Runway at BRS was unsafe. [Archive]

WHBM

9th Jan 2009, 13:50

One of the things that strikes me is the "Risk Assessment" of the task, which nowadays is compulsory for such works as otherwise the HSE will get you for being "unsafe", never even considered any aviation issues about operating on a temporary surface that was not up to standard, but just documented a few random peripheral things like airfield vehicles and construction vehicles being in each others way - and even then it just says who is therefore responsible for that aspect, rather than giving concrete guidance.

Many of us feel that the " 'elf an' safety" so-called profession (as opposed to real flight safety overview done by aviation professionals) is nothing more than a make-work for those who follow it, and here is a typical example.

J.O.

9th Jan 2009, 17:47

A risk assessment is only effective if all of the stakeholders are at the table when the risks are being listed and mitigated. By the sound of things, they never even considered asking the air operators to join them.

WHBM

9th Jan 2009, 18:51

One would have thought that a licenced airfield operator would be able to realise this without needing to discuss it with the airlines. But then of course they're more interested with the profitability of the shops and overpricing the car parks than with anything on the aviation side.

The list of "risks" does indeed seem to have been generated principally from the construction contractor's experience of works rather than anything from the airport's side at all.

Is the MD of Bristol Airport, who I seem to recall at the time telling the media that the runway was perfectly safe and up to spec, still in post ?

Pinkman

9th Jan 2009, 19:45

From the BRS website:

"Paul Kehoe was appointed as Chief Executive Officer in May following the departure of Managing Director, Andrew Skipp. Paul, who was previously responsible for the management of Luton and Belfast International joined the airport on 4th June. Prior to Andrew's departure the £17m runway resurfacing project was officially completed - to schedule and on budget. "

boaclhryul

9th Jan 2009, 20:19

Prior to Andrew's departure the £17m runway resurfacing project was officially completed - to schedule and on budget.

And the traditional third criterion - you can only ever meet two of the three - is of course quality.

Michael

Tinytim

10th Jan 2009, 08:41

WindSheer

10th Jan 2009, 13:10

I worked all through that. The airport 'officials' were a disgrace, entirely blaming the airlines, and giving absolutely no updated operational information/performance figures.

No wonder skippy resigned.....it was a shambles!

Spitoon

10th Jan 2009, 14:03

I noticed the Ops Manager is now working for Eurocontrol.....as an airports expert.

PAXboy

10th Jan 2009, 18:17

TinytimHad fatalities occurred there would have been a very strong case for manslaughter charges against this arrogant man.Except that this is Britain and all the legislation to have charges of Corporate Manslaughter - usually result in acquittal. There seems (I don't have figures) to be no improvement in companies being brought to book for failures - whether it is one death or many.

Tinytim

11th Jan 2009, 12:02

The corporate maslaughter and corporate homicide act introduced in 2007 set out a very clear offence which was designed to catch arrogant know- it- alls like Skipp.

As to whther or not an offence would stick would depend on the degree of negligence.

I suggest that there was evidence of recklessness on his part (ie a greater default than mere negligence) since he was expressly advised on numerous occasions that we, the operating pilots, had very serious concerns about operating from this runway which he was busy re-laying at night.

Of course, had the unthinkable happened, yours truly might well have been in the frame as well for knowingly operating an aircraft onto a runway that we had reason to believe was unsafe.

StaceyF

11th Jan 2009, 15:26

And we all remember the interview with Andrew Skipp stridently asserting that the runway was safe and by implication us mere pilots did not know what we were talking about.

His attitude to the safe well being of his customers was utterly reckless.

There were three "offs" before we finally refused to operate from BRS and countless near misses as we skidded to a halt.

Had fatalities occured there would have been a very strong case for manslaughter charges against this arrogant man.

I trust his current and any future employers are made aware of these facts.

:D:D:D:D:D

Excellent post; I can still remember listening to a live interview he gave on BBC Radio Bristol just after an airline (RyanAir maybe?) had bailed out of Bristol until it was sorted.

His arrogance was beyond belief; he simply stated the runway was perfectly safe, and that it was regrettable that some of the budget airlines worked to "different operating parameters" (yep, ad verbatim).

The interviewer even went as far as to say that surely the pilots knew what they were doing and he just repeated the "different operating parameters" line.

The clincher was when he was asked if he would be losing any sleep over the state of the runway and he said no :ugh::ugh::ugh:

As you say Tinytim, I hope his present employers are aware of his blase attitude to safety.

Silvertop

11th Jan 2009, 20:14

Excellent post; I can still remember listening to a live interview he gave on BBC Radio Bristol just after an airline (RyanAir maybe?) had bailed out of Bristol until it was sorted.

I think you will find that it was easyJet that took the initiative to de-camp to CWL until the surface friction issues were satisfactorily resolved.

As I remember, I belive that Ryanair decided to continue to operate from BRS, but I'm ready to be corrected.

Cheers Silvertop

Farfield monitor

11th Jan 2009, 21:05

It was a pain for the many passengers being diverted during the Closure of the runway including crew.
However I was under the impression that Mr Skipp was acting on information from the CAA, (not just his team) stating the runway was safe?

