard.
– We can not address more than one manufacturer,
– What about retrofit ?

24

ULM and Engine failures

25

Fly Synthesis Storch
Summer 2009
• After propeller replacement, and subsequent
engine ground tests, the pilot took off for a
flight test.
• He encountered heavy engine vibration, that
forced him to an emergency landing.
• Airplane was slightly damaged.
Cause was identified as Vapor Lock.
26

1/5/2010 – FK9
Emergency landing after in-flight engine failure.
• Lots of corrosion found in carburettor.
Corrosion comes from water condensation in
fuel system (tank, lines, pump,…- MOGAS)
during long immobilisation periods.
- how to prevent ? Filling up, draining ?

• Fuel system was modified in-service, by
addition of a pressure regulator.
27

France
20/5/2010 – Mistral
23/5/2010 – CT Short Wing
Mistral: Engine failure in flight.
Emergency landing in field; terrain was very soft, airplane
severely damaged.
CT Short Wing: In short final, the engine suddenly stops
The pilot attempts to land, but hit trees, and crashes – wings
ripped off.
RH wing tank empty, 15-25 l fuel remaining in LH tank.
During LH turn, fuel system unprimed, engine stopped by
fuel starvation.
28

4 /6/2010: SG Rally
Damaged during landing
• Due to engine problems (heavy vibrations), the
pilot performed emergency landing on EBHN.
Coming in too fast, the landing was brutal, and
Nose Landing Gear collapsed.

29

Conclusion
• Engine in-flight failure are not exceptional.
– Use of MOGAS (water content, flash point,..)
– Local modifications,
– Other specific to the configuration of the
specific airplane.
And..
– Traditional causes (engine starvation,..)
30

Solutions
• In this case, we can design some generic
recommendations:
– Human Factors; ULM pilots should be more
prepared to react to engine failures at any time
(awareness, briefing, training,…)
– Generic technical solutions; impact on the use
of MOGAS.
• Protection of the equipment during winter,
• Risk of Vapour lock.

31

• Designing stop-gaps, accident after accidents
may not be satisfactory;
What can we do we make sure ULM flying
improves up to an acceptable level and, more
important, remains at that level ?

• More Regulation ?

32

Aviation Regulation and the ULM
• No significant changes in Regulation.
– ULM defined by capacity, weight, structural and stall speed limitation.
– => Extensive use of carbon fiber, Flaps, etc

• CS-VLA.
– 750 kg.
– “light” CS-23.
– Expensive.

• Lower Requirements for licencing,
– What about competence ?
– Human Factors training

• National requirements in Europe.
– EASA Flight Permit per Part 21A.701.

33

Evolution: new EU Regulation on
Accident Investigation.
* Every civil aviation accident or serious incident involving
aircraft other than specified in Annex II to the Regulation (EC)
No 216/2008 of the European Parliament and of the Council
shall be the subject of a safety investigation

( = No obligation of enquiry for ULMs)
• Safety investigation authorities may decide to investigate
incidents other than those referred to in paragraph 1 as well as
accidents or serious incidents to other types of aircraft, in
accordance with the national legislation of the Member States,
when they expect to draw safety lessons from them.
34

• US. NTSB; no enquiry for ULM crashes.
• To-day already, in some EU countries, ULM
crash investigations are given a low priority,
unless the Public determines otherwise.
• Common sense dictates that the initiative
to improve safety must come from the
ULM community itself.

35

Reason Model
• aviation is a complex socio-technical
system, where safety is ensured by a
series of defense barriers.
• Each barrier may present flaws (latent
or active) whose combination can lead
to an accident.
• An usafe act (active failure) alone
would not cause an accident.
• Latent failures are more easily
detected and corrected that human
errors, which are (globally) inevitable.

36

• The ULM community should reinforce its
Defense Barriers.
• Organisation: Federation and Clubs.
Create a Safety Climate
- Norms and rules
- Safety Programs

- To define a Safety Climate, we need to
assess the potential risk, and for that we
need data: YOUR experience.
37

Pyramid of Heinrich
• If a fatal accident is caused by
a specific combination of
events, an uncomplete series
of events causes INCIDENTS.
• If we identify all potentially
dangerous events AND with
that information, build-up the
defenses, we can avoid
ACCIDENTS.
38

SHARING EXPERIENCE
• By informing the Federation of the small
events and incidents that spoiled one of
your flights, you allow the Community to
understand the potential dangers and act
upon. (and respect confidentiality)
“Learn from mistakes of others; you won’t
live long enough to make them all by
yourself”
39

Human Factors
• To err is human.
• Human life (and flying) is full of decisions.
• It is therefore more important to know yourself
than to know how to fly your aircraft.
– Get-home-itis, Distraction, Communication,..

• Understanding human factors is a very important
step in improving your defenses.
40

Competence and Readiness
• You hold a pilot licence; but are you a
competent flyer ?
• How will you react when faced with a
potential dangerous situation?
• Assessing your competences with an
instructor is an opportunity to improve.
• When flying, be ready.
41

What is the Authority doing for
you ?

42

A series of work groups
within EASA are thinking
about how to improve
flight safety.(ESSI)
One of them is about General
Aviation (EGAST).

Initiative includes a leaflet
On Collision Avoidance,
and has been relayed to you
by the Federation.
There are technical Work
Groups dealing with MOGAS
43

and

An initiative to develop
Posters with comic strips
On high risk topics.
The first goes about taking
The right decision when the
Weather is below minimum.
They are expected in the
Coming months.

44

For Belgium, Accident reports are made public on the SPF/FOD website.
Recent reports (from 1st May 2007) are directly available through
hyperlinks.
Reports are written in English.
Information Notes are also available in order to highlight specific danger
area: Nr 2010 is about engine cold start.
We would like to develop more Notes, for ULM in collaboration with
the Federation.
Historical reports: currently a list is posted.
The list is fairly complete from 1972.
2 ancient reports (1936 and 1965).
The reports (Fr /Nl) are desidentified and available on request.
The list will be completed as we go along in reviewing archives.

45

Thank you for your attention, and
AAIU (Belgium) wishes you
many happy landings

Photos credit:
MRA / KLM

46


Slide 29

10 JULY 1910 - 2010
100 YEARS ULM ACCIDENTS

Belgian ULM Federation – Safety
1
Conference 10/10/2010

The Air Safety Investigation
• As part of the global Aviation sphere, an investigation is
conducted for each accident and serious incident by an
independent enquiry body, aimed to;
– Determine the causes of the accident.
– Determine if all conditions that were defined by rules and
regulations to ensure flight safety were followed (such as risk
factors in design).
– Define recommendations in order to prevent future accidents.

• It is not the purpose of this investigation to apportion
blame or liability.

2

In Belgium; the Air Accident
Investigation Unit.
• All accidents and serious incidents occurring in Belgium,
on aircraft, helicopters, gliders, balloons, ULM, DPM,
regardless of their registration is investigated by a cell
functionnally independent from the BCAA, and all other
interrested parties.
• Independent doesn’t mean isolated; it is part of the world’s
network of the State’s Aviation Investigation Bodies.
• The cell reports to the President of the Board of the
SPF/FOD Mobility and Transport.
3

4

ULM
• First pendular (Delta Plane Motorized)
design in 1966
• First crossing of the Channel in 1978 by Mr
D. Cook.
• Commercial development from 1979.
• Evolution from 2-axis to 3-axis.
• In Belgium, first ULM registered (501) in
1982.

5

6

Evolution
• 1982: Weedhopper, Chickinox
– 80…100 km/h
– Basic – 2/3 axis
– Range: … 200 km…

• 2010: VL-3 Sprint, DynAero MCR01, WT9 Dynamic….
– 220….250 km/h,
– flaps, retractable gear, avionics,
– Range over 1000 km

• 550 OO- registered ULM;
• 571 ULM pilot licence (363 training licences)
• 300-400 foreign-registered ULM.
7

1000
900
800
700
600
500
400
300
200
100

Number of valid registration

8

Estimation of flying OO-regd ULM

20
10

20
08

20
06

20
04

20
02

20
00

19
98

19
96

19
94

19
92

19
90

19
88

19
86

19
84

19
82

0

Evolution in pilot’s / owner’s
expectations
• In 1982, ULM /DPM, a sporting way of flying,
outside the limits of parachuting, delta plane.

• In 2010, an efficient alternative to general
(certified) aviation. ULM becomes a means of
transport.
• Beyond 2010 ?? – The Need for Speed ?
9

Evolution
• From the user’s perspective, the difference between
General Aviation and ULM becomes very thin.
• However, ULMs are characterized by a huge variety of
different design types, with low production rate and
configuration variation between individual airplanes.
– Manufacturers come and go,
– Assembly of the same ULM type by different companies induce
differences in built configuration.

• The above makes it more and more difficult to speak about
ULMs in a general way; variation in quality is wider than
General (certified) Aviation.
10

EVOLUTION: MORE ULM FATAL ACCIDENTS ?

Fatalities: (up to now), In Belgium, on average 2 /year,
comparable to General (certified) Aviation.
Number of fatalities
12
10
8
6
4
2

Number of fatalities

11

20
10

20
08

20
06

20
04

20
02

20
00

19
98

19
96

19
94

19
92

19
90

19
88

19
86

19
84

0

19
82

FATALITIES:
Figures limited to
Belgium.
2009: + 2 in France.
2010: + 5 in France.

WHAT ARE THE EXPECTATIONS
FOR THE
ULM-ACCIDENTS CASUALITY
RATE ?
• On Belgian soil, 4 deads in 2010.
(casuality rate of U.S. Forces in Iraq 3.6 killed /1000
troop / year – 8 years – 152000 troops – 4424 killed).

• In France and Belgium in 2010, 9 Belgian
deads to-date.
12

Comparison with the road
• In Belgium, the road kills 1000 people on average per year
.
• Fleet of vehicles: 6 000 000 units (5 mio cars).
• For 1000 cars, the road kills on average 0.16 person per
year.
• If we combine these figures with the yearly utilization rate
of cars (1 h per day) versus ULM (40 h per year), we can
conclude that ULM / General Aviation flying is
considerably deadlier than the road.

13

What can we learn from accident
investigation ?

14

The investigation process
A long process (Months)
• Collect all factual elements,
–
–
–
–
–
–

The flow of events;
The pilot (training, experience, …)
The aircraft (contact w/manufacturer)
Meteo, Comm, Radar,
Flt recorders (GPS, ECU, camera, …)
Impact, aircraft damage,

• Analysis. (incl. simulation, testing,…)
• Define all possible causes.
• From the causes, define remedial action.
The depth of the investigation is somewhat influenced by the
expected ROI.
15

Accident analysis
• Accidents do not occur “by accident”; Accident are
caused by a series of events.
• There are no “isolated cases”; causes of accidents are often
recurrent.
• Out of the ULM accident data base, we can conclude;
– There are recurrent technical problems specific to ULM.
– The traditional causes of aviation accidents are also known to
ULM (fuel shortage)

– 80% of the causal factors are human-related.

16

Main causal factors (122 accidents –
fixed wing and ULM)
Loss of control Take-off
11%

Fuel Starvation
15%

Loss of control Flight & collision
12%

Technical
11%
Low piloting
experience
8%

Loss of control Landing
16%
Icing
3%

Low flying /
aerobatics obstacles - CFIT
24%

17

Specific problems with ULM
• Technical causes can be (easily) identified;
but fire can be devastating.
• There’s another problem for the
investigator, a lot of landmarks are missing.
– ULM requirements are national,
– Certification not applicable.
– Wide variety of products.
18

About certification.
• Everyone would agree that ULMs of to-day are as good,
even a lot better than the ‘certified’ airplane.
• ULMs are designed to fly.
ULM are quality products; they meet your expectations
(simple to handle, fly fast, cheap in usage, …)
• Certification means that a manufacturer must demonstrate
that his product meets a minimum level of safety, as
defined (ultimately) by the Aviation Community.
• The minimum level of safety is defined in the Certification
Specifications – For small aircraft, it is called CS23.
19

Technical.
• AAIU(be) is currently investigating on:
– Instrument Board lay-out design.
– Electrical System design.
– Emergency Parachute.
Why is it that (for the last cases) parachute did not save lifes ?
• Late decision ?
• Handle easy to grab ?
• Safety pin not removed before flight ?

20

Same ULM Type, instrument panel somewhat different.
Difference in Ergonomy.
Parachute handle – on pilot’s side, or on passenger’s side ?

21

Regulation: certification:
CS 23.671 General
(b) Controls must be arranged and identified
to provide for convenience in operation and
to prevent the possibility of confusion and
subsequent inadvertent operation.

For ULM, CS 23 is not applicable.
Each designer has his own solution, and
they will be challenged only by YOUR
experience.
22

Other example
The passenger door opens in
flight, causing the pilot to take
appropriate actions, that
eventually force him to an
emergency landing.

• Door lock (simple – crude).
Plexy flexible. Once opened in
flight, difficult to close.
CS 23.783
(1) There must be means to lock and safeguard the door against
inadvertent opening during flight by persons, by cargo, or as a
result of mechanical failure.
23

The problem
• Once we determine a technical problem, we
can define recommendations to improve the
product, but:
What do we do with the recommendation ?
– We can not improve the Standard, there’s no standard.
– We can not address more than one manufacturer,
– What about retrofit ?

24

ULM and Engine failures

25

Fly Synthesis Storch
Summer 2009
• After propeller replacement, and subsequent
engine ground tests, the pilot took off for a
flight test.
• He encountered heavy engine vibration, that
forced him to an emergency landing.
• Airplane was slightly damaged.
Cause was identified as Vapor Lock.
26

1/5/2010 – FK9
Emergency landing after in-flight engine failure.
• Lots of corrosion found in carburettor.
Corrosion comes from water condensation in
fuel system (tank, lines, pump,…- MOGAS)
during long immobilisation periods.
- how to prevent ? Filling up, draining ?

• Fuel system was modified in-service, by
addition of a pressure regulator.
27

France
20/5/2010 – Mistral
23/5/2010 – CT Short Wing
Mistral: Engine failure in flight.
Emergency landing in field; terrain was very soft, airplane
severely damaged.
CT Short Wing: In short final, the engine suddenly stops
The pilot attempts to land, but hit trees, and crashes – wings
ripped off.
RH wing tank empty, 15-25 l fuel remaining in LH tank.
During LH turn, fuel system unprimed, engine stopped by
fuel starvation.
28

4 /6/2010: SG Rally
Damaged during landing
• Due to engine problems (heavy vibrations), the
pilot performed emergency landing on EBHN.
Coming in too fast, the landing was brutal, and
Nose Landing Gear collapsed.

29

Conclusion
• Engine in-flight failure are not exceptional.
– Use of MOGAS (water content, flash point,..)
– Local modifications,
– Other specific to the configuration of the
specific airplane.
And..
– Traditional causes (engine starvation,..)
30

Solutions
• In this case, we can design some generic
recommendations:
– Human Factors; ULM pilots should be more
prepared to react to engine failures at any time
(awareness, briefing, training,…)
– Generic technical solutions; impact on the use
of MOGAS.
• Protection of the equipment during winter,
• Risk of Vapour lock.

31

• Designing stop-gaps, accident after accidents
may not be satisfactory;
What can we do we make sure ULM flying
improves up to an acceptable level and, more
important, remains at that level ?

• More Regulation ?

32

Aviation Regulation and the ULM
• No significant changes in Regulation.
– ULM defined by capacity, weight, structural and stall speed limitation.
– => Extensive use of carbon fiber, Flaps, etc

• CS-VLA.
– 750 kg.
– “light” CS-23.
– Expensive.

• Lower Requirements for licencing,
– What about competence ?
– Human Factors training

• National requirements in Europe.
– EASA Flight Permit per Part 21A.701.

33

Evolution: new EU Regulation on
Accident Investigation.
* Every civil aviation accident or serious incident involving
aircraft other than specified in Annex II to the Regulation (EC)
No 216/2008 of the European Parliament and of the Council
shall be the subject of a safety investigation

( = No obligation of enquiry for ULMs)
• Safety investigation authorities may decide to investigate
incidents other than those referred to in paragraph 1 as well as
accidents or serious incidents to other types of aircraft, in
accordance with the national legislation of the Member States,
when they expect to draw safety lessons from them.
34

• US. NTSB; no enquiry for ULM crashes.
• To-day already, in some EU countries, ULM
crash investigations are given a low priority,
unless the Public determines otherwise.
• Common sense dictates that the initiative
to improve safety must come from the
ULM community itself.

35

Reason Model
• aviation is a complex socio-technical
system, where safety is ensured by a
series of defense barriers.
• Each barrier may present flaws (latent
or active) whose combination can lead
to an accident.
• An usafe act (active failure) alone
would not cause an accident.
• Latent failures are more easily
detected and corrected that human
errors, which are (globally) inevitable.

36

• The ULM community should reinforce its
Defense Barriers.
• Organisation: Federation and Clubs.
Create a Safety Climate
- Norms and rules
- Safety Programs

- To define a Safety Climate, we need to
assess the potential risk, and for that we
need data: YOUR experience.
37

Pyramid of Heinrich
• If a fatal accident is caused by
a specific combination of
events, an uncomplete series
of events causes INCIDENTS.
• If we identify all potentially
dangerous events AND with
that information, build-up the
defenses, we can avoid
ACCIDENTS.
38

SHARING EXPERIENCE
• By informing the Federation of the small
events and incidents that spoiled one of
your flights, you allow the Community to
understand the potential dangers and act
upon. (and respect confidentiality)
“Learn from mistakes of others; you won’t
live long enough to make them all by
yourself”
39

Human Factors
• To err is human.
• Human life (and flying) is full of decisions.
• It is therefore more important to know yourself
than to know how to fly your aircraft.
– Get-home-itis, Distraction, Communication,..

• Understanding human factors is a very important
step in improving your defenses.
40

Competence and Readiness
• You hold a pilot licence; but are you a
competent flyer ?
• How will you react when faced with a
potential dangerous situation?
• Assessing your competences with an
instructor is an opportunity to improve.
• When flying, be ready.
41

What is the Authority doing for
you ?

42

A series of work groups
within EASA are thinking
about how to improve
flight safety.(ESSI)
One of them is about General
Aviation (EGAST).

Initiative includes a leaflet
On Collision Avoidance,
and has been relayed to you
by the Federation.
There are technical Work
Groups dealing with MOGAS
43

and

An initiative to develop
Posters with comic strips
On high risk topics.
The first goes about taking
The right decision when the
Weather is below minimum.
They are expected in the
Coming months.

44

For Belgium, Accident reports are made public on the SPF/FOD website.
Recent reports (from 1st May 2007) are directly available through
hyperlinks.
Reports are written in English.
Information Notes are also available in order to highlight specific danger
area: Nr 2010 is about engine cold start.
We would like to develop more Notes, for ULM in collaboration with
the Federation.
Historical reports: currently a list is posted.
The list is fairly complete from 1972.
2 ancient reports (1936 and 1965).
The reports (Fr /Nl) are desidentified and available on request.
The list will be completed as we go along in reviewing archives.

45

Thank you for your attention, and
AAIU (Belgium) wishes you
many happy landings

Photos credit:
MRA / KLM

46


Slide 30

10 JULY 1910 - 2010
100 YEARS ULM ACCIDENTS

Belgian ULM Federation – Safety
1
Conference 10/10/2010

The Air Safety Investigation
• As part of the global Aviation sphere, an investigation is
conducted for each accident and serious incident by an
independent enquiry body, aimed to;
– Determine the causes of the accident.
– Determine if all conditions that were defined by rules and
regulations to ensure flight safety were followed (such as risk
factors in design).
– Define recommendations in order to prevent future accidents.

• It is not the purpose of this investigation to apportion
blame or liability.

2

In Belgium; the Air Accident
Investigation Unit.
• All accidents and serious incidents occurring in Belgium,
on aircraft, helicopters, gliders, balloons, ULM, DPM,
regardless of their registration is investigated by a cell
functionnally independent from the BCAA, and all other
interrested parties.
• Independent doesn’t mean isolated; it is part of the world’s
network of the State’s Aviation Investigation Bodies.
• The cell reports to the President of the Board of the
SPF/FOD Mobility and Transport.
3

4

ULM
• First pendular (Delta Plane Motorized)
design in 1966
• First crossing of the Channel in 1978 by Mr
D. Cook.
• Commercial development from 1979.
• Evolution from 2-axis to 3-axis.
• In Belgium, first ULM registered (501) in
1982.

5

6

Evolution
• 1982: Weedhopper, Chickinox
– 80…100 km/h
– Basic – 2/3 axis
– Range: … 200 km…

• 2010: VL-3 Sprint, DynAero MCR01, WT9 Dynamic….
– 220….250 km/h,
– flaps, retractable gear, avionics,
– Range over 1000 km

• 550 OO- registered ULM;
• 571 ULM pilot licence (363 training licences)
• 300-400 foreign-registered ULM.
7

1000
900
800
700
600
500
400
300
200
100

Number of valid registration

8

Estimation of flying OO-regd ULM

20
10

20
08

20
06

20
04

20
02

20
00

19
98

19
96

19
94

19
92

19
90

19
88

19
86

19
84

19
82

0

Evolution in pilot’s / owner’s
expectations
• In 1982, ULM /DPM, a sporting way of flying,
outside the limits of parachuting, delta plane.

• In 2010, an efficient alternative to general
(certified) aviation. ULM becomes a means of
transport.
• Beyond 2010 ?? – The Need for Speed ?
9

Evolution
• From the user’s perspective, the difference between
General Aviation and ULM becomes very thin.
• However, ULMs are characterized by a huge variety of
different design types, with low production rate and
configuration variation between individual airplanes.
– Manufacturers come and go,
– Assembly of the same ULM type by different companies induce
differences in built configuration.

• The above makes it more and more difficult to speak about
ULMs in a general way; variation in quality is wider than
General (certified) Aviation.
10

EVOLUTION: MORE ULM FATAL ACCIDENTS ?

Fatalities: (up to now), In Belgium, on average 2 /year,
comparable to General (certified) Aviation.
Number of fatalities
12
10
8
6
4
2

Number of fatalities

11

20
10

20
08

20
06

20
04

20
02

20
00

19
98

19
96

19
94

19
92

19
90

19
88

19
86

19
84

0

19
82

FATALITIES:
Figures limited to
Belgium.
2009: + 2 in France.
2010: + 5 in France.

WHAT ARE THE EXPECTATIONS
FOR THE
ULM-ACCIDENTS CASUALITY
RATE ?
• On Belgian soil, 4 deads in 2010.
(casuality rate of U.S. Forces in Iraq 3.6 killed /1000
troop / year – 8 years – 152000 troops – 4424 killed).

• In France and Belgium in 2010, 9 Belgian
deads to-date.
12

Comparison with the road
• In Belgium, the road kills 1000 people on average per year
.
• Fleet of vehicles: 6 000 000 units (5 mio cars).
• For 1000 cars, the road kills on average 0.16 person per
year.
• If we combine these figures with the yearly utilization rate
of cars (1 h per day) versus ULM (40 h per year), we can
conclude that ULM / General Aviation flying is
considerably deadlier than the road.

13

What can we learn from accident
investigation ?

14

The investigation process
A long process (Months)
• Collect all factual elements,
–
–
–
–
–
–

The flow of events;
The pilot (training, experience, …)
The aircraft (contact w/manufacturer)
Meteo, Comm, Radar,
Flt recorders (GPS, ECU, camera, …)
Impact, aircraft damage,

• Analysis. (incl. simulation, testing,…)
• Define all possible causes.
• From the causes, define remedial action.
The depth of the investigation is somewhat influenced by the
expected ROI.
15

Accident analysis
• Accidents do not occur “by accident”; Accident are
caused by a series of events.
• There are no “isolated cases”; causes of accidents are often
recurrent.
• Out of the ULM accident data base, we can conclude;
– There are recurrent technical problems specific to ULM.
– The traditional causes of aviation accidents are also known to
ULM (fuel shortage)

– 80% of the causal factors are human-related.

16

Main causal factors (122 accidents –
fixed wing and ULM)
Loss of control Take-off
11%

Fuel Starvation
15%

Loss of control Flight & collision
12%

Technical
11%
Low piloting
experience
8%

Loss of control Landing
16%
Icing
3%

Low flying /
aerobatics obstacles - CFIT
24%

17

Specific problems with ULM
• Technical causes can be (easily) identified;
but fire can be devastating.
• There’s another problem for the
investigator, a lot of landmarks are missing.
– ULM requirements are national,
– Certification not applicable.
– Wide variety of products.
18

About certification.
• Everyone would agree that ULMs of to-day are as good,
even a lot better than the ‘certified’ airplane.
• ULMs are designed to fly.
ULM are quality products; they meet your expectations
(simple to handle, fly fast, cheap in usage, …)
• Certification means that a manufacturer must demonstrate
that his product meets a minimum level of safety, as
defined (ultimately) by the Aviation Community.
• The minimum level of safety is defined in the Certification
Specifications – For small aircraft, it is called CS23.
19

Technical.
• AAIU(be) is currently investigating on:
– Instrument Board lay-out design.
– Electrical System design.
– Emergency Parachute.
Why is it that (for the last cases) parachute did not save lifes ?
• Late decision ?
• Handle easy to grab ?
• Safety pin not removed before flight ?

20

Same ULM Type, instrument panel somewhat different.
Difference in Ergonomy.
Parachute handle – on pilot’s side, or on passenger’s side ?

21

Regulation: certification:
CS 23.671 General
(b) Controls must be arranged and identified
to provide for convenience in operation and
to prevent the possibility of confusion and
subsequent inadvertent operation.

For ULM, CS 23 is not applicable.
Each designer has his own solution, and
they will be challenged only by YOUR
experience.
22

Other example
The passenger door opens in
flight, causing the pilot to take
appropriate actions, that
eventually force him to an
emergency landing.

• Door lock (simple – crude).
Plexy flexible. Once opened in
flight, difficult to close.
CS 23.783
(1) There must be means to lock and safeguard the door against
inadvertent opening during flight by persons, by cargo, or as a
result of mechanical failure.
23

The problem
• Once we determine a technical problem, we
can define recommendations to improve the
product, but:
What do we do with the recommendation ?
– We can not improve the Standard, there’s no standard.
– We can not address more than one manufacturer,
– What about retrofit ?

24

ULM and Engine failures

25

Fly Synthesis Storch
Summer 2009
• After propeller replacement, and subsequent
engine ground tests, the pilot took off for a
flight test.
• He encountered heavy engine vibration, that
forced him to an emergency landing.
• Airplane was slightly damaged.
Cause was identified as Vapor Lock.
26

1/5/2010 – FK9
Emergency landing after in-flight engine failure.
• Lots of corrosion found in carburettor.
Corrosion comes from water condensation in
fuel system (tank, lines, pump,…- MOGAS)
during long immobilisation periods.
- how to prevent ? Filling up, draining ?

• Fuel system was modified in-service, by
addition of a pressure regulator.
27

France
20/5/2010 – Mistral
23/5/2010 – CT Short Wing
Mistral: Engine failure in flight.
Emergency landing in field; terrain was very soft, airplane
severely damaged.
CT Short Wing: In short final, the engine suddenly stops
The pilot attempts to land, but hit trees, and crashes – wings
ripped off.
RH wing tank empty, 15-25 l fuel remaining in LH tank.
During LH turn, fuel system unprimed, engine stopped by
fuel starvation.
28

4 /6/2010: SG Rally
Damaged during landing
• Due to engine problems (heavy vibrations), the
pilot performed emergency landing on EBHN.
Coming in too fast, the landing was brutal, and
Nose Landing Gear collapsed.

29

Conclusion
• Engine in-flight failure are not exceptional.
– Use of MOGAS (water content, flash point,..)
– Local modifications,
– Other specific to the configuration of the
specific airplane.
And..
– Traditional causes (engine starvation,..)
30

Solutions
• In this case, we can design some generic
recommendations:
– Human Factors; ULM pilots should be more
prepared to react to engine failures at any time
(awareness, briefing, training,…)
– Generic technical solutions; impact on the use
of MOGAS.
• Protection of the equipment during winter,
• Risk of Vapour lock.

31

• Designing stop-gaps, accident after accidents
may not be satisfactory;
What can we do we make sure ULM flying
improves up to an acceptable level and, more
important, remains at that level ?

• More Regulation ?

32

Aviation Regulation and the ULM
• No significant changes in Regulation.
– ULM defined by capacity, weight, structural and stall speed limitation.
– => Extensive use of carbon fiber, Flaps, etc

• CS-VLA.
– 750 kg.
– “light” CS-23.
– Expensive.

• Lower Requirements for licencing,
– What about competence ?
– Human Factors training

• National requirements in Europe.
– EASA Flight Permit per Part 21A.701.

33

Evolution: new EU Regulation on
Accident Investigation.
* Every civil aviation accident or serious incident involving
aircraft other than specified in Annex II to the Regulation (EC)
No 216/2008 of the European Parliament and of the Council
shall be the subject of a safety investigation

( = No obligation of enquiry for ULMs)
• Safety investigation authorities may decide to investigate
incidents other than those referred to in paragraph 1 as well as
accidents or serious incidents to other types of aircraft, in
accordance with the national legislation of the Member States,
when they expect to draw safety lessons from them.
34

• US. NTSB; no enquiry for ULM crashes.
• To-day already, in some EU countries, ULM
crash investigations are given a low priority,
unless the Public determines otherwise.
• Common sense dictates that the initiative
to improve safety must come from the
ULM community itself.

35

Reason Model
• aviation is a complex socio-technical
system, where safety is ensured by a
series of defense barriers.
• Each barrier may present flaws (latent
or active) whose combination can lead
to an accident.
• An usafe act (active failure) alone
would not cause an accident.
• Latent failures are more easily
detected and corrected that human
errors, which are (globally) inevitable.

