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-   -   British Airways Incident at Johannesburg (https://www.pprune.org/african-aviation/530468-british-airways-incident-johannesburg.html)

Romeo E.T. 24th Dec 2013 18:43

view from a B737 cockpit earlier today, turn left, don't go straight, building on the right where the vehicles are congregated.
http://s21.postimg.org/6end69zw7/image_Dan_Per.jpg

kungfu panda 24th Dec 2013 18:50

That puts the mistake into perspective.

Oakape 24th Dec 2013 18:53

Interesting photo. Bit short on taxiway signs, aren't they?

JNB was always a bit of a nightmare to taxi around. Lots of traps for the unwary or distracted!

TopBunk 24th Dec 2013 19:03

SW

Check it out.
I believe my source!
Check what out? What source?

I fear you are yet another troll:ugh:

Zulualpha 24th Dec 2013 19:23

If one looks at the photo posted one will see that there are lights on the taxi line that take you around the corner. It may have been that the lights were off but it's not at all usual for them to be off at night time. I've taxied out there loads of times but I can't recall if taxiway M is light at night time. As far as I know M is only used by aircraft under tow.

I do know though that it is common to be behind the BA aircraft in Joburg while they are apparently waiting for the figures to be sent to the aircraft. This reason is given to the ATC by the BA crew when being asked if they are ready for take-off.


Perhaps BA crew could say if it's standard for the figures to be sent out to the aircraft while the aircraft is on the move or if SOPS/NOPS require this to be done before start? Surely if it is standard for the figures to be sent after start the airline must have some policy as to how the figures must be inserted into the FMS or accepted by the crew? If it is SOPS/NOPS airline management should surely shoulder some responsibility for this.

The Ancient Geek 24th Dec 2013 19:27


Interesting photo. Bit short on taxiway signs, aren't they?

JNB was always a bit of a nightmare to taxi around. Lots of traps for the unwary or distracted!
Indeed.

Now consider that one on a dark night.
All they need is to dogleg the narrow taxiway 20 yards to the left and all would be well, A few signs would help though.

M.Mouse 24th Dec 2013 19:34

This thread really is quite unblievable for the amount of unadulterated crap being spouted.

In no particular order we have people expressing sympathy with the crew but at the same time being castigated as if they had a lack of sympathy with the Korean crew of the recent SFO crash! While the cultural issues are well known the effectiveness of the conversion training has to be questioned when the P/UT fundamentally did not understand the autothrust system. The two pilots have to live with the awful knowledge that they killed many people in the crash. I cannot begin to understand the culture but I would not be human if I did not have sympathy with the crew of that one.

In the JNB incident the picture above dramatically illustrates to the pious and the mischievous how easily it can be to miss the turn towards 03L and that is in daylight! Many airfields are like black holes at night and with poor signing and lighting making an error is all too easy to make.

In recent years far more emphasis has been placed on both pilots looking out of the windows with minimal other tasks being dealt with once on the move but is inevitable that at times only one pilot will be looking out if only for a brief period.

The captain will no doubt pay dearly for something for which he carried the ultimate responsibility whether that be in demotion, dismissal or just having to live with the knowledge of being responsible for the accident.

I know from personal experience that the standards are high in BA as well as many other airlines but show me any long established international carrier which hasn't had incidents or accidents which shouldn't have occurred in a perfect world.

kungfu panda 24th Dec 2013 19:55

Just looking at that picture, if there were centerline lights going in both directions it was obviously a fcuk up just waiting to happen... Wait for the report but for me it appears to be a bad system rather than a bad crew.

Oakape 24th Dec 2013 20:15

Taxing down 'B' for runway 19 at Brisbane is a very similar situation. However, Brisbane is very well signed. Even so, there has been the occasional incident where a wide body has gone straight ahead instead of making the right turn. Night is much worse & you have to pay attention, even if you know the airport well. It obviously wouldn't take much at JNB to end up in the wrong place, like this crew did.

And, as for those who feel that the crew should have known that the building was too close - you either haven't had to taxy in a very confined area or have never taxied a jet airliner. When taxing in a confined space it always looks close - often too damn close! You just have to make sure you are on the line &, if other aircraft are nearby, make sure they are on their line as well. Then you just have to trust that the airport has done the right thing & painted the lines in the correct place & if you are being marshalled, that they know what they are doing. Even that can go wrong. I came within a metre of collecting a 747 wingtip one night in India when under the marshaller's guidance. It was only my instinct that led me to ignore his instructions & turn early.