Airlines force runway closure at Bristol airport | Business | The Guardian (http://www.guardian.co.uk/business/2007/jan/08/theairlineindustry.transportintheuk)

Idiot, Daisy the

11th Jan 2009, 22:47

Risk assessment was flawed as it failed to even consider the scenario that ungrooved parts of the runway were a hazard in wet and windy conditions despite the fact that these conditions could have reasonably been forseen to occur at Bristol in any normal winter (both Belfast City and Luton considered such risks and the contractor was aware of such a risk).
Rumour has it that despite being told about pilot reports re-aquaplaning prior to any of the incidents in the report, a senior airport manager denied that this could occur and that the pilots concerned didn't know what they were talking about. Mind you, it's only a rumour and this is a rumour network.

Spitoon

12th Jan 2009, 06:03

However I was under the impression that Mr Skipp was acting on information from the CAA, (not just his team) stating the runway was safe?You're referring to a newspaper report from, I think, a non-specialist reporter, quoting someone whose credibility is being fairly conistently questioned by posters on PPRuNe.

In my experience, the CAA does not confirm that things are safe nor does it endorse work - at best it accepts that the proposals meet the rules. How this is perceived by the other party no doubt varies. What appears to be a weakness in this instance is that the CAA did not challenge the scope of the risk assessment. Nonetheless, the facts appear to remain that even when faced with serious incidents no significant action was taken to assure aircraft safety until the business' finances were affected.

In theory, the airport had to have a safety management system. In theory that SMS had to have been assessed in some way by the CAA and accepted. The CAA should then have gained assurance that the SMS was being applied and was achieving suitable results. Perhaps it is surprising that these points did not receive greater consideration in the investigation. The whole world seems to be going down the SMS route, at least in aviation, if it doesn't work then maybe a big rethink is needed. And yet the UK AAIB barely mentions it.

Helen49

12th Jan 2009, 06:34

I don't think the fault lies with Safety Management Systems but rather with management who fail to use the Safety Management System. They have all provided splendid SMS documents to the CAA and thereby obtained the tick in the box.

However, the next problems then frequently rear their heads. Eg. The SMS document sits in a bookshelf unused; the SMS uses high falluting language and concepts which are often a mystery; Managers fail to grasp and/or 'buy into' the philosophy of SMS; Safety Management Systems can be and often are overly bureaucratic; many of the CAA inspectors/regulators have never actually operated a SMS themselves etc etc.

The concept of having a 'system' for managing safety is excellent without question. Its introduction into the world of Airports has been haphazard [although not always]. As spitoon says, it is remarkable that even the AAIB make scant reference to SMS in most of their reports.

Helen49

Pinkman

12th Jan 2009, 08:19

You describe to a T the problem with ALL safety, health and environment management systems and risk assessments, whether proscribed by CAP, ISO, EMAS, etc etc

Having a safety system and conforming to a standard does not mean you are safe. It USUALLY means that there is some kind of consistency of documentation that purports to demonstrate that you have achieved a certain standard at some point in the recent past, but doesn't necessarily tell you about the exceptions and the culture, which are key determinants of safety.

That is why when you see exceptions such as the TAP whiteout examples on Maintainance reports (elsewhere on PPrune), while the individual exception per se may be trivial, any decent systems auditor looking at that would straight away have the hairs on the back of his/her neck go up and start digging into the culture aspects.

The current regulatory trend to self-assessment coupled with management systems and risk-based regulatory audits does work if you have those audits done by competent people and they are not just a form filling exercise.

But the current example is even more basic. I am from the oil industry and not qualified to comment on the AAIB report; I am sure that the AAIB conclusions are correct but I was surprised that there was not more explanation of causality and culture to enable learning points for other operators to be bought out so this doesn't happen again. That would include a re-statement of best practices and an explanation of the detailed procedures for risk assessment. Would be interested to have the benefit of Overrun's and other's opinion.

A quick read of "The safe management of civil airfield pavements" - Barling & Fleming's excellent 2005 paper - would have told Bristol most everything they needed to know to plan and execute the maintenance according to best practices and regs outlined by CAP, the ANO, and BAA, or at least realize that they needed to employ someone who could manage that process. There are templates there and loads of good information. It took me - a non-specialist - five minutes to find it on the internet and an hour and a half to read and understand it.

Pinkman

Farfield monitor

12th Jan 2009, 18:20

You're referring to a newspaper report from, I think, a non-specialist reporter, quoting someone whose credibility is being fairly conistently questioned by posters on PPRuNe.

Not just the newspapers were quoting this Spitoon :ugh:

BBC NEWS | England | Bristol | Bristol runway shut in safety row (http://news.bbc.co.uk/1/hi/england/bristol/6238311.stm)

frontlefthamster

13th Jan 2009, 06:04

Spitoon said:

And yet the UK AAIB barely mentions it.

and I wonder if he needs to re-read the report; I thought it made it quite clear that the 'risk assessment' carried out failed to identify the hazards to aircraft operation. These processes can be very helpful, but only work if appropriate groups of competent individuals are given the time required to work through the problem.

GroundBunnie

13th Jan 2009, 12:52

Silvertop

I worked all the way through it, for an airline now acquired by another. We had a 145 go farming, but the pilot managed to get it back on the runway. I was the station manager for the airline, and by the time I got airside, the a/c landing lights were pointing in my direction at the terminal. The pilot also managed to taxi to stand, where the pax were unloaded and I had to talk to them in the terminal. Not many had brown trousers on, unfortunately.

You were right about EZY, they went to CWL, and RYR carried on operating until BIA made the decision to close. We stopped operating after EZY went, and I became in charge of a coaching operation for the next 3 days.

