Over the past year or so, I've written about a couple of topics that seem to have converged into this post. Airport professionalism, the application of aerodrome regulations (twice), runway strip standards and accidents were topics I recently explored and after doing so more research I stumbled across a couple of incident investigations in Australia that bring these previous articles together.
The thesis of the article is that incident investigations are letting us down and we are not learning all the lessons that we could be from events that, but for chance, didn't end up in catastrophe.
Yes, this is going to be a critical post. I'm not criticising individuals, I'm critising the system and if there are factors of which I am not aware, then I am also blaming the system for obscuring them from me for I think I've done a reasonable level of due diligence.
The purpose here is to call for better from our aviation safety system. To highlight, the missed opportunities that could one day bite us and to shine some light on some recent decisions and reports that, I believe, to be reducing aerodrome safety standards without appropriate analysis, communication and review.
Down a Runway Strip Rabbit Hole
Following the relative success of my post on the Pegasus runway excursion in Turkey, I started to do a bit of research to see if there were any related events. I soon discovered an ATSB report issued May 2017 relating to an incident that occurred in January 2017.
The incident involved a BAe-146 (or RJ-85 or AVRO 146, or whatever you call it) landing on the runway strip of an unsealed runway at a remote mining aerodrome in Western Australia. Obviously, the aircraft should have landed on the runway but in a nutshell, dust obscured part of the runway/runway strip and the pilot flying mistakenly lined up on the runway strip. Luckily, they landed without further incident and taxied via the runway back to the apron.
Some Valid Analysis
The ATSB conducted an occurrence investigation given the actual outcome of the incident and issued its findings as part of an Aviation Short Investigations Bulletin. The report focussed on the positioning of aiming point markers outside the runway strip. Given that the runway is unsealed and aiming point markings cannot be provided, the aerodrome operator had elected to establish aiming point markers abeam the aiming point location.
This particular aircraft operator flies into four other unsealed runways who have also established aiming point markers abeam their aiming points. The problem identified by the investigation is that some of these other airports have placed the markers within the runway strip (i.e. close to the runway) and the incident airport placed them outside the runway strip.
This difference contributed to the pilot's assumption that the runway strip to which they were aligning themselves was the runway. They identified parallel lines of cones and a least one aiming point marker immediately adjacent to the runway - dust was thought to be obscuring the other side's marker.
The investigation goes further to suggest that the outside the runway strip positioning is less desirable than the within the runway strip location due to greater use of peripheral vision required to maintain a scan of the runway and the markers.
These points, and in particular this last issue, show the strengths of the ATSB's long history of human factor expertise.
However ... I believe the report falls short in two areas.
The first is relatively minor. With the best of intentions, the report attempts to analyse the regulatory background to these markers but makes a few errors. It confuses markers and markings and as such, makes incorrect interpretations of the regulatory requirements. It also takes a few standards out of context and this leads to incorrect conclusions. If this was the limit of the failings in this report, then I probably would still not have been happy with the report and have written a long post on the correct interpretation of these standards but as it is, I think there is a bigger problem here.
As I was reading the report, I kept asking myself about the PAPI (Precision Approach Path Indicator) system. The fact that the event involved a jet aircraft on an unsealed runway already had me primed for this question. Aerodrome standards nerds in Australia know that CASR 139.190 requires aerodrome operators to provide PAPI (or VASIS) on runways used by jet-propelled passenger transport aircraft.
For me, if PAPI had been installed on the runway strip then this event would not have occurred. The pilot would have identified that they were lined up on the runway strip and altered course to line up with the runway. If they couldn't identify the runway then they would go-around and wait for the dust to clear.
Where Are the PAPI?
So, why was this requirement not raised in the report? This seems to me like a significant regulatory oversight that needs to be addressed. I did search for an exemption but could not locate one on the CASA website.
I asked some friends for help and was pointed to the federal register instead. There I found CASA EX171/16 which was issued less than two months before the event. This instrument is a blanket exemption from the VASIS requirements for runways that are used by jet-propelled charter aircraft. As a mining aerodrome, this flight was most likely a charter flight albeit probably a regularly scheduled flight operating from airline like facilities (at least at the Perth end).
I'm not privy to the decision making process relating to this exemption. One would hope that it was the result of thorough safety analysis before it was signed and promulgated. And further, one would hope that this sort of decision would feature in any subsequent incident investigation where it might have impacted the event.
Am I Asking Too Much?
Maybe I am. After all, PAPI doesn't provide horizontal guidance. But I believe that it was a fundamental question for the investigator to ask about the PAPI as part of the investigation. Its presence on the runway strip would have alerted the crew to their misalignment.
Why Do We Do Investigations?
The ATSB proudly conducts investigations not to apportion blame but to "prevent the occurrence of future accidents". So, here we are discussing whether this investigation will achieve that goal and unfortunately we have proof that it didn't. However, again, we are lucky that the event passed with no significant injury or damage.
The Preventable Incident
This time an EMB-135LR landed just short of a runway in Queensland and took out some runway lights.
The analysis included in the investigation was again good from a human factors and flying operations point of view but it did not ask the aerodrome-standards-related question of where was the PAPI/VASIS? It got really close by identifying that this airport was the only one flown to by the operator that did not have a VASIS and that it was the first time the pilot had flown a jet to a runway without a VASIS. It even listed the absence as a finding but failed to follow up on that point.
I am honestly stumped as to why the decision to exempt these airports from a safety requirement that was in place within the previous year was not discussed. This is the second of two events that could have been averted, directly or indirectly, had the previous regulatory requirement been met. But the analyses and lessons contained in the reports don't seem to delve far enough into the aviation system. They are limited to the front-end operators and not the airport or the regulator and these are truly missed opportunities.
We Deserve More from Our Aviation System
I know that root causes and incident investigation analysis stops where the money stops but I thought the scope of investigations would be broad enough to identify systemic issues including the regulator/regulations. The points I have raised above would not have added substantial time or costs to these simple investigations but the benefits could have been significant.
If you'll indulge me; had the issue of jet operations into runways without VASIS been flagged in May 2017 and a recommendation to CASA to identify aerodromes that were not complying with the previous regulatory requirement, then the later August 2017 event might not have occurred at all.
And since the issue still hasn't been raised, are we simply waiting for the next jet landing incident to occur? We might be lucky and it won't. We might be lucky and it will be like these to events with no significant adverse outcome. Or we might not be lucky at all.
We Can All Do More
I'm not content to simply have a whinge at people that are unlikely to read this post. Instead, these issues can impact any of our investigations. It is easy, firstly, to look at the outcome of an incident and apply resources based on how bad it was. No bad outcome = simple investigation or no investigation at all.
But these events are gifts. Instead, look at what could have reasonably happened. Thanks to the lack of a bad outcome, you now have access to all the people involved, they are likely to want to contribute to the investigation and you have the potential to highlight the good behaviours and strengthen them while addressing deficiencies that you might identify as well.
I know resources are limited and time frames can be tight but always try to ask "why?" a few more times just to make sure you don't have a bigger issue lurking, ready to bite.