You can't just get out & have a look & in this business, you often just have to trust that others have done their job correctly.

Aluminium shuffler 24th Dec 2013 20:16

The photo of the junction paint a thousand words - this is one of those instances where in the dark, with the lack of sign posting and using just the aircraft lighting, the mistake is going to happen at some point. There are plenty of airports with awful layouts, marking and signs, and they exist in north west European capital airports too - how many major EU airports have no centreline lighting on the apron, so when it rains at night the lines disappear under the sheen of reflected orange sodium lights? Luton has only just got marshallers for god's sake, all parking having been achieved by picking a piece of terminal structure or ground equipment to aim at as the yellow line disappears under the nose and checking for obstructions yourself.

As for the industry being one that learns from its mistakes, I have yet to see any evidence of this oft cited remark after 20 years working in it. Fatigue? Language barriers? Alcohol in airports and on board? The weight of carry on baggage? Assumed weights for load sheets? Security issues? The frank reality is that the industry is run by accountants who only spend money on what will gain more money back. Safety issues can go swing - EASA has shown clearly on the FTL issue that it is more interested in commercial than safety issues, so even the regulators won't push the hard learned lessons to be adopted. Anyone who works in aviation knows that the industry never learns the lessons...

exeng 24th Dec 2013 20:18

Taxied to 03L many times - in daylight! I can quite understand how this incident could occur - particularly at night.

Don't forget that this may have been a crew who have never visited JNB before (apart from training) and so may be quite unfamiliar with the nuances of this place.

Have I ever made errors in taxing? Yes but I have managed to taxy away with nothing more than a red face, admonishment from ATC and a tittering F/O.

Holes in cheese is what this is about - and the photo above gives an indication as to a large hole which the airport authority chose to ignore. It would be interesting to know if this was the first such occurrence of an aircraft 'continuing' along the taxiway to runway 03L for departure.. I'd bet my next salary it was not the first.

What an awful Christmas for all those involved.


Regards
Exeng

kaikohe76 24th Dec 2013 21:02

There have been many posts re this particular incident & likely to be many more. Let's all put our hand on our hearts & swear, `we have never been subject to the potential, for just this type of incident`. Certainly it would appear, that more & better signage & lighting (centre line etc), would have helped. We all learn from our own & others mistakes, none of us is God, so let's continue to be carefull out there.
Regards to all.

J.O. 24th Dec 2013 21:07

Cultures differ in different parts of the world. That is a given and to ignore it is to do a disservice to safety. I have no doubt that if the BA FO had spoke up about the taxi route or the proximity of that building, the captain would have stopped and confirmed their position. Sadly, in some other parts of the world, the FO wouldn't even dare speak up in such a situation.

As for the specifics, put the photo shown above in the context of an environment which is often darker than the inside of a cow and I can see exactly how this incident happened.

I.R.PIRATE 24th Dec 2013 21:07

Exeng - not the first.

M.Mouse 24th Dec 2013 21:16


I have no doubt that if the BA FO had spoke up about the taxi route or the proximity of that building, the captain would have stopped and confirmed their position.
You assume it was the captain taxiing.

Ulster 24th Dec 2013 21:16


I have no doubt that if the BA FO had spoke up about the taxi route or the proximity of that building, the captain would have stopped and confirmed their position
Would it be right to assume (I'm not a commercial pilot) that the FO would be the more likely of the two to spot the conflict, since he is physically on the right side ? Or is lookout generally delegated to one or the other, irrespective of side ?

misd-agin 24th Dec 2013 21:18

The photo also shows -

Taxi edge lights vs. no edge lights.
Pavement width reduction by 2/3's.
Side markings vs. no markings.
Taxiway centerline lights at the turn.

nitpicker330 24th Dec 2013 21:19

Yep totally agree, we could all have made a similar error on a dark night. Sometimes :mad: happens, luckily no one died.

The RPLL intl apron area springs to my mind when I think of places where the local signs/apron lines are a error waiting to happen.

It may be the fault of the crew however the FAJS Airport have to accept responsibility as well.

Ulster 24th Dec 2013 21:32


Taxiway centerline lights at the turn
Just one more question from a non-expert : is it known if those lights were actually switched ON at the time of this incident ? :confused:

PukinDog 24th Dec 2013 22:00

Obviously a breakdown of SA inside the cockpit while the aircraft was moving.

I will be interested to find out whether the crew's pre-start briefing included the expected taxi route to the runway in use and whether they discussed any changes to what was previously expected and briefed, if any.