Nightmare I wouldn't want to repeat

GB

Spitoon

13th Jan 2009, 15:53

Spitoon said:
Quote:
And yet the UK AAIB barely mentions it.
and I wonder if he needs to re-read the report; I thought it made it quite clear that the 'risk assessment' carried out failed to identify the hazards to aircraft operation. These processes can be very helpful, but only work if appropriate groups of competent individuals are given the time required to work through the problem.frontlefthamster, I have re-read the report. You are quite right that it states that the risk assessment failed to identify hazards to aircraft operation. It also mentions a Safety Case produced by the airport. In fact, it devotes about a page and a half to the topics - this out of over 60 pages of facts, analysis and conclusion.

Safety Management Systems are 'marketed', by some anyway, as the generic way to assure that things will be safe, irrespective of the technologies used or the environment. ICAO has gone for this in a big way, perhaps because keeping the SARPs 'up-to-date' and relevant to modern operations was becoming increasingly difficult. So in this context the SMS is the lynchpin for all other safety activities. And at Bristol it seems to have failed. This still seems to me to have more significance than is reflected in the AAIB report.

I also believe that it is wholly misleading to equate 'doing a risk assessment', flawed or otherwise, or producing a Safety Case to operating a SMS. An effective SMS is not easily described - it is a way of working, a set of procedures that are clear, do what they are intended to do and are used, both pro-active and reactive to event, a culture that pervades the organisation. The way in which the organisation appears to have permitted information that all things may not be well to be ignored - OK, perhaps that's unfair, shall we say over-ridden by commercial imperatives - is a good example of an ineffective SMS.

Just in case it is not apparent, I am a believer in this SMS thing - I always have been - because I think it works. It makes things safer. And it's not difficult to do. Most of it is little more that common sense and professionalism. Sadly, where SMSs appear to fail it seems almost always to be failings not of the concept but of the implementation, and usually from the top.

OK, I guess that's the rant over.

Farfield monitor

13th Jan 2009, 19:11

And just like magic the CAA produced this doc last summer...

http://www.caa.co.uk/docs/33/CAP781.pdf

:D

commit aviation

13th Jan 2009, 19:45

Spitoon

Good post: I think the critical word in your post regarding SMS was "generic". Whilst a safety case or risk assessment may be cribbed from a previous version - perhaps used at another airport or maybe another industry, it is critical that a "one size fits all" / tick in the box culture isn't allowed to develop.
You need to take local factors into account as no 2 airfields / industries are the same.

PAXboy

14th Jan 2009, 11:45

With regards to prosecution for 'Corporate Manslaughter', Tinytim is correct that the law was tightened but my cynicism is based on reading of a prosecution last year brought under the new law (if only I could remember the details!) where the case was dropped before it reached court. Howls from the families involved but 'not enough evidence' and all that. The Brits have a very bad record in prosecuting corporate manslaughter.

As Pinkman says - no one is learning the lessons from other airfields. Do you think that the other regional fields of the UK all thought, "Wow! Let's read up our regulations and make sure we know what to do." ?? Do you think the CAA has decided, "The next time a field announces a resurfacing project, we'll be sure to make sure that they have learnt from others. After all, our job is safety." ??

No. Me neither.

WindSheer

14th Jan 2009, 12:55

I can remember being in my office monitoring atc when this issue really started to 'kick off'.
An easy 319 lined up for departure on 27. Upon receiving t/o clearance along with the surface wind, they declined the clearance stating that the crosswind was over their 'revised limits'. ATC questioned this, as one can expect. The pilots informed them that they had received a fax from easy ops stating concern over the low adhesion at BRS, and had put a revised crosswind limit in place. ATC then informed them that there was no issue, and again cleared them for take off. The pilots declined and actually read out the fax to atc. The wind was then monitored for about 2 minutes until it was within limts, and the aircraft departed.

This all happened about 24 hours prior to the airline 'evacuation' from the airfield.
What I was amazed at was the pressure put on the pilots by atc, and that they were in a way 'defending' their runway. The easy pilots were unbelievably vigilant and steped over any 'advice' passed to them over the frequency. They departed when THEY declared it safe.

What a massive break down in communication. Easyjet ops obviously deemed the issue/risk serious enough to call a meeting, and produce a document for all BRS arrivals and departures. BIA buried their heads in the sand, and did a poor job of updating the guys in atc, the men and women at the forefront of the BIA operations.

24 hours later the airport was in chaos as airlines pulled out 1 by 1, BIA management then even appeared on TV slamming the airlines for withdrawing over speculation.

I hope lessons will be learned nationwide.......:ok:

P.S Again, credit to the ezy pilots who were a shining example of proffesionalism!!

safetypee

14th Jan 2009, 13:28

We should not forget that the operators should also have had a SMS in place, which could have triggered action. In some instances operators did react, others did not; this variability identifies with some of the problems of SMS’s.
SMS are a good concept which theoretically should improve safety, however not all situations can be identified with proactive work, e.g. audit. Thus, there has to be reliance on knowledge and planning – resulting in procedures, recommendations, which in turn relies on communication and a potential user’s understanding.
In the instances at BRS the knowledge and planning aspects appeared weak across many levels of management – regulators, airport, and operators, and in combination with weaknesses in communication there were many opportunities for error.
The result, like many implementations of SMS, is that the safety system relies on reactive involvement of all parties involved.

