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ATSB report into runway incursion at Perth Airport

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ATSB report into runway incursion at Perth Airport

Old 9th Oct 2020, 22:28
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So to be clear, how many years did this taxiway orientation exist? How many thousands of aircraft and crews had NO PROBLEM? But the answer is close the taxiway.
If you read the report this may have answered your question:

Of the 44 incursions, 16 involved taxiway J2 on both runway 03/21 and runway 06/24. For that reason, the taxiway intersection of J2, J1 and A with runway 06/24 was marked as a runway incursion hot spot on aerodrome charts.
And that was between 2015 and 2018 so clearly there was a problem with that taxiway. The incident highlighted the potential for a collision at that intersection, now that J2 has been removed that potential no longer exists.
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Old 10th Oct 2020, 00:41
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Quote:
So to be clear, how many years did this taxiway orientation exist? How many thousands of aircraft and crews had NO PROBLEM? But the answer is close the taxiway.


If you read the report this may have answered your question:
I don't think the report answered either of my questions. Can you show me where it says how many thousands of crews had no problem?
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Old 10th Oct 2020, 23:03
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Originally Posted by Icarus2001
Can you show me where it says how many thousands of crews had no problem?
A better metric would be how many crews managed to hold short of runway 06 when it was active and they were instructed to.

Despite that though, 43 crews other than this one had a significant enough potential conflict on this particular runway/taxiway intersection to warrant some action. That would seem to deem physical response being necessary rather than just a visual or verbal mitigator which seems to have failed 44 previous times.
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Old 11th Oct 2020, 02:56
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Originally Posted by Icarus2001
I don't think the report answered either of my questions. Can you show me where it says how many thousands of crews had no problem?
You obviously don’t understand threat identification and mitigation. Just because thousands of crews had no problem, the fact that 44 didn’t shows there was an obvious threat that wasn’t being managed by other means every time, so the safest mitigation was to close it.
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Old 11th Oct 2020, 03:55
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Given the position of the holding point on J2 was a long way back from the gable markers to allow aircraft to also pass on taxiway A, it would be interesting to see how many of the 43 got close to even the gable markers versus just crossing the holding point without a clearance. No idea how you could determine that from historical data but I suspect if we had that information the answer may not have been to simply remove the J2 option.
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Old 11th Oct 2020, 04:28
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Could go back to 1965 where all aircraft STOPPED, looked both ways and awaited clearance.
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Old 11th Oct 2020, 04:51
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Can you show me where it says how many thousands of crews had no problem
After any accident/incident/close call you can point to thousands, if not millions, of prior successful operations, but following a failure you learn from the lesson imparted and endeavor to do something about it. 747 that had the slats retract at rotation not so long ago, never a problem prior, would you expect the authorities to do something about it, or dismiss it, as it's never happened before? The question is why did it take 16 of the 44 total occurrences before it was made an issue, anyone of those events could have had the possibility of metal and bodies strewn across the landscape.
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Old 11th Oct 2020, 21:56
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And how about the numerous non reported NON occurrences because 1 member of the crew managed to relay a STOP message to the PF. J2 became a part of my approach brief into Perth
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Old 12th Oct 2020, 01:21
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Originally Posted by rockarpee
And how about the numerous non reported NON occurrences because 1 member of the crew managed to relay a STOP message to the PF. J2 became a part of my approach brief into Perth
yeah it was frequently mentioned ime also
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Old 12th Oct 2020, 14:38
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Likewise. How many times does a potential life threatening “poor design” need to be pointed out before anything is done?

A lot, it seems.
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Old 12th Oct 2020, 23:07
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How many times does a potential life threatening “poor design” need to be pointed out before anything is done?
This is one of the worst things about "safety". You are not allowed to challenge the system. Quite often systems or airports are not design properly or corners cut to save money creating a safety hazard. When this is pointed out through safety reporting the safety department leaps to the defence of the system regardless to the obvious hazards. It isn't until there is a near disaster that the safety position is untenable and miraculously things get fixed.




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Old 12th Oct 2020, 23:51
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Its a good point nev. Safety is driven by data and risk assessment. The old common sense rule has been replaced by quantitative evidence. A good example is the table in the report that shows the classification of ICAO runway incursion severity. Most of the incursions are in the lower risk category so Perth Airport could say there was nothing wrong with the position of J2 therefore money doesn't have to be spent to fix it. Once this incident put it into the significant risk category then the risk assessment matrix started to move into the red end of the likelihood and consequence box. Now the cost of potential litigation outweighed the cost of removing it The ridiculous part is all they had to do was alter the entry into J2 from runway 03 so that any aircraft had to slow to a normal taxi speed and the risk of incursion would be significantly reduced. Taxiway E2 off 05 in Adelaide shows how that could be achieved.
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Old 13th Oct 2020, 01:02
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Originally Posted by neville_nobody
This is one of the worst things about "safety". You are not allowed to challenge the system. Quite often systems or airports are not design properly or corners cut to save money creating a safety hazard. When this is pointed out through safety reporting the safety department leaps to the defence of the system regardless to the obvious hazards. It isn't until there is a near disaster that the safety position is untenable and miraculously things get fixed.
That is why as pilots, we should all slow down, knocking back the track shortening/high speed descent, throwing that extra ton of fuel, knocking back a duty extension, etc. Unless there is absolutely no reason not to. The answer should be NO unless there is clear evidence for a YES. You will always be blamed for poor safety design.
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Old 13th Oct 2020, 09:39
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Originally Posted by neville_nobody
This is one of the worst things about "safety". You are not allowed to challenge the system. Quite often systems or airports are not design properly or corners cut to save money creating a safety hazard. When this is pointed out through safety reporting the safety department leaps to the defence of the system regardless to the obvious hazards. It isn't until there is a near disaster that the safety position is untenable and miraculously things get fixed.
Try working in air traffic control with Australia's #1 civil ANSP, system changes to Tower equipment are nearly impossible to make.