Anyone operating into less-than-ideal airports KNOWS it may be substandard to what we're used to seeing in the 1st world, and considers things like lack of or poor signage and markings a threat, and is discussed just like bad weather, terrain, etc. A proper brief will discuss the taxi route and (in this case) the jog to the left, the expectation to look for the red hold-short sign for the runway (as clearly seen in the picture) and the fact that there's a taxiway leading straight ahead you don't want to take. The whole purpose of briefing beforehand it is to figure out the traps before you begin taxiing and arrive there because there are cockpit chore and duty distractions in between. If you expect there to be no traps or have them all magically erased you're in the wrong business.

All the technology and niceties in the world aren't going to make a difference if the fundamentals aren't there, and SA is lost. Moving a/c displays aren't always accurate and all the hotspot notes on a plate aren't going to help if you don't know you're there in the first place.

Moaning about less-than-perfect airport lighting/facilities does nothing to prevent something like this from recurring. A thorough briefing of taxi route (expected and cleared-for), recognizing threats beforehand, and maintaining vigilance will and is the biggest tool in the shed to plug up what could be the first big hole in the cheese.

It's also incumbent upon us to do our professional best to not be guilty of a runway incursion, and without doing all of the above (even at the most nicely laid-out and lighted/signed) airport, you aren't. Both pilots knowing where they are on the ground and how we've been cleared is also the first red flag for us if we subsequently receive a bogus clearance from ATC that may put us or others at risk.

Gigajoules 24th Dec 2013 22:42

The picture posted by Romeo ET shows the view from the camera's perspective. Humans are blessed with a much wider field of view than a camera. What cues would be available to the pilot to the left of the taxiway? Would the runway threshold not be visible already from just before the turn?

twochai 24th Dec 2013 22:57

Nothing new in the world! Airbus Industrie managed to bury the wingtip of an A-380 demo aircraft into the corner of FSI's simulator center building at Le Bourget not so long ago, in front of thousands attending Paris Air Show!

RatherBeFlying 24th Dec 2013 23:08

The daylight picture goes part way to understanding the situation.

Could somebody take a nighttime snap -- please?

M.Mouse 24th Dec 2013 23:22

Not to make excuses but anybody who has taxied a B747 in the dark on a relatively poorly lit airfield with it not possible to see your wingtips will have an appreciation of what is being discussed that is only possible to gain from actually experiencing it.

I did a similar thing as a first officer in Bogota, the captain had been momentarily distracted and I followed a taxiway not approved for the B747. Fortunately it was only short and although narrow there were no obstructions. Funny enough that was at night too! The only thing to be damaged was my pride but it did teach me a valuable lesson about the hazards of taxiing.

wilsr 24th Dec 2013 23:38

Pukindog:

>>Anyone operating into less-than-ideal airports KNOWS it may be substandard to what we're used to seeing in the 1st world, and considers things like lack of or poor signage and markings a threat, and is discussed just like bad weather, terrain, etc. A proper brief will discuss the taxi route and (in this case) the jog to the left, the expectation to look for the red hold-short sign for the runway (as clearly seen in the picture) and the fact that there's a taxiway leading straight ahead you don't want to take. The whole purpose of briefing beforehand it is to figure out the traps before you begin taxiing and arrive there because there are cockpit chore and duty distractions in between. If you expect there to be no traps or have them all magically erased you're in the wrong business.<<

Correct - but your post is in response to a previous incident and is idealistic.

Say the aircraft had got airborne as planned and suffered a double engine failure (birdstrikes?) at 100'. You might then post criticising the captain for not briefing for the double engine failure, the low level terrain, the emergency fuel dump procedure, the immediate return for an overweight landing on the reciprocal runway, the evac procedure after the resulting brake fires etc etc.

It's all very well being wise after the event but it's clearly impractical to brief for every eventuality. Hindsight is a wonderful attribute.

PAXboy 24th Dec 2013 23:47

As an outsider and one who has merely beein paxing into FAJS for 48 years.

The photo shows that there is no big 'turn left' sign and, we are told, fewer signs are illuminated at night at JNB. Really?? But then, this is Africa.

I can see two mgmts involved. the SA airports mgmt who have not plugged this whole (despite seeing ever more a/c from ever more countries bring their precious tourists that SA so desperately needs) .

Then I see a potential mgmt involved in the sending of numbers after the push. Sounds like a good way to save time? Hmmm.