This begs the question, how many incidents do you have to have before the hazard is significant? As an example, on a good runway surface, an aircraft could land in very wet conditions and report poor braking, yet the problem could have been with that aircraft alone. Thus for an effective system all aircraft would have to report braking effectiveness, but then this is subjective and depends on aircraft type.
The issue at BRS was that what information was known about poor runway surfaces were not well communicated, not clearly understood, or when obvious appropriate action was slow. The human element – in SMS, like in most operations can be a dominating contribution in incidents.

The background to the UK CAA activity is here: Factor F01/2009: Serious Incidents to: Boeing 737-81Q,G-XLAC on 29 December 2006, ATR-72-202, G-BWDA on 29 December 2006, EMB-145EU, G-EMBO on 29 December 2006, and Boeing 737-81Q,G-XLAC on 3 January 2007 at Bristol International Airport. | Publicati (http://www.caa.co.uk/application.aspx?catid=33&pagetype=65&appid=11&mode=detail&id=3379)

For operators who wish to use runways that are ‘slippery when wet’, what additional information do you expect to get from the airport that will help a decision to operate or not – see CAA advice to ask airports.
For crews, if a runway is ‘slippery when wet’, is it treated like a contaminated runway – very wet friction like ice, if so then with any crosswind, landings should not be considered.
But have we learnt this after the fact?

RVF750

14th Jan 2009, 14:59

What have we learned? A lot of UK airports have been or are in the process of re-surfacing sincee the BRS affair. GUR, NQY and IOM to name but three.

The IOM did an excellent job of nightime re-surfacing and kept airlines informed throughout. There was only ever one 100m section with top coat ungrooved at any time and the weather was fine throughout. The new surface is very grippy indeed, and no problem even in the very wet conditions encountered there over, well, the 11 1/2 half month winter period. NQY were also very good in providing information of works. GUR will no doubt also put the lessons learned into good use when they bigin.

jimworcs

14th Jan 2009, 15:03

Statement from Bristol International Airport
(09/01/09)
Bristol International Airport welcomes the Air Accidents Investigation Branch (AAIB) report published today regarding the runway incidents which occurred in December 2006 and January 2007.

The report relates to four incidents which occurred under a combination of exceptional circumstances, including runway resurfacing work which takes place once every 15-20 years, heavy rainfall and severe cross-winds.

The Airport consulted at length with the Civil Aviation Authority before the runway resurfacing began and engaged the leading expert designers, engineers and contractors in this specialist field. Standard industry practices were followed and aircraft operators were kept informed of the work in progress.

Safety remains of paramount importance at Bristol International. The Airport is proud of its strong track record in this area and its reputation as a successful regional airport serving Bristol and the South West.

Is it just me, or does this response seem insufficiently contrite?

Spitoon

14th Jan 2009, 16:25

We should not forget that the operators should also have had a SMS in place, which could have triggered action.Not strictly true. Aircraft operators have only been required to have a SMS in place since the start of this year. That said, any UK AOC holder will have had to have something in their Ops Manual that should have triggered action - the CAA will have insisted.

ivor toolbox

16th Jan 2009, 18:32

At last a result worthy of pprune.

I too worked for the same airline as 'groundbunnie', albeit on the other side of the airside divide, I oversaw recovery of one from the grass, then had to work on another that happened the same evening.

Whats' not been mentioned is how many similar reports at the time were put through the company ASR scheme,and did they make it to the investigators?

IIRC, the airport management were relying on Mu-meter readings,
being set against what subsequently turned out to be out of date information,by 'ranger one's department.

ttfn

PAXboy

17th Jan 2009, 00:19

Thanks for posting jimworcs, that is a 100% example of modern corporate non-speak. It is the reason that most folks do not trust corporates because they cannot back down, they are too scared to admit they are wrong, because then they have to pay money. They also have to explain previous golden handshakes and ... no, I'd better stop because those paragraphs say it all.

OverRun

17th Jan 2009, 01:29

That’s a very nice piece of work on planning runway rehabilitation projects by CAA SRG in CAP 781. I quote from its introduction:

As runways can have up to a 30 year life span depending on traffic levels, it is quite possible that, at a number of aerodromes, those in charge of the project will never have attempted to rehabilitate a runway nor will ever be involved with such a project again. Only at the biggest, most heavily trafficked airports is it likely that resurfacing part or all of a runway occurs more frequently and hence a body of knowledge and experience can be assembled.
Over the last few years the changes in the UK air transport industry have seen a number of factors affect aerodromes. Due to the national increase in passengers travelling, smaller regional aerodromes have experienced a consequent increase in runway use accelerating the need for major maintenance. Another important impact has been the loss of aviation operational experience from the industry and an increasing number of senior managers entering from other spheres, instead of rising through the operational ranks.
These, together with recent experiences at a number of aerodromes, have led the CAA to identify an increased level of risk in the case of runway rehabilitation projects, especially those being undertaken by ALHs with little or no experience of such a project where public transport jet or turboprop movements are to continue during the work. The CAA believes that the provision of guidance material regarding the management of a rehabilitation programme will be beneficial to industry in helping to reduce these risks.

That document, and those exact words, have circulated amongst airport engineers in more countries than just the UK. The loss of expertise and the increased level of risk in runway rehabilitation projects can be just as easily found in other countries, and the CAP 781 has much to commend it for many countries.

