Re: non-event (assuming they did not touch short)
It's coming back slowly, fdr is getting a free shirt. Annex 13 may not be relevant (luckily for everyone) but the operator's SMS still is.
The proper wording in my good old company was 'occurrence', recorded, tracked and evaluated with appropriate levels of intensity but systematically in a similar fashion to an incident.
Everyone understands the iceberg theory, it's occurrences (again, luckily) that are the daily bread of operator's SMS discovery process. Not all occurences are equal as per the rarity/severity matrix. Here's a one with a significant learning potential.
Other words, squeezing this or similar thorughly is the whole reason why we bother with FDM/SMS at all. Nothing significant happened, everybody knows it was not right but we are incapable (limited in competence) to point a finger onto something deterministic, and there are zero identifiable defences in place why it could not happen again anytime later.
Typical findings (no mater which type of authority looks at it)
- training on short runways does not cover the differences explanation for aiming markers with regards to AFM compliant threshold clearance
- line pilot awareness of proper AFM aiming technique is low, with a possibility of forming a customary long habit on 2400+ m ICAO marked runways.
- PAPI relevance for landing is not understood by large proportion of line pilots leading to both over-use and/or ignorance
- NPA runways are unobserved territory for TCH and short touchdown distance given current technological limitations of FDM systems, moreover so on marginally short runways with low flight count rate typical for seasonal airports.
- in case of PAPI unusable there is no easily identifiable limit the line crews could observe and respect with regards to abandoning the approach in case of a profile which is too low
- this particular airport operate a 'contested wheel clearance' environment but at the same time installed PAPI does not provide any guidance for near approach profile due technical reasons and for extended periods of time, suggesting a lack of understanding and coherence from the QA team of airport operator and the NAA oversight.
- one of the benefits of stable approach technique is that below the threshold (1000 or 500) the flight path control requirement is reduced to maintaining a steady direct trajectory towards the landing. This enables crews to mentally unload and re-focus ahead of the aircraft before the landing itself which is a precursor to a desirable go-around mindset.
Given the inherent low experience of crews visitung JSI due lack of exposure, safety margins could be increased by publishing a 3D RNAV / RNP approach for the runway (acceptably in a form of prescribed visual manoeuvring track and profile). This will enable the use of present on-board technology to reduce crew workload by creating a perception scenario that is well rehearsed in daily operstions, laying ground for optimal cognitive performance during very short approach and transition to flare.
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The discussion here, not despite but thanks to the widely differing opinions at certain moments, is a wonderful case of true safety work.
The way I see it, at a game of golf one plays the ball against the perils of the course and own performance, counting the strokes and being honest about it. Whereas the Rules of Golf (R&A USGA) are a mere attempt at a technical specification of what 'honest' actually means in the context.
SMS + Flt Ops QA is all the same. Building published standards on how to deal with things, but at the same time actually working safety is not confined to inside SMS/QA (and also not assured by formal following of the audited guidelines).
Prime example here in few simple steps
+ occurrence discovered by coincidence
+ list the available limits and guidance at present
+ shake the tree hard and see what the wider pool thinks of it before telling them what went missing
+ evaluate probability of re-occurence and hazard level facing the defences already in place
+ determine the cheese holes and requirements to close them
Events where the crew gets it (even very) wrong but scratches no paint are the iceberg tips. Making sure the underwater piece is evaluated in full is how a pro-active risk management should run.
Last edited by FlightDetent; 25th Aug 2022 at 01:04.