36

• The ULM community should reinforce its
Defense Barriers.
• Organisation: Federation and Clubs.
Create a Safety Climate
- Norms and rules
- Safety Programs

- To define a Safety Climate, we need to
assess the potential risk, and for that we
need data: YOUR experience.
37

Pyramid of Heinrich
• If a fatal accident is caused by
a specific combination of
events, an uncomplete series
of events causes INCIDENTS.
• If we identify all potentially
dangerous events AND with
that information, build-up the
defenses, we can avoid
ACCIDENTS.
38

SHARING EXPERIENCE
• By informing the Federation of the small
events and incidents that spoiled one of
your flights, you allow the Community to
understand the potential dangers and act
upon. (and respect confidentiality)
“Learn from mistakes of others; you won’t
live long enough to make them all by
yourself”
39

Human Factors
• To err is human.
• Human life (and flying) is full of decisions.
• It is therefore more important to know yourself
than to know how to fly your aircraft.
– Get-home-itis, Distraction, Communication,..

• Understanding human factors is a very important
step in improving your defenses.
40

Competence and Readiness
• You hold a pilot licence; but are you a
competent flyer ?
• How will you react when faced with a
potential dangerous situation?
• Assessing your competences with an
instructor is an opportunity to improve.
• When flying, be ready.
41

What is the Authority doing for
you ?

42

A series of work groups
within EASA are thinking
about how to improve
flight safety.(ESSI)
One of them is about General
Aviation (EGAST).

Initiative includes a leaflet
On Collision Avoidance,
and has been relayed to you
by the Federation.
There are technical Work
Groups dealing with MOGAS
43

and

An initiative to develop
Posters with comic strips
On high risk topics.
The first goes about taking
The right decision when the
Weather is below minimum.
They are expected in the
Coming months.

44

For Belgium, Accident reports are made public on the SPF/FOD website.
Recent reports (from 1st May 2007) are directly available through
hyperlinks.
Reports are written in English.
Information Notes are also available in order to highlight specific danger
area: Nr 2010 is about engine cold start.
We would like to develop more Notes, for ULM in collaboration with
the Federation.
Historical reports: currently a list is posted.
The list is fairly complete from 1972.
2 ancient reports (1936 and 1965).
The reports (Fr /Nl) are desidentified and available on request.
The list will be completed as we go along in reviewing archives.

45

Thank you for your attention, and
AAIU (Belgium) wishes you
many happy landings

Photos credit:
MRA / KLM

46


Slide 31

10 JULY 1910 - 2010
100 YEARS ULM ACCIDENTS

Belgian ULM Federation – Safety
1
Conference 10/10/2010

The Air Safety Investigation
• As part of the global Aviation sphere, an investigation is
conducted for each accident and serious incident by an
independent enquiry body, aimed to;
– Determine the causes of the accident.
– Determine if all conditions that were defined by rules and
regulations to ensure flight safety were followed (such as risk
factors in design).
– Define recommendations in order to prevent future accidents.

• It is not the purpose of this investigation to apportion
blame or liability.

2

In Belgium; the Air Accident
Investigation Unit.
• All accidents and serious incidents occurring in Belgium,
on aircraft, helicopters, gliders, balloons, ULM, DPM,
regardless of their registration is investigated by a cell
functionnally independent from the BCAA, and all other
interrested parties.
• Independent doesn’t mean isolated; it is part of the world’s
network of the State’s Aviation Investigation Bodies.
• The cell reports to the President of the Board of the
SPF/FOD Mobility and Transport.
3

4

ULM
• First pendular (Delta Plane Motorized)
design in 1966
• First crossing of the Channel in 1978 by Mr
D. Cook.
• Commercial development from 1979.
• Evolution from 2-axis to 3-axis.
• In Belgium, first ULM registered (501) in
1982.

5

6

Evolution
• 1982: Weedhopper, Chickinox
– 80…100 km/h
– Basic – 2/3 axis
– Range: … 200 km…

• 2010: VL-3 Sprint, DynAero MCR01, WT9 Dynamic….
– 220….250 km/h,
– flaps, retractable gear, avionics,
– Range over 1000 km

• 550 OO- registered ULM;
• 571 ULM pilot licence (363 training licences)
• 300-400 foreign-registered ULM.
7

1000
900
800
700
600
500
400
300
200
100

Number of valid registration

8

Estimation of flying OO-regd ULM

20
10

20
08

20
06

20
04

20
02

20
00

19
98

19
96

19
94

19
92

19
90

19
88

19
86

19
84

19
82

0

Evolution in pilot’s / owner’s
expectations
• In 1982, ULM /DPM, a sporting way of flying,
outside the limits of parachuting, delta plane.

• In 2010, an efficient alternative to general
(certified) aviation. ULM becomes a means of
transport.
• Beyond 2010 ?? – The Need for Speed ?
9

Evolution
• From the user’s perspective, the difference between
General Aviation and ULM becomes very thin.
• However, ULMs are characterized by a huge variety of
different design types, with low production rate and
configuration variation between individual airplanes.
– Manufacturers come and go,
– Assembly of the same ULM type by different companies induce
differences in built configuration.

• The above makes it more and more difficult to speak about
ULMs in a general way; variation in quality is wider than
General (certified) Aviation.
10

EVOLUTION: MORE ULM FATAL ACCIDENTS ?

Fatalities: (up to now), In Belgium, on average 2 /year,
comparable to General (certified) Aviation.
Number of fatalities
12
10
8
6
4
2

Number of fatalities

11

20
10

20
08

20
06

20
04

20
02

20
00

19
98

19
96

19
94

19
92

19
90

19
88

19
86

19
84

0

19
82

FATALITIES:
Figures limited to
Belgium.
2009: + 2 in France.
2010: + 5 in France.

WHAT ARE THE EXPECTATIONS
FOR THE
ULM-ACCIDENTS CASUALITY
RATE ?
• On Belgian soil, 4 deads in 2010.
(casuality rate of U.S. Forces in Iraq 3.6 killed /1000
troop / year – 8 years – 152000 troops – 4424 killed).

• In France and Belgium in 2010, 9 Belgian
deads to-date.
12

Comparison with the road
• In Belgium, the road kills 1000 people on average per year
.
• Fleet of vehicles: 6 000 000 units (5 mio cars).
• For 1000 cars, the road kills on average 0.16 person per
year.
• If we combine these figures with the yearly utilization rate
of cars (1 h per day) versus ULM (40 h per year), we can
conclude that ULM / General Aviation flying is
considerably deadlier than the road.

13

What can we learn from accident
investigation ?

14

The investigation process
A long process (Months)
• Collect all factual elements,
–
–
–
–
–
–

The flow of events;
The pilot (training, experience, …)
The aircraft (contact w/manufacturer)
Meteo, Comm, Radar,
Flt recorders (GPS, ECU, camera, …)
Impact, aircraft damage,

• Analysis. (incl. simulation, testing,…)
• Define all possible causes.
• From the causes, define remedial action.
The depth of the investigation is somewhat influenced by the
expected ROI.
15

Accident analysis
• Accidents do not occur “by accident”; Accident are
caused by a series of events.
• There are no “isolated cases”; causes of accidents are often
recurrent.
• Out of the ULM accident data base, we can conclude;
– There are recurrent technical problems specific to ULM.
– The traditional causes of aviation accidents are also known to
ULM (fuel shortage)

– 80% of the causal factors are human-related.

16

Main causal factors (122 accidents –
fixed wing and ULM)
Loss of control Take-off
11%

Fuel Starvation
15%

Loss of control Flight & collision
12%

Technical
11%
Low piloting
experience
8%

Loss of control Landing
16%
Icing
3%

Low flying /
aerobatics obstacles - CFIT
24%

17

Specific problems with ULM
• Technical causes can be (easily) identified;
but fire can be devastating.
• There’s another problem for the
investigator, a lot of landmarks are missing.
– ULM requirements are national,
– Certification not applicable.
– Wide variety of products.
18

About certification.
• Everyone would agree that ULMs of to-day are as good,
even a lot better than the ‘certified’ airplane.
• ULMs are designed to fly.
ULM are quality products; they meet your expectations
(simple to handle, fly fast, cheap in usage, …)
• Certification means that a manufacturer must demonstrate
that his product meets a minimum level of safety, as
defined (ultimately) by the Aviation Community.
• The minimum level of safety is defined in the Certification
Specifications – For small aircraft, it is called CS23.
19

Technical.
• AAIU(be) is currently investigating on:
– Instrument Board lay-out design.
– Electrical System design.
– Emergency Parachute.
Why is it that (for the last cases) parachute did not save lifes ?
• Late decision ?
• Handle easy to grab ?
• Safety pin not removed before flight ?

20

Same ULM Type, instrument panel somewhat different.
Difference in Ergonomy.
Parachute handle – on pilot’s side, or on passenger’s side ?

21

Regulation: certification:
CS 23.671 General
(b) Controls must be arranged and identified
to provide for convenience in operation and
to prevent the possibility of confusion and
subsequent inadvertent operation.

For ULM, CS 23 is not applicable.
Each designer has his own solution, and
they will be challenged only by YOUR
experience.
22

Other example
The passenger door opens in
flight, causing the pilot to take
appropriate actions, that
eventually force him to an
emergency landing.

• Door lock (simple – crude).
Plexy flexible. Once opened in
flight, difficult to close.
CS 23.783
(1) There must be means to lock and safeguard the door against
inadvertent opening during flight by persons, by cargo, or as a
result of mechanical failure.
23

The problem
• Once we determine a technical problem, we
can define recommendations to improve the
product, but:
What do we do with the recommendation ?
– We can not improve the Standard, there’s no standard.
– We can not address more than one manufacturer,
– What about retrofit ?

24

ULM and Engine failures

25

Fly Synthesis Storch
Summer 2009
• After propeller replacement, and subsequent
engine ground tests, the pilot took off for a
flight test.
• He encountered heavy engine vibration, that
forced him to an emergency landing.
• Airplane was slightly damaged.
Cause was identified as Vapor Lock.
26

1/5/2010 – FK9
Emergency landing after in-flight engine failure.
• Lots of corrosion found in carburettor.
Corrosion comes from water condensation in
fuel system (tank, lines, pump,…- MOGAS)
during long immobilisation periods.
- how to prevent ? Filling up, draining ?

• Fuel system was modified in-service, by
addition of a pressure regulator.
27

France
20/5/2010 – Mistral
23/5/2010 – CT Short Wing
Mistral: Engine failure in flight.
Emergency landing in field; terrain was very soft, airplane
severely damaged.
CT Short Wing: In short final, the engine suddenly stops
The pilot attempts to land, but hit trees, and crashes – wings
ripped off.
RH wing tank empty, 15-25 l fuel remaining in LH tank.
During LH turn, fuel system unprimed, engine stopped by
fuel starvation.
28

4 /6/2010: SG Rally
Damaged during landing
• Due to engine problems (heavy vibrations), the
pilot performed emergency landing on EBHN.
Coming in too fast, the landing was brutal, and
Nose Landing Gear collapsed.

29

Conclusion
• Engine in-flight failure are not exceptional.
– Use of MOGAS (water content, flash point,..)
– Local modifications,
– Other specific to the configuration of the
specific airplane.
And..
– Traditional causes (engine starvation,..)
30

Solutions
• In this case, we can design some generic
recommendations:
– Human Factors; ULM pilots should be more
prepared to react to engine failures at any time
(awareness, briefing, training,…)
– Generic technical solutions; impact on the use
of MOGAS.
• Protection of the equipment during winter,
• Risk of Vapour lock.

31

• Designing stop-gaps, accident after accidents
may not be satisfactory;
What can we do we make sure ULM flying
improves up to an acceptable level and, more
important, remains at that level ?

• More Regulation ?

32

Aviation Regulation and the ULM
• No significant changes in Regulation.
– ULM defined by capacity, weight, structural and stall speed limitation.
– => Extensive use of carbon fiber, Flaps, etc

• CS-VLA.
– 750 kg.
– “light” CS-23.
– Expensive.

• Lower Requirements for licencing,
– What about competence ?
– Human Factors training

• National requirements in Europe.
– EASA Flight Permit per Part 21A.701.

33

Evolution: new EU Regulation on
Accident Investigation.
* Every civil aviation accident or serious incident involving
aircraft other than specified in Annex II to the Regulation (EC)
No 216/2008 of the European Parliament and of the Council
shall be the subject of a safety investigation

( = No obligation of enquiry for ULMs)
• Safety investigation authorities may decide to investigate
incidents other than those referred to in paragraph 1 as well as
accidents or serious incidents to other types of aircraft, in
accordance with the national legislation of the Member States,
when they expect to draw safety lessons from them.
34

• US. NTSB; no enquiry for ULM crashes.
• To-day already, in some EU countries, ULM
crash investigations are given a low priority,
unless the Public determines otherwise.
• Common sense dictates that the initiative
to improve safety must come from the
ULM community itself.

35

Reason Model
• aviation is a complex socio-technical
system, where safety is ensured by a
series of defense barriers.
• Each barrier may present flaws (latent
or active) whose combination can lead
to an accident.
• An usafe act (active failure) alone
would not cause an accident.
• Latent failures are more easily
detected and corrected that human
errors, which are (globally) inevitable.

36

• The ULM community should reinforce its
Defense Barriers.
• Organisation: Federation and Clubs.
Create a Safety Climate
- Norms and rules
- Safety Programs

- To define a Safety Climate, we need to
assess the potential risk, and for that we
need data: YOUR experience.
37

Pyramid of Heinrich
• If a fatal accident is caused by
a specific combination of
events, an uncomplete series
of events causes INCIDENTS.
• If we identify all potentially
dangerous events AND with
that information, build-up the
defenses, we can avoid
ACCIDENTS.
38

SHARING EXPERIENCE
• By informing the Federation of the small
events and incidents that spoiled one of
your flights, you allow the Community to
understand the potential dangers and act
upon. (and respect confidentiality)
“Learn from mistakes of others; you won’t
live long enough to make them all by
yourself”
39

Human Factors
• To err is human.
• Human life (and flying) is full of decisions.
• It is therefore more important to know yourself
than to know how to fly your aircraft.
– Get-home-itis, Distraction, Communication,..

• Understanding human factors is a very important
step in improving your defenses.
40

Competence and Readiness
• You hold a pilot licence; but are you a
competent flyer ?
• How will you react when faced with a
potential dangerous situation?
• Assessing your competences with an
instructor is an opportunity to improve.
• When flying, be ready.
41

What is the Authority doing for
you ?

42

A series of work groups
within EASA are thinking
about how to improve
flight safety.(ESSI)
One of them is about General
Aviation (EGAST).

Initiative includes a leaflet
On Collision Avoidance,
and has been relayed to you
by the Federation.
There are technical Work
Groups dealing with MOGAS
43

and

An initiative to develop
Posters with comic strips
On high risk topics.
The first goes about taking
The right decision when the
Weather is below minimum.
They are expected in the
Coming months.

44

For Belgium, Accident reports are made public on the SPF/FOD website.
Recent reports (from 1st May 2007) are directly available through
hyperlinks.
Reports are written in English.
Information Notes are also available in order to highlight specific danger
area: Nr 2010 is about engine cold start.
We would like to develop more Notes, for ULM in collaboration with
the Federation.
Historical reports: currently a list is posted.
The list is fairly complete from 1972.
2 ancient reports (1936 and 1965).
The reports (Fr /Nl) are desidentified and available on request.
The list will be completed as we go along in reviewing archives.

45

Thank you for your attention, and
AAIU (Belgium) wishes you
many happy landings

Photos credit:
MRA / KLM

46


Slide 32

10 JULY 1910 - 2010
100 YEARS ULM ACCIDENTS

Belgian ULM Federation – Safety
1
Conference 10/10/2010

The Air Safety Investigation
• As part of the global Aviation sphere, an investigation is
conducted for each accident and serious incident by an
independent enquiry body, aimed to;
– Determine the causes of the accident.
– Determine if all conditions that were defined by rules and
regulations to ensure flight safety were followed (such as risk
factors in design).
– Define recommendations in order to prevent future accidents.

• It is not the purpose of this investigation to apportion
blame or liability.

2

In Belgium; the Air Accident
Investigation Unit.
• All accidents and serious incidents occurring in Belgium,
on aircraft, helicopters, gliders, balloons, ULM, DPM,
regardless of their registration is investigated by a cell
functionnally independent from the BCAA, and all other
interrested parties.
• Independent doesn’t mean isolated; it is part of the world’s
network of the State’s Aviation Investigation Bodies.
• The cell reports to the President of the Board of the
SPF/FOD Mobility and Transport.
3

4

ULM
• First pendular (Delta Plane Motorized)
design in 1966
• First crossing of the Channel in 1978 by Mr
D. Cook.
• Commercial development from 1979.
• Evolution from 2-axis to 3-axis.
• In Belgium, first ULM registered (501) in
1982.

5

6

Evolution
• 1982: Weedhopper, Chickinox
– 80…100 km/h
– Basic – 2/3 axis
– Range: … 200 km…

• 2010: VL-3 Sprint, DynAero MCR01, WT9 Dynamic….
– 220….250 km/h,
– flaps, retractable gear, avionics,
– Range over 1000 km

• 550 OO- registered ULM;
• 571 ULM pilot licence (363 training licences)
• 300-400 foreign-registered ULM.
7

1000
900
800
700
600
500
400
300
200
100

Number of valid registration

8

Estimation of flying OO-regd ULM

20
10

20
08

20
06

20
04

20
02

20
00

19
98

19
96

19
94

19
92

19
90

19
88

19
86

19
84

19
82

0

Evolution in pilot’s / owner’s
expectations
• In 1982, ULM /DPM, a sporting way of flying,
outside the limits of parachuting, delta plane.

• In 2010, an efficient alternative to general
(certified) aviation. ULM becomes a means of
transport.
• Beyond 2010 ?? – The Need for Speed ?
9

Evolution
• From the user’s perspective, the difference between
General Aviation and ULM becomes very thin.
• However, ULMs are characterized by a huge variety of
different design types, with low production rate and
configuration variation between individual airplanes.
– Manufacturers come and go,
– Assembly of the same ULM type by different companies induce
differences in built configuration.

• The above makes it more and more difficult to speak about
ULMs in a general way; variation in quality is wider than
General (certified) Aviation.
10

EVOLUTION: MORE ULM FATAL ACCIDENTS ?

Fatalities: (up to now), In Belgium, on average 2 /year,
comparable to General (certified) Aviation.
Number of fatalities
12
10
8
6
4
2

Number of fatalities

11

20
10

20
08

20
06

20
04

20
02

20
00

19
98

19
96

19
94

19
92

19
90

19
88

19
86

19
84

0

19
82

FATALITIES:
Figures limited to
Belgium.
2009: + 2 in France.
2010: + 5 in France.

WHAT ARE THE EXPECTATIONS
FOR THE
ULM-ACCIDENTS CASUALITY
RATE ?
• On Belgian soil, 4 deads in 2010.
(casuality rate of U.S. Forces in Iraq 3.6 killed /1000
troop / year – 8 years – 152000 troops – 4424 killed).

• In France and Belgium in 2010, 9 Belgian
deads to-date.
12

Comparison with the road
• In Belgium, the road kills 1000 people on average per year
.
• Fleet of vehicles: 6 000 000 units (5 mio cars).
• For 1000 cars, the road kills on average 0.16 person per
year.
• If we combine these figures with the yearly utilization rate
of cars (1 h per day) versus ULM (40 h per year), we can
conclude that ULM / General Aviation flying is
considerably deadlier than the road.

13

What can we learn from accident
investigation ?

14

The investigation process
A long process (Months)
• Collect all factual elements,
–
–
–
–
–
–

The flow of events;
The pilot (training, experience, …)
The aircraft (contact w/manufacturer)
Meteo, Comm, Radar,
Flt recorders (GPS, ECU, camera, …)
Impact, aircraft damage,

• Analysis. (incl. simulation, testing,…)
• Define all possible causes.
• From the causes, define remedial action.
The depth of the investigation is somewhat influenced by the
expected ROI.
15

Accident analysis
• Accidents do not occur “by accident”; Accident are
caused by a series of events.
• There are no “isolated cases”; causes of accidents are often
recurrent.
• Out of the ULM accident data base, we can conclude;
– There are recurrent technical problems specific to ULM.
– The traditional causes of aviation accidents are also known to
ULM (fuel shortage)

– 80% of the causal factors are human-related.

16

Main causal factors (122 accidents –
fixed wing and ULM)
Loss of control Take-off
11%

Fuel Starvation
15%

Loss of control Flight & collision
12%

Technical
11%
Low piloting
experience
8%

Loss of control Landing
16%
Icing
3%

Low flying /
aerobatics obstacles - CFIT
24%

17

Specific problems with ULM
• Technical causes can be (easily) identified;
but fire can be devastating.
• There’s another problem for the
investigator, a lot of landmarks are missing.
– ULM requirements are national,
– Certification not applicable.
– Wide variety of products.
18

About certification.
• Everyone would agree that ULMs of to-day are as good,
even a lot better than the ‘certified’ airplane.
• ULMs are designed to fly.
ULM are quality products; they meet your expectations
(simple to handle, fly fast, cheap in usage, …)
• Certification means that a manufacturer must demonstrate
that his product meets a minimum level of safety, as
defined (ultimately) by the Aviation Community.
• The minimum level of safety is defined in the Certification
Specifications – For small aircraft, it is called CS23.
19

Technical.
• AAIU(be) is currently investigating on:
– Instrument Board lay-out design.
– Electrical System design.
– Emergency Parachute.
Why is it that (for the last cases) parachute did not save lifes ?
• Late decision ?
• Handle easy to grab ?
• Safety pin not removed before flight ?

20

Same ULM Type, instrument panel somewhat different.
Difference in Ergonomy.
Parachute handle – on pilot’s side, or on passenger’s side ?

21

Regulation: certification:
CS 23.671 General
(b) Controls must be arranged and identified
to provide for convenience in operation and
to prevent the possibility of confusion and
subsequent inadvertent operation.

For ULM, CS 23 is not applicable.
Each designer has his own solution, and
they will be challenged only by YOUR
experience.
22

Other example
The passenger door opens in
flight, causing the pilot to take
appropriate actions, that
eventually force him to an
emergency landing.

• Door lock (simple – crude).
Plexy flexible. Once opened in
flight, difficult to close.
CS 23.783
(1) There must be means to lock and safeguard the door against
inadvertent opening during flight by persons, by cargo, or as a
result of mechanical failure.
23

The problem
• Once we determine a technical problem, we
can define recommendations to improve the
product, but:
What do we do with the recommendation ?
– We can not improve the Standard, there’s no standard.
– We can not address more than one manufacturer,
– What about retrofit ?

24

ULM and Engine failures

25

Fly Synthesis Storch
Summer 2009
• After propeller replacement, and subsequent
engine ground tests, the pilot took off for a
flight test.
• He encountered heavy engine vibration, that
forced him to an emergency landing.
• Airplane was slightly damaged.
Cause was identified as Vapor Lock.
26

1/5/2010 – FK9
Emergency landing after in-flight engine failure.
• Lots of corrosion found in carburettor.
Corrosion comes from water condensation in
fuel system (tank, lines, pump,…- MOGAS)
during long immobilisation periods.
- how to prevent ? Filling up, draining ?

• Fuel system was modified in-service, by
addition of a pressure regulator.
27

France
20/5/2010 – Mistral
23/5/2010 – CT Short Wing
Mistral: Engine failure in flight.
Emergency landing in field; terrain was very soft, airplane
severely damaged.
CT Short Wing: In short final, the engine suddenly stops
The pilot attempts to land, but hit trees, and crashes – wings
ripped off.
RH wing tank empty, 15-25 l fuel remaining in LH tank.
During LH turn, fuel system unprimed, engine stopped by
fuel starvation.
28

4 /6/2010: SG Rally
Damaged during landing
• Due to engine problems (heavy vibrations), the
pilot performed emergency landing on EBHN.
Coming in too fast, the landing was brutal, and
Nose Landing Gear collapsed.

29

Conclusion
• Engine in-flight failure are not exceptional.
– Use of MOGAS (water content, flash point,..)
– Local modifications,
– Other specific to the configuration of the
specific airplane.
And..
– Traditional causes (engine starvation,..)
30

Solutions
• In this case, we can design some generic
recommendations:
– Human Factors; ULM pilots should be more
prepared to react to engine failures at any time
(awareness, briefing, training,…)
– Generic technical solutions; impact on the use
of MOGAS.
• Protection of the equipment during winter,
• Risk of Vapour lock.

31

• Designing stop-gaps, accident after accidents
may not be satisfactory;
What can we do we make sure ULM flying
improves up to an acceptable level and, more
important, remains at that level ?

• More Regulation ?

32

Aviation Regulation and the ULM
• No significant changes in Regulation.
– ULM defined by capacity, weight, structural and stall speed limitation.
– => Extensive use of carbon fiber, Flaps, etc

• CS-VLA.
– 750 kg.
– “light” CS-23.
– Expensive.

• Lower Requirements for licencing,
– What about competence ?
– Human Factors training

• National requirements in Europe.
– EASA Flight Permit per Part 21A.701.

33

Evolution: new EU Regulation on
Accident Investigation.
* Every civil aviation accident or serious incident involving
aircraft other than specified in Annex II to the Regulation (EC)
No 216/2008 of the European Parliament and of the Council
shall be the subject of a safety investigation

( = No obligation of enquiry for ULMs)
• Safety investigation authorities may decide to investigate
incidents other than those referred to in paragraph 1 as well as
accidents or serious incidents to other types of aircraft, in
accordance with the national legislation of the Member States,
when they expect to draw safety lessons from them.
34

• US. NTSB; no enquiry for ULM crashes.
• To-day already, in some EU countries, ULM
crash investigations are given a low priority,
unless the Public determines otherwise.
• Common sense dictates that the initiative
to improve safety must come from the
ULM community itself.

35

Reason Model
• aviation is a complex socio-technical
system, where safety is ensured by a
series of defense barriers.
• Each barrier may present flaws (latent
or active) whose combination can lead
to an accident.
• An usafe act (active failure) alone
would not cause an accident.
• Latent failures are more easily
detected and corrected that human
errors, which are (globally) inevitable.

36

• The ULM community should reinforce its
Defense Barriers.
• Organisation: Federation and Clubs.
Create a Safety Climate
- Norms and rules
- Safety Programs

- To define a Safety Climate, we need to
assess the potential risk, and for that we
need data: YOUR experience.
37

Pyramid of Heinrich
• If a fatal accident is caused by
a specific combination of
events, an uncomplete series
of events causes INCIDENTS.
• If we identify all potentially
dangerous events AND with
that information, build-up the
defenses, we can avoid
ACCIDENTS.
38

SHARING EXPERIENCE
• By informing the Federation of the small
events and incidents that spoiled one of
your flights, you allow the Community to
understand the potential dangers and act
upon. (and respect confidentiality)
“Learn from mistakes of others; you won’t
live long enough to make them all by
yourself”
39

Human Factors
• To err is human.
• Human life (and flying) is full of decisions.
• It is therefore more important to know yourself
than to know how to fly your aircraft.
– Get-home-itis, Distraction, Communication,..

• Understanding human factors is a very important
step in improving your defenses.
40

Competence and Readiness
• You hold a pilot licence; but are you a
competent flyer ?
• How will you react when faced with a
potential dangerous situation?
• Assessing your competences with an
instructor is an opportunity to improve.
• When flying, be ready.
41

What is the Authority doing for
you ?

42

A series of work groups
within EASA are thinking
about how to improve
flight safety.(ESSI)
One of them is about General
Aviation (EGAST).

Initiative includes a leaflet
On Collision Avoidance,
and has been relayed to you
by the Federation.
There are technical Work
Groups dealing with MOGAS
43

and

An initiative to develop
Posters with comic strips
On high risk topics.
The first goes about taking
The right decision when the
Weather is below minimum.
They are expected in the
Coming months.

44

For Belgium, Accident reports are made public on the SPF/FOD website.
Recent reports (from 1st May 2007) are directly available through
hyperlinks.
Reports are written in English.
Information Notes are also available in order to highlight specific danger
area: Nr 2010 is about engine cold start.
We would like to develop more Notes, for ULM in collaboration with
the Federation.
Historical reports: currently a list is posted.
The list is fairly complete from 1972.
2 ancient reports (1936 and 1965).
The reports (Fr /Nl) are desidentified and available on request.
The list will be completed as we go along in reviewing archives.

45

Thank you for your attention, and
AAIU (Belgium) wishes you
many happy landings

Photos credit:
MRA / KLM

46


Slide 33

10 JULY 1910 - 2010
100 YEARS ULM ACCIDENTS

Belgian ULM Federation – Safety
1
Conference 10/10/2010

The Air Safety Investigation
• As part of the global Aviation sphere, an investigation is
conducted for each accident and serious incident by an
independent enquiry body, aimed to;
– Determine the causes of the accident.
– Determine if all conditions that were defined by rules and
regulations to ensure flight safety were followed (such as risk
factors in design).
– Define recommendations in order to prevent future accidents.

• It is not the purpose of this investigation to apportion
blame or liability.

2

In Belgium; the Air Accident
Investigation Unit.
• All accidents and serious incidents occurring in Belgium,
on aircraft, helicopters, gliders, balloons, ULM, DPM,
regardless of their registration is investigated by a cell
functionnally independent from the BCAA, and all other
interrested parties.
• Independent doesn’t mean isolated; it is part of the world’s
network of the State’s Aviation Investigation Bodies.
• The cell reports to the President of the Board of the
SPF/FOD Mobility and Transport.
3

4

ULM
• First pendular (Delta Plane Motorized)
design in 1966
• First crossing of the Channel in 1978 by Mr
D. Cook.
• Commercial development from 1979.
• Evolution from 2-axis to 3-axis.
• In Belgium, first ULM registered (501) in
1982.

5

6

Evolution
• 1982: Weedhopper, Chickinox
– 80…100 km/h
– Basic – 2/3 axis
– Range: … 200 km…

• 2010: VL-3 Sprint, DynAero MCR01, WT9 Dynamic….
– 220….250 km/h,
– flaps, retractable gear, avionics,
– Range over 1000 km

• 550 OO- registered ULM;
• 571 ULM pilot licence (363 training licences)
• 300-400 foreign-registered ULM.
7

1000
900
800
700
600
500
400
300
200
100

Number of valid registration

8

Estimation of flying OO-regd ULM

20
10

20
08

20
06

20
04

20
02

20
00

19
98

19
96

19
94

19
92

19
90

19
88

19
86

19
84

19
82

0

Evolution in pilot’s / owner’s
expectations
• In 1982, ULM /DPM, a sporting way of flying,
outside the limits of parachuting, delta plane.