This document did come directly from the lessons of other airfields, and it pulls together a lot of industry knowledge (and not just from the UK). I suspect that in the UK now, all regional airports considering resurfacing read this document beforehand. And Paxboy, I do believe that CAA-SRG really did decide that "The next time a field announces a resurfacing project, we'll be sure to make sure that they have learnt from others. After all, our job is safety."

Now let me turn my attention to Bristol International Airport. And my wrath after reading their statement. Have they learned nothing from the incident? Do they think that we are as big a fool as they are, and will believe this? I explained at the time that this was not ‘runway resurfacing’ work. It was large scale work better described as reconstruction or rebuilding, not as resurfacing. Reconstruction is a whole different ball game. While resurfacing usually happens while the runway is left in service, reconstruction is usually not.

At the time I said There is a subset of airports that might be characterised as those with only one runway and non aviation people in charge. Some airport managers/boards are not aviation people at all, and neither understand the concept of redundancy nor care about operations. They operate inadequately, and others suffer as a result. This is NOTHING to do with the aviation professionals that work at the airport, and everything to do with the Board and most senior management of the airport company.

I guess not too much has changed at Bristol.

Maybe they’ve got Skippy back doing their press releases?

PAXboy

17th Jan 2009, 02:21

Thanks OverRun that is very reassuring. In my (main) field of telecommunications, the loss of operational expertise has also happened. Older folks got retired early, or chose to leave rather than put up with the new style 'managers' telling them how to b@lls it up.

As a result, when something goes wrong the company may not have someone who can say, "Hang, I remember when something like this happened NN years ago. On that occasions we found that X was the problem." The turnover of generations accelerated in the late 80s and throughout the 90s, to be faster than before.

Pinkman

17th Jan 2009, 11:41

Building on Overrun's post, and the above SMS discussions, yes, SRG's CAP 781 (i've read it) is good and the various revisions and discussions behind the scenes in its revision didn't go unnoticed. But in the scheme of things you are still left with the fact that its is just a document. A good document, but it requires that people read it, believe in it, understand it, and implement it.

There is a famous graph (which I can't seem to find, maybe Overrun has a copy) that shows how industry in general has progressively improved safety and lowered incident rates over time, firstly through the application of better engineering and hardware, then when the law of diminishing returns kicked in, through management systems, and thence to culture and behaviour. CAP 781 represents the middle one. Without a fundamental change in culture, the lessons of BRS will soon fade and improvements will stall.

Pinkman

OverRun

17th Jan 2009, 12:07

I think the graph is here http://www.geocities.com/profemery/SMS.jpg

Spitoon

17th Jan 2009, 17:43

OverRun points us toward toward CAP 781, which indeed appears to include some useful information (although much of it should not be new to experienced project managers). As Pinkman points out, it's just a document - but let's assume for a moment that people take the advice that it contains..

Super - next time an airport needs to rehabilitate a runway they can get the book off the shelf and benefit from the advice. And before long they will probably have no idea how hard won the compilation of that advice was. Sadly the one passing reference in the document to the airport's SMS is unlikely to do much to feed the advice, in generic terms, into that SMS. So if the airport is going to do some other form of work on the runway (or anywhere else come to that), any relevant guidance in CAP 781 will probably be overlooked. I guess we'll get a CAP about working on runway lighting 18 months after there are a string of incidents related to some AGL project.....

Strange really that the UK CAA, or at least some of its staff, have claimed to be world leaders in SMS application and so rarely promotes effective implementation.

PAXboy

17th Jan 2009, 18:30

Writing beautiful documents, guidelines and examples of best practice and hard earned experience is, relatively, cheap.

The cost of sending experienced, high quality humans out to a regional airport to train the staff embarking on a big project and then to monitor their project ...??? That takes long pound notes.

Knowing nothing about the CAA but a lot about living and working in the UK, I would wager that the CAA does not do that any more - if it ever did. One of the pillars of the temple was removed when Thatcher & Co implemented the 'Light touch of regulation'. They might have started with the likes of British Telecom but the path was set. Another pillar was removed when 'agencies' were created from govt departments and another pillar was the budgeting of said agencies.

Further, I would guess (note that I am mere pax and know nothing and I am GUESSING) that the CAA and others (not all) involved in UK airline safety (ground and airborne) are currently running on their reputation. That and the very hard work of the front line people who are keeping vigilant.

I hope I'm wrong but the law of familiarity will have it's way.

zalt

17th Jan 2009, 18:56

Spitoon

Strange really that the UK CAA, or at least some of its staff, have claimed to be world leaders in SMS application and so rarely promotes effective implementation.

Surely they are leaders in tombstone thinking - they even have one outside their HQ.

ADDED - On the Hudson ditching thread this report has been highlighted:
http://www.caa.co.uk/docs/1437/srg_acp_00018-01-030303.pdf
It certainly shows the UK CAA can think outside the box an anticipate genuine emerging risks when it puts its mind to it.

Pinkman

18th Jan 2009, 06:26

Fair comments, in some respects. Unfair perhaps to have a go at SRG on the timing of CAP 781 because my understanding is that it was already in preparation before the incidents at BRS. It was then further delayed by a review in the light of what happened at Bristol before the draft was finalised. Its irrelevant anyway because CAP 760 which WAS published before the incidents has as much if not more relevance.

To my mind it is very simple. The AAIB report should have asked and answered the following questions:

- Was there a performance failure by the individual aircraft operators?
- Was there a performance failure by the aerodrome operator - BRS?
- Was there a failure in oversight by the regulator - SRG?

and a more general question:

- Is there a need to review the system by which aerodromes are licensed and their performance and management assessed?