BTW, when I read this report I wonder what the SMC/Delivery/Supervisor was doing - 3 positions and poor prioritisation and what appears to be a lack of situational awareness involving a critical hot spot. Asking whether an aircraft is on frequency rather than issuing a safety alert seems rather odd, telling them they had crossed a stop bar also seems odd or is it just me?

The arrival would've heard the line-up clearance for the departure but I guess the arrival was task focussed. Surely a departure lining up on RWY 06 would be a threat when your landing on RWY 03.

And why the ADC didn't roll the arrival through to TWY Delta to assist the SMC or am I expecting too much?

Last edited by sunnySA; 13th Oct 2020 at 13:29. Reason: grammar
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Old 13th Oct 2020, 10:31
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Gordonf...

I agree totally.

A high speed descent below 10,000’ at say 320 kts to 5000’ vs 250 below 10000 will save around 1 minute:30 seconds. Never been one to see the point...burn more gas, increase the chance of getting out of shape, etc for what.

Only reasons I see for speed if you have been held up and need the speed to get down. In the normal event 250 kts gives a smidge extra time to finish the coffee thank you very much..

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Old 13th Oct 2020, 11:29
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Originally Posted by Square Bear
Gordonf...

I agree totally.

A high speed descent below 10,000’ at say 320 kts to 5000’ vs 250 below 10000 will save around 1 minute:30 seconds. Never been one to see the point...burn more gas, increase the chance of getting out of shape, etc for what.

Only reasons I see for speed if you have been held up and need the speed to get down. In the normal event 250 kts gives a smidge extra time to finish the coffee thank you very much..
Depends, if you are told about it beforehand, you can plan for it and I see no reason to be getting out of shape.

Why do so many people make this job look so difficult, it’s not rocket science and doing a high speed descent should be a normal low risk task
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Old 13th Oct 2020, 14:10
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Originally Posted by morno
Depends, if you are told about it beforehand, you can plan for it and I see no reason to be getting out of shape.

Why do so many people make this job look so difficult, it’s not rocket science and doing a high speed descent should be a normal low risk task
The only risk I ever see during a high speed descent is clipping CTA steps (a by product of stupid Australian airspace design).
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Old 13th Oct 2020, 20:59
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Originally Posted by morno
Depends, if you are told about it beforehand, you can plan for it and I see no reason to be getting out of shape.

Why do so many people make this job look so difficult, it’s not rocket science and doing a high speed descent should be a normal low risk task
Hence, and to quote myself, “The answer should be NO unless there is clear evidence for a YES

I fly with a lot of pilots who have the opposite approach. They lack the ability to approach decision points with any critical thinking. For these types, TEM is either too hard or displays some level of weakness. They also fail to recognise that system is set up to point the finger at us. ATC, flight operations et al, will always say “they could have said NO, but they didn’t, not our fault.”

The thrust of my post was that people need to slow down, spend a few seconds thinking about the cost of the gains they seek. Believe me, you repent at leisure.


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Old 14th Oct 2020, 10:41
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Originally Posted by gordonfvckingramsay
Hence, and to quote myself, “The answer should be NO unless there is clear evidence for a YES

I fly with a lot of pilots who have the opposite approach. They lack the ability to approach decision points with any critical thinking. For these types, TEM is either too hard or displays some level of weakness. They also fail to recognise that system is set up to point the finger at us. ATC, flight operations et al, will always say “they could have said NO, but they didn’t, not our fault.”

The thrust of my post was that people need to slow down, spend a few seconds thinking about the cost of the gains they seek. Believe me, you repent at leisure.
I agree with a lot of what you said, except the bit about the system being setup to point the finger at us.

In all my years of flying, I’ve never come across a blame system, and normally the ones who believe it is, have f***ed up somewhere along the line and went about it the wrong way. I’ve had my fair share of f**k ups, like all of us, but have never encountered any blame. I’ve always just acknowledged it, put my hand up and said I made a mistake, and it’s been put to bed pretty quickly, in some cases there’s even been acknowledgement that there’s something wrong and the threat has been fixed.

Paranoid, stress free flying is what makes you a more effective and efficient pilot. At least that’s how I fly, 20 years in.
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Old 14th Oct 2020, 10:51
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n all my years of flying, I’ve never come across a blame system, and normally the ones who believe it is, have f***ed up somewhere along the line and went about it the wrong way. I’ve had my fair share of f**k ups, like all of us, but have never encountered any blame. I’ve always just acknowledged it, put my hand up and said I made a mistake, and it’s been put to bed pretty quickly, in some cases there’s even been acknowledgement that there’s something wrong and the threat has been fixed.
That all depends on who you fly for. Certainly some companies are just as you say whilst others are out to nail the PIC at any opportunity.
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