• In 2010, an efficient alternative to general
(certified) aviation. ULM becomes a means of
transport.
• Beyond 2010 ?? – The Need for Speed ?
9

Evolution
• From the user’s perspective, the difference between
General Aviation and ULM becomes very thin.
• However, ULMs are characterized by a huge variety of
different design types, with low production rate and
configuration variation between individual airplanes.
– Manufacturers come and go,
– Assembly of the same ULM type by different companies induce
differences in built configuration.

• The above makes it more and more difficult to speak about
ULMs in a general way; variation in quality is wider than
General (certified) Aviation.
10

EVOLUTION: MORE ULM FATAL ACCIDENTS ?

Fatalities: (up to now), In Belgium, on average 2 /year,
comparable to General (certified) Aviation.
Number of fatalities
12
10
8
6
4
2

Number of fatalities

11

20
10

20
08

20
06

20
04

20
02

20
00

19
98

19
96

19
94

19
92

19
90

19
88

19
86

19
84

0

19
82

FATALITIES:
Figures limited to
Belgium.
2009: + 2 in France.
2010: + 5 in France.

WHAT ARE THE EXPECTATIONS
FOR THE
ULM-ACCIDENTS CASUALITY
RATE ?
• On Belgian soil, 4 deads in 2010.
(casuality rate of U.S. Forces in Iraq 3.6 killed /1000
troop / year – 8 years – 152000 troops – 4424 killed).

• In France and Belgium in 2010, 9 Belgian
deads to-date.
12

Comparison with the road
• In Belgium, the road kills 1000 people on average per year
.
• Fleet of vehicles: 6 000 000 units (5 mio cars).
• For 1000 cars, the road kills on average 0.16 person per
year.
• If we combine these figures with the yearly utilization rate
of cars (1 h per day) versus ULM (40 h per year), we can
conclude that ULM / General Aviation flying is
considerably deadlier than the road.

13

What can we learn from accident
investigation ?

14

The investigation process
A long process (Months)
• Collect all factual elements,
–
–
–
–
–
–

The flow of events;
The pilot (training, experience, …)
The aircraft (contact w/manufacturer)
Meteo, Comm, Radar,
Flt recorders (GPS, ECU, camera, …)
Impact, aircraft damage,

• Analysis. (incl. simulation, testing,…)
• Define all possible causes.
• From the causes, define remedial action.
The depth of the investigation is somewhat influenced by the
expected ROI.
15

Accident analysis
• Accidents do not occur “by accident”; Accident are
caused by a series of events.
• There are no “isolated cases”; causes of accidents are often
recurrent.
• Out of the ULM accident data base, we can conclude;
– There are recurrent technical problems specific to ULM.
– The traditional causes of aviation accidents are also known to
ULM (fuel shortage)

– 80% of the causal factors are human-related.

16

Main causal factors (122 accidents –
fixed wing and ULM)
Loss of control Take-off
11%

Fuel Starvation
15%

Loss of control Flight & collision
12%

Technical
11%
Low piloting
experience
8%

Loss of control Landing
16%
Icing
3%

Low flying /
aerobatics obstacles - CFIT
24%

17

Specific problems with ULM
• Technical causes can be (easily) identified;
but fire can be devastating.
• There’s another problem for the
investigator, a lot of landmarks are missing.
– ULM requirements are national,
– Certification not applicable.
– Wide variety of products.
18

About certification.
• Everyone would agree that ULMs of to-day are as good,
even a lot better than the ‘certified’ airplane.
• ULMs are designed to fly.
ULM are quality products; they meet your expectations
(simple to handle, fly fast, cheap in usage, …)
• Certification means that a manufacturer must demonstrate
that his product meets a minimum level of safety, as
defined (ultimately) by the Aviation Community.
• The minimum level of safety is defined in the Certification
Specifications – For small aircraft, it is called CS23.
19

Technical.
• AAIU(be) is currently investigating on:
– Instrument Board lay-out design.
– Electrical System design.
– Emergency Parachute.
Why is it that (for the last cases) parachute did not save lifes ?
• Late decision ?
• Handle easy to grab ?
• Safety pin not removed before flight ?

20

Same ULM Type, instrument panel somewhat different.
Difference in Ergonomy.
Parachute handle – on pilot’s side, or on passenger’s side ?

21

Regulation: certification:
CS 23.671 General
(b) Controls must be arranged and identified
to provide for convenience in operation and
to prevent the possibility of confusion and
subsequent inadvertent operation.

For ULM, CS 23 is not applicable.
Each designer has his own solution, and
they will be challenged only by YOUR
experience.
22

Other example
The passenger door opens in
flight, causing the pilot to take
appropriate actions, that
eventually force him to an
emergency landing.

• Door lock (simple – crude).
Plexy flexible. Once opened in
flight, difficult to close.
CS 23.783
(1) There must be means to lock and safeguard the door against
inadvertent opening during flight by persons, by cargo, or as a
result of mechanical failure.
23

The problem
• Once we determine a technical problem, we
can define recommendations to improve the
product, but:
What do we do with the recommendation ?
– We can not improve the Standard, there’s no standard.
– We can not address more than one manufacturer,
– What about retrofit ?

24

ULM and Engine failures

25

Fly Synthesis Storch
Summer 2009
• After propeller replacement, and subsequent
engine ground tests, the pilot took off for a
flight test.
• He encountered heavy engine vibration, that
forced him to an emergency landing.
• Airplane was slightly damaged.
Cause was identified as Vapor Lock.
26

1/5/2010 – FK9
Emergency landing after in-flight engine failure.
• Lots of corrosion found in carburettor.
Corrosion comes from water condensation in
fuel system (tank, lines, pump,…- MOGAS)
during long immobilisation periods.
- how to prevent ? Filling up, draining ?

• Fuel system was modified in-service, by
addition of a pressure regulator.
27

France
20/5/2010 – Mistral
23/5/2010 – CT Short Wing
Mistral: Engine failure in flight.
Emergency landing in field; terrain was very soft, airplane
severely damaged.
CT Short Wing: In short final, the engine suddenly stops
The pilot attempts to land, but hit trees, and crashes – wings
ripped off.
RH wing tank empty, 15-25 l fuel remaining in LH tank.
During LH turn, fuel system unprimed, engine stopped by
fuel starvation.
28

4 /6/2010: SG Rally
Damaged during landing
• Due to engine problems (heavy vibrations), the
pilot performed emergency landing on EBHN.
Coming in too fast, the landing was brutal, and
Nose Landing Gear collapsed.

29

Conclusion
• Engine in-flight failure are not exceptional.
– Use of MOGAS (water content, flash point,..)
– Local modifications,
– Other specific to the configuration of the
specific airplane.
And..
– Traditional causes (engine starvation,..)
30

Solutions
• In this case, we can design some generic
recommendations:
– Human Factors; ULM pilots should be more
prepared to react to engine failures at any time
(awareness, briefing, training,…)
– Generic technical solutions; impact on the use
of MOGAS.
• Protection of the equipment during winter,
• Risk of Vapour lock.

31

• Designing stop-gaps, accident after accidents
may not be satisfactory;
What can we do we make sure ULM flying
improves up to an acceptable level and, more
important, remains at that level ?

• More Regulation ?

32

Aviation Regulation and the ULM
• No significant changes in Regulation.
– ULM defined by capacity, weight, structural and stall speed limitation.
– => Extensive use of carbon fiber, Flaps, etc

• CS-VLA.
– 750 kg.
– “light” CS-23.
– Expensive.

• Lower Requirements for licencing,
– What about competence ?
– Human Factors training

• National requirements in Europe.
– EASA Flight Permit per Part 21A.701.

33

Evolution: new EU Regulation on
Accident Investigation.
* Every civil aviation accident or serious incident involving
aircraft other than specified in Annex II to the Regulation (EC)
No 216/2008 of the European Parliament and of the Council
shall be the subject of a safety investigation

( = No obligation of enquiry for ULMs)
• Safety investigation authorities may decide to investigate
incidents other than those referred to in paragraph 1 as well as
accidents or serious incidents to other types of aircraft, in
accordance with the national legislation of the Member States,
when they expect to draw safety lessons from them.
34

• US. NTSB; no enquiry for ULM crashes.
• To-day already, in some EU countries, ULM
crash investigations are given a low priority,
unless the Public determines otherwise.
• Common sense dictates that the initiative
to improve safety must come from the
ULM community itself.

35

Reason Model
• aviation is a complex socio-technical
system, where safety is ensured by a
series of defense barriers.
• Each barrier may present flaws (latent
or active) whose combination can lead
to an accident.
• An usafe act (active failure) alone
would not cause an accident.
• Latent failures are more easily
detected and corrected that human
errors, which are (globally) inevitable.

36

• The ULM community should reinforce its
Defense Barriers.
• Organisation: Federation and Clubs.
Create a Safety Climate
- Norms and rules
- Safety Programs

- To define a Safety Climate, we need to
assess the potential risk, and for that we
need data: YOUR experience.
37

Pyramid of Heinrich
• If a fatal accident is caused by
a specific combination of
events, an uncomplete series
of events causes INCIDENTS.
• If we identify all potentially
dangerous events AND with
that information, build-up the
defenses, we can avoid
ACCIDENTS.
38

SHARING EXPERIENCE
• By informing the Federation of the small
events and incidents that spoiled one of
your flights, you allow the Community to
understand the potential dangers and act
upon. (and respect confidentiality)
“Learn from mistakes of others; you won’t
live long enough to make them all by
yourself”
39

Human Factors
• To err is human.
• Human life (and flying) is full of decisions.
• It is therefore more important to know yourself
than to know how to fly your aircraft.
– Get-home-itis, Distraction, Communication,..

• Understanding human factors is a very important
step in improving your defenses.
40

Competence and Readiness
• You hold a pilot licence; but are you a
competent flyer ?
• How will you react when faced with a
potential dangerous situation?
• Assessing your competences with an
instructor is an opportunity to improve.
• When flying, be ready.
41

What is the Authority doing for
you ?

42

A series of work groups
within EASA are thinking
about how to improve
flight safety.(ESSI)
One of them is about General
Aviation (EGAST).

Initiative includes a leaflet
On Collision Avoidance,
and has been relayed to you
by the Federation.
There are technical Work
Groups dealing with MOGAS
43

and

An initiative to develop
Posters with comic strips
On high risk topics.
The first goes about taking
The right decision when the
Weather is below minimum.
They are expected in the
Coming months.

44

For Belgium, Accident reports are made public on the SPF/FOD website.
Recent reports (from 1st May 2007) are directly available through
hyperlinks.
Reports are written in English.
Information Notes are also available in order to highlight specific danger
area: Nr 2010 is about engine cold start.
We would like to develop more Notes, for ULM in collaboration with
the Federation.
Historical reports: currently a list is posted.
The list is fairly complete from 1972.
2 ancient reports (1936 and 1965).
The reports (Fr /Nl) are desidentified and available on request.
The list will be completed as we go along in reviewing archives.

45

Thank you for your attention, and
AAIU (Belgium) wishes you
many happy landings

Photos credit:
MRA / KLM

46


Slide 34

10 JULY 1910 - 2010
100 YEARS ULM ACCIDENTS

Belgian ULM Federation – Safety
1
Conference 10/10/2010

The Air Safety Investigation
• As part of the global Aviation sphere, an investigation is
conducted for each accident and serious incident by an
independent enquiry body, aimed to;
– Determine the causes of the accident.
– Determine if all conditions that were defined by rules and
regulations to ensure flight safety were followed (such as risk
factors in design).
– Define recommendations in order to prevent future accidents.

• It is not the purpose of this investigation to apportion
blame or liability.

2

In Belgium; the Air Accident
Investigation Unit.
• All accidents and serious incidents occurring in Belgium,
on aircraft, helicopters, gliders, balloons, ULM, DPM,
regardless of their registration is investigated by a cell
functionnally independent from the BCAA, and all other
interrested parties.
• Independent doesn’t mean isolated; it is part of the world’s
network of the State’s Aviation Investigation Bodies.
• The cell reports to the President of the Board of the
SPF/FOD Mobility and Transport.
3

4

ULM
• First pendular (Delta Plane Motorized)
design in 1966
• First crossing of the Channel in 1978 by Mr
D. Cook.
• Commercial development from 1979.
• Evolution from 2-axis to 3-axis.
• In Belgium, first ULM registered (501) in
1982.

5

6

Evolution
• 1982: Weedhopper, Chickinox
– 80…100 km/h
– Basic – 2/3 axis
– Range: … 200 km…

• 2010: VL-3 Sprint, DynAero MCR01, WT9 Dynamic….
– 220….250 km/h,
– flaps, retractable gear, avionics,
– Range over 1000 km

• 550 OO- registered ULM;
• 571 ULM pilot licence (363 training licences)
• 300-400 foreign-registered ULM.
7

1000
900
800
700
600
500
400
300
200
100

Number of valid registration

8

Estimation of flying OO-regd ULM

20
10

20
08

20
06

20
04

20
02

20
00

19
98

19
96

19
94

19
92

19
90

19
88

19
86

19
84

19
82

0

Evolution in pilot’s / owner’s
expectations
• In 1982, ULM /DPM, a sporting way of flying,
outside the limits of parachuting, delta plane.

• In 2010, an efficient alternative to general
(certified) aviation. ULM becomes a means of
transport.
• Beyond 2010 ?? – The Need for Speed ?
9

Evolution
• From the user’s perspective, the difference between
General Aviation and ULM becomes very thin.
• However, ULMs are characterized by a huge variety of
different design types, with low production rate and
configuration variation between individual airplanes.
– Manufacturers come and go,
– Assembly of the same ULM type by different companies induce
differences in built configuration.

• The above makes it more and more difficult to speak about
ULMs in a general way; variation in quality is wider than
General (certified) Aviation.
10

EVOLUTION: MORE ULM FATAL ACCIDENTS ?

Fatalities: (up to now), In Belgium, on average 2 /year,
comparable to General (certified) Aviation.
Number of fatalities
12
10
8
6
4
2

Number of fatalities

11

20
10

20
08

20
06

20
04

20
02

20
00

19
98

19
96

19
94

19
92

19
90

19
88

19
86

19
84

0

19
82

FATALITIES:
Figures limited to
Belgium.
2009: + 2 in France.
2010: + 5 in France.

WHAT ARE THE EXPECTATIONS
FOR THE
ULM-ACCIDENTS CASUALITY
RATE ?
• On Belgian soil, 4 deads in 2010.
(casuality rate of U.S. Forces in Iraq 3.6 killed /1000
troop / year – 8 years – 152000 troops – 4424 killed).

• In France and Belgium in 2010, 9 Belgian
deads to-date.
12

Comparison with the road
• In Belgium, the road kills 1000 people on average per year
.
• Fleet of vehicles: 6 000 000 units (5 mio cars).
• For 1000 cars, the road kills on average 0.16 person per
year.
• If we combine these figures with the yearly utilization rate
of cars (1 h per day) versus ULM (40 h per year), we can
conclude that ULM / General Aviation flying is
considerably deadlier than the road.

13

What can we learn from accident
investigation ?

14

The investigation process
A long process (Months)
• Collect all factual elements,
–
–
–
–
–
–

The flow of events;
The pilot (training, experience, …)
The aircraft (contact w/manufacturer)
Meteo, Comm, Radar,
Flt recorders (GPS, ECU, camera, …)
Impact, aircraft damage,

• Analysis. (incl. simulation, testing,…)
• Define all possible causes.
• From the causes, define remedial action.
The depth of the investigation is somewhat influenced by the
expected ROI.
15

Accident analysis
• Accidents do not occur “by accident”; Accident are
caused by a series of events.
• There are no “isolated cases”; causes of accidents are often
recurrent.
• Out of the ULM accident data base, we can conclude;
– There are recurrent technical problems specific to ULM.
– The traditional causes of aviation accidents are also known to
ULM (fuel shortage)

– 80% of the causal factors are human-related.

16

Main causal factors (122 accidents –
fixed wing and ULM)
Loss of control Take-off
11%

Fuel Starvation
15%

Loss of control Flight & collision
12%

Technical
11%
Low piloting
experience
8%

Loss of control Landing
16%
Icing
3%

Low flying /
aerobatics obstacles - CFIT
24%

17

Specific problems with ULM
• Technical causes can be (easily) identified;
but fire can be devastating.
• There’s another problem for the
investigator, a lot of landmarks are missing.
– ULM requirements are national,
– Certification not applicable.
– Wide variety of products.
18

About certification.
• Everyone would agree that ULMs of to-day are as good,
even a lot better than the ‘certified’ airplane.
• ULMs are designed to fly.
ULM are quality products; they meet your expectations
(simple to handle, fly fast, cheap in usage, …)
• Certification means that a manufacturer must demonstrate
that his product meets a minimum level of safety, as
defined (ultimately) by the Aviation Community.
• The minimum level of safety is defined in the Certification
Specifications – For small aircraft, it is called CS23.
19

Technical.
• AAIU(be) is currently investigating on:
– Instrument Board lay-out design.
– Electrical System design.
– Emergency Parachute.
Why is it that (for the last cases) parachute did not save lifes ?
• Late decision ?
• Handle easy to grab ?
• Safety pin not removed before flight ?

20

Same ULM Type, instrument panel somewhat different.
Difference in Ergonomy.
Parachute handle – on pilot’s side, or on passenger’s side ?

21

Regulation: certification:
CS 23.671 General
(b) Controls must be arranged and identified
to provide for convenience in operation and
to prevent the possibility of confusion and
subsequent inadvertent operation.

For ULM, CS 23 is not applicable.
Each designer has his own solution, and
they will be challenged only by YOUR
experience.
22

Other example
The passenger door opens in
flight, causing the pilot to take
appropriate actions, that
eventually force him to an
emergency landing.

• Door lock (simple – crude).
Plexy flexible. Once opened in
flight, difficult to close.
CS 23.783
(1) There must be means to lock and safeguard the door against
inadvertent opening during flight by persons, by cargo, or as a
result of mechanical failure.
23

The problem
• Once we determine a technical problem, we
can define recommendations to improve the
product, but:
What do we do with the recommendation ?
– We can not improve the Standard, there’s no standard.
– We can not address more than one manufacturer,
– What about retrofit ?

24

ULM and Engine failures

25

Fly Synthesis Storch
Summer 2009
• After propeller replacement, and subsequent
engine ground tests, the pilot took off for a
flight test.
• He encountered heavy engine vibration, that
forced him to an emergency landing.
• Airplane was slightly damaged.
Cause was identified as Vapor Lock.
26

1/5/2010 – FK9
Emergency landing after in-flight engine failure.
• Lots of corrosion found in carburettor.
Corrosion comes from water condensation in
fuel system (tank, lines, pump,…- MOGAS)
during long immobilisation periods.
- how to prevent ? Filling up, draining ?

• Fuel system was modified in-service, by
addition of a pressure regulator.
27

France
20/5/2010 – Mistral
23/5/2010 – CT Short Wing
Mistral: Engine failure in flight.
Emergency landing in field; terrain was very soft, airplane
severely damaged.
CT Short Wing: In short final, the engine suddenly stops
The pilot attempts to land, but hit trees, and crashes – wings
ripped off.
RH wing tank empty, 15-25 l fuel remaining in LH tank.
During LH turn, fuel system unprimed, engine stopped by
fuel starvation.
28

4 /6/2010: SG Rally
Damaged during landing
• Due to engine problems (heavy vibrations), the
pilot performed emergency landing on EBHN.
Coming in too fast, the landing was brutal, and
Nose Landing Gear collapsed.

29

Conclusion
• Engine in-flight failure are not exceptional.
– Use of MOGAS (water content, flash point,..)
– Local modifications,
– Other specific to the configuration of the
specific airplane.
And..
– Traditional causes (engine starvation,..)
30

Solutions
• In this case, we can design some generic
recommendations:
– Human Factors; ULM pilots should be more
prepared to react to engine failures at any time
(awareness, briefing, training,…)
– Generic technical solutions; impact on the use
of MOGAS.
• Protection of the equipment during winter,
• Risk of Vapour lock.

31

• Designing stop-gaps, accident after accidents
may not be satisfactory;
What can we do we make sure ULM flying
improves up to an acceptable level and, more
important, remains at that level ?

• More Regulation ?

32

Aviation Regulation and the ULM
• No significant changes in Regulation.
– ULM defined by capacity, weight, structural and stall speed limitation.
– => Extensive use of carbon fiber, Flaps, etc

• CS-VLA.
– 750 kg.
– “light” CS-23.
– Expensive.

• Lower Requirements for licencing,
– What about competence ?
– Human Factors training

• National requirements in Europe.
– EASA Flight Permit per Part 21A.701.

33

Evolution: new EU Regulation on
Accident Investigation.
* Every civil aviation accident or serious incident involving
aircraft other than specified in Annex II to the Regulation (EC)
No 216/2008 of the European Parliament and of the Council
shall be the subject of a safety investigation

( = No obligation of enquiry for ULMs)
• Safety investigation authorities may decide to investigate
incidents other than those referred to in paragraph 1 as well as
accidents or serious incidents to other types of aircraft, in
accordance with the national legislation of the Member States,
when they expect to draw safety lessons from them.
34

• US. NTSB; no enquiry for ULM crashes.
• To-day already, in some EU countries, ULM
crash investigations are given a low priority,
unless the Public determines otherwise.
• Common sense dictates that the initiative
to improve safety must come from the
ULM community itself.

35

Reason Model
• aviation is a complex socio-technical
system, where safety is ensured by a
series of defense barriers.
• Each barrier may present flaws (latent
or active) whose combination can lead
to an accident.
• An usafe act (active failure) alone
would not cause an accident.
• Latent failures are more easily
detected and corrected that human
errors, which are (globally) inevitable.

36

• The ULM community should reinforce its
Defense Barriers.
• Organisation: Federation and Clubs.
Create a Safety Climate
- Norms and rules
- Safety Programs

- To define a Safety Climate, we need to
assess the potential risk, and for that we
need data: YOUR experience.
37

Pyramid of Heinrich
• If a fatal accident is caused by
a specific combination of
events, an uncomplete series
of events causes INCIDENTS.
• If we identify all potentially
dangerous events AND with
that information, build-up the
defenses, we can avoid
ACCIDENTS.
38

SHARING EXPERIENCE
• By informing the Federation of the small
events and incidents that spoiled one of
your flights, you allow the Community to
understand the potential dangers and act
upon. (and respect confidentiality)
“Learn from mistakes of others; you won’t
live long enough to make them all by
yourself”
39

Human Factors
• To err is human.
• Human life (and flying) is full of decisions.
• It is therefore more important to know yourself
than to know how to fly your aircraft.
– Get-home-itis, Distraction, Communication,..

• Understanding human factors is a very important
step in improving your defenses.
40

Competence and Readiness
• You hold a pilot licence; but are you a
competent flyer ?
• How will you react when faced with a
potential dangerous situation?
• Assessing your competences with an
instructor is an opportunity to improve.
• When flying, be ready.
41

What is the Authority doing for
you ?

42

A series of work groups
within EASA are thinking
about how to improve
flight safety.(ESSI)
One of them is about General
Aviation (EGAST).

Initiative includes a leaflet
On Collision Avoidance,
and has been relayed to you
by the Federation.
There are technical Work
Groups dealing with MOGAS
43

and

An initiative to develop
Posters with comic strips
On high risk topics.
The first goes about taking
The right decision when the
Weather is below minimum.
They are expected in the
Coming months.

44

For Belgium, Accident reports are made public on the SPF/FOD website.
Recent reports (from 1st May 2007) are directly available through
hyperlinks.
Reports are written in English.
Information Notes are also available in order to highlight specific danger
area: Nr 2010 is about engine cold start.
We would like to develop more Notes, for ULM in collaboration with
the Federation.
Historical reports: currently a list is posted.
The list is fairly complete from 1972.
2 ancient reports (1936 and 1965).
The reports (Fr /Nl) are desidentified and available on request.
The list will be completed as we go along in reviewing archives.

45

Thank you for your attention, and
AAIU (Belgium) wishes you
many happy landings

Photos credit:
MRA / KLM

46


Slide 35

10 JULY 1910 - 2010
100 YEARS ULM ACCIDENTS

Belgian ULM Federation – Safety
1
Conference 10/10/2010

The Air Safety Investigation
• As part of the global Aviation sphere, an investigation is
conducted for each accident and serious incident by an
independent enquiry body, aimed to;
– Determine the causes of the accident.
– Determine if all conditions that were defined by rules and
regulations to ensure flight safety were followed (such as risk
factors in design).
– Define recommendations in order to prevent future accidents.

• It is not the purpose of this investigation to apportion
blame or liability.

2

In Belgium; the Air Accident
Investigation Unit.
• All accidents and serious incidents occurring in Belgium,
on aircraft, helicopters, gliders, balloons, ULM, DPM,
regardless of their registration is investigated by a cell
functionnally independent from the BCAA, and all other
interrested parties.
• Independent doesn’t mean isolated; it is part of the world’s
network of the State’s Aviation Investigation Bodies.
• The cell reports to the President of the Board of the
SPF/FOD Mobility and Transport.
3

4

ULM
• First pendular (Delta Plane Motorized)
design in 1966
• First crossing of the Channel in 1978 by Mr
D. Cook.
• Commercial development from 1979.
• Evolution from 2-axis to 3-axis.
• In Belgium, first ULM registered (501) in
1982.

5

6

Evolution
• 1982: Weedhopper, Chickinox
– 80…100 km/h
– Basic – 2/3 axis
– Range: … 200 km…

• 2010: VL-3 Sprint, DynAero MCR01, WT9 Dynamic….
– 220….250 km/h,
– flaps, retractable gear, avionics,
– Range over 1000 km

• 550 OO- registered ULM;
• 571 ULM pilot licence (363 training licences)
• 300-400 foreign-registered ULM.
7

1000
900
800
700
600
500
400
300
200
100

Number of valid registration

8

Estimation of flying OO-regd ULM

20
10

20
08

20
06

20
04

20
02

20
00

19
98

19
96

19
94

19
92

19
90

19
88

19
86

19
84

19
82

0

Evolution in pilot’s / owner’s
expectations
• In 1982, ULM /DPM, a sporting way of flying,
outside the limits of parachuting, delta plane.

• In 2010, an efficient alternative to general
(certified) aviation. ULM becomes a means of
transport.
• Beyond 2010 ?? – The Need for Speed ?
9

Evolution
• From the user’s perspective, the difference between
General Aviation and ULM becomes very thin.
• However, ULMs are characterized by a huge variety of
different design types, with low production rate and
configuration variation between individual airplanes.
– Manufacturers come and go,
– Assembly of the same ULM type by different companies induce
differences in built configuration.

• The above makes it more and more difficult to speak about
ULMs in a general way; variation in quality is wider than
General (certified) Aviation.
10

EVOLUTION: MORE ULM FATAL ACCIDENTS ?

Fatalities: (up to now), In Belgium, on average 2 /year,
comparable to General (certified) Aviation.
Number of fatalities
12
10
8
6
4
2

Number of fatalities

11

20
10

20
08

20
06

20
04

20
02

20
00

19
98

19
96

19
94

19
92

19
90

19
88

19
86

19
84

0

19
82

FATALITIES:
Figures limited to
Belgium.
2009: + 2 in France.
2010: + 5 in France.

WHAT ARE THE EXPECTATIONS
FOR THE
ULM-ACCIDENTS CASUALITY
RATE ?
• On Belgian soil, 4 deads in 2010.
(casuality rate of U.S. Forces in Iraq 3.6 killed /1000
troop / year – 8 years – 152000 troops – 4424 killed).

• In France and Belgium in 2010, 9 Belgian
deads to-date.
12

Comparison with the road
• In Belgium, the road kills 1000 people on average per year
.
• Fleet of vehicles: 6 000 000 units (5 mio cars).
• For 1000 cars, the road kills on average 0.16 person per
year.
• If we combine these figures with the yearly utilization rate
of cars (1 h per day) versus ULM (40 h per year), we can
conclude that ULM / General Aviation flying is
considerably deadlier than the road.

13

What can we learn from accident
investigation ?

14

The investigation process
A long process (Months)
• Collect all factual elements,
–
–
–
–
–
–

The flow of events;
The pilot (training, experience, …)
The aircraft (contact w/manufacturer)
Meteo, Comm, Radar,
Flt recorders (GPS, ECU, camera, …)
Impact, aircraft damage,

• Analysis. (incl. simulation, testing,…)
• Define all possible causes.
• From the causes, define remedial action.
The depth of the investigation is somewhat influenced by the
expected ROI.
15

Accident analysis
• Accidents do not occur “by accident”; Accident are
caused by a series of events.
• There are no “isolated cases”; causes of accidents are often
recurrent.
• Out of the ULM accident data base, we can conclude;
– There are recurrent technical problems specific to ULM.
– The traditional causes of aviation accidents are also known to
ULM (fuel shortage)

– 80% of the causal factors are human-related.

16

Main causal factors (122 accidents –
fixed wing and ULM)
Loss of control Take-off
11%

Fuel Starvation
15%

Loss of control Flight & collision
12%

Technical
11%
Low piloting
experience
8%

Loss of control Landing
16%
Icing
3%

Low flying /
aerobatics obstacles - CFIT
24%

17

Specific problems with ULM
• Technical causes can be (easily) identified;
but fire can be devastating.
• There’s another problem for the
investigator, a lot of landmarks are missing.
– ULM requirements are national,
– Certification not applicable.
– Wide variety of products.
18

About certification.
• Everyone would agree that ULMs of to-day are as good,
even a lot better than the ‘certified’ airplane.
• ULMs are designed to fly.
ULM are quality products; they meet your expectations
(simple to handle, fly fast, cheap in usage, …)
• Certification means that a manufacturer must demonstrate
that his product meets a minimum level of safety, as
defined (ultimately) by the Aviation Community.
• The minimum level of safety is defined in the Certification
Specifications – For small aircraft, it is called CS23.
19

Technical.
• AAIU(be) is currently investigating on:
– Instrument Board lay-out design.
– Electrical System design.
– Emergency Parachute.
Why is it that (for the last cases) parachute did not save lifes ?
• Late decision ?
• Handle easy to grab ?
• Safety pin not removed before flight ?