If these questions have not ALL been addressed then IMHO the report is deficient. And there is no reason as far as I can see why the AAIB (which reports to the department for transport) could not thoroughly assess the role of the SRG (which reports to the CAA, an independantly funded and operated specialist public body) in the context of this incident. The questions go back to the credibility and independance of the AAIB.

More worryingly, if the AAIB isn't prepared to thoroughly review the actions of its peers then how, as a nation, can the Brits criticize the French and the cozy government/Airbus relationship? It could be the death of our national sport...

OverRun

18th Jan 2009, 11:33

AAIB report? Bit thin I thought.

zalt

18th Jan 2009, 12:16

It does seem to focus on science of paving rather than SMS & airport management. Perhaps the AAIB needed to take on a specialist in the field to advise.

Sir George Cayley

18th Jan 2009, 15:50

Although a number of areas in aviation are having to come to terms with SMS, UK licensed airports are not. That's because Aerodrome Standards (and Air Traffic Standards) took onboard SMS quite some years ago.

It would seem that the CAA publications that have been issued over the years have gradually started with SMS as a given when addressing airport managers. Funnily enough, CAP 772 the Bird Hazard Bible, when reissued from CAP680, certainly seems to take airports SMS as already in place.

To some extent, that managers at aerodromes keep changing and hence their replacements have to be "programmed" into SMS (not sure if they have it at Costco) is a nub of the problem. But there again the CAA's own management of safety should systematically look for these failings and address them?

Lastly, the flocking birds report is actually from some time ago, I seem to remember it around the millenium.

Sir George Cayley

zalt

18th Jan 2009, 18:12

Sir George

That was my point - the paper on 'large flockers' was done years before what seems to have been the first hull loss last week (done in about about 2002 or 2003).

Interesting if airport managers aern't coming from aviation. Even more reason for the AAIB to look at more then 'the technicalities'.

Pinkman

18th Jan 2009, 21:29

Agreed...

The problem you describe (the rise of "business managers" who are there to generate income, are from another industry, who are not thought to need to know the minutiae of the business, and who turn over very quickly) is evident everywhere. It was mentioned by Paxboy as being in telecommunications, and it is certainly starting to happen in my industry. When explaining to these wunderkind that they will face regulatory action and loss of profits or liberty if they compromise on safety, and if you can show through your risk assessment that this is a real possibility, all of a sudden you can compete with cash projects and safety can take its place alongside financial objectives. Because business drivers are leading to the hiring of administrators who dont understand the technical side of the business at the same time that as a society we are moving to a self assessment model for compliance then the corollary is that regular audits and proper incident investigations need to be carried out by people who ARE technically competent. And THAT is why the AAIB report should have addressed the "why" it was permitted to happen as well as the "how" it actually did happen.

PAXboy

19th Jan 2009, 00:25

Slightly off topic but stick with me.

My Saturday job as a 16 year old was as counter staff in a department store. The General Manager had started as Saturday staff, been through the loading bay and warehouse, then back to the counter, then junior manager and so on - all the way to GM. The organisations or business where that happens now must be very few.

In the late 1980s, I recall a conversation with a pal who ran the telecommunications of a major UK hospital (I won't be more specific). He needed a completely new telephone system (about £1M or so) but they chose to refurbish an operating theatre. The next year they turned him down for another project. In the end he demonstrated how the failing phone system was costing lives. He got the money.

Without being political it was the Tories who promoted the idea that any good manager could manage anything. I did not agree in the 1980s and nothing I have seen in UK govt, privatised industries or banking has changed my mind. But - how we restart the culture of working your way up - I have no idea.

I am biased, as I have always worked in service industries. I worked my way up in comms and then in the work I do now. Oh yes, and I'm middle aged and I've seen it before. :hmm:

WHBM

19th Jan 2009, 10:19

One thing does not come out in the AAIB report.

We have had runway resurfacing/regrading rojects for many years, almost all airports worldwide do them from time to time. Also, the bulk of commercial airports in the UK have only one significant runway, and continue operations during such projects, even where the physical work is done during nighttime closures. And yet there has never been an experience of four aircraft getting off the runway in a few days during such a project.

So what was different on this occasion ? This is surely what the AAIB should put their finger on, so it may be avoided in the future. Runways will continue to be rebuilt, what aspect should be avoided to prevent getting into the same situation again. Was it some aspect of the work sequence, or the materials or work method, or aircraft procedures, or limits, or what ? I don't see this addressed in the report

Musket90

19th Jan 2009, 13:29

So what was different on this occasion ?

A few thoughts

Maybe the runway profile, including the ramping, during the period concerned didn't allow water to quickly drain off the ungrooved surface. strong crosswinds with rain may have had similar effect.
The re-profiling of the runway which required base course to be laid separately which other airport resufacing projects may not require.
This re-profiling and consequent areas of ungrooved base course shown in Figure 5 of the report seem to be spread across a lot of the surface which may not have helped.
The wet weather preventing an accurate friction assessment to be carried out using self wetting device (always a problem during winter months).
Unfamiliarity with friction runs and reporting under such conditions.