Lastly, it has been stated that the F and WT+ pax did NOT disembark first. Due to the physical layout, the unloaded from the last row, down steps to busses.

This was a cheese and like all cheses, all the parts were known about in advance. And I'll bet that two lots of mgmt (SA and BA) will not have their careers blighted by this. besides, of those that took the decisions, most will already be retired. As always. THAT'S why i feel sympathy for the crew.

nitpicker330 24th Dec 2013 23:54

Yes as usual there are many holes in the Swiss cheese and unfortunately they lined up on the night.

It's not just the Captain that is at fault.

PukinDog 25th Dec 2013 00:03


wilsr
Pukindog:

>>Anyone operating into less-than-ideal airports KNOWS it may be substandard to what we're used to seeing in the 1st world, and considers things like lack of or poor signage and markings a threat, and is discussed just like bad weather, terrain, etc. A proper brief will discuss the taxi route and (in this case) the jog to the left, the expectation to look for the red hold-short sign for the runway (as clearly seen in the picture) and the fact that there's a taxiway leading straight ahead you don't want to take. The whole purpose of briefing beforehand it is to figure out the traps before you begin taxiing and arrive there because there are cockpit chore and duty distractions in between. If you expect there to be no traps or have them all magically erased you're in the wrong business.<<

Correct - but your post is in response to a previous incident and is idealistic.

Say the aircraft had got airborne as planned and suffered a double engine failure (birdstrikes?) at 100'. You might then post criticising the captain for not briefing for the double engine failure, the low level terrain, the emergency fuel dump procedure, the immediate return for an overweight landing on the reciprocal runway, the evac procedure after the resulting brake fires etc etc.

It's all very well being wise after the event but it's clearly impractical to brief for every eventuality. Hindsight is a wonderful attribute.
I'm not dealing with hindsight or "every eventuality". The subject is getting lost while taxiing. As i stated, the best tool in the shed for THIS type of incident (as well as preventing runway incursions or accepting a bogus clearance) is a thorough brief as to taxi expectations then adjusted for the actual clearance and reviewing it before you're moving. This is something that should be done TODAY and TOMORROW, not only in hindsight. Apparently, you haven't seen most pilots here stating we have been confused at some point or another during taxi. We taxi aircraft at least twice each flight. However, most responses are moaning about bad lighting, bad signage, etc etc. Yes, that's the real world out there where everything isn't perfect.

What has been lost as far as things that could prevent this has nothing to do with depending on some 3rd world airport authority to rectify problems that will never be rectified. What hasn't been addressed is what we as pilots do to mitigate these threats up until that day (which will never come) where everything is perfectly laid-out for us and we don't even have to think ahead.

And lastly, I didn't criticize this captain. I stated at the very beginning I'm interested in hearing as to whether a proper and thorough brief of taxi expectations and clearance were done. Doing so is SOP. It's routine (or should be). That isn't 'idealism" as you put it, it's professionalism and is only one of the many things we're paid to do.

It sounds to me like you don't bother with briefing the taxi route/clearance. Is it not that important to you or just don't think it's needed? Do you even recognize it's importance?

neila83 25th Dec 2013 00:21

It gets worse.

Wisr. Seriously? As I understand it, getting to the runway is considered a necessary routine part of any flight and part of pilots training, and something planes are designed for. I believe double engine failures are outside most expectations. Hence sensible to brief the taxi. Your post seems to imply you don't consider a taxi briefing necessary, and as appropriate as briefing for hypothetical 1 in a billion events.

The poster didn't suggest briefing for any eventuality. They suggested briefing for a known necessary part of the flight, which your colleagues have said is the most dangerous part at night, so that seems sensible does it not? Maybe it's time you start doing a taxi briefing....or if you really think you can't fly to JNB without an unacceptable risk of killing people, then don't. It sounds like some here are as scared of taxiing as the Asiana crew were of visual approaches.

Surely the crew had briefed well enough to know there was a turn in that area? If I crash a car into another car, injure or kill people, and say 'the signs weren't good enough', you know what, they don't care, I get jail time. This guy won't, and shouldn't, but, just understand, you're not being picked on. I think some of us just want to know pilots take this king of thing seriously, and most of you do, it's just scary some don't, that's all.