20

Same ULM Type, instrument panel somewhat different.
Difference in Ergonomy.
Parachute handle – on pilot’s side, or on passenger’s side ?

21

Regulation: certification:
CS 23.671 General
(b) Controls must be arranged and identified
to provide for convenience in operation and
to prevent the possibility of confusion and
subsequent inadvertent operation.

For ULM, CS 23 is not applicable.
Each designer has his own solution, and
they will be challenged only by YOUR
experience.
22

Other example
The passenger door opens in
flight, causing the pilot to take
appropriate actions, that
eventually force him to an
emergency landing.

• Door lock (simple – crude).
Plexy flexible. Once opened in
flight, difficult to close.
CS 23.783
(1) There must be means to lock and safeguard the door against
inadvertent opening during flight by persons, by cargo, or as a
result of mechanical failure.
23

The problem
• Once we determine a technical problem, we
can define recommendations to improve the
product, but:
What do we do with the recommendation ?
– We can not improve the Standard, there’s no standard.
– We can not address more than one manufacturer,
– What about retrofit ?

24

ULM and Engine failures

25

Fly Synthesis Storch
Summer 2009
• After propeller replacement, and subsequent
engine ground tests, the pilot took off for a
flight test.
• He encountered heavy engine vibration, that
forced him to an emergency landing.
• Airplane was slightly damaged.
Cause was identified as Vapor Lock.
26

1/5/2010 – FK9
Emergency landing after in-flight engine failure.
• Lots of corrosion found in carburettor.
Corrosion comes from water condensation in
fuel system (tank, lines, pump,…- MOGAS)
during long immobilisation periods.
- how to prevent ? Filling up, draining ?

• Fuel system was modified in-service, by
addition of a pressure regulator.
27

France
20/5/2010 – Mistral
23/5/2010 – CT Short Wing
Mistral: Engine failure in flight.
Emergency landing in field; terrain was very soft, airplane
severely damaged.
CT Short Wing: In short final, the engine suddenly stops
The pilot attempts to land, but hit trees, and crashes – wings
ripped off.
RH wing tank empty, 15-25 l fuel remaining in LH tank.
During LH turn, fuel system unprimed, engine stopped by
fuel starvation.
28

4 /6/2010: SG Rally
Damaged during landing
• Due to engine problems (heavy vibrations), the
pilot performed emergency landing on EBHN.
Coming in too fast, the landing was brutal, and
Nose Landing Gear collapsed.

29

Conclusion
• Engine in-flight failure are not exceptional.
– Use of MOGAS (water content, flash point,..)
– Local modifications,
– Other specific to the configuration of the
specific airplane.
And..
– Traditional causes (engine starvation,..)
30

Solutions
• In this case, we can design some generic
recommendations:
– Human Factors; ULM pilots should be more
prepared to react to engine failures at any time
(awareness, briefing, training,…)
– Generic technical solutions; impact on the use
of MOGAS.
• Protection of the equipment during winter,
• Risk of Vapour lock.

31

• Designing stop-gaps, accident after accidents
may not be satisfactory;
What can we do we make sure ULM flying
improves up to an acceptable level and, more
important, remains at that level ?

• More Regulation ?

32

Aviation Regulation and the ULM
• No significant changes in Regulation.
– ULM defined by capacity, weight, structural and stall speed limitation.
– => Extensive use of carbon fiber, Flaps, etc

• CS-VLA.
– 750 kg.
– “light” CS-23.
– Expensive.

• Lower Requirements for licencing,
– What about competence ?
– Human Factors training

• National requirements in Europe.
– EASA Flight Permit per Part 21A.701.

33

Evolution: new EU Regulation on
Accident Investigation.
* Every civil aviation accident or serious incident involving
aircraft other than specified in Annex II to the Regulation (EC)
No 216/2008 of the European Parliament and of the Council
shall be the subject of a safety investigation

( = No obligation of enquiry for ULMs)
• Safety investigation authorities may decide to investigate
incidents other than those referred to in paragraph 1 as well as
accidents or serious incidents to other types of aircraft, in
accordance with the national legislation of the Member States,
when they expect to draw safety lessons from them.
34

• US. NTSB; no enquiry for ULM crashes.
• To-day already, in some EU countries, ULM
crash investigations are given a low priority,
unless the Public determines otherwise.
• Common sense dictates that the initiative
to improve safety must come from the
ULM community itself.

35

Reason Model
• aviation is a complex socio-technical
system, where safety is ensured by a
series of defense barriers.
• Each barrier may present flaws (latent
or active) whose combination can lead
to an accident.
• An usafe act (active failure) alone
would not cause an accident.
• Latent failures are more easily
detected and corrected that human
errors, which are (globally) inevitable.

36

• The ULM community should reinforce its
Defense Barriers.
• Organisation: Federation and Clubs.
Create a Safety Climate
- Norms and rules
- Safety Programs

- To define a Safety Climate, we need to
assess the potential risk, and for that we
need data: YOUR experience.
37

Pyramid of Heinrich
• If a fatal accident is caused by
a specific combination of
events, an uncomplete series
of events causes INCIDENTS.
• If we identify all potentially
dangerous events AND with
that information, build-up the
defenses, we can avoid
ACCIDENTS.
38

SHARING EXPERIENCE
• By informing the Federation of the small
events and incidents that spoiled one of
your flights, you allow the Community to
understand the potential dangers and act
upon. (and respect confidentiality)
“Learn from mistakes of others; you won’t
live long enough to make them all by
yourself”
39

Human Factors
• To err is human.
• Human life (and flying) is full of decisions.
• It is therefore more important to know yourself
than to know how to fly your aircraft.
– Get-home-itis, Distraction, Communication,..

• Understanding human factors is a very important
step in improving your defenses.
40

Competence and Readiness
• You hold a pilot licence; but are you a
competent flyer ?
• How will you react when faced with a
potential dangerous situation?
• Assessing your competences with an
instructor is an opportunity to improve.
• When flying, be ready.
41

What is the Authority doing for
you ?

42

A series of work groups
within EASA are thinking
about how to improve
flight safety.(ESSI)
One of them is about General
Aviation (EGAST).

Initiative includes a leaflet
On Collision Avoidance,
and has been relayed to you
by the Federation.
There are technical Work
Groups dealing with MOGAS
43

and

An initiative to develop
Posters with comic strips
On high risk topics.
The first goes about taking
The right decision when the
Weather is below minimum.
They are expected in the
Coming months.

44

For Belgium, Accident reports are made public on the SPF/FOD website.
Recent reports (from 1st May 2007) are directly available through
hyperlinks.
Reports are written in English.
Information Notes are also available in order to highlight specific danger
area: Nr 2010 is about engine cold start.
We would like to develop more Notes, for ULM in collaboration with
the Federation.
Historical reports: currently a list is posted.
The list is fairly complete from 1972.
2 ancient reports (1936 and 1965).
The reports (Fr /Nl) are desidentified and available on request.
The list will be completed as we go along in reviewing archives.

45

Thank you for your attention, and
AAIU (Belgium) wishes you
many happy landings

Photos credit:
MRA / KLM

46


Slide 36

10 JULY 1910 - 2010
100 YEARS ULM ACCIDENTS

Belgian ULM Federation – Safety
1
Conference 10/10/2010

The Air Safety Investigation
• As part of the global Aviation sphere, an investigation is
conducted for each accident and serious incident by an
independent enquiry body, aimed to;
– Determine the causes of the accident.
– Determine if all conditions that were defined by rules and
regulations to ensure flight safety were followed (such as risk
factors in design).
– Define recommendations in order to prevent future accidents.

• It is not the purpose of this investigation to apportion
blame or liability.

2

In Belgium; the Air Accident
Investigation Unit.
• All accidents and serious incidents occurring in Belgium,
on aircraft, helicopters, gliders, balloons, ULM, DPM,
regardless of their registration is investigated by a cell
functionnally independent from the BCAA, and all other
interrested parties.
• Independent doesn’t mean isolated; it is part of the world’s
network of the State’s Aviation Investigation Bodies.
• The cell reports to the President of the Board of the
SPF/FOD Mobility and Transport.
3

4

ULM
• First pendular (Delta Plane Motorized)
design in 1966
• First crossing of the Channel in 1978 by Mr
D. Cook.
• Commercial development from 1979.
• Evolution from 2-axis to 3-axis.
• In Belgium, first ULM registered (501) in
1982.

5

6

Evolution
• 1982: Weedhopper, Chickinox
– 80…100 km/h
– Basic – 2/3 axis
– Range: … 200 km…

• 2010: VL-3 Sprint, DynAero MCR01, WT9 Dynamic….
– 220….250 km/h,
– flaps, retractable gear, avionics,
– Range over 1000 km

• 550 OO- registered ULM;
• 571 ULM pilot licence (363 training licences)
• 300-400 foreign-registered ULM.
7

1000
900
800
700
600
500
400
300
200
100

Number of valid registration

8

Estimation of flying OO-regd ULM

20
10

20
08

20
06

20
04

20
02

20
00

19
98

19
96

19
94

19
92

19
90

19
88

19
86

19
84

19
82

0

Evolution in pilot’s / owner’s
expectations
• In 1982, ULM /DPM, a sporting way of flying,
outside the limits of parachuting, delta plane.

• In 2010, an efficient alternative to general
(certified) aviation. ULM becomes a means of
transport.
• Beyond 2010 ?? – The Need for Speed ?
9

Evolution
• From the user’s perspective, the difference between
General Aviation and ULM becomes very thin.
• However, ULMs are characterized by a huge variety of
different design types, with low production rate and
configuration variation between individual airplanes.
– Manufacturers come and go,
– Assembly of the same ULM type by different companies induce
differences in built configuration.

• The above makes it more and more difficult to speak about
ULMs in a general way; variation in quality is wider than
General (certified) Aviation.
10

EVOLUTION: MORE ULM FATAL ACCIDENTS ?

Fatalities: (up to now), In Belgium, on average 2 /year,
comparable to General (certified) Aviation.
Number of fatalities
12
10
8
6
4
2

Number of fatalities

11

20
10

20
08

20
06

20
04

20
02

20
00

19
98

19
96

19
94

19
92

19
90

19
88

19
86

19
84

0

19
82

FATALITIES:
Figures limited to
Belgium.
2009: + 2 in France.
2010: + 5 in France.

WHAT ARE THE EXPECTATIONS
FOR THE
ULM-ACCIDENTS CASUALITY
RATE ?
• On Belgian soil, 4 deads in 2010.
(casuality rate of U.S. Forces in Iraq 3.6 killed /1000
troop / year – 8 years – 152000 troops – 4424 killed).

• In France and Belgium in 2010, 9 Belgian
deads to-date.
12

Comparison with the road
• In Belgium, the road kills 1000 people on average per year
.
• Fleet of vehicles: 6 000 000 units (5 mio cars).
• For 1000 cars, the road kills on average 0.16 person per
year.
• If we combine these figures with the yearly utilization rate
of cars (1 h per day) versus ULM (40 h per year), we can
conclude that ULM / General Aviation flying is
considerably deadlier than the road.

13

What can we learn from accident
investigation ?

14

The investigation process
A long process (Months)
• Collect all factual elements,
–
–
–
–
–
–

The flow of events;
The pilot (training, experience, …)
The aircraft (contact w/manufacturer)
Meteo, Comm, Radar,
Flt recorders (GPS, ECU, camera, …)
Impact, aircraft damage,

• Analysis. (incl. simulation, testing,…)
• Define all possible causes.
• From the causes, define remedial action.
The depth of the investigation is somewhat influenced by the
expected ROI.
15

Accident analysis
• Accidents do not occur “by accident”; Accident are
caused by a series of events.
• There are no “isolated cases”; causes of accidents are often
recurrent.
• Out of the ULM accident data base, we can conclude;
– There are recurrent technical problems specific to ULM.
– The traditional causes of aviation accidents are also known to
ULM (fuel shortage)

– 80% of the causal factors are human-related.

16

Main causal factors (122 accidents –
fixed wing and ULM)
Loss of control Take-off
11%

Fuel Starvation
15%

Loss of control Flight & collision
12%

Technical
11%
Low piloting
experience
8%

Loss of control Landing
16%
Icing
3%

Low flying /
aerobatics obstacles - CFIT
24%

17

Specific problems with ULM
• Technical causes can be (easily) identified;
but fire can be devastating.
• There’s another problem for the
investigator, a lot of landmarks are missing.
– ULM requirements are national,
– Certification not applicable.
– Wide variety of products.
18

About certification.
• Everyone would agree that ULMs of to-day are as good,
even a lot better than the ‘certified’ airplane.
• ULMs are designed to fly.
ULM are quality products; they meet your expectations
(simple to handle, fly fast, cheap in usage, …)
• Certification means that a manufacturer must demonstrate
that his product meets a minimum level of safety, as
defined (ultimately) by the Aviation Community.
• The minimum level of safety is defined in the Certification
Specifications – For small aircraft, it is called CS23.
19

Technical.
• AAIU(be) is currently investigating on:
– Instrument Board lay-out design.
– Electrical System design.
– Emergency Parachute.
Why is it that (for the last cases) parachute did not save lifes ?
• Late decision ?
• Handle easy to grab ?
• Safety pin not removed before flight ?

20

Same ULM Type, instrument panel somewhat different.
Difference in Ergonomy.
Parachute handle – on pilot’s side, or on passenger’s side ?

21

Regulation: certification:
CS 23.671 General
(b) Controls must be arranged and identified
to provide for convenience in operation and
to prevent the possibility of confusion and
subsequent inadvertent operation.

For ULM, CS 23 is not applicable.
Each designer has his own solution, and
they will be challenged only by YOUR
experience.
22

Other example
The passenger door opens in
flight, causing the pilot to take
appropriate actions, that
eventually force him to an
emergency landing.

• Door lock (simple – crude).
Plexy flexible. Once opened in
flight, difficult to close.
CS 23.783
(1) There must be means to lock and safeguard the door against
inadvertent opening during flight by persons, by cargo, or as a
result of mechanical failure.
23

The problem
• Once we determine a technical problem, we
can define recommendations to improve the
product, but:
What do we do with the recommendation ?
– We can not improve the Standard, there’s no standard.
– We can not address more than one manufacturer,
– What about retrofit ?

24

ULM and Engine failures

25

Fly Synthesis Storch
Summer 2009
• After propeller replacement, and subsequent
engine ground tests, the pilot took off for a
flight test.
• He encountered heavy engine vibration, that
forced him to an emergency landing.
• Airplane was slightly damaged.
Cause was identified as Vapor Lock.
26

1/5/2010 – FK9
Emergency landing after in-flight engine failure.
• Lots of corrosion found in carburettor.
Corrosion comes from water condensation in
fuel system (tank, lines, pump,…- MOGAS)
during long immobilisation periods.
- how to prevent ? Filling up, draining ?

• Fuel system was modified in-service, by
addition of a pressure regulator.
27

France
20/5/2010 – Mistral
23/5/2010 – CT Short Wing
Mistral: Engine failure in flight.
Emergency landing in field; terrain was very soft, airplane
severely damaged.
CT Short Wing: In short final, the engine suddenly stops
The pilot attempts to land, but hit trees, and crashes – wings
ripped off.
RH wing tank empty, 15-25 l fuel remaining in LH tank.
During LH turn, fuel system unprimed, engine stopped by
fuel starvation.
28

4 /6/2010: SG Rally
Damaged during landing
• Due to engine problems (heavy vibrations), the
pilot performed emergency landing on EBHN.
Coming in too fast, the landing was brutal, and
Nose Landing Gear collapsed.

29

Conclusion
• Engine in-flight failure are not exceptional.
– Use of MOGAS (water content, flash point,..)
– Local modifications,
– Other specific to the configuration of the
specific airplane.
And..
– Traditional causes (engine starvation,..)
30

Solutions
• In this case, we can design some generic
recommendations:
– Human Factors; ULM pilots should be more
prepared to react to engine failures at any time
(awareness, briefing, training,…)
– Generic technical solutions; impact on the use
of MOGAS.
• Protection of the equipment during winter,
• Risk of Vapour lock.

31

• Designing stop-gaps, accident after accidents
may not be satisfactory;
What can we do we make sure ULM flying
improves up to an acceptable level and, more
important, remains at that level ?

• More Regulation ?

32

Aviation Regulation and the ULM
• No significant changes in Regulation.
– ULM defined by capacity, weight, structural and stall speed limitation.
– => Extensive use of carbon fiber, Flaps, etc

• CS-VLA.
– 750 kg.
– “light” CS-23.
– Expensive.

• Lower Requirements for licencing,
– What about competence ?
– Human Factors training

• National requirements in Europe.
– EASA Flight Permit per Part 21A.701.

33

Evolution: new EU Regulation on
Accident Investigation.
* Every civil aviation accident or serious incident involving
aircraft other than specified in Annex II to the Regulation (EC)
No 216/2008 of the European Parliament and of the Council
shall be the subject of a safety investigation

( = No obligation of enquiry for ULMs)
• Safety investigation authorities may decide to investigate
incidents other than those referred to in paragraph 1 as well as
accidents or serious incidents to other types of aircraft, in
accordance with the national legislation of the Member States,
when they expect to draw safety lessons from them.
34

• US. NTSB; no enquiry for ULM crashes.
• To-day already, in some EU countries, ULM
crash investigations are given a low priority,
unless the Public determines otherwise.
• Common sense dictates that the initiative
to improve safety must come from the
ULM community itself.

35

Reason Model
• aviation is a complex socio-technical
system, where safety is ensured by a
series of defense barriers.
• Each barrier may present flaws (latent
or active) whose combination can lead
to an accident.
• An usafe act (active failure) alone
would not cause an accident.
• Latent failures are more easily
detected and corrected that human
errors, which are (globally) inevitable.

36

• The ULM community should reinforce its
Defense Barriers.
• Organisation: Federation and Clubs.
Create a Safety Climate
- Norms and rules
- Safety Programs

- To define a Safety Climate, we need to
assess the potential risk, and for that we
need data: YOUR experience.
37

Pyramid of Heinrich
• If a fatal accident is caused by
a specific combination of
events, an uncomplete series
of events causes INCIDENTS.
• If we identify all potentially
dangerous events AND with
that information, build-up the
defenses, we can avoid
ACCIDENTS.
38

SHARING EXPERIENCE
• By informing the Federation of the small
events and incidents that spoiled one of
your flights, you allow the Community to
understand the potential dangers and act
upon. (and respect confidentiality)
“Learn from mistakes of others; you won’t
live long enough to make them all by
yourself”
39

Human Factors
• To err is human.
• Human life (and flying) is full of decisions.
• It is therefore more important to know yourself
than to know how to fly your aircraft.
– Get-home-itis, Distraction, Communication,..

• Understanding human factors is a very important
step in improving your defenses.
40

Competence and Readiness
• You hold a pilot licence; but are you a
competent flyer ?
• How will you react when faced with a
potential dangerous situation?
• Assessing your competences with an
instructor is an opportunity to improve.
• When flying, be ready.
41

What is the Authority doing for
you ?

42

A series of work groups
within EASA are thinking
about how to improve
flight safety.(ESSI)
One of them is about General
Aviation (EGAST).

Initiative includes a leaflet
On Collision Avoidance,
and has been relayed to you
by the Federation.
There are technical Work
Groups dealing with MOGAS
43

and

An initiative to develop
Posters with comic strips
On high risk topics.
The first goes about taking
The right decision when the
Weather is below minimum.
They are expected in the
Coming months.

44

For Belgium, Accident reports are made public on the SPF/FOD website.
Recent reports (from 1st May 2007) are directly available through
hyperlinks.
Reports are written in English.
Information Notes are also available in order to highlight specific danger
area: Nr 2010 is about engine cold start.
We would like to develop more Notes, for ULM in collaboration with
the Federation.
Historical reports: currently a list is posted.
The list is fairly complete from 1972.
2 ancient reports (1936 and 1965).
The reports (Fr /Nl) are desidentified and available on request.
The list will be completed as we go along in reviewing archives.

45

Thank you for your attention, and
AAIU (Belgium) wishes you
many happy landings

Photos credit:
MRA / KLM

46


Slide 37

10 JULY 1910 - 2010
100 YEARS ULM ACCIDENTS

Belgian ULM Federation – Safety
1
Conference 10/10/2010

The Air Safety Investigation
• As part of the global Aviation sphere, an investigation is
conducted for each accident and serious incident by an
independent enquiry body, aimed to;
– Determine the causes of the accident.
– Determine if all conditions that were defined by rules and
regulations to ensure flight safety were followed (such as risk
factors in design).
– Define recommendations in order to prevent future accidents.

• It is not the purpose of this investigation to apportion
blame or liability.

2

In Belgium; the Air Accident
Investigation Unit.
• All accidents and serious incidents occurring in Belgium,
on aircraft, helicopters, gliders, balloons, ULM, DPM,
regardless of their registration is investigated by a cell
functionnally independent from the BCAA, and all other
interrested parties.
• Independent doesn’t mean isolated; it is part of the world’s
network of the State’s Aviation Investigation Bodies.
• The cell reports to the President of the Board of the
SPF/FOD Mobility and Transport.
3

4

ULM
• First pendular (Delta Plane Motorized)
design in 1966
• First crossing of the Channel in 1978 by Mr
D. Cook.
• Commercial development from 1979.
• Evolution from 2-axis to 3-axis.
• In Belgium, first ULM registered (501) in
1982.

5

6

Evolution
• 1982: Weedhopper, Chickinox
– 80…100 km/h
– Basic – 2/3 axis
– Range: … 200 km…

• 2010: VL-3 Sprint, DynAero MCR01, WT9 Dynamic….
– 220….250 km/h,
– flaps, retractable gear, avionics,
– Range over 1000 km

• 550 OO- registered ULM;
• 571 ULM pilot licence (363 training licences)
• 300-400 foreign-registered ULM.
7

1000
900
800
700
600
500
400
300
200
100

Number of valid registration

8

Estimation of flying OO-regd ULM

20
10

20
08

20
06

20
04

20
02

20
00

19
98

19
96

19
94

19
92

19
90

19
88

19
86

19
84

19
82

0

Evolution in pilot’s / owner’s
expectations
• In 1982, ULM /DPM, a sporting way of flying,
outside the limits of parachuting, delta plane.

• In 2010, an efficient alternative to general
(certified) aviation. ULM becomes a means of
transport.
• Beyond 2010 ?? – The Need for Speed ?
9

Evolution
• From the user’s perspective, the difference between
General Aviation and ULM becomes very thin.
• However, ULMs are characterized by a huge variety of
different design types, with low production rate and
configuration variation between individual airplanes.
– Manufacturers come and go,
– Assembly of the same ULM type by different companies induce
differences in built configuration.

• The above makes it more and more difficult to speak about
ULMs in a general way; variation in quality is wider than
General (certified) Aviation.
10

EVOLUTION: MORE ULM FATAL ACCIDENTS ?

Fatalities: (up to now), In Belgium, on average 2 /year,
comparable to General (certified) Aviation.
Number of fatalities
12
10
8
6
4
2

Number of fatalities

11

20
10

20
08

20
06

20
04

20
02

20
00

19
98

19
96

19
94

19
92

19
90

19
88

19
86

19
84

0

19
82

FATALITIES:
Figures limited to
Belgium.
2009: + 2 in France.
2010: + 5 in France.

WHAT ARE THE EXPECTATIONS
FOR THE
ULM-ACCIDENTS CASUALITY
RATE ?
• On Belgian soil, 4 deads in 2010.
(casuality rate of U.S. Forces in Iraq 3.6 killed /1000
troop / year – 8 years – 152000 troops – 4424 killed).

• In France and Belgium in 2010, 9 Belgian
deads to-date.
12

Comparison with the road
• In Belgium, the road kills 1000 people on average per year
.
• Fleet of vehicles: 6 000 000 units (5 mio cars).
• For 1000 cars, the road kills on average 0.16 person per
year.
• If we combine these figures with the yearly utilization rate
of cars (1 h per day) versus ULM (40 h per year), we can
conclude that ULM / General Aviation flying is
considerably deadlier than the road.

13

What can we learn from accident
investigation ?

14

The investigation process
A long process (Months)
• Collect all factual elements,
–
–
–
–
–
–

The flow of events;
The pilot (training, experience, …)
The aircraft (contact w/manufacturer)
Meteo, Comm, Radar,
Flt recorders (GPS, ECU, camera, …)
Impact, aircraft damage,

• Analysis. (incl. simulation, testing,…)
• Define all possible causes.
• From the causes, define remedial action.
The depth of the investigation is somewhat influenced by the
expected ROI.
15

Accident analysis
• Accidents do not occur “by accident”; Accident are
caused by a series of events.
• There are no “isolated cases”; causes of accidents are often
recurrent.
• Out of the ULM accident data base, we can conclude;
– There are recurrent technical problems specific to ULM.
– The traditional causes of aviation accidents are also known to
ULM (fuel shortage)

– 80% of the causal factors are human-related.

16

Main causal factors (122 accidents –
fixed wing and ULM)
Loss of control Take-off
11%

Fuel Starvation
15%

Loss of control Flight & collision
12%

Technical
11%
Low piloting
experience
8%

Loss of control Landing
16%
Icing
3%

Low flying /
aerobatics obstacles - CFIT
24%

17

Specific problems with ULM
• Technical causes can be (easily) identified;
but fire can be devastating.
• There’s another problem for the
investigator, a lot of landmarks are missing.
– ULM requirements are national,
– Certification not applicable.
– Wide variety of products.
18

About certification.
• Everyone would agree that ULMs of to-day are as good,
even a lot better than the ‘certified’ airplane.
• ULMs are designed to fly.
ULM are quality products; they meet your expectations
(simple to handle, fly fast, cheap in usage, …)
• Certification means that a manufacturer must demonstrate
that his product meets a minimum level of safety, as
defined (ultimately) by the Aviation Community.
• The minimum level of safety is defined in the Certification
Specifications – For small aircraft, it is called CS23.
19

Technical.
• AAIU(be) is currently investigating on:
– Instrument Board lay-out design.
– Electrical System design.
– Emergency Parachute.
Why is it that (for the last cases) parachute did not save lifes ?
• Late decision ?
• Handle easy to grab ?
• Safety pin not removed before flight ?

20

Same ULM Type, instrument panel somewhat different.
Difference in Ergonomy.
Parachute handle – on pilot’s side, or on passenger’s side ?

21

Regulation: certification:
CS 23.671 General
(b) Controls must be arranged and identified
to provide for convenience in operation and
to prevent the possibility of confusion and
subsequent inadvertent operation.

For ULM, CS 23 is not applicable.
Each designer has his own solution, and
they will be challenged only by YOUR
experience.
22

Other example
The passenger door opens in
flight, causing the pilot to take
appropriate actions, that
eventually force him to an
emergency landing.

• Door lock (simple – crude).
Plexy flexible. Once opened in
flight, difficult to close.
CS 23.783
(1) There must be means to lock and safeguard the door against
inadvertent opening during flight by persons, by cargo, or as a
result of mechanical failure.
23

The problem
• Once we determine a technical problem, we
can define recommendations to improve the
product, but:
What do we do with the recommendation ?
– We can not improve the Standard, there’s no standard.
– We can not address more than one manufacturer,
– What about retrofit ?

24

ULM and Engine failures

25

Fly Synthesis Storch
Summer 2009
• After propeller replacement, and subsequent
engine ground tests, the pilot took off for a
flight test.
• He encountered heavy engine vibration, that
forced him to an emergency landing.
• Airplane was slightly damaged.
Cause was identified as Vapor Lock.
26

1/5/2010 – FK9
Emergency landing after in-flight engine failure.
• Lots of corrosion found in carburettor.
Corrosion comes from water condensation in
fuel system (tank, lines, pump,…- MOGAS)
during long immobilisation periods.
- how to prevent ? Filling up, draining ?

• Fuel system was modified in-service, by
addition of a pressure regulator.
27

France
20/5/2010 – Mistral
23/5/2010 – CT Short Wing
Mistral: Engine failure in flight.
Emergency landing in field; terrain was very soft, airplane
severely damaged.
CT Short Wing: In short final, the engine suddenly stops
The pilot attempts to land, but hit trees, and crashes – wings
ripped off.
RH wing tank empty, 15-25 l fuel remaining in LH tank.
During LH turn, fuel system unprimed, engine stopped by
fuel starvation.
28

4 /6/2010: SG Rally
Damaged during landing
• Due to engine problems (heavy vibrations), the
pilot performed emergency landing on EBHN.
Coming in too fast, the landing was brutal, and
Nose Landing Gear collapsed.

29

Conclusion
• Engine in-flight failure are not exceptional.
– Use of MOGAS (water content, flash point,..)
– Local modifications,
– Other specific to the configuration of the
specific airplane.
And..
– Traditional causes (engine starvation,..)
30

Solutions
• In this case, we can design some generic
recommendations:
– Human Factors; ULM pilots should be more
prepared to react to engine failures at any time
(awareness, briefing, training,…)
– Generic technical solutions; impact on the use
of MOGAS.
• Protection of the equipment during winter,
• Risk of Vapour lock.

31

• Designing stop-gaps, accident after accidents
may not be satisfactory;
What can we do we make sure ULM flying
improves up to an acceptable level and, more
important, remains at that level ?

• More Regulation ?

32

Aviation Regulation and the ULM
• No significant changes in Regulation.
– ULM defined by capacity, weight, structural and stall speed limitation.
– => Extensive use of carbon fiber, Flaps, etc

• CS-VLA.
– 750 kg.
– “light” CS-23.
– Expensive.

• Lower Requirements for licencing,
– What about competence ?
– Human Factors training

• National requirements in Europe.
– EASA Flight Permit per Part 21A.701.

33

Evolution: new EU Regulation on
Accident Investigation.
* Every civil aviation accident or serious incident involving
aircraft other than specified in Annex II to the Regulation (EC)
No 216/2008 of the European Parliament and of the Council
shall be the subject of a safety investigation

( = No obligation of enquiry for ULMs)
• Safety investigation authorities may decide to investigate
incidents other than those referred to in paragraph 1 as well as
accidents or serious incidents to other types of aircraft, in
accordance with the national legislation of the Member States,
when they expect to draw safety lessons from them.
34

• US. NTSB; no enquiry for ULM crashes.
• To-day already, in some EU countries, ULM
crash investigations are given a low priority,
unless the Public determines otherwise.
• Common sense dictates that the initiative
to improve safety must come from the
ULM community itself.

