Many of the issues questioned (and some answered) by ‘unprofessional’ posters, or by people who still wish to allocate blame; or even those who insist that they have done ‘it’ without undue problems, suggests that they all exhibit lack of knowledge of the situation, the technicalities of landing and stopping, or particularly of human vulnerability to error.
If we are to allocate blame (natural human behaviour), then we should consider blaming ourselves as part of the overall system that, when it fails, can lead to this type of accident.
Probably all of us have transgressed one or more of the landing parameters without problems, but how many realised how close the landing was to becoming a serious incident of even an accident.
1. Statistically we land fast (just check the FDM data); we tend to land long, or accept long landings in proportion to the length of the runway (SEMSA data).
2. We land on wet runways, but how wet is wet? The small difference between 2.5 mm and 3.1 mm of water is probably not detectable during operations, but increasing water depth has a significant effect on braking effectiveness? When does wet become contaminated – ‘wet with water patches ?’ – I have never heard a 'wet contaminated' report broadcast.
3. We have the perception that a grooved runway surface is more effective (JAR-OPS tells us so), but how do we know if the grooves are clear or blocked with rubber etc? Do we really understand the differences in friction between a good porous black top and the often quite low friction on concrete runways? Do we know how well drained the runway is, and even with good drainage it takes time to be effective which could be degraded in crosswinds (damming effect).
4. We often land in tailwinds, but do we actually know what change of wind occurs after the last wind check – and was the last ‘wind’ given on short final or 5 mins ago from ATIS.
5. Do we always know the actual touchdown speed, and where was the point of touchdown with respect to the optimum?
6. We land with Cbs in the vicinity of airports, but how many checks are made on short final to determine storm movement and current position? We may consider the threat of windshear when in the air and carry additional speed, but do we consider loosing that energy before or during landing; and what if the windshear hits when you are on the ground?
I suggest that few pilots actual know what all of the conditions are during a landing, thus it is futile to ask why didn’t a crew do that – because it is most probable that they did not know - no one else knew, no one told them, or the crew/others failed to observe or understand the relevance of the information they had.
Very few pilots actually know what safety margins remain during normal landings; those that do, should have some red annotated experiences in their flying logbook. (i.e. wet landing at LCY in a crosswind at night).
In many cases our lack of basic knowledge about aircraft performance fails to set an appropriate safety line. This can be degraded further by examples of poor operating practices from both our peers and our own behaviour, and a wide range of other human factors.
One of the human problems is that we tend to reset our safety line to the last ‘successful’ landing. Few of us conduct a self-debrief to consider what the actual margin of safety was, and ask ‘what would happen if’ any other parameter approached the limit and what would the consequences be. A debrief, self and with crew, is a powerful means of readjusting positively or reconfirming our personal safety limits on which the industry depends on.
Do we really consider any of the individual transgressions as a threat to safety? What happens if there were simultaneous transgressions - wet runway and tailwind; then what margin is there for error - incorrect wind, misread friction level, incorrect airspeed, long landing, windshear?
If you want blame, then we should blame ourselves.
However, we are able to change how we operate as individuals and we can influence others with positive examples, and if we see an uncontrolled threat then we can report it e.g. slick surface, large quantities of paint / rubber / de-icing fluid on the runway.
For those other, rare circumstances, then we have to respect the weather and be aware of our and others fallibility. With two or more transgressions (amber alerts) do we promote the threat to a red warning level and follow TEM rule 1:- Avoid the threats.
We can and must improve knowledge and thus our own professionalism throughout our career. This is not the forum for the unprofessional or the “I can do’ers”, but for those who wish to learn then let us have an open and educating exchange of information.
Errors in aviation decision making.
How good pilots make bad decisions.
Managing threats
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