The events in this thread describe a James Reason ‘organisational’ accident. The many dormant issues and a few active failures which have been identified indicate a poor state of safety health in this segment of our aviation system – a systematic failure.
I hope that the relevant investigative authorities and even those not charged with formal investigation, undertake reviews that match the revolutionary report into the Dryden (Air Ontario) accident, by identifying and discussing the root contributors.
There are many issues yet to be understood and answered i.e.
Why after safety reports had been submitted about the runway, were no actions / communications forthcoming? Does this reflect a major weakness in the MOR system – an essential component of the CAA’s SMS?
Apparently there weaknesses in operational knowledge about reported braking action (friction level) and how this relates to landing performance; also about the inaccuracies of friction measurement and the hazards of landing on ‘slippery’ runways.
The hazard of new tarmac ‘sweating had been identified in a previous overrun accident – UK built aircraft, but overseas investigation / report. Even when the industry communicates, do we remember?
Complacency in applying landing performance and crosswind limits. Human error, human factors – ‘I know better’, ‘It won’t happen to me … because it worked before (I got away with it)’. Did similar patterns of thought contribute at management levels?
Why apparently, are particular aircraft types appearing more often than others in the overrun statistics?
Etc, etc.
This is not a call for a ‘blame’ seeking investigation, but something that provides the industry with more than the usual description of events and allocation of responsibility; we require substance that we might include in our personal, organisational, or regulatory accountability for safety.
A few contributions from whilst awaiting the report:
Managing the Threats and Errors during Approach and Landing..
Stopping on Slippery Runways. Boeing slippery runways.
Landing on Slippery Runways (Based on Boeing info).
AIC 14/2006 Landing performance of large transport aeroplanes. via
http://www.ais.org.uk
AIC 15/2006 Risks and factors associated with operations on runways affected by snow, slush or water. via
http://www.ais.org.uk
UK Air Pilot AD 1.1.1 section 15 Wheel Braking Action on Wet and contaminated Runways. via
http://www.ais.org.uk
Runway Friction Accountability Risk Assessment.
CRFI.
Croswind limits.
Overruns on landing.
Getting to Grips with Aircraft Performance – Airbus publication via ‘wingfiles’
History of ICAO ice and snow tables.
Braking action.
Good, Fair, Poor, Nil.
Benefit-Cost Analysis of Procedures for Accounting for Runway Friction on Landing.
Overview of the Joint Winter Runway Friction Measurement Program, November 2004 (TP 13361).
Running Out of Runway: Analysis of 35 Years of Landing-overrun Accidents, Gerard van Es National Aerospace Laboratory (NLR), 58th annual lASS “Safety Is Everybody’s Business” Moscow, Russia November 2005.
From a positive aspect, this episode could be a ground breaking event for corporate (management) involvement in flight safety, an example of good safety culture (assuming action was taken as son as the information was available) and a basis of improving public understanding of flight safety.