35

Reason Model
• aviation is a complex socio-technical
system, where safety is ensured by a
series of defense barriers.
• Each barrier may present flaws (latent
or active) whose combination can lead
to an accident.
• An usafe act (active failure) alone
would not cause an accident.
• Latent failures are more easily
detected and corrected that human
errors, which are (globally) inevitable.

36

• The ULM community should reinforce its
Defense Barriers.
• Organisation: Federation and Clubs.
Create a Safety Climate
- Norms and rules
- Safety Programs

- To define a Safety Climate, we need to
assess the potential risk, and for that we
need data: YOUR experience.
37

Pyramid of Heinrich
• If a fatal accident is caused by
a specific combination of
events, an uncomplete series
of events causes INCIDENTS.
• If we identify all potentially
dangerous events AND with
that information, build-up the
defenses, we can avoid
ACCIDENTS.
38

SHARING EXPERIENCE
• By informing the Federation of the small
events and incidents that spoiled one of
your flights, you allow the Community to
understand the potential dangers and act
upon. (and respect confidentiality)
“Learn from mistakes of others; you won’t
live long enough to make them all by
yourself”
39

Human Factors
• To err is human.
• Human life (and flying) is full of decisions.
• It is therefore more important to know yourself
than to know how to fly your aircraft.
– Get-home-itis, Distraction, Communication,..

• Understanding human factors is a very important
step in improving your defenses.
40

Competence and Readiness
• You hold a pilot licence; but are you a
competent flyer ?
• How will you react when faced with a
potential dangerous situation?
• Assessing your competences with an
instructor is an opportunity to improve.
• When flying, be ready.
41

What is the Authority doing for
you ?

42

A series of work groups
within EASA are thinking
about how to improve
flight safety.(ESSI)
One of them is about General
Aviation (EGAST).

Initiative includes a leaflet
On Collision Avoidance,
and has been relayed to you
by the Federation.
There are technical Work
Groups dealing with MOGAS
43

and

An initiative to develop
Posters with comic strips
On high risk topics.
The first goes about taking
The right decision when the
Weather is below minimum.
They are expected in the
Coming months.

44

For Belgium, Accident reports are made public on the SPF/FOD website.
Recent reports (from 1st May 2007) are directly available through
hyperlinks.
Reports are written in English.
Information Notes are also available in order to highlight specific danger
area: Nr 2010 is about engine cold start.
We would like to develop more Notes, for ULM in collaboration with
the Federation.
Historical reports: currently a list is posted.
The list is fairly complete from 1972.
2 ancient reports (1936 and 1965).
The reports (Fr /Nl) are desidentified and available on request.
The list will be completed as we go along in reviewing archives.

45

Thank you for your attention, and
AAIU (Belgium) wishes you
many happy landings

Photos credit:
MRA / KLM

46


Slide 38

10 JULY 1910 - 2010
100 YEARS ULM ACCIDENTS

Belgian ULM Federation – Safety
1
Conference 10/10/2010

The Air Safety Investigation
• As part of the global Aviation sphere, an investigation is
conducted for each accident and serious incident by an
independent enquiry body, aimed to;
– Determine the causes of the accident.
– Determine if all conditions that were defined by rules and
regulations to ensure flight safety were followed (such as risk
factors in design).
– Define recommendations in order to prevent future accidents.

• It is not the purpose of this investigation to apportion
blame or liability.

2

In Belgium; the Air Accident
Investigation Unit.
• All accidents and serious incidents occurring in Belgium,
on aircraft, helicopters, gliders, balloons, ULM, DPM,
regardless of their registration is investigated by a cell
functionnally independent from the BCAA, and all other
interrested parties.
• Independent doesn’t mean isolated; it is part of the world’s
network of the State’s Aviation Investigation Bodies.
• The cell reports to the President of the Board of the
SPF/FOD Mobility and Transport.
3

4

ULM
• First pendular (Delta Plane Motorized)
design in 1966
• First crossing of the Channel in 1978 by Mr
D. Cook.
• Commercial development from 1979.
• Evolution from 2-axis to 3-axis.
• In Belgium, first ULM registered (501) in
1982.

5

6

Evolution
• 1982: Weedhopper, Chickinox
– 80…100 km/h
– Basic – 2/3 axis
– Range: … 200 km…

• 2010: VL-3 Sprint, DynAero MCR01, WT9 Dynamic….
– 220….250 km/h,
– flaps, retractable gear, avionics,
– Range over 1000 km

• 550 OO- registered ULM;
• 571 ULM pilot licence (363 training licences)
• 300-400 foreign-registered ULM.
7

1000
900
800
700
600
500
400
300
200
100

Number of valid registration

8

Estimation of flying OO-regd ULM

20
10

20
08

20
06

20
04

20
02

20
00

19
98

19
96

19
94

19
92

19
90

19
88

19
86

19
84

19
82

0

Evolution in pilot’s / owner’s
expectations
• In 1982, ULM /DPM, a sporting way of flying,
outside the limits of parachuting, delta plane.

• In 2010, an efficient alternative to general
(certified) aviation. ULM becomes a means of
transport.
• Beyond 2010 ?? – The Need for Speed ?
9

Evolution
• From the user’s perspective, the difference between
General Aviation and ULM becomes very thin.
• However, ULMs are characterized by a huge variety of
different design types, with low production rate and
configuration variation between individual airplanes.
– Manufacturers come and go,
– Assembly of the same ULM type by different companies induce
differences in built configuration.

• The above makes it more and more difficult to speak about
ULMs in a general way; variation in quality is wider than
General (certified) Aviation.
10

EVOLUTION: MORE ULM FATAL ACCIDENTS ?

Fatalities: (up to now), In Belgium, on average 2 /year,
comparable to General (certified) Aviation.
Number of fatalities
12
10
8
6
4
2

Number of fatalities

11

20
10

20
08

20
06

20
04

20
02

20
00

19
98

19
96

19
94

19
92

19
90

19
88

19
86

19
84

0

19
82

FATALITIES:
Figures limited to
Belgium.
2009: + 2 in France.
2010: + 5 in France.

WHAT ARE THE EXPECTATIONS
FOR THE
ULM-ACCIDENTS CASUALITY
RATE ?
• On Belgian soil, 4 deads in 2010.
(casuality rate of U.S. Forces in Iraq 3.6 killed /1000
troop / year – 8 years – 152000 troops – 4424 killed).

• In France and Belgium in 2010, 9 Belgian
deads to-date.
12

Comparison with the road
• In Belgium, the road kills 1000 people on average per year
.
• Fleet of vehicles: 6 000 000 units (5 mio cars).
• For 1000 cars, the road kills on average 0.16 person per
year.
• If we combine these figures with the yearly utilization rate
of cars (1 h per day) versus ULM (40 h per year), we can
conclude that ULM / General Aviation flying is
considerably deadlier than the road.

13

What can we learn from accident
investigation ?

14

The investigation process
A long process (Months)
• Collect all factual elements,
–
–
–
–
–
–

The flow of events;
The pilot (training, experience, …)
The aircraft (contact w/manufacturer)
Meteo, Comm, Radar,
Flt recorders (GPS, ECU, camera, …)
Impact, aircraft damage,

• Analysis. (incl. simulation, testing,…)
• Define all possible causes.
• From the causes, define remedial action.
The depth of the investigation is somewhat influenced by the
expected ROI.
15

Accident analysis
• Accidents do not occur “by accident”; Accident are
caused by a series of events.
• There are no “isolated cases”; causes of accidents are often
recurrent.
• Out of the ULM accident data base, we can conclude;
– There are recurrent technical problems specific to ULM.
– The traditional causes of aviation accidents are also known to
ULM (fuel shortage)

– 80% of the causal factors are human-related.

16

Main causal factors (122 accidents –
fixed wing and ULM)
Loss of control Take-off
11%

Fuel Starvation
15%

Loss of control Flight & collision
12%

Technical
11%
Low piloting
experience
8%

Loss of control Landing
16%
Icing
3%

Low flying /
aerobatics obstacles - CFIT
24%

17

Specific problems with ULM
• Technical causes can be (easily) identified;
but fire can be devastating.
• There’s another problem for the
investigator, a lot of landmarks are missing.
– ULM requirements are national,
– Certification not applicable.
– Wide variety of products.
18

About certification.
• Everyone would agree that ULMs of to-day are as good,
even a lot better than the ‘certified’ airplane.
• ULMs are designed to fly.
ULM are quality products; they meet your expectations
(simple to handle, fly fast, cheap in usage, …)
• Certification means that a manufacturer must demonstrate
that his product meets a minimum level of safety, as
defined (ultimately) by the Aviation Community.
• The minimum level of safety is defined in the Certification
Specifications – For small aircraft, it is called CS23.
19

Technical.
• AAIU(be) is currently investigating on:
– Instrument Board lay-out design.
– Electrical System design.
– Emergency Parachute.
Why is it that (for the last cases) parachute did not save lifes ?
• Late decision ?
• Handle easy to grab ?
• Safety pin not removed before flight ?

20

Same ULM Type, instrument panel somewhat different.
Difference in Ergonomy.
Parachute handle – on pilot’s side, or on passenger’s side ?

21

Regulation: certification:
CS 23.671 General
(b) Controls must be arranged and identified
to provide for convenience in operation and
to prevent the possibility of confusion and
subsequent inadvertent operation.

For ULM, CS 23 is not applicable.
Each designer has his own solution, and
they will be challenged only by YOUR
experience.
22

Other example
The passenger door opens in
flight, causing the pilot to take
appropriate actions, that
eventually force him to an
emergency landing.

• Door lock (simple – crude).
Plexy flexible. Once opened in
flight, difficult to close.
CS 23.783
(1) There must be means to lock and safeguard the door against
inadvertent opening during flight by persons, by cargo, or as a
result of mechanical failure.
23

The problem
• Once we determine a technical problem, we
can define recommendations to improve the
product, but:
What do we do with the recommendation ?
– We can not improve the Standard, there’s no standard.
– We can not address more than one manufacturer,
– What about retrofit ?

24

ULM and Engine failures

25

Fly Synthesis Storch
Summer 2009
• After propeller replacement, and subsequent
engine ground tests, the pilot took off for a
flight test.
• He encountered heavy engine vibration, that
forced him to an emergency landing.
• Airplane was slightly damaged.
Cause was identified as Vapor Lock.
26

1/5/2010 – FK9
Emergency landing after in-flight engine failure.
• Lots of corrosion found in carburettor.
Corrosion comes from water condensation in
fuel system (tank, lines, pump,…- MOGAS)
during long immobilisation periods.
- how to prevent ? Filling up, draining ?

• Fuel system was modified in-service, by
addition of a pressure regulator.
27

France
20/5/2010 – Mistral
23/5/2010 – CT Short Wing
Mistral: Engine failure in flight.
Emergency landing in field; terrain was very soft, airplane
severely damaged.
CT Short Wing: In short final, the engine suddenly stops
The pilot attempts to land, but hit trees, and crashes – wings
ripped off.
RH wing tank empty, 15-25 l fuel remaining in LH tank.
During LH turn, fuel system unprimed, engine stopped by
fuel starvation.
28

4 /6/2010: SG Rally
Damaged during landing
• Due to engine problems (heavy vibrations), the
pilot performed emergency landing on EBHN.
Coming in too fast, the landing was brutal, and
Nose Landing Gear collapsed.

29

Conclusion
• Engine in-flight failure are not exceptional.
– Use of MOGAS (water content, flash point,..)
– Local modifications,
– Other specific to the configuration of the
specific airplane.
And..
– Traditional causes (engine starvation,..)
30

Solutions
• In this case, we can design some generic
recommendations:
– Human Factors; ULM pilots should be more
prepared to react to engine failures at any time
(awareness, briefing, training,…)
– Generic technical solutions; impact on the use
of MOGAS.
• Protection of the equipment during winter,
• Risk of Vapour lock.

31

• Designing stop-gaps, accident after accidents
may not be satisfactory;
What can we do we make sure ULM flying
improves up to an acceptable level and, more
important, remains at that level ?

• More Regulation ?

32

Aviation Regulation and the ULM
• No significant changes in Regulation.
– ULM defined by capacity, weight, structural and stall speed limitation.
– => Extensive use of carbon fiber, Flaps, etc

• CS-VLA.
– 750 kg.
– “light” CS-23.
– Expensive.

• Lower Requirements for licencing,
– What about competence ?
– Human Factors training

• National requirements in Europe.
– EASA Flight Permit per Part 21A.701.

33

Evolution: new EU Regulation on
Accident Investigation.
* Every civil aviation accident or serious incident involving
aircraft other than specified in Annex II to the Regulation (EC)
No 216/2008 of the European Parliament and of the Council
shall be the subject of a safety investigation

( = No obligation of enquiry for ULMs)
• Safety investigation authorities may decide to investigate
incidents other than those referred to in paragraph 1 as well as
accidents or serious incidents to other types of aircraft, in
accordance with the national legislation of the Member States,
when they expect to draw safety lessons from them.
34

• US. NTSB; no enquiry for ULM crashes.
• To-day already, in some EU countries, ULM
crash investigations are given a low priority,
unless the Public determines otherwise.
• Common sense dictates that the initiative
to improve safety must come from the
ULM community itself.

35

Reason Model
• aviation is a complex socio-technical
system, where safety is ensured by a
series of defense barriers.
• Each barrier may present flaws (latent
or active) whose combination can lead
to an accident.
• An usafe act (active failure) alone
would not cause an accident.
• Latent failures are more easily
detected and corrected that human
errors, which are (globally) inevitable.

36

• The ULM community should reinforce its
Defense Barriers.
• Organisation: Federation and Clubs.
Create a Safety Climate
- Norms and rules
- Safety Programs

- To define a Safety Climate, we need to
assess the potential risk, and for that we
need data: YOUR experience.
37

Pyramid of Heinrich
• If a fatal accident is caused by
a specific combination of
events, an uncomplete series
of events causes INCIDENTS.
• If we identify all potentially
dangerous events AND with
that information, build-up the
defenses, we can avoid
ACCIDENTS.
38

SHARING EXPERIENCE
• By informing the Federation of the small
events and incidents that spoiled one of
your flights, you allow the Community to
understand the potential dangers and act
upon. (and respect confidentiality)
“Learn from mistakes of others; you won’t
live long enough to make them all by
yourself”
39

Human Factors
• To err is human.
• Human life (and flying) is full of decisions.
• It is therefore more important to know yourself
than to know how to fly your aircraft.
– Get-home-itis, Distraction, Communication,..

• Understanding human factors is a very important
step in improving your defenses.
40

Competence and Readiness
• You hold a pilot licence; but are you a
competent flyer ?
• How will you react when faced with a
potential dangerous situation?
• Assessing your competences with an
instructor is an opportunity to improve.
• When flying, be ready.
41

What is the Authority doing for
you ?

42

A series of work groups
within EASA are thinking
about how to improve
flight safety.(ESSI)
One of them is about General
Aviation (EGAST).

Initiative includes a leaflet
On Collision Avoidance,
and has been relayed to you
by the Federation.
There are technical Work
Groups dealing with MOGAS
43

and

An initiative to develop
Posters with comic strips
On high risk topics.
The first goes about taking
The right decision when the
Weather is below minimum.
They are expected in the
Coming months.

44

For Belgium, Accident reports are made public on the SPF/FOD website.
Recent reports (from 1st May 2007) are directly available through
hyperlinks.
Reports are written in English.
Information Notes are also available in order to highlight specific danger
area: Nr 2010 is about engine cold start.
We would like to develop more Notes, for ULM in collaboration with
the Federation.
Historical reports: currently a list is posted.
The list is fairly complete from 1972.
2 ancient reports (1936 and 1965).
The reports (Fr /Nl) are desidentified and available on request.
The list will be completed as we go along in reviewing archives.

45

Thank you for your attention, and
AAIU (Belgium) wishes you
many happy landings

Photos credit:
MRA / KLM

46


Slide 39

10 JULY 1910 - 2010
100 YEARS ULM ACCIDENTS

Belgian ULM Federation – Safety
1
Conference 10/10/2010

The Air Safety Investigation
• As part of the global Aviation sphere, an investigation is
conducted for each accident and serious incident by an
independent enquiry body, aimed to;
– Determine the causes of the accident.
– Determine if all conditions that were defined by rules and
regulations to ensure flight safety were followed (such as risk
factors in design).
– Define recommendations in order to prevent future accidents.

• It is not the purpose of this investigation to apportion
blame or liability.

2

In Belgium; the Air Accident
Investigation Unit.
• All accidents and serious incidents occurring in Belgium,
on aircraft, helicopters, gliders, balloons, ULM, DPM,
regardless of their registration is investigated by a cell
functionnally independent from the BCAA, and all other
interrested parties.
• Independent doesn’t mean isolated; it is part of the world’s
network of the State’s Aviation Investigation Bodies.
• The cell reports to the President of the Board of the
SPF/FOD Mobility and Transport.
3

4

ULM
• First pendular (Delta Plane Motorized)
design in 1966
• First crossing of the Channel in 1978 by Mr
D. Cook.
• Commercial development from 1979.
• Evolution from 2-axis to 3-axis.
• In Belgium, first ULM registered (501) in
1982.

5

6

Evolution
• 1982: Weedhopper, Chickinox
– 80…100 km/h
– Basic – 2/3 axis
– Range: … 200 km…

• 2010: VL-3 Sprint, DynAero MCR01, WT9 Dynamic….
– 220….250 km/h,
– flaps, retractable gear, avionics,
– Range over 1000 km

• 550 OO- registered ULM;
• 571 ULM pilot licence (363 training licences)
• 300-400 foreign-registered ULM.
7

1000
900
800
700
600
500
400
300
200
100

Number of valid registration

8

Estimation of flying OO-regd ULM

20
10

20
08

20
06

20
04

20
02

20
00

19
98

19
96

19
94

19
92

19
90

19
88

19
86

19
84

19
82

0

Evolution in pilot’s / owner’s
expectations
• In 1982, ULM /DPM, a sporting way of flying,
outside the limits of parachuting, delta plane.

• In 2010, an efficient alternative to general
(certified) aviation. ULM becomes a means of
transport.
• Beyond 2010 ?? – The Need for Speed ?
9

Evolution
• From the user’s perspective, the difference between
General Aviation and ULM becomes very thin.
• However, ULMs are characterized by a huge variety of
different design types, with low production rate and
configuration variation between individual airplanes.
– Manufacturers come and go,
– Assembly of the same ULM type by different companies induce
differences in built configuration.

• The above makes it more and more difficult to speak about
ULMs in a general way; variation in quality is wider than
General (certified) Aviation.
10

EVOLUTION: MORE ULM FATAL ACCIDENTS ?

Fatalities: (up to now), In Belgium, on average 2 /year,
comparable to General (certified) Aviation.
Number of fatalities
12
10
8
6
4
2

Number of fatalities

11

20
10

20
08

20
06

20
04

20
02

20
00

19
98

19
96

19
94

19
92

19
90

19
88

19
86

19
84

0

19
82

FATALITIES:
Figures limited to
Belgium.
2009: + 2 in France.
2010: + 5 in France.

WHAT ARE THE EXPECTATIONS
FOR THE
ULM-ACCIDENTS CASUALITY
RATE ?
• On Belgian soil, 4 deads in 2010.
(casuality rate of U.S. Forces in Iraq 3.6 killed /1000
troop / year – 8 years – 152000 troops – 4424 killed).

• In France and Belgium in 2010, 9 Belgian
deads to-date.
12

Comparison with the road
• In Belgium, the road kills 1000 people on average per year
.
• Fleet of vehicles: 6 000 000 units (5 mio cars).
• For 1000 cars, the road kills on average 0.16 person per
year.
• If we combine these figures with the yearly utilization rate
of cars (1 h per day) versus ULM (40 h per year), we can
conclude that ULM / General Aviation flying is
considerably deadlier than the road.

13

What can we learn from accident
investigation ?

14

The investigation process
A long process (Months)
• Collect all factual elements,
–
–
–
–
–
–

The flow of events;
The pilot (training, experience, …)
The aircraft (contact w/manufacturer)
Meteo, Comm, Radar,
Flt recorders (GPS, ECU, camera, …)
Impact, aircraft damage,

• Analysis. (incl. simulation, testing,…)
• Define all possible causes.
• From the causes, define remedial action.
The depth of the investigation is somewhat influenced by the
expected ROI.
15

Accident analysis
• Accidents do not occur “by accident”; Accident are
caused by a series of events.
• There are no “isolated cases”; causes of accidents are often
recurrent.
• Out of the ULM accident data base, we can conclude;
– There are recurrent technical problems specific to ULM.
– The traditional causes of aviation accidents are also known to
ULM (fuel shortage)

– 80% of the causal factors are human-related.

16

Main causal factors (122 accidents –
fixed wing and ULM)
Loss of control Take-off
11%

Fuel Starvation
15%

Loss of control Flight & collision
12%

Technical
11%
Low piloting
experience
8%

Loss of control Landing
16%
Icing
3%

Low flying /
aerobatics obstacles - CFIT
24%

17

Specific problems with ULM
• Technical causes can be (easily) identified;
but fire can be devastating.
• There’s another problem for the
investigator, a lot of landmarks are missing.
– ULM requirements are national,
– Certification not applicable.
– Wide variety of products.
18

About certification.
• Everyone would agree that ULMs of to-day are as good,
even a lot better than the ‘certified’ airplane.
• ULMs are designed to fly.
ULM are quality products; they meet your expectations
(simple to handle, fly fast, cheap in usage, …)
• Certification means that a manufacturer must demonstrate
that his product meets a minimum level of safety, as
defined (ultimately) by the Aviation Community.
• The minimum level of safety is defined in the Certification
Specifications – For small aircraft, it is called CS23.
19

Technical.
• AAIU(be) is currently investigating on:
– Instrument Board lay-out design.
– Electrical System design.
– Emergency Parachute.
Why is it that (for the last cases) parachute did not save lifes ?
• Late decision ?
• Handle easy to grab ?
• Safety pin not removed before flight ?

20

Same ULM Type, instrument panel somewhat different.
Difference in Ergonomy.
Parachute handle – on pilot’s side, or on passenger’s side ?

21

Regulation: certification:
CS 23.671 General
(b) Controls must be arranged and identified
to provide for convenience in operation and
to prevent the possibility of confusion and
subsequent inadvertent operation.

For ULM, CS 23 is not applicable.
Each designer has his own solution, and
they will be challenged only by YOUR
experience.
22

Other example
The passenger door opens in
flight, causing the pilot to take
appropriate actions, that
eventually force him to an
emergency landing.

• Door lock (simple – crude).
Plexy flexible. Once opened in
flight, difficult to close.
CS 23.783
(1) There must be means to lock and safeguard the door against
inadvertent opening during flight by persons, by cargo, or as a
result of mechanical failure.
23

The problem
• Once we determine a technical problem, we
can define recommendations to improve the
product, but:
What do we do with the recommendation ?
– We can not improve the Standard, there’s no standard.
– We can not address more than one manufacturer,
– What about retrofit ?

24

ULM and Engine failures

25

Fly Synthesis Storch
Summer 2009
• After propeller replacement, and subsequent
engine ground tests, the pilot took off for a
flight test.
• He encountered heavy engine vibration, that
forced him to an emergency landing.
• Airplane was slightly damaged.
Cause was identified as Vapor Lock.
26

1/5/2010 – FK9
Emergency landing after in-flight engine failure.
• Lots of corrosion found in carburettor.
Corrosion comes from water condensation in
fuel system (tank, lines, pump,…- MOGAS)
during long immobilisation periods.
- how to prevent ? Filling up, draining ?

• Fuel system was modified in-service, by
addition of a pressure regulator.
27

France
20/5/2010 – Mistral
23/5/2010 – CT Short Wing
Mistral: Engine failure in flight.
Emergency landing in field; terrain was very soft, airplane
severely damaged.
CT Short Wing: In short final, the engine suddenly stops
The pilot attempts to land, but hit trees, and crashes – wings
ripped off.
RH wing tank empty, 15-25 l fuel remaining in LH tank.
During LH turn, fuel system unprimed, engine stopped by
fuel starvation.
28

4 /6/2010: SG Rally
Damaged during landing
• Due to engine problems (heavy vibrations), the
pilot performed emergency landing on EBHN.
Coming in too fast, the landing was brutal, and
Nose Landing Gear collapsed.

29

Conclusion
• Engine in-flight failure are not exceptional.
– Use of MOGAS (water content, flash point,..)
– Local modifications,
– Other specific to the configuration of the
specific airplane.
And..
– Traditional causes (engine starvation,..)
30

Solutions
• In this case, we can design some generic
recommendations:
– Human Factors; ULM pilots should be more
prepared to react to engine failures at any time
(awareness, briefing, training,…)
– Generic technical solutions; impact on the use
of MOGAS.
• Protection of the equipment during winter,
• Risk of Vapour lock.

31

• Designing stop-gaps, accident after accidents
may not be satisfactory;
What can we do we make sure ULM flying
improves up to an acceptable level and, more
important, remains at that level ?

• More Regulation ?

32

Aviation Regulation and the ULM
• No significant changes in Regulation.
– ULM defined by capacity, weight, structural and stall speed limitation.
– => Extensive use of carbon fiber, Flaps, etc

• CS-VLA.
– 750 kg.
– “light” CS-23.
– Expensive.

• Lower Requirements for licencing,
– What about competence ?
– Human Factors training

• National requirements in Europe.
– EASA Flight Permit per Part 21A.701.

33

Evolution: new EU Regulation on
Accident Investigation.
* Every civil aviation accident or serious incident involving
aircraft other than specified in Annex II to the Regulation (EC)
No 216/2008 of the European Parliament and of the Council
shall be the subject of a safety investigation

( = No obligation of enquiry for ULMs)
• Safety investigation authorities may decide to investigate
incidents other than those referred to in paragraph 1 as well as
accidents or serious incidents to other types of aircraft, in
accordance with the national legislation of the Member States,
when they expect to draw safety lessons from them.
34

• US. NTSB; no enquiry for ULM crashes.
• To-day already, in some EU countries, ULM
crash investigations are given a low priority,
unless the Public determines otherwise.
• Common sense dictates that the initiative
to improve safety must come from the
ULM community itself.

35

Reason Model
• aviation is a complex socio-technical
system, where safety is ensured by a
series of defense barriers.
• Each barrier may present flaws (latent
or active) whose combination can lead
to an accident.
• An usafe act (active failure) alone
would not cause an accident.
• Latent failures are more easily
detected and corrected that human
errors, which are (globally) inevitable.

36

• The ULM community should reinforce its
Defense Barriers.
• Organisation: Federation and Clubs.
Create a Safety Climate
- Norms and rules
- Safety Programs

- To define a Safety Climate, we need to
assess the potential risk, and for that we
need data: YOUR experience.
37

Pyramid of Heinrich
• If a fatal accident is caused by
a specific combination of
events, an uncomplete series
of events causes INCIDENTS.
• If we identify all potentially
dangerous events AND with
that information, build-up the
defenses, we can avoid
ACCIDENTS.
38

SHARING EXPERIENCE
• By informing the Federation of the small
events and incidents that spoiled one of
your flights, you allow the Community to
understand the potential dangers and act
upon. (and respect confidentiality)
“Learn from mistakes of others; you won’t
live long enough to make them all by
yourself”
39

Human Factors
• To err is human.
• Human life (and flying) is full of decisions.
• It is therefore more important to know yourself
than to know how to fly your aircraft.
– Get-home-itis, Distraction, Communication,..

• Understanding human factors is a very important
step in improving your defenses.
40

Competence and Readiness
• You hold a pilot licence; but are you a
competent flyer ?
• How will you react when faced with a
potential dangerous situation?
• Assessing your competences with an
instructor is an opportunity to improve.
• When flying, be ready.
41

What is the Authority doing for
you ?

42

A series of work groups
within EASA are thinking
about how to improve
flight safety.(ESSI)
One of them is about General
Aviation (EGAST).

Initiative includes a leaflet
On Collision Avoidance,
and has been relayed to you
by the Federation.
There are technical Work
Groups dealing with MOGAS
43

and

An initiative to develop
Posters with comic strips
On high risk topics.
The first goes about taking
The right decision when the
Weather is below minimum.
They are expected in the
Coming months.

44

For Belgium, Accident reports are made public on the SPF/FOD website.
Recent reports (from 1st May 2007) are directly available through
hyperlinks.
Reports are written in English.
Information Notes are also available in order to highlight specific danger
area: Nr 2010 is about engine cold start.
We would like to develop more Notes, for ULM in collaboration with
the Federation.
Historical reports: currently a list is posted.
The list is fairly complete from 1972.
2 ancient reports (1936 and 1965).
The reports (Fr /Nl) are desidentified and available on request.
The list will be completed as we go along in reviewing archives.

45

Thank you for your attention, and
AAIU (Belgium) wishes you
many happy landings

Photos credit:
MRA / KLM

46


Slide 40

10 JULY 1910 - 2010
100 YEARS ULM ACCIDENTS

Belgian ULM Federation – Safety
1
Conference 10/10/2010

The Air Safety Investigation
• As part of the global Aviation sphere, an investigation is
conducted for each accident and serious incident by an
independent enquiry body, aimed to;
– Determine the causes of the accident.
– Determine if all conditions that were defined by rules and
regulations to ensure flight safety were followed (such as risk
factors in design).
– Define recommendations in order to prevent future accidents.

• It is not the purpose of this investigation to apportion
blame or liability.

2

In Belgium; the Air Accident
Investigation Unit.
• All accidents and serious incidents occurring in Belgium,
on aircraft, helicopters, gliders, balloons, ULM, DPM,
regardless of their registration is investigated by a cell
functionnally independent from the BCAA, and all other
interrested parties.
• Independent doesn’t mean isolated; it is part of the world’s
network of the State’s Aviation Investigation Bodies.
• The cell reports to the President of the Board of the
SPF/FOD Mobility and Transport.
3

4

ULM
• First pendular (Delta Plane Motorized)
design in 1966
• First crossing of the Channel in 1978 by Mr
D. Cook.
• Commercial development from 1979.
• Evolution from 2-axis to 3-axis.
• In Belgium, first ULM registered (501) in
1982.

