My hat off to Accident and Incident Investigations Division (of SACAA). Well done, and as Pinkman says - incredibly thorough.
The delay in the release of the report speaks volumes about the pressures that must have been applied. It is a pity that the summary forgot to adequately mention the missing taxiway lighting and darkened sign, and still gets confused about the difference between a taxilane and a taxiway. But the body of the report does a good job and has lessons for all of us to ponder.
Originally Posted by
Pinkman
I have ploughed through it. The oddly written introduction/Executive summary was clearly written by somebody different to the main report which is by and large well written and incredibly thorough. It would have benefited from some additional proofreading and tech review but the typos don't in any way alter the conclusions which are as succinctly summarized by the Ancient Geek.
The tensions between ACSA and SACAA are evident and there is some finger pointing in a way you wouldn't find in an AAIB report. Its slightly odd that the dual role of SACAA involves it mentioning itself in the context of the incident which it is investigating but you'd be hard pushed to find fault with the particular instances where that occurs.
The conclusions of OverRun in the PPrune thread at the time that "M" was constructed as a Taxiway were vindicated, as was the decision by BA to return the flight crew to flying duties soon after the incident.. the picture indicating the failed centerline lighting and signage onto Bravo was pretty damning. Jury is out in my mind on whose fault it was that the lessons were not learned or engineered out from the carbon copy incident of a previous BA 744 incident in the same location.
Worth the wait.