OverRun

19th Jan 2009, 22:52

And one more thought on what was wrong:

There was far too-short a period for closure. In the hours available during closure, the contractor must:

adjust markings/lighting
mobilise equipment onto runway
remove asphalt ramps from previous night
if needed remove light fittings
milling out old asphalt
laying new asphalt
compaction
cooling
possibly laying another layer and cooling
if used, temporary grooving
if needed, cut runway lighting slots and cores
if needed, install light fittings
lay asphalt ramps
adjust markings/lighting
demobilise equipment from runway
runway safety inspection
re-open

The typical minimum time is 8 hours, and it usually does involve some rescheduling of aircraft on some days. The pressure from the commercial mangers (and most non-engineering airport management) is that the airport must be kept open and no flights can be disrupted. The two goals conflict, and with an overbearing airport general manager and a weak airport engineering manager, the wrong goal can take precedence. The closure time at BRS was, AFAIK, 6 hours.

With all the peripheral activities required, the actual asphalt laying part of the job within the 6 hour timeframe is very short. This has the effect that (a) many more days of construction are needed, which increases the number of aircraft exposed to these constrained operations; (b) the lack of time forces shortcuts in the works needed to leave the runway in a safe condition; and (c) the quality is poor meaning that the next runway rehabilitation occurs sooner.

Turning back to the Statement from Bristol International Airport (09/01/09). They claimed that they engaged the leading expert designers, engineers and contractors in this specialist field. Standard industry practices were followed
I don’t think it is relevant if the contractor is experienced in these matters. The experience of a contractor is that of delivering their product close enough to the specification and as cheaply as possible so as to make a profit. They are not airport engineers, nor are they going to overrule the superintendent/consultant engineers on technical matters. The contractors are used to lots of silly ideas in specifications, and one more isn’t going to phase them. If they are given an overly tight timeline, then they’ll simply try to meet it.

And the claim that ‘standard industry practices were followed’ is a subtle alarm bell. You see, the industry of the contractor is that of the ‘road asphalt industry’; there is no such thing as an ‘airport asphalt industry’. All across the world, asphalt comes from contractors who work on roads and highways with only the occasional job on airports. Even if a contractor has surfaced several airports before, the majority of that contractor’s staff, quality controllers, systems, and operators have gathered their expertise from the road sides of things. There are subtle differences between roads and airports. I’m sure the contractor was following standard industry practices of his own ‘road industry’, but what was needed was for the airport engineers to adjust those practices to airport requirements.

One of the reasons that I am positive about CAP 781 is that it contains a number of those subtle differences.

WHBM

19th Jan 2009, 23:18

if used, temporary grooving
So, is temporary grooving normal ? Or is it normal should rain and/or crosswinds be forecast ? Or is the contractor asked to stop works if such conditions are forecast ? The surface is normally temporary only for one night, the works move on to the next section next night.

OverRun

20th Jan 2009, 01:23

Temporary grooving is one option. I think there are better engineering solutions, and so it is pretty rare to find. I do not think it is particularly efficient or cost-effective, but sometimes I guess one gets stuck in a poor situation and so it gets chosen. I recall that was used at BRS eventually. CAP 781 (section 3.1.5) refers to it as an option.

I’m uncomfortable with the thought that temporary grooving should be considered normal should rain and/or crosswinds be forecast. If it is raining to any extent, then asphalt laying shouldn’t take place for normal construction quality reasons. Normally major construction is planned around weather patterns, and is done in the drier seasons (if applicable). Yes, if unexpected rain is forecast on the night, the works are temporarily stopped.

But the works planning at BRS combined winter with rain and crosswinds on what is a single very short runway. The risk of aircraft overruns under those conditions is considerably higher, and the planning for the works failed to recognise this and so they were simply hazardous. And were shown to be so in practice.

PAXboy

20th Jan 2009, 10:53

Thank you OverRun, most interesting. Just a regular pax here.

BRS has an increasing number of summer destinations, both schedule and charter, so the commercial imperative to resurface in winter would be clear.

In recent years in the UK, many complex engineering projects, such as bridges, tunnel repairs and railway improvements (both permanent way and platform) have changed their timing of works. It was usual to do a little bit every night for, perhaps, months. Then it was realised to be far more cost effective and ultimately less disruptive, to close the road/railway/bridge for an intensive period of work - say three days, one week or one month of 24x7 as opposed to five months of night time working. Not least as the plant is then not standing idle for 16 hours a day.

I realise, of course, that airlines are not keen on such things but do you know of any single runway fields that have used the full shut down route, rather than night time working?

mad_jock

20th Jan 2009, 11:36

Its a case of re-inventing the wheel and not looking at history.

A 100 years plus ago heavy industry went through all these hassels with plant and unplanned shut downs.

They started doing the fair fortnights. Glasgow still does it to a large extent and there are a few other ones around the country.

Basically all heavy industry shuts down for a fortnight. All the staff have a holiday apart from the maintence boys. Which is why its best to check when the Glasgow fair is because it doesn't matter where you go there will be some pissed up idiot in a rangers or celtic top.

All the big projects are completed all parts that are due in the next 6 months are swapped out early everyone is happy.

Now personally if I was relaying a runway, a year in advance I would tell everyone that the airport was going to be shut for 3 weeks. Tell the staff to book holidays for that date or get those training cources booked, book the contractors and materials with hefty penalty clauses. Portacabins to sleep in and on site catering, laundery. 2 weeks jobs done. 1 week for cockups and inspections rectification lighting etc. Public arn't pissed off, airline arn't pissed off. Jobs done. But then again I am an ex mech eng the bean counters wouldn't go for it. Its taken years for the oil industry to learn that sometimes the engineers actually know what they are talking about when it comes to project managment.