5

6

Evolution
• 1982: Weedhopper, Chickinox
– 80…100 km/h
– Basic – 2/3 axis
– Range: … 200 km…

• 2010: VL-3 Sprint, DynAero MCR01, WT9 Dynamic….
– 220….250 km/h,
– flaps, retractable gear, avionics,
– Range over 1000 km

• 550 OO- registered ULM;
• 571 ULM pilot licence (363 training licences)
• 300-400 foreign-registered ULM.
7

1000
900
800
700
600
500
400
300
200
100

Number of valid registration

8

Estimation of flying OO-regd ULM

20
10

20
08

20
06

20
04

20
02

20
00

19
98

19
96

19
94

19
92

19
90

19
88

19
86

19
84

19
82

0

Evolution in pilot’s / owner’s
expectations
• In 1982, ULM /DPM, a sporting way of flying,
outside the limits of parachuting, delta plane.

• In 2010, an efficient alternative to general
(certified) aviation. ULM becomes a means of
transport.
• Beyond 2010 ?? – The Need for Speed ?
9

Evolution
• From the user’s perspective, the difference between
General Aviation and ULM becomes very thin.
• However, ULMs are characterized by a huge variety of
different design types, with low production rate and
configuration variation between individual airplanes.
– Manufacturers come and go,
– Assembly of the same ULM type by different companies induce
differences in built configuration.

• The above makes it more and more difficult to speak about
ULMs in a general way; variation in quality is wider than
General (certified) Aviation.
10

EVOLUTION: MORE ULM FATAL ACCIDENTS ?

Fatalities: (up to now), In Belgium, on average 2 /year,
comparable to General (certified) Aviation.
Number of fatalities
12
10
8
6
4
2

Number of fatalities

11

20
10

20
08

20
06

20
04

20
02

20
00

19
98

19
96

19
94

19
92

19
90

19
88

19
86

19
84

0

19
82

FATALITIES:
Figures limited to
Belgium.
2009: + 2 in France.
2010: + 5 in France.

WHAT ARE THE EXPECTATIONS
FOR THE
ULM-ACCIDENTS CASUALITY
RATE ?
• On Belgian soil, 4 deads in 2010.
(casuality rate of U.S. Forces in Iraq 3.6 killed /1000
troop / year – 8 years – 152000 troops – 4424 killed).

• In France and Belgium in 2010, 9 Belgian
deads to-date.
12

Comparison with the road
• In Belgium, the road kills 1000 people on average per year
.
• Fleet of vehicles: 6 000 000 units (5 mio cars).
• For 1000 cars, the road kills on average 0.16 person per
year.
• If we combine these figures with the yearly utilization rate
of cars (1 h per day) versus ULM (40 h per year), we can
conclude that ULM / General Aviation flying is
considerably deadlier than the road.

13

What can we learn from accident
investigation ?

14

The investigation process
A long process (Months)
• Collect all factual elements,
–
–
–
–
–
–

The flow of events;
The pilot (training, experience, …)
The aircraft (contact w/manufacturer)
Meteo, Comm, Radar,
Flt recorders (GPS, ECU, camera, …)
Impact, aircraft damage,

• Analysis. (incl. simulation, testing,…)
• Define all possible causes.
• From the causes, define remedial action.
The depth of the investigation is somewhat influenced by the
expected ROI.
15

Accident analysis
• Accidents do not occur “by accident”; Accident are
caused by a series of events.
• There are no “isolated cases”; causes of accidents are often
recurrent.
• Out of the ULM accident data base, we can conclude;
– There are recurrent technical problems specific to ULM.
– The traditional causes of aviation accidents are also known to
ULM (fuel shortage)

– 80% of the causal factors are human-related.

16

Main causal factors (122 accidents –
fixed wing and ULM)
Loss of control Take-off
11%

Fuel Starvation
15%

Loss of control Flight & collision
12%

Technical
11%
Low piloting
experience
8%

Loss of control Landing
16%
Icing
3%

Low flying /
aerobatics obstacles - CFIT
24%

17

Specific problems with ULM
• Technical causes can be (easily) identified;
but fire can be devastating.
• There’s another problem for the
investigator, a lot of landmarks are missing.
– ULM requirements are national,
– Certification not applicable.
– Wide variety of products.
18

About certification.
• Everyone would agree that ULMs of to-day are as good,
even a lot better than the ‘certified’ airplane.
• ULMs are designed to fly.
ULM are quality products; they meet your expectations
(simple to handle, fly fast, cheap in usage, …)
• Certification means that a manufacturer must demonstrate
that his product meets a minimum level of safety, as
defined (ultimately) by the Aviation Community.
• The minimum level of safety is defined in the Certification
Specifications – For small aircraft, it is called CS23.
19

Technical.
• AAIU(be) is currently investigating on:
– Instrument Board lay-out design.
– Electrical System design.
– Emergency Parachute.
Why is it that (for the last cases) parachute did not save lifes ?
• Late decision ?
• Handle easy to grab ?
• Safety pin not removed before flight ?

20

Same ULM Type, instrument panel somewhat different.
Difference in Ergonomy.
Parachute handle – on pilot’s side, or on passenger’s side ?

21

Regulation: certification:
CS 23.671 General
(b) Controls must be arranged and identified
to provide for convenience in operation and
to prevent the possibility of confusion and
subsequent inadvertent operation.

For ULM, CS 23 is not applicable.
Each designer has his own solution, and
they will be challenged only by YOUR
experience.
22

Other example
The passenger door opens in
flight, causing the pilot to take
appropriate actions, that
eventually force him to an
emergency landing.

• Door lock (simple – crude).
Plexy flexible. Once opened in
flight, difficult to close.
CS 23.783
(1) There must be means to lock and safeguard the door against
inadvertent opening during flight by persons, by cargo, or as a
result of mechanical failure.
23

The problem
• Once we determine a technical problem, we
can define recommendations to improve the
product, but:
What do we do with the recommendation ?
– We can not improve the Standard, there’s no standard.
– We can not address more than one manufacturer,
– What about retrofit ?

24

ULM and Engine failures

25

Fly Synthesis Storch
Summer 2009
• After propeller replacement, and subsequent
engine ground tests, the pilot took off for a
flight test.
• He encountered heavy engine vibration, that
forced him to an emergency landing.
• Airplane was slightly damaged.
Cause was identified as Vapor Lock.
26

1/5/2010 – FK9
Emergency landing after in-flight engine failure.
• Lots of corrosion found in carburettor.
Corrosion comes from water condensation in
fuel system (tank, lines, pump,…- MOGAS)
during long immobilisation periods.
- how to prevent ? Filling up, draining ?

• Fuel system was modified in-service, by
addition of a pressure regulator.
27

France
20/5/2010 – Mistral
23/5/2010 – CT Short Wing
Mistral: Engine failure in flight.
Emergency landing in field; terrain was very soft, airplane
severely damaged.
CT Short Wing: In short final, the engine suddenly stops
The pilot attempts to land, but hit trees, and crashes – wings
ripped off.
RH wing tank empty, 15-25 l fuel remaining in LH tank.
During LH turn, fuel system unprimed, engine stopped by
fuel starvation.
28

4 /6/2010: SG Rally
Damaged during landing
• Due to engine problems (heavy vibrations), the
pilot performed emergency landing on EBHN.
Coming in too fast, the landing was brutal, and
Nose Landing Gear collapsed.

29

Conclusion
• Engine in-flight failure are not exceptional.
– Use of MOGAS (water content, flash point,..)
– Local modifications,
– Other specific to the configuration of the
specific airplane.
And..
– Traditional causes (engine starvation,..)
30

Solutions
• In this case, we can design some generic
recommendations:
– Human Factors; ULM pilots should be more
prepared to react to engine failures at any time
(awareness, briefing, training,…)
– Generic technical solutions; impact on the use
of MOGAS.
• Protection of the equipment during winter,
• Risk of Vapour lock.

31

• Designing stop-gaps, accident after accidents
may not be satisfactory;
What can we do we make sure ULM flying
improves up to an acceptable level and, more
important, remains at that level ?

• More Regulation ?

32

Aviation Regulation and the ULM
• No significant changes in Regulation.
– ULM defined by capacity, weight, structural and stall speed limitation.
– => Extensive use of carbon fiber, Flaps, etc

• CS-VLA.
– 750 kg.
– “light” CS-23.
– Expensive.

• Lower Requirements for licencing,
– What about competence ?
– Human Factors training

• National requirements in Europe.
– EASA Flight Permit per Part 21A.701.

33

Evolution: new EU Regulation on
Accident Investigation.
* Every civil aviation accident or serious incident involving
aircraft other than specified in Annex II to the Regulation (EC)
No 216/2008 of the European Parliament and of the Council
shall be the subject of a safety investigation

( = No obligation of enquiry for ULMs)
• Safety investigation authorities may decide to investigate
incidents other than those referred to in paragraph 1 as well as
accidents or serious incidents to other types of aircraft, in
accordance with the national legislation of the Member States,
when they expect to draw safety lessons from them.
34

• US. NTSB; no enquiry for ULM crashes.
• To-day already, in some EU countries, ULM
crash investigations are given a low priority,
unless the Public determines otherwise.
• Common sense dictates that the initiative
to improve safety must come from the
ULM community itself.

35

Reason Model
• aviation is a complex socio-technical
system, where safety is ensured by a
series of defense barriers.
• Each barrier may present flaws (latent
or active) whose combination can lead
to an accident.
• An usafe act (active failure) alone
would not cause an accident.
• Latent failures are more easily
detected and corrected that human
errors, which are (globally) inevitable.

36

• The ULM community should reinforce its
Defense Barriers.
• Organisation: Federation and Clubs.
Create a Safety Climate
- Norms and rules
- Safety Programs

- To define a Safety Climate, we need to
assess the potential risk, and for that we
need data: YOUR experience.
37

Pyramid of Heinrich
• If a fatal accident is caused by
a specific combination of
events, an uncomplete series
of events causes INCIDENTS.
• If we identify all potentially
dangerous events AND with
that information, build-up the
defenses, we can avoid
ACCIDENTS.
38

SHARING EXPERIENCE
• By informing the Federation of the small
events and incidents that spoiled one of
your flights, you allow the Community to
understand the potential dangers and act
upon. (and respect confidentiality)
“Learn from mistakes of others; you won’t
live long enough to make them all by
yourself”
39

Human Factors
• To err is human.
• Human life (and flying) is full of decisions.
• It is therefore more important to know yourself
than to know how to fly your aircraft.
– Get-home-itis, Distraction, Communication,..

• Understanding human factors is a very important
step in improving your defenses.
40

Competence and Readiness
• You hold a pilot licence; but are you a
competent flyer ?
• How will you react when faced with a
potential dangerous situation?
• Assessing your competences with an
instructor is an opportunity to improve.
• When flying, be ready.
41

What is the Authority doing for
you ?

42

A series of work groups
within EASA are thinking
about how to improve
flight safety.(ESSI)
One of them is about General
Aviation (EGAST).

Initiative includes a leaflet
On Collision Avoidance,
and has been relayed to you
by the Federation.
There are technical Work
Groups dealing with MOGAS
43

and

An initiative to develop
Posters with comic strips
On high risk topics.
The first goes about taking
The right decision when the
Weather is below minimum.
They are expected in the
Coming months.

44

For Belgium, Accident reports are made public on the SPF/FOD website.
Recent reports (from 1st May 2007) are directly available through
hyperlinks.
Reports are written in English.
Information Notes are also available in order to highlight specific danger
area: Nr 2010 is about engine cold start.
We would like to develop more Notes, for ULM in collaboration with
the Federation.
Historical reports: currently a list is posted.
The list is fairly complete from 1972.
2 ancient reports (1936 and 1965).
The reports (Fr /Nl) are desidentified and available on request.
The list will be completed as we go along in reviewing archives.

45

Thank you for your attention, and
AAIU (Belgium) wishes you
many happy landings

Photos credit:
MRA / KLM

46


Slide 41

10 JULY 1910 - 2010
100 YEARS ULM ACCIDENTS

Belgian ULM Federation – Safety
1
Conference 10/10/2010

The Air Safety Investigation
• As part of the global Aviation sphere, an investigation is
conducted for each accident and serious incident by an
independent enquiry body, aimed to;
– Determine the causes of the accident.
– Determine if all conditions that were defined by rules and
regulations to ensure flight safety were followed (such as risk
factors in design).
– Define recommendations in order to prevent future accidents.

• It is not the purpose of this investigation to apportion
blame or liability.

2

In Belgium; the Air Accident
Investigation Unit.
• All accidents and serious incidents occurring in Belgium,
on aircraft, helicopters, gliders, balloons, ULM, DPM,
regardless of their registration is investigated by a cell
functionnally independent from the BCAA, and all other
interrested parties.
• Independent doesn’t mean isolated; it is part of the world’s
network of the State’s Aviation Investigation Bodies.
• The cell reports to the President of the Board of the
SPF/FOD Mobility and Transport.
3

4

ULM
• First pendular (Delta Plane Motorized)
design in 1966
• First crossing of the Channel in 1978 by Mr
D. Cook.
• Commercial development from 1979.
• Evolution from 2-axis to 3-axis.
• In Belgium, first ULM registered (501) in
1982.

5

6

Evolution
• 1982: Weedhopper, Chickinox
– 80…100 km/h
– Basic – 2/3 axis
– Range: … 200 km…

• 2010: VL-3 Sprint, DynAero MCR01, WT9 Dynamic….
– 220….250 km/h,
– flaps, retractable gear, avionics,
– Range over 1000 km

• 550 OO- registered ULM;
• 571 ULM pilot licence (363 training licences)
• 300-400 foreign-registered ULM.
7

1000
900
800
700
600
500
400
300
200
100

Number of valid registration

8

Estimation of flying OO-regd ULM

20
10

20
08

20
06

20
04

20
02

20
00

19
98

19
96

19
94

19
92

19
90

19
88

19
86

19
84

19
82

0

Evolution in pilot’s / owner’s
expectations
• In 1982, ULM /DPM, a sporting way of flying,
outside the limits of parachuting, delta plane.

• In 2010, an efficient alternative to general
(certified) aviation. ULM becomes a means of
transport.
• Beyond 2010 ?? – The Need for Speed ?
9

Evolution
• From the user’s perspective, the difference between
General Aviation and ULM becomes very thin.
• However, ULMs are characterized by a huge variety of
different design types, with low production rate and
configuration variation between individual airplanes.
– Manufacturers come and go,
– Assembly of the same ULM type by different companies induce
differences in built configuration.

• The above makes it more and more difficult to speak about
ULMs in a general way; variation in quality is wider than
General (certified) Aviation.
10

EVOLUTION: MORE ULM FATAL ACCIDENTS ?

Fatalities: (up to now), In Belgium, on average 2 /year,
comparable to General (certified) Aviation.
Number of fatalities
12
10
8
6
4
2

Number of fatalities

11

20
10

20
08

20
06

20
04

20
02

20
00

19
98

19
96

19
94

19
92

19
90

19
88

19
86

19
84

0

19
82

FATALITIES:
Figures limited to
Belgium.
2009: + 2 in France.
2010: + 5 in France.

WHAT ARE THE EXPECTATIONS
FOR THE
ULM-ACCIDENTS CASUALITY
RATE ?
• On Belgian soil, 4 deads in 2010.
(casuality rate of U.S. Forces in Iraq 3.6 killed /1000
troop / year – 8 years – 152000 troops – 4424 killed).

• In France and Belgium in 2010, 9 Belgian
deads to-date.
12

Comparison with the road
• In Belgium, the road kills 1000 people on average per year
.
• Fleet of vehicles: 6 000 000 units (5 mio cars).
• For 1000 cars, the road kills on average 0.16 person per
year.
• If we combine these figures with the yearly utilization rate
of cars (1 h per day) versus ULM (40 h per year), we can
conclude that ULM / General Aviation flying is
considerably deadlier than the road.

13

What can we learn from accident
investigation ?

14

The investigation process
A long process (Months)
• Collect all factual elements,
–
–
–
–
–
–

The flow of events;
The pilot (training, experience, …)
The aircraft (contact w/manufacturer)
Meteo, Comm, Radar,
Flt recorders (GPS, ECU, camera, …)
Impact, aircraft damage,

• Analysis. (incl. simulation, testing,…)
• Define all possible causes.
• From the causes, define remedial action.
The depth of the investigation is somewhat influenced by the
expected ROI.
15

Accident analysis
• Accidents do not occur “by accident”; Accident are
caused by a series of events.
• There are no “isolated cases”; causes of accidents are often
recurrent.
• Out of the ULM accident data base, we can conclude;
– There are recurrent technical problems specific to ULM.
– The traditional causes of aviation accidents are also known to
ULM (fuel shortage)

– 80% of the causal factors are human-related.

16

Main causal factors (122 accidents –
fixed wing and ULM)
Loss of control Take-off
11%

Fuel Starvation
15%

Loss of control Flight & collision
12%

Technical
11%
Low piloting
experience
8%

Loss of control Landing
16%
Icing
3%

Low flying /
aerobatics obstacles - CFIT
24%

17

Specific problems with ULM
• Technical causes can be (easily) identified;
but fire can be devastating.
• There’s another problem for the
investigator, a lot of landmarks are missing.
– ULM requirements are national,
– Certification not applicable.
– Wide variety of products.
18

About certification.
• Everyone would agree that ULMs of to-day are as good,
even a lot better than the ‘certified’ airplane.
• ULMs are designed to fly.
ULM are quality products; they meet your expectations
(simple to handle, fly fast, cheap in usage, …)
• Certification means that a manufacturer must demonstrate
that his product meets a minimum level of safety, as
defined (ultimately) by the Aviation Community.
• The minimum level of safety is defined in the Certification
Specifications – For small aircraft, it is called CS23.
19

Technical.
• AAIU(be) is currently investigating on:
– Instrument Board lay-out design.
– Electrical System design.
– Emergency Parachute.
Why is it that (for the last cases) parachute did not save lifes ?
• Late decision ?
• Handle easy to grab ?
• Safety pin not removed before flight ?

20

Same ULM Type, instrument panel somewhat different.
Difference in Ergonomy.
Parachute handle – on pilot’s side, or on passenger’s side ?

21

Regulation: certification:
CS 23.671 General
(b) Controls must be arranged and identified
to provide for convenience in operation and
to prevent the possibility of confusion and
subsequent inadvertent operation.

For ULM, CS 23 is not applicable.
Each designer has his own solution, and
they will be challenged only by YOUR
experience.
22

Other example
The passenger door opens in
flight, causing the pilot to take
appropriate actions, that
eventually force him to an
emergency landing.

• Door lock (simple – crude).
Plexy flexible. Once opened in
flight, difficult to close.
CS 23.783
(1) There must be means to lock and safeguard the door against
inadvertent opening during flight by persons, by cargo, or as a
result of mechanical failure.
23

The problem
• Once we determine a technical problem, we
can define recommendations to improve the
product, but:
What do we do with the recommendation ?
– We can not improve the Standard, there’s no standard.
– We can not address more than one manufacturer,
– What about retrofit ?

24

ULM and Engine failures

25

Fly Synthesis Storch
Summer 2009
• After propeller replacement, and subsequent
engine ground tests, the pilot took off for a
flight test.
• He encountered heavy engine vibration, that
forced him to an emergency landing.
• Airplane was slightly damaged.
Cause was identified as Vapor Lock.
26

1/5/2010 – FK9
Emergency landing after in-flight engine failure.
• Lots of corrosion found in carburettor.
Corrosion comes from water condensation in
fuel system (tank, lines, pump,…- MOGAS)
during long immobilisation periods.
- how to prevent ? Filling up, draining ?

• Fuel system was modified in-service, by
addition of a pressure regulator.
27

France
20/5/2010 – Mistral
23/5/2010 – CT Short Wing
Mistral: Engine failure in flight.
Emergency landing in field; terrain was very soft, airplane
severely damaged.
CT Short Wing: In short final, the engine suddenly stops
The pilot attempts to land, but hit trees, and crashes – wings
ripped off.
RH wing tank empty, 15-25 l fuel remaining in LH tank.
During LH turn, fuel system unprimed, engine stopped by
fuel starvation.
28

4 /6/2010: SG Rally
Damaged during landing
• Due to engine problems (heavy vibrations), the
pilot performed emergency landing on EBHN.
Coming in too fast, the landing was brutal, and
Nose Landing Gear collapsed.

29

Conclusion
• Engine in-flight failure are not exceptional.
– Use of MOGAS (water content, flash point,..)
– Local modifications,
– Other specific to the configuration of the
specific airplane.
And..
– Traditional causes (engine starvation,..)
30

Solutions
• In this case, we can design some generic
recommendations:
– Human Factors; ULM pilots should be more
prepared to react to engine failures at any time
(awareness, briefing, training,…)
– Generic technical solutions; impact on the use
of MOGAS.
• Protection of the equipment during winter,
• Risk of Vapour lock.

31

• Designing stop-gaps, accident after accidents
may not be satisfactory;
What can we do we make sure ULM flying
improves up to an acceptable level and, more
important, remains at that level ?

• More Regulation ?

32

Aviation Regulation and the ULM
• No significant changes in Regulation.
– ULM defined by capacity, weight, structural and stall speed limitation.
– => Extensive use of carbon fiber, Flaps, etc

• CS-VLA.
– 750 kg.
– “light” CS-23.
– Expensive.

• Lower Requirements for licencing,
– What about competence ?
– Human Factors training

• National requirements in Europe.
– EASA Flight Permit per Part 21A.701.

33

Evolution: new EU Regulation on
Accident Investigation.
* Every civil aviation accident or serious incident involving
aircraft other than specified in Annex II to the Regulation (EC)
No 216/2008 of the European Parliament and of the Council
shall be the subject of a safety investigation

( = No obligation of enquiry for ULMs)
• Safety investigation authorities may decide to investigate
incidents other than those referred to in paragraph 1 as well as
accidents or serious incidents to other types of aircraft, in
accordance with the national legislation of the Member States,
when they expect to draw safety lessons from them.
34

• US. NTSB; no enquiry for ULM crashes.
• To-day already, in some EU countries, ULM
crash investigations are given a low priority,
unless the Public determines otherwise.
• Common sense dictates that the initiative
to improve safety must come from the
ULM community itself.

35

Reason Model
• aviation is a complex socio-technical
system, where safety is ensured by a
series of defense barriers.
• Each barrier may present flaws (latent
or active) whose combination can lead
to an accident.
• An usafe act (active failure) alone
would not cause an accident.
• Latent failures are more easily
detected and corrected that human
errors, which are (globally) inevitable.

36

• The ULM community should reinforce its
Defense Barriers.
• Organisation: Federation and Clubs.
Create a Safety Climate
- Norms and rules
- Safety Programs

- To define a Safety Climate, we need to
assess the potential risk, and for that we
need data: YOUR experience.
37

Pyramid of Heinrich
• If a fatal accident is caused by
a specific combination of
events, an uncomplete series
of events causes INCIDENTS.
• If we identify all potentially
dangerous events AND with
that information, build-up the
defenses, we can avoid
ACCIDENTS.
38

SHARING EXPERIENCE
• By informing the Federation of the small
events and incidents that spoiled one of
your flights, you allow the Community to
understand the potential dangers and act
upon. (and respect confidentiality)
“Learn from mistakes of others; you won’t
live long enough to make them all by
yourself”
39

Human Factors
• To err is human.
• Human life (and flying) is full of decisions.
• It is therefore more important to know yourself
than to know how to fly your aircraft.
– Get-home-itis, Distraction, Communication,..

• Understanding human factors is a very important
step in improving your defenses.
40

Competence and Readiness
• You hold a pilot licence; but are you a
competent flyer ?
• How will you react when faced with a
potential dangerous situation?
• Assessing your competences with an
instructor is an opportunity to improve.
• When flying, be ready.
41

What is the Authority doing for
you ?

42

A series of work groups
within EASA are thinking
about how to improve
flight safety.(ESSI)
One of them is about General
Aviation (EGAST).

Initiative includes a leaflet
On Collision Avoidance,
and has been relayed to you
by the Federation.
There are technical Work
Groups dealing with MOGAS
43

and

An initiative to develop
Posters with comic strips
On high risk topics.
The first goes about taking
The right decision when the
Weather is below minimum.
They are expected in the
Coming months.

44

For Belgium, Accident reports are made public on the SPF/FOD website.
Recent reports (from 1st May 2007) are directly available through
hyperlinks.
Reports are written in English.
Information Notes are also available in order to highlight specific danger
area: Nr 2010 is about engine cold start.
We would like to develop more Notes, for ULM in collaboration with
the Federation.
Historical reports: currently a list is posted.
The list is fairly complete from 1972.
2 ancient reports (1936 and 1965).
The reports (Fr /Nl) are desidentified and available on request.
The list will be completed as we go along in reviewing archives.

45

Thank you for your attention, and
AAIU (Belgium) wishes you
many happy landings

Photos credit:
MRA / KLM

46


Slide 42

10 JULY 1910 - 2010
100 YEARS ULM ACCIDENTS

Belgian ULM Federation – Safety
1
Conference 10/10/2010

The Air Safety Investigation
• As part of the global Aviation sphere, an investigation is
conducted for each accident and serious incident by an
independent enquiry body, aimed to;
– Determine the causes of the accident.
– Determine if all conditions that were defined by rules and
regulations to ensure flight safety were followed (such as risk
factors in design).
– Define recommendations in order to prevent future accidents.

• It is not the purpose of this investigation to apportion
blame or liability.

2

In Belgium; the Air Accident
Investigation Unit.
• All accidents and serious incidents occurring in Belgium,
on aircraft, helicopters, gliders, balloons, ULM, DPM,
regardless of their registration is investigated by a cell
functionnally independent from the BCAA, and all other
interrested parties.
• Independent doesn’t mean isolated; it is part of the world’s
network of the State’s Aviation Investigation Bodies.
• The cell reports to the President of the Board of the
SPF/FOD Mobility and Transport.
3

4

ULM
• First pendular (Delta Plane Motorized)
design in 1966
• First crossing of the Channel in 1978 by Mr
D. Cook.
• Commercial development from 1979.
• Evolution from 2-axis to 3-axis.
• In Belgium, first ULM registered (501) in
1982.

5

6

Evolution
• 1982: Weedhopper, Chickinox
– 80…100 km/h
– Basic – 2/3 axis
– Range: … 200 km…

• 2010: VL-3 Sprint, DynAero MCR01, WT9 Dynamic….
– 220….250 km/h,
– flaps, retractable gear, avionics,
– Range over 1000 km

• 550 OO- registered ULM;
• 571 ULM pilot licence (363 training licences)
• 300-400 foreign-registered ULM.
7

1000
900
800
700
600
500
400
300
200
100

Number of valid registration

8

Estimation of flying OO-regd ULM

20
10

20
08

20
06

20
04

20
02

20
00

19
98

19
96

19
94

19
92

19
90

19
88

19
86

19
84

19
82

0

Evolution in pilot’s / owner’s
expectations
• In 1982, ULM /DPM, a sporting way of flying,
outside the limits of parachuting, delta plane.

• In 2010, an efficient alternative to general
(certified) aviation. ULM becomes a means of
transport.
• Beyond 2010 ?? – The Need for Speed ?
9

Evolution
• From the user’s perspective, the difference between
General Aviation and ULM becomes very thin.
• However, ULMs are characterized by a huge variety of
different design types, with low production rate and
configuration variation between individual airplanes.
– Manufacturers come and go,
– Assembly of the same ULM type by different companies induce
differences in built configuration.

• The above makes it more and more difficult to speak about
ULMs in a general way; variation in quality is wider than
General (certified) Aviation.
10

EVOLUTION: MORE ULM FATAL ACCIDENTS ?

Fatalities: (up to now), In Belgium, on average 2 /year,
comparable to General (certified) Aviation.
Number of fatalities
12
10
8
6
4
2

Number of fatalities

11

20
10

20
08

20
06

20
04

20
02

20
00

19
98

19
96

19
94

19
92

19
90

19
88

19
86

19
84

0

19
82

FATALITIES:
Figures limited to
Belgium.
2009: + 2 in France.
2010: + 5 in France.

WHAT ARE THE EXPECTATIONS
FOR THE
ULM-ACCIDENTS CASUALITY
RATE ?
• On Belgian soil, 4 deads in 2010.
(casuality rate of U.S. Forces in Iraq 3.6 killed /1000
troop / year – 8 years – 152000 troops – 4424 killed).

• In France and Belgium in 2010, 9 Belgian
deads to-date.
12

Comparison with the road
• In Belgium, the road kills 1000 people on average per year
.
• Fleet of vehicles: 6 000 000 units (5 mio cars).
• For 1000 cars, the road kills on average 0.16 person per
year.
• If we combine these figures with the yearly utilization rate
of cars (1 h per day) versus ULM (40 h per year), we can
conclude that ULM / General Aviation flying is
considerably deadlier than the road.

13

What can we learn from accident
investigation ?

14

The investigation process
A long process (Months)
• Collect all factual elements,
–
–
–
–
–
–

The flow of events;
The pilot (training, experience, …)
The aircraft (contact w/manufacturer)
Meteo, Comm, Radar,
Flt recorders (GPS, ECU, camera, …)
Impact, aircraft damage,

• Analysis. (incl. simulation, testing,…)
• Define all possible causes.
• From the causes, define remedial action.
The depth of the investigation is somewhat influenced by the
expected ROI.
15

Accident analysis
• Accidents do not occur “by accident”; Accident are
caused by a series of events.
• There are no “isolated cases”; causes of accidents are often
recurrent.
• Out of the ULM accident data base, we can conclude;
– There are recurrent technical problems specific to ULM.
– The traditional causes of aviation accidents are also known to
ULM (fuel shortage)

– 80% of the causal factors are human-related.

