Safety Management
A wider view of this accident (based on information in this thread) might conclude that the operation had insufficient safety margin – ‘too close to the edge’.
The ‘short’ runway without an overrun area lacks the safety margin available at other airports. An operator could consider a landing weight limit, less than the certificated performance. There is no regulatory need to for this - so it is not done.
An operation with reverse MEL’ed also reduces the safety margin, and it adds to the crew’s workload with the need to control asymmetric thrust. Thus a rev inop configuration could be prohibited, or an additional wet / crosswind limit applied, again with commercial implications.
Do the crew / operators consider the variable (reduced) safety margins in the range of wet runway conditions, or how close a wet operation might be to a contaminated condition with a heavy shower or ‘damming’ wind’. What effect would / should this have on the policy to tanker fuel?
Do the crew consider (plan / train for) a spoiler failure? In performance terms the increased landing distance may well be within the certificated safety margin (do we know our own type?). The continued landing requires immediate recognition of the problem and a change to the planned operation – maximum braking. It also assumes that the landing was made at a reasonable speed and touchdown position, as both of these reduce the existing safety margin that will be relied on for the spoiler failure. Also consider the importance of the ‘spoiler’ call, how often is this made by habit when the spoilers have not deployed. IIRC at least two accidents involved aspects of this (146 at Aberdeen and MD80 Little Rock); safety recommendations were that only the failure of a system should be called, removing the superfluous ‘by rote’ call.
With a temporary ungrooved runway other restrictions could be applied. Would either the airport authority or an operator consider the reduced braking effectiveness as a need to reconsider performance, and additionally any effect due to new tarmac ‘sweating’? Perhaps more commercial issues.
Thus there are many seemingly inconsequential issues to consider, but we rarely think about these or the probability of a sufficient number of them happening together to lead to an accident. Unfortunately history shows that it only takes one of these issues in conjunction with a human error (perhaps originating from other avoidable issues – documentation, SOPs, training) to cause an accident.
The premise of a Safety Management System is that operators and individuals think about these issues, their combinations and the hazards. A judgement is required which increasingly relies on specialist knowledge, and correlation with previous events, incidents, and accidents elsewhere or involving other types – a problem of communication. The managers in this decision process must provide a balanced judgement of safety against commercial interests (safety is a commercial issue – the first issue), they must avoid bias, and heed the lessons from the apparently increasing number of accidents where this balance appears to be incorrect.
This might sound like CRM for management within a SMS – an issue of oversight by the regulatory authority?
An intriguing thought is, that this is exactly what thread is undertaking - a SMS process, with hindsight, and with all of the associated CRM strengths and weaknesses, to seek ‘the’ safety judgement for this operation, but perhaps without commercial bias?