I have seen oil yards when the poo hits the fan turn round 50 million pounds worth of kit after one phone call and the whole thing is setup by an old boy with a ONC to his name in 10 mins

1. tell the boys they are on double time until it finishes
2. Book every artic you can get your hands on and start dumping trailers in the yard
3. Tell the butty van to park up in the corner.
4. If i see anyone without PSE on they will be cleaning the bog in the bothie.

And PAX boy the RAF to my knowledge are the only ones who shut down all flight ops to get things sorted Brize was the last one to my knowledge but that was shut for months not weeks

AirportsEd

20th Jan 2009, 14:14

Weeze in Germany - the former RAF Laarbruch - closed down for two weeks in the spring of 2007 in order to resurface the runway and some of its taxiways, while also taking the opportunity to install part of an airfield lighting / ILS upgrade.
The lighting aspect of the work was completed after the airport had re-opened.

OverRun

20th Jan 2009, 23:09

Single runway airports – shut down? Several in Nigeria – Kaduna Airport and Maiduguri Airport for unknown periods. Chapel Hill in USA for 21 days. Aspen USA for 2 months. Broome in Australia for 11 days. Pune, India for 2 weeks. Bloemfontein, South Africa for two weekends (2 runways, so the main runway was closed for 2 months and this total closure was just for the intersection). Google News showed 8790 news items on ‘airport closure works’ for the last 10 years, so a guess of 100-200 might be reasonable.

There are some single runway airports which are very long, and works can shut one end and operations safely continue at the other. Walvis Bay in Namibia, and Auckland in New Zealand are examples.

Mostly, airports have more than one runway, and can then close one runway (although even that takes considerable organisation and planning). It is a popular option in Australia, with Perth and Melbourne doing that recently. Dubai did that a couple of years ago.

Mad_jock has the right idea though. I’ve got something like the 'fair fortnight' coming up soon – and everyone from every maintenance department is going to share in the shutdown. I only wish I had heard his advice earlier about allowing 2 weeks jobs done. 1 week for cockups and inspections rectification lighting etc. Got the 2 weeks bit right on another airport. Forgot to allow for the 1 week bit. Things were a bit hectic towards the end of the closure.:O

mad_jock

21st Jan 2009, 00:41

and as its an airport book calibrator for 5 days before planned opening. Again the fannys on the lighting will take 4 days to find a bulb which will be the whole ball ache of passing regulation check.

OverRun

21st Jan 2009, 03:17

mad_jock - was that you the other day on the new eastern runway at Doha installing lights and PAPI?

mad_jock

21st Jan 2009, 12:37

No I only drive the aircraft but have noticed the more important the bulb the longer it takes to get a new one. And also the more important the bulb the less they carry in stock and if its mission critical they won't carry a spare.

The other thing that seems obvious to me is that if you install a double unit with 2 bulbs of the same batch the likely hood is they are going to fail at the same time. So you swap one of them after a month and carry 2 in stock. This then gives you at least 2 weeks to get more in.

But if you suggest concepts like this you get blank looks and "why do you want us to change a working bulb?" And bulb can be swaped for any unit mechanical or electrical which is a consumable unit.

WHBM

21st Jan 2009, 13:10

Mostly, airports have more than one runway, and can then close one runway
Certainly here in the UK very few airports have two jet-capable runways, probably no more than half a dozen in all in the whole country, and the few that do have them generally have no ILS etc. Quite different to the situation in the USA for example. Many places used to have more, but have squeezed down to the minimum due to the commercial people thinking it can all be done with a minimum of investment. Which is probably where we came in .......

Sir George Cayley

21st Jan 2009, 17:01

Quick 180 'n backtrack to post #53 Musket90, if I may.

Looking at the AAIB report I read it that the contractors downed tools for the 2006 Xmas break leaving "The Patch" exposed until their planned resumption in the new year. It was in that boring bit, between Boxing Day and New Years Eve, when you've played with all the kids pressies, fallen out with the in-laws and been to the Saturday football match that the major off's occured.

Had the contractor adjusted the programme to leave the runway with no Patch we probably wouldn't have anything to gossip about, but hey isn't hindsight wonderful.

As you were:ok:

Sir George Cayley

WHBM

21st Jan 2009, 21:51

Looking at the AAIB report I read it that the contractors downed tools for the 2006 Xmas break leaving "The Patch" exposed until their planned resumption in the new year. It was in that boring bit, between Boxing Day and New Years Eve, when you've played with all the kids pressies, fallen out with the in-laws and been to the Saturday football match that the major off's occured.

Had the contractor adjusted the programme to leave the runway with no Patch we probably wouldn't have anything to gossip about, but hey isn't hindsight wonderful.
I'm sure the contractors would have been delighted to have carried on working through this time, just as contractors (possibly the same ones) do on the railway at such times. The fact is that the mainstream UK construction industry shuts down for two weeks over Christmas/New Year (giving that big boost to travel aviation gets to Ireland and Poland at that time), and any works done during that time is with labour paid at a premium rate, which of course would have added to the price quoted. It's not just the contractors on site, but all the materials delivery plants for bulk concrete and asphalt, and the truckers, etc, that you need to keep open.

And yes, contractors are used to organising this sort of premium-rate work. It's actually more profitable for them than regular work, and many of their men like the extra money. But was the client at the airport owners prepared to pay that premium to continue work over this period ? You've got your answer.