16

Main causal factors (122 accidents –
fixed wing and ULM)
Loss of control Take-off
11%

Fuel Starvation
15%

Loss of control Flight & collision
12%

Technical
11%
Low piloting
experience
8%

Loss of control Landing
16%
Icing
3%

Low flying /
aerobatics obstacles - CFIT
24%

17

Specific problems with ULM
• Technical causes can be (easily) identified;
but fire can be devastating.
• There’s another problem for the
investigator, a lot of landmarks are missing.
– ULM requirements are national,
– Certification not applicable.
– Wide variety of products.
18

About certification.
• Everyone would agree that ULMs of to-day are as good,
even a lot better than the ‘certified’ airplane.
• ULMs are designed to fly.
ULM are quality products; they meet your expectations
(simple to handle, fly fast, cheap in usage, …)
• Certification means that a manufacturer must demonstrate
that his product meets a minimum level of safety, as
defined (ultimately) by the Aviation Community.
• The minimum level of safety is defined in the Certification
Specifications – For small aircraft, it is called CS23.
19

Technical.
• AAIU(be) is currently investigating on:
– Instrument Board lay-out design.
– Electrical System design.
– Emergency Parachute.
Why is it that (for the last cases) parachute did not save lifes ?
• Late decision ?
• Handle easy to grab ?
• Safety pin not removed before flight ?

20

Same ULM Type, instrument panel somewhat different.
Difference in Ergonomy.
Parachute handle – on pilot’s side, or on passenger’s side ?

21

Regulation: certification:
CS 23.671 General
(b) Controls must be arranged and identified
to provide for convenience in operation and
to prevent the possibility of confusion and
subsequent inadvertent operation.

For ULM, CS 23 is not applicable.
Each designer has his own solution, and
they will be challenged only by YOUR
experience.
22

Other example
The passenger door opens in
flight, causing the pilot to take
appropriate actions, that
eventually force him to an
emergency landing.

• Door lock (simple – crude).
Plexy flexible. Once opened in
flight, difficult to close.
CS 23.783
(1) There must be means to lock and safeguard the door against
inadvertent opening during flight by persons, by cargo, or as a
result of mechanical failure.
23

The problem
• Once we determine a technical problem, we
can define recommendations to improve the
product, but:
What do we do with the recommendation ?
– We can not improve the Standard, there’s no standard.
– We can not address more than one manufacturer,
– What about retrofit ?

24

ULM and Engine failures

25

Fly Synthesis Storch
Summer 2009
• After propeller replacement, and subsequent
engine ground tests, the pilot took off for a
flight test.
• He encountered heavy engine vibration, that
forced him to an emergency landing.
• Airplane was slightly damaged.
Cause was identified as Vapor Lock.
26

1/5/2010 – FK9
Emergency landing after in-flight engine failure.
• Lots of corrosion found in carburettor.
Corrosion comes from water condensation in
fuel system (tank, lines, pump,…- MOGAS)
during long immobilisation periods.
- how to prevent ? Filling up, draining ?

• Fuel system was modified in-service, by
addition of a pressure regulator.
27

France
20/5/2010 – Mistral
23/5/2010 – CT Short Wing
Mistral: Engine failure in flight.
Emergency landing in field; terrain was very soft, airplane
severely damaged.
CT Short Wing: In short final, the engine suddenly stops
The pilot attempts to land, but hit trees, and crashes – wings
ripped off.
RH wing tank empty, 15-25 l fuel remaining in LH tank.
During LH turn, fuel system unprimed, engine stopped by
fuel starvation.
28

4 /6/2010: SG Rally
Damaged during landing
• Due to engine problems (heavy vibrations), the
pilot performed emergency landing on EBHN.
Coming in too fast, the landing was brutal, and
Nose Landing Gear collapsed.

29

Conclusion
• Engine in-flight failure are not exceptional.
– Use of MOGAS (water content, flash point,..)
– Local modifications,
– Other specific to the configuration of the
specific airplane.
And..
– Traditional causes (engine starvation,..)
30

Solutions
• In this case, we can design some generic
recommendations:
– Human Factors; ULM pilots should be more
prepared to react to engine failures at any time
(awareness, briefing, training,…)
– Generic technical solutions; impact on the use
of MOGAS.
• Protection of the equipment during winter,
• Risk of Vapour lock.

31

• Designing stop-gaps, accident after accidents
may not be satisfactory;
What can we do we make sure ULM flying
improves up to an acceptable level and, more
important, remains at that level ?

• More Regulation ?

32

Aviation Regulation and the ULM
• No significant changes in Regulation.
– ULM defined by capacity, weight, structural and stall speed limitation.
– => Extensive use of carbon fiber, Flaps, etc

• CS-VLA.
– 750 kg.
– “light” CS-23.
– Expensive.

• Lower Requirements for licencing,
– What about competence ?
– Human Factors training

• National requirements in Europe.
– EASA Flight Permit per Part 21A.701.

33

Evolution: new EU Regulation on
Accident Investigation.
* Every civil aviation accident or serious incident involving
aircraft other than specified in Annex II to the Regulation (EC)
No 216/2008 of the European Parliament and of the Council
shall be the subject of a safety investigation

( = No obligation of enquiry for ULMs)
• Safety investigation authorities may decide to investigate
incidents other than those referred to in paragraph 1 as well as
accidents or serious incidents to other types of aircraft, in
accordance with the national legislation of the Member States,
when they expect to draw safety lessons from them.
34

• US. NTSB; no enquiry for ULM crashes.
• To-day already, in some EU countries, ULM
crash investigations are given a low priority,
unless the Public determines otherwise.
• Common sense dictates that the initiative
to improve safety must come from the
ULM community itself.

35

Reason Model
• aviation is a complex socio-technical
system, where safety is ensured by a
series of defense barriers.
• Each barrier may present flaws (latent
or active) whose combination can lead
to an accident.
• An usafe act (active failure) alone
would not cause an accident.
• Latent failures are more easily
detected and corrected that human
errors, which are (globally) inevitable.

36

• The ULM community should reinforce its
Defense Barriers.
• Organisation: Federation and Clubs.
Create a Safety Climate
- Norms and rules
- Safety Programs

- To define a Safety Climate, we need to
assess the potential risk, and for that we
need data: YOUR experience.
37

Pyramid of Heinrich
• If a fatal accident is caused by
a specific combination of
events, an uncomplete series
of events causes INCIDENTS.
• If we identify all potentially
dangerous events AND with
that information, build-up the
defenses, we can avoid
ACCIDENTS.
38

SHARING EXPERIENCE
• By informing the Federation of the small
events and incidents that spoiled one of
your flights, you allow the Community to
understand the potential dangers and act
upon. (and respect confidentiality)
“Learn from mistakes of others; you won’t
live long enough to make them all by
yourself”
39

Human Factors
• To err is human.
• Human life (and flying) is full of decisions.
• It is therefore more important to know yourself
than to know how to fly your aircraft.
– Get-home-itis, Distraction, Communication,..

• Understanding human factors is a very important
step in improving your defenses.
40

Competence and Readiness
• You hold a pilot licence; but are you a
competent flyer ?
• How will you react when faced with a
potential dangerous situation?
• Assessing your competences with an
instructor is an opportunity to improve.
• When flying, be ready.
41

What is the Authority doing for
you ?

42

A series of work groups
within EASA are thinking
about how to improve
flight safety.(ESSI)
One of them is about General
Aviation (EGAST).

Initiative includes a leaflet
On Collision Avoidance,
and has been relayed to you
by the Federation.
There are technical Work
Groups dealing with MOGAS
43

and

An initiative to develop
Posters with comic strips
On high risk topics.
The first goes about taking
The right decision when the
Weather is below minimum.
They are expected in the
Coming months.

44

For Belgium, Accident reports are made public on the SPF/FOD website.
Recent reports (from 1st May 2007) are directly available through
hyperlinks.
Reports are written in English.
Information Notes are also available in order to highlight specific danger
area: Nr 2010 is about engine cold start.
We would like to develop more Notes, for ULM in collaboration with
the Federation.
Historical reports: currently a list is posted.
The list is fairly complete from 1972.
2 ancient reports (1936 and 1965).
The reports (Fr /Nl) are desidentified and available on request.
The list will be completed as we go along in reviewing archives.

45

Thank you for your attention, and
AAIU (Belgium) wishes you
many happy landings

Photos credit:
MRA / KLM

46


Slide 43

10 JULY 1910 - 2010
100 YEARS ULM ACCIDENTS

Belgian ULM Federation – Safety
1
Conference 10/10/2010

The Air Safety Investigation
• As part of the global Aviation sphere, an investigation is
conducted for each accident and serious incident by an
independent enquiry body, aimed to;
– Determine the causes of the accident.
– Determine if all conditions that were defined by rules and
regulations to ensure flight safety were followed (such as risk
factors in design).
– Define recommendations in order to prevent future accidents.

• It is not the purpose of this investigation to apportion
blame or liability.

2

In Belgium; the Air Accident
Investigation Unit.
• All accidents and serious incidents occurring in Belgium,
on aircraft, helicopters, gliders, balloons, ULM, DPM,
regardless of their registration is investigated by a cell
functionnally independent from the BCAA, and all other
interrested parties.
• Independent doesn’t mean isolated; it is part of the world’s
network of the State’s Aviation Investigation Bodies.
• The cell reports to the President of the Board of the
SPF/FOD Mobility and Transport.
3

4

ULM
• First pendular (Delta Plane Motorized)
design in 1966
• First crossing of the Channel in 1978 by Mr
D. Cook.
• Commercial development from 1979.
• Evolution from 2-axis to 3-axis.
• In Belgium, first ULM registered (501) in
1982.

5

6

Evolution
• 1982: Weedhopper, Chickinox
– 80…100 km/h
– Basic – 2/3 axis
– Range: … 200 km…

• 2010: VL-3 Sprint, DynAero MCR01, WT9 Dynamic….
– 220….250 km/h,
– flaps, retractable gear, avionics,
– Range over 1000 km

• 550 OO- registered ULM;
• 571 ULM pilot licence (363 training licences)
• 300-400 foreign-registered ULM.
7

1000
900
800
700
600
500
400
300
200
100

Number of valid registration

8

Estimation of flying OO-regd ULM

20
10

20
08

20
06

20
04

20
02

20
00

19
98

19
96

19
94

19
92

19
90

19
88

19
86

19
84

19
82

0

Evolution in pilot’s / owner’s
expectations
• In 1982, ULM /DPM, a sporting way of flying,
outside the limits of parachuting, delta plane.

• In 2010, an efficient alternative to general
(certified) aviation. ULM becomes a means of
transport.
• Beyond 2010 ?? – The Need for Speed ?
9

Evolution
• From the user’s perspective, the difference between
General Aviation and ULM becomes very thin.
• However, ULMs are characterized by a huge variety of
different design types, with low production rate and
configuration variation between individual airplanes.
– Manufacturers come and go,
– Assembly of the same ULM type by different companies induce
differences in built configuration.

• The above makes it more and more difficult to speak about
ULMs in a general way; variation in quality is wider than
General (certified) Aviation.
10

EVOLUTION: MORE ULM FATAL ACCIDENTS ?

Fatalities: (up to now), In Belgium, on average 2 /year,
comparable to General (certified) Aviation.
Number of fatalities
12
10
8
6
4
2

Number of fatalities

11

20
10

20
08

20
06

20
04

20
02

20
00

19
98

19
96

19
94

19
92

19
90

19
88

19
86

19
84

0

19
82

FATALITIES:
Figures limited to
Belgium.
2009: + 2 in France.
2010: + 5 in France.

WHAT ARE THE EXPECTATIONS
FOR THE
ULM-ACCIDENTS CASUALITY
RATE ?
• On Belgian soil, 4 deads in 2010.
(casuality rate of U.S. Forces in Iraq 3.6 killed /1000
troop / year – 8 years – 152000 troops – 4424 killed).

• In France and Belgium in 2010, 9 Belgian
deads to-date.
12

Comparison with the road
• In Belgium, the road kills 1000 people on average per year
.
• Fleet of vehicles: 6 000 000 units (5 mio cars).
• For 1000 cars, the road kills on average 0.16 person per
year.
• If we combine these figures with the yearly utilization rate
of cars (1 h per day) versus ULM (40 h per year), we can
conclude that ULM / General Aviation flying is
considerably deadlier than the road.

13

What can we learn from accident
investigation ?

14

The investigation process
A long process (Months)
• Collect all factual elements,
–
–
–
–
–
–

The flow of events;
The pilot (training, experience, …)
The aircraft (contact w/manufacturer)
Meteo, Comm, Radar,
Flt recorders (GPS, ECU, camera, …)
Impact, aircraft damage,

• Analysis. (incl. simulation, testing,…)
• Define all possible causes.
• From the causes, define remedial action.
The depth of the investigation is somewhat influenced by the
expected ROI.
15

Accident analysis
• Accidents do not occur “by accident”; Accident are
caused by a series of events.
• There are no “isolated cases”; causes of accidents are often
recurrent.
• Out of the ULM accident data base, we can conclude;
– There are recurrent technical problems specific to ULM.
– The traditional causes of aviation accidents are also known to
ULM (fuel shortage)

– 80% of the causal factors are human-related.

16

Main causal factors (122 accidents –
fixed wing and ULM)
Loss of control Take-off
11%

Fuel Starvation
15%

Loss of control Flight & collision
12%

Technical
11%
Low piloting
experience
8%

Loss of control Landing
16%
Icing
3%

Low flying /
aerobatics obstacles - CFIT
24%

17

Specific problems with ULM
• Technical causes can be (easily) identified;
but fire can be devastating.
• There’s another problem for the
investigator, a lot of landmarks are missing.
– ULM requirements are national,
– Certification not applicable.
– Wide variety of products.
18

About certification.
• Everyone would agree that ULMs of to-day are as good,
even a lot better than the ‘certified’ airplane.
• ULMs are designed to fly.
ULM are quality products; they meet your expectations
(simple to handle, fly fast, cheap in usage, …)
• Certification means that a manufacturer must demonstrate
that his product meets a minimum level of safety, as
defined (ultimately) by the Aviation Community.
• The minimum level of safety is defined in the Certification
Specifications – For small aircraft, it is called CS23.
19

Technical.
• AAIU(be) is currently investigating on:
– Instrument Board lay-out design.
– Electrical System design.
– Emergency Parachute.
Why is it that (for the last cases) parachute did not save lifes ?
• Late decision ?
• Handle easy to grab ?
• Safety pin not removed before flight ?

20

Same ULM Type, instrument panel somewhat different.
Difference in Ergonomy.
Parachute handle – on pilot’s side, or on passenger’s side ?

21

Regulation: certification:
CS 23.671 General
(b) Controls must be arranged and identified
to provide for convenience in operation and
to prevent the possibility of confusion and
subsequent inadvertent operation.

For ULM, CS 23 is not applicable.
Each designer has his own solution, and
they will be challenged only by YOUR
experience.
22

Other example
The passenger door opens in
flight, causing the pilot to take
appropriate actions, that
eventually force him to an
emergency landing.

• Door lock (simple – crude).
Plexy flexible. Once opened in
flight, difficult to close.
CS 23.783
(1) There must be means to lock and safeguard the door against
inadvertent opening during flight by persons, by cargo, or as a
result of mechanical failure.
23

The problem
• Once we determine a technical problem, we
can define recommendations to improve the
product, but:
What do we do with the recommendation ?
– We can not improve the Standard, there’s no standard.
– We can not address more than one manufacturer,
– What about retrofit ?

24

ULM and Engine failures

25

Fly Synthesis Storch
Summer 2009
• After propeller replacement, and subsequent
engine ground tests, the pilot took off for a
flight test.
• He encountered heavy engine vibration, that
forced him to an emergency landing.
• Airplane was slightly damaged.
Cause was identified as Vapor Lock.
26

1/5/2010 – FK9
Emergency landing after in-flight engine failure.
• Lots of corrosion found in carburettor.
Corrosion comes from water condensation in
fuel system (tank, lines, pump,…- MOGAS)
during long immobilisation periods.
- how to prevent ? Filling up, draining ?

• Fuel system was modified in-service, by
addition of a pressure regulator.
27

France
20/5/2010 – Mistral
23/5/2010 – CT Short Wing
Mistral: Engine failure in flight.
Emergency landing in field; terrain was very soft, airplane
severely damaged.
CT Short Wing: In short final, the engine suddenly stops
The pilot attempts to land, but hit trees, and crashes – wings
ripped off.
RH wing tank empty, 15-25 l fuel remaining in LH tank.
During LH turn, fuel system unprimed, engine stopped by
fuel starvation.
28

4 /6/2010: SG Rally
Damaged during landing
• Due to engine problems (heavy vibrations), the
pilot performed emergency landing on EBHN.
Coming in too fast, the landing was brutal, and
Nose Landing Gear collapsed.

29

Conclusion
• Engine in-flight failure are not exceptional.
– Use of MOGAS (water content, flash point,..)
– Local modifications,
– Other specific to the configuration of the
specific airplane.
And..
– Traditional causes (engine starvation,..)
30

Solutions
• In this case, we can design some generic
recommendations:
– Human Factors; ULM pilots should be more
prepared to react to engine failures at any time
(awareness, briefing, training,…)
– Generic technical solutions; impact on the use
of MOGAS.
• Protection of the equipment during winter,
• Risk of Vapour lock.

31

• Designing stop-gaps, accident after accidents
may not be satisfactory;
What can we do we make sure ULM flying
improves up to an acceptable level and, more
important, remains at that level ?

• More Regulation ?

32

Aviation Regulation and the ULM
• No significant changes in Regulation.
– ULM defined by capacity, weight, structural and stall speed limitation.
– => Extensive use of carbon fiber, Flaps, etc

• CS-VLA.
– 750 kg.
– “light” CS-23.
– Expensive.

• Lower Requirements for licencing,
– What about competence ?
– Human Factors training

• National requirements in Europe.
– EASA Flight Permit per Part 21A.701.

33

Evolution: new EU Regulation on
Accident Investigation.
* Every civil aviation accident or serious incident involving
aircraft other than specified in Annex II to the Regulation (EC)
No 216/2008 of the European Parliament and of the Council
shall be the subject of a safety investigation

( = No obligation of enquiry for ULMs)
• Safety investigation authorities may decide to investigate
incidents other than those referred to in paragraph 1 as well as
accidents or serious incidents to other types of aircraft, in
accordance with the national legislation of the Member States,
when they expect to draw safety lessons from them.
34

• US. NTSB; no enquiry for ULM crashes.
• To-day already, in some EU countries, ULM
crash investigations are given a low priority,
unless the Public determines otherwise.
• Common sense dictates that the initiative
to improve safety must come from the
ULM community itself.

35

Reason Model
• aviation is a complex socio-technical
system, where safety is ensured by a
series of defense barriers.
• Each barrier may present flaws (latent
or active) whose combination can lead
to an accident.
• An usafe act (active failure) alone
would not cause an accident.
• Latent failures are more easily
detected and corrected that human
errors, which are (globally) inevitable.

36

• The ULM community should reinforce its
Defense Barriers.
• Organisation: Federation and Clubs.
Create a Safety Climate
- Norms and rules
- Safety Programs

- To define a Safety Climate, we need to
assess the potential risk, and for that we
need data: YOUR experience.
37

Pyramid of Heinrich
• If a fatal accident is caused by
a specific combination of
events, an uncomplete series
of events causes INCIDENTS.
• If we identify all potentially
dangerous events AND with
that information, build-up the
defenses, we can avoid
ACCIDENTS.
38

SHARING EXPERIENCE
• By informing the Federation of the small
events and incidents that spoiled one of
your flights, you allow the Community to
understand the potential dangers and act
upon. (and respect confidentiality)
“Learn from mistakes of others; you won’t
live long enough to make them all by
yourself”
39

Human Factors
• To err is human.
• Human life (and flying) is full of decisions.
• It is therefore more important to know yourself
than to know how to fly your aircraft.
– Get-home-itis, Distraction, Communication,..

• Understanding human factors is a very important
step in improving your defenses.
40

Competence and Readiness
• You hold a pilot licence; but are you a
competent flyer ?
• How will you react when faced with a
potential dangerous situation?
• Assessing your competences with an
instructor is an opportunity to improve.
• When flying, be ready.
41

What is the Authority doing for
you ?

42

A series of work groups
within EASA are thinking
about how to improve
flight safety.(ESSI)
One of them is about General
Aviation (EGAST).

Initiative includes a leaflet
On Collision Avoidance,
and has been relayed to you
by the Federation.
There are technical Work
Groups dealing with MOGAS
43

and

An initiative to develop
Posters with comic strips
On high risk topics.
The first goes about taking
The right decision when the
Weather is below minimum.
They are expected in the
Coming months.

44

For Belgium, Accident reports are made public on the SPF/FOD website.
Recent reports (from 1st May 2007) are directly available through
hyperlinks.
Reports are written in English.
Information Notes are also available in order to highlight specific danger
area: Nr 2010 is about engine cold start.
We would like to develop more Notes, for ULM in collaboration with
the Federation.
Historical reports: currently a list is posted.
The list is fairly complete from 1972.
2 ancient reports (1936 and 1965).
The reports (Fr /Nl) are desidentified and available on request.
The list will be completed as we go along in reviewing archives.

45

Thank you for your attention, and
AAIU (Belgium) wishes you
many happy landings

Photos credit:
MRA / KLM

46


Slide 44

10 JULY 1910 - 2010
100 YEARS ULM ACCIDENTS

Belgian ULM Federation – Safety
1
Conference 10/10/2010

The Air Safety Investigation
• As part of the global Aviation sphere, an investigation is
conducted for each accident and serious incident by an
independent enquiry body, aimed to;
– Determine the causes of the accident.
– Determine if all conditions that were defined by rules and
regulations to ensure flight safety were followed (such as risk
factors in design).
– Define recommendations in order to prevent future accidents.

• It is not the purpose of this investigation to apportion
blame or liability.

2

In Belgium; the Air Accident
Investigation Unit.
• All accidents and serious incidents occurring in Belgium,
on aircraft, helicopters, gliders, balloons, ULM, DPM,
regardless of their registration is investigated by a cell
functionnally independent from the BCAA, and all other
interrested parties.
• Independent doesn’t mean isolated; it is part of the world’s
network of the State’s Aviation Investigation Bodies.
• The cell reports to the President of the Board of the
SPF/FOD Mobility and Transport.
3

4

ULM
• First pendular (Delta Plane Motorized)
design in 1966
• First crossing of the Channel in 1978 by Mr
D. Cook.
• Commercial development from 1979.
• Evolution from 2-axis to 3-axis.
• In Belgium, first ULM registered (501) in
1982.

5

6

Evolution
• 1982: Weedhopper, Chickinox
– 80…100 km/h
– Basic – 2/3 axis
– Range: … 200 km…

• 2010: VL-3 Sprint, DynAero MCR01, WT9 Dynamic….
– 220….250 km/h,
– flaps, retractable gear, avionics,
– Range over 1000 km

• 550 OO- registered ULM;
• 571 ULM pilot licence (363 training licences)
• 300-400 foreign-registered ULM.
7

1000
900
800
700
600
500
400
300
200
100

Number of valid registration

8

Estimation of flying OO-regd ULM

20
10

20
08

20
06

20
04

20
02

20
00

19
98

19
96

19
94

19
92

19
90

19
88

19
86

19
84

19
82

0

Evolution in pilot’s / owner’s
expectations
• In 1982, ULM /DPM, a sporting way of flying,
outside the limits of parachuting, delta plane.

• In 2010, an efficient alternative to general
(certified) aviation. ULM becomes a means of
transport.
• Beyond 2010 ?? – The Need for Speed ?
9

Evolution
• From the user’s perspective, the difference between
General Aviation and ULM becomes very thin.
• However, ULMs are characterized by a huge variety of
different design types, with low production rate and
configuration variation between individual airplanes.
– Manufacturers come and go,
– Assembly of the same ULM type by different companies induce
differences in built configuration.

• The above makes it more and more difficult to speak about
ULMs in a general way; variation in quality is wider than
General (certified) Aviation.
10

EVOLUTION: MORE ULM FATAL ACCIDENTS ?

Fatalities: (up to now), In Belgium, on average 2 /year,
comparable to General (certified) Aviation.
Number of fatalities
12
10
8
6
4
2

Number of fatalities

11

20
10

20
08

20
06

20
04

20
02

20
00

19
98

19
96

19
94

19
92

19
90

19
88

19
86

19
84

0

19
82

FATALITIES:
Figures limited to
Belgium.
2009: + 2 in France.
2010: + 5 in France.

WHAT ARE THE EXPECTATIONS
FOR THE
ULM-ACCIDENTS CASUALITY
RATE ?
• On Belgian soil, 4 deads in 2010.
(casuality rate of U.S. Forces in Iraq 3.6 killed /1000
troop / year – 8 years – 152000 troops – 4424 killed).

• In France and Belgium in 2010, 9 Belgian
deads to-date.
12

Comparison with the road
• In Belgium, the road kills 1000 people on average per year
.
• Fleet of vehicles: 6 000 000 units (5 mio cars).
• For 1000 cars, the road kills on average 0.16 person per
year.
• If we combine these figures with the yearly utilization rate
of cars (1 h per day) versus ULM (40 h per year), we can
conclude that ULM / General Aviation flying is
considerably deadlier than the road.

13

What can we learn from accident
investigation ?

14

The investigation process
A long process (Months)
• Collect all factual elements,
–
–
–
–
–
–

The flow of events;
The pilot (training, experience, …)
The aircraft (contact w/manufacturer)
Meteo, Comm, Radar,
Flt recorders (GPS, ECU, camera, …)
Impact, aircraft damage,

• Analysis. (incl. simulation, testing,…)
• Define all possible causes.
• From the causes, define remedial action.
The depth of the investigation is somewhat influenced by the
expected ROI.
15

Accident analysis
• Accidents do not occur “by accident”; Accident are
caused by a series of events.
• There are no “isolated cases”; causes of accidents are often
recurrent.
• Out of the ULM accident data base, we can conclude;
– There are recurrent technical problems specific to ULM.
– The traditional causes of aviation accidents are also known to
ULM (fuel shortage)

– 80% of the causal factors are human-related.

16

Main causal factors (122 accidents –
fixed wing and ULM)
Loss of control Take-off
11%

Fuel Starvation
15%

Loss of control Flight & collision
12%

Technical
11%
Low piloting
experience
8%

Loss of control Landing
16%
Icing
3%

Low flying /
aerobatics obstacles - CFIT
24%

17

Specific problems with ULM
• Technical causes can be (easily) identified;
but fire can be devastating.
• There’s another problem for the
investigator, a lot of landmarks are missing.
– ULM requirements are national,
– Certification not applicable.
– Wide variety of products.
18

About certification.
• Everyone would agree that ULMs of to-day are as good,
even a lot better than the ‘certified’ airplane.
• ULMs are designed to fly.
ULM are quality products; they meet your expectations
(simple to handle, fly fast, cheap in usage, …)
• Certification means that a manufacturer must demonstrate
that his product meets a minimum level of safety, as
defined (ultimately) by the Aviation Community.
• The minimum level of safety is defined in the Certification
Specifications – For small aircraft, it is called CS23.
19

Technical.
• AAIU(be) is currently investigating on:
– Instrument Board lay-out design.
– Electrical System design.
– Emergency Parachute.
Why is it that (for the last cases) parachute did not save lifes ?
• Late decision ?
• Handle easy to grab ?
• Safety pin not removed before flight ?

20

Same ULM Type, instrument panel somewhat different.
Difference in Ergonomy.
Parachute handle – on pilot’s side, or on passenger’s side ?

21

Regulation: certification:
CS 23.671 General
(b) Controls must be arranged and identified
to provide for convenience in operation and
to prevent the possibility of confusion and
subsequent inadvertent operation.

For ULM, CS 23 is not applicable.
Each designer has his own solution, and
they will be challenged only by YOUR
experience.
22

Other example
The passenger door opens in
flight, causing the pilot to take
appropriate actions, that
eventually force him to an
emergency landing.

• Door lock (simple – crude).
Plexy flexible. Once opened in
flight, difficult to close.
CS 23.783
(1) There must be means to lock and safeguard the door against
inadvertent opening during flight by persons, by cargo, or as a
result of mechanical failure.
23

The problem
• Once we determine a technical problem, we
can define recommendations to improve the
product, but:
What do we do with the recommendation ?
– We can not improve the Standard, there’s no standard.
– We can not address more than one manufacturer,
– What about retrofit ?

24

ULM and Engine failures

25

Fly Synthesis Storch
Summer 2009
• After propeller replacement, and subsequent
engine ground tests, the pilot took off for a
flight test.
• He encountered heavy engine vibration, that
forced him to an emergency landing.
• Airplane was slightly damaged.
Cause was identified as Vapor Lock.
26

1/5/2010 – FK9
Emergency landing after in-flight engine failure.
• Lots of corrosion found in carburettor.
Corrosion comes from water condensation in
fuel system (tank, lines, pump,…- MOGAS)
during long immobilisation periods.
- how to prevent ? Filling up, draining ?

• Fuel system was modified in-service, by
addition of a pressure regulator.
27

France
20/5/2010 – Mistral
23/5/2010 – CT Short Wing
Mistral: Engine failure in flight.
Emergency landing in field; terrain was very soft, airplane
severely damaged.
CT Short Wing: In short final, the engine suddenly stops
The pilot attempts to land, but hit trees, and crashes – wings
ripped off.
RH wing tank empty, 15-25 l fuel remaining in LH tank.
During LH turn, fuel system unprimed, engine stopped by
fuel starvation.
28

4 /6/2010: SG Rally
Damaged during landing
• Due to engine problems (heavy vibrations), the
pilot performed emergency landing on EBHN.
Coming in too fast, the landing was brutal, and
Nose Landing Gear collapsed.

29

Conclusion
• Engine in-flight failure are not exceptional.
– Use of MOGAS (water content, flash point,..)
– Local modifications,
– Other specific to the configuration of the
specific airplane.
And..
– Traditional causes (engine starvation,..)
30

Solutions
• In this case, we can design some generic
recommendations:
– Human Factors; ULM pilots should be more
prepared to react to engine failures at any time
(awareness, briefing, training,…)
– Generic technical solutions; impact on the use
of MOGAS.
• Protection of the equipment during winter,
• Risk of Vapour lock.