I spent the last 2 years living in the Pacific working on shipping, and if you think your navaids are bad, try steering into a Pacific port in a barely seaworthy boat, in a storm. And if it sinks, the captain, in the unlikely event he lives, certainly doesn't get another go. Deal with your responsibility, you earn more than 5% (probably more) of people in Britain, doing a job I assume you chose to do, rather than one you are forced to do like most people.

llondel 25th Dec 2013 01:17

I had a look on Google Maps at the area, and also at the photo (equivalent to Street View:)). In daylight I don't think I'd make the mistake, but depending on lights, I could well see making an error in the dark. When I'm in my car I tend to check out new routes in advance, but sometimes I still go wrong if I miss a landmark even if I'm looking for it, or if a signpost doesn't actually say what I expect and so go past it (that was last month). I tend to realise fairly quickly that it's happened, but I don't think the crew had that much time.

Even if you're briefed, it's quite possible to miss something when you're unfamiliar with the route, especially with lots of other stuff going on at the same time. It wouldn't surprise me to find that there was a distraction in the cockpit at the critical moment approaching the turn.

PukinDog 25th Dec 2013 02:25

When you're identifying threats in a brief, you're prioritizing things to maintain vigilance for once you get going, and "unfamiliarity" is one of these things and a well-known and talked-about threat. So is bad signage, so is weather that could obscure identifiers like the lines and markings (snow packed surfaces, standing water, fog, etc etc) causing you to get lost. The stakes are high, much higher than a super-pranged wing, a runway incursion being the most obvious. In this accident, people in that building could have easily been killed.

You can't really equate briefing yourself on your route in a car to this. Missing your turn-off in a car and having to go back is not the same thing as inadvertently winding up on a runway under a landing or rolling-out aircraft in the dark (or this incident). If those were the stakes when you checked your route in a car, where missing your turn means not simply turning around in embarrassment but being T-boned by a truck killing everyone or driving off a cliff, you would check your route, check your progress a LOT more strictly along the way, and slow down at the first hint of doubt as to where you are.

Part of airmanship is managing distractions and maintaining priorities sometimes by adjusting what can be adjusted (delaying a checklist, telling someone to stby, etc) as necessary. It's what we do.

bertpig 25th Dec 2013 03:15

Question from an outsider; The raised bank by the fence that is visible in the daylight pic from post #50 seems to be strewn with a lot of debris. It also appears from the other photos that the outboard engine may have been in close proximity to this area. Is it likely that the engine will have ingested and potentially have been damaged by any of that?

Thanks.

llondel 25th Dec 2013 03:38


Part of airmanship is managing distractions and maintaining priorities sometimes by adjusting what can be adjusted (delaying a checklist, telling someone to stby, etc) as necessary. It's what we do.
Clearly it doesn't always work and like everyone else I'm interested to see the report with probable cause.

When taxiing in the dark, what sort of view does the aircraft lights give of what's off to the side of the taxiway in front? Or does it pretty much just show the area immediately in front of the aircraft (especially high up in a 747). Also, from how far away are the red runway signs visible, especially in the presence of other lighting? It looks very small and low down in that picture.

GBV 25th Dec 2013 03:54

What taxiway is usually used when taxing to RWY03L, A or B?

Sydy 25th Dec 2013 04:45

Small correction, it was the Embraer Service Center in Le Bourget. We still have the wing fence to prove it... LOL

ynwa 25th Dec 2013 06:58

I'm assuming that the building didn't have any obstacle lights?
If this is the case, then the crew might have been alerted of the
wing tip clearance and consequently they were down the wrong
taxiway.
It seems that the crew are partly to blame for this incident (pending the official report) but everyone makes mistakes and good airport infrastructure is needed to safeguard any errors made.

Eddie787 25th Dec 2013 08:14

"Anyone operating into less-than-ideal airports KNOWS it may be substandard to what we're used to seeing in the 1st world and considers things like lack of or poor signage and markings a threat, and is discussed just like bad weather, terrain, etc. A proper brief will discuss the taxi route and (in this case) the"

Nonsense, O R Tambo is as good as a first world airport.

Tacitus 25th Dec 2013 08:50


Just curious,
Why was a BA 747 towed out for takeoff at Johannesburg RW03L this evening?
Any updates on this one?

I.R.PIRATE 25th Dec 2013 08:55

I've heard the towing story is a rumour only.

Other rumour is that BA normally taxi on A, but had been parked in an unusual spot for them on the night in question, necessitating B.

Albert Driver 25th Dec 2013 09:33

To all the folk on this thread who have never been in command of a jumbo operating in Africa at night but still want to give us all the benefit of their total inexperience .......

Merry Christmas to you!


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