31

• Designing stop-gaps, accident after accidents
may not be satisfactory;
What can we do we make sure ULM flying
improves up to an acceptable level and, more
important, remains at that level ?

• More Regulation ?

32

Aviation Regulation and the ULM
• No significant changes in Regulation.
– ULM defined by capacity, weight, structural and stall speed limitation.
– => Extensive use of carbon fiber, Flaps, etc

• CS-VLA.
– 750 kg.
– “light” CS-23.
– Expensive.

• Lower Requirements for licencing,
– What about competence ?
– Human Factors training

• National requirements in Europe.
– EASA Flight Permit per Part 21A.701.

33

Evolution: new EU Regulation on
Accident Investigation.
* Every civil aviation accident or serious incident involving
aircraft other than specified in Annex II to the Regulation (EC)
No 216/2008 of the European Parliament and of the Council
shall be the subject of a safety investigation

( = No obligation of enquiry for ULMs)
• Safety investigation authorities may decide to investigate
incidents other than those referred to in paragraph 1 as well as
accidents or serious incidents to other types of aircraft, in
accordance with the national legislation of the Member States,
when they expect to draw safety lessons from them.
34

• US. NTSB; no enquiry for ULM crashes.
• To-day already, in some EU countries, ULM
crash investigations are given a low priority,
unless the Public determines otherwise.
• Common sense dictates that the initiative
to improve safety must come from the
ULM community itself.

35

Reason Model
• aviation is a complex socio-technical
system, where safety is ensured by a
series of defense barriers.
• Each barrier may present flaws (latent
or active) whose combination can lead
to an accident.
• An usafe act (active failure) alone
would not cause an accident.
• Latent failures are more easily
detected and corrected that human
errors, which are (globally) inevitable.

36

• The ULM community should reinforce its
Defense Barriers.
• Organisation: Federation and Clubs.
Create a Safety Climate
- Norms and rules
- Safety Programs

- To define a Safety Climate, we need to
assess the potential risk, and for that we
need data: YOUR experience.
37

Pyramid of Heinrich
• If a fatal accident is caused by
a specific combination of
events, an uncomplete series
of events causes INCIDENTS.
• If we identify all potentially
dangerous events AND with
that information, build-up the
defenses, we can avoid
ACCIDENTS.
38

SHARING EXPERIENCE
• By informing the Federation of the small
events and incidents that spoiled one of
your flights, you allow the Community to
understand the potential dangers and act
upon. (and respect confidentiality)
“Learn from mistakes of others; you won’t
live long enough to make them all by
yourself”
39

Human Factors
• To err is human.
• Human life (and flying) is full of decisions.
• It is therefore more important to know yourself
than to know how to fly your aircraft.
– Get-home-itis, Distraction, Communication,..

• Understanding human factors is a very important
step in improving your defenses.
40

Competence and Readiness
• You hold a pilot licence; but are you a
competent flyer ?
• How will you react when faced with a
potential dangerous situation?
• Assessing your competences with an
instructor is an opportunity to improve.
• When flying, be ready.
41

What is the Authority doing for
you ?

42

A series of work groups
within EASA are thinking
about how to improve
flight safety.(ESSI)
One of them is about General
Aviation (EGAST).

Initiative includes a leaflet
On Collision Avoidance,
and has been relayed to you
by the Federation.
There are technical Work
Groups dealing with MOGAS
43

and

An initiative to develop
Posters with comic strips
On high risk topics.
The first goes about taking
The right decision when the
Weather is below minimum.
They are expected in the
Coming months.

44

For Belgium, Accident reports are made public on the SPF/FOD website.
Recent reports (from 1st May 2007) are directly available through
hyperlinks.
Reports are written in English.
Information Notes are also available in order to highlight specific danger
area: Nr 2010 is about engine cold start.
We would like to develop more Notes, for ULM in collaboration with
the Federation.
Historical reports: currently a list is posted.
The list is fairly complete from 1972.
2 ancient reports (1936 and 1965).
The reports (Fr /Nl) are desidentified and available on request.
The list will be completed as we go along in reviewing archives.

45

Thank you for your attention, and
AAIU (Belgium) wishes you
many happy landings

Photos credit:
MRA / KLM

46


Slide 45

10 JULY 1910 - 2010
100 YEARS ULM ACCIDENTS

Belgian ULM Federation – Safety
1
Conference 10/10/2010

The Air Safety Investigation
• As part of the global Aviation sphere, an investigation is
conducted for each accident and serious incident by an
independent enquiry body, aimed to;
– Determine the causes of the accident.
– Determine if all conditions that were defined by rules and
regulations to ensure flight safety were followed (such as risk
factors in design).
– Define recommendations in order to prevent future accidents.

• It is not the purpose of this investigation to apportion
blame or liability.

2

In Belgium; the Air Accident
Investigation Unit.
• All accidents and serious incidents occurring in Belgium,
on aircraft, helicopters, gliders, balloons, ULM, DPM,
regardless of their registration is investigated by a cell
functionnally independent from the BCAA, and all other
interrested parties.
• Independent doesn’t mean isolated; it is part of the world’s
network of the State’s Aviation Investigation Bodies.
• The cell reports to the President of the Board of the
SPF/FOD Mobility and Transport.
3

4

ULM
• First pendular (Delta Plane Motorized)
design in 1966
• First crossing of the Channel in 1978 by Mr
D. Cook.
• Commercial development from 1979.
• Evolution from 2-axis to 3-axis.
• In Belgium, first ULM registered (501) in
1982.

5

6

Evolution
• 1982: Weedhopper, Chickinox
– 80…100 km/h
– Basic – 2/3 axis
– Range: … 200 km…

• 2010: VL-3 Sprint, DynAero MCR01, WT9 Dynamic….
– 220….250 km/h,
– flaps, retractable gear, avionics,
– Range over 1000 km

• 550 OO- registered ULM;
• 571 ULM pilot licence (363 training licences)
• 300-400 foreign-registered ULM.
7

1000
900
800
700
600
500
400
300
200
100

Number of valid registration

8

Estimation of flying OO-regd ULM

20
10

20
08

20
06

20
04

20
02

20
00

19
98

19
96

19
94

19
92

19
90

19
88

19
86

19
84

19
82

0

Evolution in pilot’s / owner’s
expectations
• In 1982, ULM /DPM, a sporting way of flying,
outside the limits of parachuting, delta plane.

• In 2010, an efficient alternative to general
(certified) aviation. ULM becomes a means of
transport.
• Beyond 2010 ?? – The Need for Speed ?
9

Evolution
• From the user’s perspective, the difference between
General Aviation and ULM becomes very thin.
• However, ULMs are characterized by a huge variety of
different design types, with low production rate and
configuration variation between individual airplanes.
– Manufacturers come and go,
– Assembly of the same ULM type by different companies induce
differences in built configuration.

• The above makes it more and more difficult to speak about
ULMs in a general way; variation in quality is wider than
General (certified) Aviation.
10

EVOLUTION: MORE ULM FATAL ACCIDENTS ?

Fatalities: (up to now), In Belgium, on average 2 /year,
comparable to General (certified) Aviation.
Number of fatalities
12
10
8
6
4
2

Number of fatalities

11

20
10

20
08

20
06

20
04

20
02

20
00

19
98

19
96

19
94

19
92

19
90

19
88

19
86

19
84

0

19
82

FATALITIES:
Figures limited to
Belgium.
2009: + 2 in France.
2010: + 5 in France.

WHAT ARE THE EXPECTATIONS
FOR THE
ULM-ACCIDENTS CASUALITY
RATE ?
• On Belgian soil, 4 deads in 2010.
(casuality rate of U.S. Forces in Iraq 3.6 killed /1000
troop / year – 8 years – 152000 troops – 4424 killed).

• In France and Belgium in 2010, 9 Belgian
deads to-date.
12

Comparison with the road
• In Belgium, the road kills 1000 people on average per year
.
• Fleet of vehicles: 6 000 000 units (5 mio cars).
• For 1000 cars, the road kills on average 0.16 person per
year.
• If we combine these figures with the yearly utilization rate
of cars (1 h per day) versus ULM (40 h per year), we can
conclude that ULM / General Aviation flying is
considerably deadlier than the road.

13

What can we learn from accident
investigation ?

14

The investigation process
A long process (Months)
• Collect all factual elements,
–
–
–
–
–
–

The flow of events;
The pilot (training, experience, …)
The aircraft (contact w/manufacturer)
Meteo, Comm, Radar,
Flt recorders (GPS, ECU, camera, …)
Impact, aircraft damage,

• Analysis. (incl. simulation, testing,…)
• Define all possible causes.
• From the causes, define remedial action.
The depth of the investigation is somewhat influenced by the
expected ROI.
15

Accident analysis
• Accidents do not occur “by accident”; Accident are
caused by a series of events.
• There are no “isolated cases”; causes of accidents are often
recurrent.
• Out of the ULM accident data base, we can conclude;
– There are recurrent technical problems specific to ULM.
– The traditional causes of aviation accidents are also known to
ULM (fuel shortage)

– 80% of the causal factors are human-related.

16

Main causal factors (122 accidents –
fixed wing and ULM)
Loss of control Take-off
11%

Fuel Starvation
15%

Loss of control Flight & collision
12%

Technical
11%
Low piloting
experience
8%

Loss of control Landing
16%
Icing
3%

Low flying /
aerobatics obstacles - CFIT
24%

17

Specific problems with ULM
• Technical causes can be (easily) identified;
but fire can be devastating.
• There’s another problem for the
investigator, a lot of landmarks are missing.
– ULM requirements are national,
– Certification not applicable.
– Wide variety of products.
18

About certification.
• Everyone would agree that ULMs of to-day are as good,
even a lot better than the ‘certified’ airplane.
• ULMs are designed to fly.
ULM are quality products; they meet your expectations
(simple to handle, fly fast, cheap in usage, …)
• Certification means that a manufacturer must demonstrate
that his product meets a minimum level of safety, as
defined (ultimately) by the Aviation Community.
• The minimum level of safety is defined in the Certification
Specifications – For small aircraft, it is called CS23.
19

Technical.
• AAIU(be) is currently investigating on:
– Instrument Board lay-out design.
– Electrical System design.
– Emergency Parachute.
Why is it that (for the last cases) parachute did not save lifes ?
• Late decision ?
• Handle easy to grab ?
• Safety pin not removed before flight ?

20

Same ULM Type, instrument panel somewhat different.
Difference in Ergonomy.
Parachute handle – on pilot’s side, or on passenger’s side ?

21

Regulation: certification:
CS 23.671 General
(b) Controls must be arranged and identified
to provide for convenience in operation and
to prevent the possibility of confusion and
subsequent inadvertent operation.

For ULM, CS 23 is not applicable.
Each designer has his own solution, and
they will be challenged only by YOUR
experience.
22

Other example
The passenger door opens in
flight, causing the pilot to take
appropriate actions, that
eventually force him to an
emergency landing.

• Door lock (simple – crude).
Plexy flexible. Once opened in
flight, difficult to close.
CS 23.783
(1) There must be means to lock and safeguard the door against
inadvertent opening during flight by persons, by cargo, or as a
result of mechanical failure.
23

The problem
• Once we determine a technical problem, we
can define recommendations to improve the
product, but:
What do we do with the recommendation ?
– We can not improve the Standard, there’s no standard.
– We can not address more than one manufacturer,
– What about retrofit ?

24

ULM and Engine failures

25

Fly Synthesis Storch
Summer 2009
• After propeller replacement, and subsequent
engine ground tests, the pilot took off for a
flight test.
• He encountered heavy engine vibration, that
forced him to an emergency landing.
• Airplane was slightly damaged.
Cause was identified as Vapor Lock.
26

1/5/2010 – FK9
Emergency landing after in-flight engine failure.
• Lots of corrosion found in carburettor.
Corrosion comes from water condensation in
fuel system (tank, lines, pump,…- MOGAS)
during long immobilisation periods.
- how to prevent ? Filling up, draining ?

• Fuel system was modified in-service, by
addition of a pressure regulator.
27

France
20/5/2010 – Mistral
23/5/2010 – CT Short Wing
Mistral: Engine failure in flight.
Emergency landing in field; terrain was very soft, airplane
severely damaged.
CT Short Wing: In short final, the engine suddenly stops
The pilot attempts to land, but hit trees, and crashes – wings
ripped off.
RH wing tank empty, 15-25 l fuel remaining in LH tank.
During LH turn, fuel system unprimed, engine stopped by
fuel starvation.
28

4 /6/2010: SG Rally
Damaged during landing
• Due to engine problems (heavy vibrations), the
pilot performed emergency landing on EBHN.
Coming in too fast, the landing was brutal, and
Nose Landing Gear collapsed.

29

Conclusion
• Engine in-flight failure are not exceptional.
– Use of MOGAS (water content, flash point,..)
– Local modifications,
– Other specific to the configuration of the
specific airplane.
And..
– Traditional causes (engine starvation,..)
30

Solutions
• In this case, we can design some generic
recommendations:
– Human Factors; ULM pilots should be more
prepared to react to engine failures at any time
(awareness, briefing, training,…)
– Generic technical solutions; impact on the use
of MOGAS.
• Protection of the equipment during winter,
• Risk of Vapour lock.

31

• Designing stop-gaps, accident after accidents
may not be satisfactory;
What can we do we make sure ULM flying
improves up to an acceptable level and, more
important, remains at that level ?

• More Regulation ?

32

Aviation Regulation and the ULM
• No significant changes in Regulation.
– ULM defined by capacity, weight, structural and stall speed limitation.
– => Extensive use of carbon fiber, Flaps, etc

• CS-VLA.
– 750 kg.
– “light” CS-23.
– Expensive.

• Lower Requirements for licencing,
– What about competence ?
– Human Factors training

• National requirements in Europe.
– EASA Flight Permit per Part 21A.701.

33

Evolution: new EU Regulation on
Accident Investigation.
* Every civil aviation accident or serious incident involving
aircraft other than specified in Annex II to the Regulation (EC)
No 216/2008 of the European Parliament and of the Council
shall be the subject of a safety investigation

( = No obligation of enquiry for ULMs)
• Safety investigation authorities may decide to investigate
incidents other than those referred to in paragraph 1 as well as
accidents or serious incidents to other types of aircraft, in
accordance with the national legislation of the Member States,
when they expect to draw safety lessons from them.
34

• US. NTSB; no enquiry for ULM crashes.
• To-day already, in some EU countries, ULM
crash investigations are given a low priority,
unless the Public determines otherwise.
• Common sense dictates that the initiative
to improve safety must come from the
ULM community itself.

35

Reason Model
• aviation is a complex socio-technical
system, where safety is ensured by a
series of defense barriers.
• Each barrier may present flaws (latent
or active) whose combination can lead
to an accident.
• An usafe act (active failure) alone
would not cause an accident.
• Latent failures are more easily
detected and corrected that human
errors, which are (globally) inevitable.

36

• The ULM community should reinforce its
Defense Barriers.
• Organisation: Federation and Clubs.
Create a Safety Climate
- Norms and rules
- Safety Programs

- To define a Safety Climate, we need to
assess the potential risk, and for that we
need data: YOUR experience.
37

Pyramid of Heinrich
• If a fatal accident is caused by
a specific combination of
events, an uncomplete series
of events causes INCIDENTS.
• If we identify all potentially
dangerous events AND with
that information, build-up the
defenses, we can avoid
ACCIDENTS.
38

SHARING EXPERIENCE
• By informing the Federation of the small
events and incidents that spoiled one of
your flights, you allow the Community to
understand the potential dangers and act
upon. (and respect confidentiality)
“Learn from mistakes of others; you won’t
live long enough to make them all by
yourself”
39

Human Factors
• To err is human.
• Human life (and flying) is full of decisions.
• It is therefore more important to know yourself
than to know how to fly your aircraft.
– Get-home-itis, Distraction, Communication,..

• Understanding human factors is a very important
step in improving your defenses.
40

Competence and Readiness
• You hold a pilot licence; but are you a
competent flyer ?
• How will you react when faced with a
potential dangerous situation?
• Assessing your competences with an
instructor is an opportunity to improve.
• When flying, be ready.
41

What is the Authority doing for
you ?

42

A series of work groups
within EASA are thinking
about how to improve
flight safety.(ESSI)
One of them is about General
Aviation (EGAST).

Initiative includes a leaflet
On Collision Avoidance,
and has been relayed to you
by the Federation.
There are technical Work
Groups dealing with MOGAS
43

and

An initiative to develop
Posters with comic strips
On high risk topics.
The first goes about taking
The right decision when the
Weather is below minimum.
They are expected in the
Coming months.

44

For Belgium, Accident reports are made public on the SPF/FOD website.
Recent reports (from 1st May 2007) are directly available through
hyperlinks.
Reports are written in English.
Information Notes are also available in order to highlight specific danger
area: Nr 2010 is about engine cold start.
We would like to develop more Notes, for ULM in collaboration with
the Federation.
Historical reports: currently a list is posted.
The list is fairly complete from 1972.
2 ancient reports (1936 and 1965).
The reports (Fr /Nl) are desidentified and available on request.
The list will be completed as we go along in reviewing archives.

45

Thank you for your attention, and
AAIU (Belgium) wishes you
many happy landings

Photos credit:
MRA / KLM

46


Slide 46

10 JULY 1910 - 2010
100 YEARS ULM ACCIDENTS

Belgian ULM Federation – Safety
1
Conference 10/10/2010

The Air Safety Investigation
• As part of the global Aviation sphere, an investigation is
conducted for each accident and serious incident by an
independent enquiry body, aimed to;
– Determine the causes of the accident.
– Determine if all conditions that were defined by rules and
regulations to ensure flight safety were followed (such as risk
factors in design).
– Define recommendations in order to prevent future accidents.

• It is not the purpose of this investigation to apportion
blame or liability.

2

In Belgium; the Air Accident
Investigation Unit.
• All accidents and serious incidents occurring in Belgium,
on aircraft, helicopters, gliders, balloons, ULM, DPM,
regardless of their registration is investigated by a cell
functionnally independent from the BCAA, and all other
interrested parties.
• Independent doesn’t mean isolated; it is part of the world’s
network of the State’s Aviation Investigation Bodies.
• The cell reports to the President of the Board of the
SPF/FOD Mobility and Transport.
3

4

ULM
• First pendular (Delta Plane Motorized)
design in 1966
• First crossing of the Channel in 1978 by Mr
D. Cook.
• Commercial development from 1979.
• Evolution from 2-axis to 3-axis.
• In Belgium, first ULM registered (501) in
1982.

5

6

Evolution
• 1982: Weedhopper, Chickinox
– 80…100 km/h
– Basic – 2/3 axis
– Range: … 200 km…

• 2010: VL-3 Sprint, DynAero MCR01, WT9 Dynamic….
– 220….250 km/h,
– flaps, retractable gear, avionics,
– Range over 1000 km

• 550 OO- registered ULM;
• 571 ULM pilot licence (363 training licences)
• 300-400 foreign-registered ULM.
7

1000
900
800
700
600
500
400
300
200
100

Number of valid registration

8

Estimation of flying OO-regd ULM

20
10

20
08

20
06

20
04

20
02

20
00

19
98

19
96

19
94

19
92

19
90

19
88

19
86

19
84

19
82

0

Evolution in pilot’s / owner’s
expectations
• In 1982, ULM /DPM, a sporting way of flying,
outside the limits of parachuting, delta plane.

• In 2010, an efficient alternative to general
(certified) aviation. ULM becomes a means of
transport.
• Beyond 2010 ?? – The Need for Speed ?
9

Evolution
• From the user’s perspective, the difference between
General Aviation and ULM becomes very thin.
• However, ULMs are characterized by a huge variety of
different design types, with low production rate and
configuration variation between individual airplanes.
– Manufacturers come and go,
– Assembly of the same ULM type by different companies induce
differences in built configuration.

• The above makes it more and more difficult to speak about
ULMs in a general way; variation in quality is wider than
General (certified) Aviation.
10

EVOLUTION: MORE ULM FATAL ACCIDENTS ?

Fatalities: (up to now), In Belgium, on average 2 /year,
comparable to General (certified) Aviation.
Number of fatalities
12
10
8
6
4
2

Number of fatalities

11

20
10

20
08

20
06

20
04

20
02

20
00

19
98

19
96

19
94

19
92

19
90

19
88

19
86

19
84

0

19
82

FATALITIES:
Figures limited to
Belgium.
2009: + 2 in France.
2010: + 5 in France.

WHAT ARE THE EXPECTATIONS
FOR THE
ULM-ACCIDENTS CASUALITY
RATE ?
• On Belgian soil, 4 deads in 2010.
(casuality rate of U.S. Forces in Iraq 3.6 killed /1000
troop / year – 8 years – 152000 troops – 4424 killed).

• In France and Belgium in 2010, 9 Belgian
deads to-date.
12

Comparison with the road
• In Belgium, the road kills 1000 people on average per year
.
• Fleet of vehicles: 6 000 000 units (5 mio cars).
• For 1000 cars, the road kills on average 0.16 person per
year.
• If we combine these figures with the yearly utilization rate
of cars (1 h per day) versus ULM (40 h per year), we can
conclude that ULM / General Aviation flying is
considerably deadlier than the road.

13

What can we learn from accident
investigation ?

14

The investigation process
A long process (Months)
• Collect all factual elements,
–
–
–
–
–
–

The flow of events;
The pilot (training, experience, …)
The aircraft (contact w/manufacturer)
Meteo, Comm, Radar,
Flt recorders (GPS, ECU, camera, …)
Impact, aircraft damage,

• Analysis. (incl. simulation, testing,…)
• Define all possible causes.
• From the causes, define remedial action.
The depth of the investigation is somewhat influenced by the
expected ROI.
15

Accident analysis
• Accidents do not occur “by accident”; Accident are
caused by a series of events.
• There are no “isolated cases”; causes of accidents are often
recurrent.
• Out of the ULM accident data base, we can conclude;
– There are recurrent technical problems specific to ULM.
– The traditional causes of aviation accidents are also known to
ULM (fuel shortage)

– 80% of the causal factors are human-related.

16

Main causal factors (122 accidents –
fixed wing and ULM)
Loss of control Take-off
11%

Fuel Starvation
15%

Loss of control Flight & collision
12%

Technical
11%
Low piloting
experience
8%

Loss of control Landing
16%
Icing
3%

Low flying /
aerobatics obstacles - CFIT
24%

17

Specific problems with ULM
• Technical causes can be (easily) identified;
but fire can be devastating.
• There’s another problem for the
investigator, a lot of landmarks are missing.
– ULM requirements are national,
– Certification not applicable.
– Wide variety of products.
18

About certification.
• Everyone would agree that ULMs of to-day are as good,
even a lot better than the ‘certified’ airplane.
• ULMs are designed to fly.
ULM are quality products; they meet your expectations
(simple to handle, fly fast, cheap in usage, …)
• Certification means that a manufacturer must demonstrate
that his product meets a minimum level of safety, as
defined (ultimately) by the Aviation Community.
• The minimum level of safety is defined in the Certification
Specifications – For small aircraft, it is called CS23.
19

Technical.
• AAIU(be) is currently investigating on:
– Instrument Board lay-out design.
– Electrical System design.
– Emergency Parachute.
Why is it that (for the last cases) parachute did not save lifes ?
• Late decision ?
• Handle easy to grab ?
• Safety pin not removed before flight ?

20

Same ULM Type, instrument panel somewhat different.
Difference in Ergonomy.
Parachute handle – on pilot’s side, or on passenger’s side ?

21

Regulation: certification:
CS 23.671 General
(b) Controls must be arranged and identified
to provide for convenience in operation and
to prevent the possibility of confusion and
subsequent inadvertent operation.

For ULM, CS 23 is not applicable.
Each designer has his own solution, and
they will be challenged only by YOUR
experience.
22

Other example
The passenger door opens in
flight, causing the pilot to take
appropriate actions, that
eventually force him to an
emergency landing.

• Door lock (simple – crude).
Plexy flexible. Once opened in
flight, difficult to close.
CS 23.783
(1) There must be means to lock and safeguard the door against
inadvertent opening during flight by persons, by cargo, or as a
result of mechanical failure.
23

The problem
• Once we determine a technical problem, we
can define recommendations to improve the
product, but:
What do we do with the recommendation ?
– We can not improve the Standard, there’s no standard.
– We can not address more than one manufacturer,
– What about retrofit ?

24

ULM and Engine failures

25

Fly Synthesis Storch
Summer 2009
• After propeller replacement, and subsequent
engine ground tests, the pilot took off for a
flight test.
• He encountered heavy engine vibration, that
forced him to an emergency landing.
• Airplane was slightly damaged.
Cause was identified as Vapor Lock.
26

1/5/2010 – FK9
Emergency landing after in-flight engine failure.
• Lots of corrosion found in carburettor.
Corrosion comes from water condensation in
fuel system (tank, lines, pump,…- MOGAS)
during long immobilisation periods.
- how to prevent ? Filling up, draining ?

• Fuel system was modified in-service, by
addition of a pressure regulator.
27

France
20/5/2010 – Mistral
23/5/2010 – CT Short Wing
Mistral: Engine failure in flight.
Emergency landing in field; terrain was very soft, airplane
severely damaged.
CT Short Wing: In short final, the engine suddenly stops
The pilot attempts to land, but hit trees, and crashes – wings
ripped off.
RH wing tank empty, 15-25 l fuel remaining in LH tank.
During LH turn, fuel system unprimed, engine stopped by
fuel starvation.
28

4 /6/2010: SG Rally
Damaged during landing
• Due to engine problems (heavy vibrations), the
pilot performed emergency landing on EBHN.
Coming in too fast, the landing was brutal, and
Nose Landing Gear collapsed.

29

Conclusion
• Engine in-flight failure are not exceptional.
– Use of MOGAS (water content, flash point,..)
– Local modifications,
– Other specific to the configuration of the
specific airplane.
And..
– Traditional causes (engine starvation,..)
30

Solutions
• In this case, we can design some generic
recommendations:
– Human Factors; ULM pilots should be more
prepared to react to engine failures at any time
(awareness, briefing, training,…)
– Generic technical solutions; impact on the use
of MOGAS.
• Protection of the equipment during winter,
• Risk of Vapour lock.

31

• Designing stop-gaps, accident after accidents
may not be satisfactory;
What can we do we make sure ULM flying
improves up to an acceptable level and, more
important, remains at that level ?

• More Regulation ?

32

Aviation Regulation and the ULM
• No significant changes in Regulation.
– ULM defined by capacity, weight, structural and stall speed limitation.
– => Extensive use of carbon fiber, Flaps, etc

• CS-VLA.
– 750 kg.
– “light” CS-23.
– Expensive.

• Lower Requirements for licencing,
– What about competence ?
– Human Factors training

• National requirements in Europe.
– EASA Flight Permit per Part 21A.701.

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Evolution: new EU Regulation on
Accident Investigation.
* Every civil aviation accident or serious incident involving
aircraft other than specified in Annex II to the Regulation (EC)
No 216/2008 of the European Parliament and of the Council
shall be the subject of a safety investigation

( = No obligation of enquiry for ULMs)
• Safety investigation authorities may decide to investigate
incidents other than those referred to in paragraph 1 as well as
accidents or serious incidents to other types of aircraft, in
accordance with the national legislation of the Member States,
when they expect to draw safety lessons from them.
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• US. NTSB; no enquiry for ULM crashes.
• To-day already, in some EU countries, ULM
crash investigations are given a low priority,
unless the Public determines otherwise.
• Common sense dictates that the initiative
to improve safety must come from the
ULM community itself.

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Reason Model
• aviation is a complex socio-technical
system, where safety is ensured by a
series of defense barriers.
• Each barrier may present flaws (latent
or active) whose combination can lead
to an accident.
• An usafe act (active failure) alone
would not cause an accident.
• Latent failures are more easily
detected and corrected that human
errors, which are (globally) inevitable.

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• The ULM community should reinforce its
Defense Barriers.
• Organisation: Federation and Clubs.
Create a Safety Climate
- Norms and rules
- Safety Programs

- To define a Safety Climate, we need to
assess the potential risk, and for that we
need data: YOUR experience.
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Pyramid of Heinrich
• If a fatal accident is caused by
a specific combination of
events, an uncomplete series
of events causes INCIDENTS.
• If we identify all potentially
dangerous events AND with
that information, build-up the
defenses, we can avoid
ACCIDENTS.
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SHARING EXPERIENCE
• By informing the Federation of the small
events and incidents that spoiled one of
your flights, you allow the Community to
understand the potential dangers and act
upon. (and respect confidentiality)
“Learn from mistakes of others; you won’t
live long enough to make them all by
yourself”
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Human Factors
• To err is human.
• Human life (and flying) is full of decisions.
• It is therefore more important to know yourself
than to know how to fly your aircraft.
– Get-home-itis, Distraction, Communication,..

• Understanding human factors is a very important
step in improving your defenses.
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Competence and Readiness
• You hold a pilot licence; but are you a
competent flyer ?
• How will you react when faced with a
potential dangerous situation?
• Assessing your competences with an
instructor is an opportunity to improve.
• When flying, be ready.
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What is the Authority doing for
you ?

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A series of work groups
within EASA are thinking
about how to improve
flight safety.(ESSI)
One of them is about General
Aviation (EGAST).

Initiative includes a leaflet
On Collision Avoidance,
and has been relayed to you
by the Federation.
There are technical Work
Groups dealing with MOGAS
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and

An initiative to develop
Posters with comic strips
On high risk topics.
The first goes about taking
The right decision when the
Weather is below minimum.
They are expected in the
Coming months.

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For Belgium, Accident reports are made public on the SPF/FOD website.
Recent reports (from 1st May 2007) are directly available through
hyperlinks.
Reports are written in English.
Information Notes are also available in order to highlight specific danger
area: Nr 2010 is about engine cold start.
We would like to develop more Notes, for ULM in collaboration with
the Federation.
Historical reports: currently a list is posted.
The list is fairly complete from 1972.
2 ancient reports (1936 and 1965).
The reports (Fr /Nl) are desidentified and available on request.
The list will be completed as we go along in reviewing archives.

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Thank you for your attention, and
AAIU (Belgium) wishes you
many happy landings

Photos credit:
MRA / KLM

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