B717 taxiway excursion Rockhampton

[Lead Balloon]

I never cease to be amazed at the propensity of some pilots to attribute an incident to ‘100% pilot error’. The location of that ‘grass island’, combined with e.g. night/rain/poor viz/confusing marshalling, is a camouflaged trap. I have no first-hand knowledge of whether any or all of those conditions were present, but I never jump to the ‘100% pilot error’ conclusion. I thought we’d grown out of that decades ago.

If there’s some damage to the aircraft that results in an insurance claim, I’ll bet leftie that the insurers won’t simply write a cheque and write the liability off as plain pilot error.

[KRviator]

Originally Posted by SHVC

First attempt at moving has failed, tow bar snapped off looks like they’re getting jacks to lift it.

They're doing it wrong. Get these blokes to do it. They have experience recovering wayward jets from grassy drains...

https://www.facebook.com/story.php?s...12276798890833

[SHVC]

Quick look at 10-9 there is definitely clear marking to indicate no taxi way in that area off B, it’s also a long bow to blame the marshaller, I’m sure there are human factors involved. But as mentioned in post #16, I hope these guys don’t use that. CASR 91 is pretty clear and you open whole other doors!
It will be an interesting read when the report is released.

[Paragraph377]

Originally Posted by Lead Balloon

I never cease to be amazed at the propensity of some pilots to attribute an incident to ‘100% pilot error’. The location of that ‘grass island’, combined with e.g. night/rain/poor viz/confusing marshalling, is a camouflaged trap. I have no first-hand knowledge of whether any or all of those conditions were present, but I never jump to the ‘100% pilot error’ conclusion. I thought we’d grown out of that decades ago.

If there’s some damage to the aircraft that results in an insurance claim, I’ll bet leftie that the insurers won’t simply write a cheque and write the liability off as plain pilot error.

I fully concur. Rarely is there only the one contributing factor. Sure, the root cause will no doubt be identified in this case, but the contributing factors (almost always multiple in number) will paint a clear picture.

[43Inches]

There is one person in control of the tiller, one person with eyes out the window and in this case, clearly marked lines to follow. Any excursion off those lines leads to 100% failure of the person guiding the vehicle to adhere to basic rules. We have very simple rules while taxiing to prevent this exact thing, no paperwork, charts up and open to taxiway charts, with now moving map display showing the aircrafts position on the apron. And most importantly eyes out the window for the driver with the non driver monitoring the aircrafts progress via the charts and clearance. At some point the driver decided to not follow ANY lines and go straight for the bay. Mistakes can still happen but this island is not a small obstacle, its clearly marked on the charts, its clearly illuminated by blue lights, which the jet almost ran over on both sides. This is like saying they descended below minima and hit a tree, so the tree should not have been there. Oh but that minima was too high, so it wasn't their fault, they should have removed all obstacles and made the minima lower. The error here is that the steering pilot did not follow the taxiiway markings, full stop, at some point they just decided to drive straight to the bay. If the lines led the pilot somehow to the grass, fair enough, in this case they are 45 degrees and 10 meters off the nearest marked line to hit the grass. I mean numerous high speeds around the world line up with bays across grass patches, or around ground service parking etc etc. I mean if you get distracted by numerous lights on taxiways god help you if you ever land in Sydney at night.

BTW I have stuffed up this badly in another way, were there other circumstances that led to my failure to do my job, yes, am I 100% responsible for my actions hell yes. The % of other factors are just what leads you down the garden path, but 1 person is responsible for the final action in mine and this circumstance, own it and move on, its better for your mental health than finding others to blame.

[lucille]

Is there no display of 10-9 with aircraft position available on one of the displays in a 717 cockpit? Or maybe it’s just Rocky Airport’s 10-9 that’s not geo-referenced?

At night in rain, with confusing advice from the RHS, it makes it a very difficult task; all too easy to criticise from the comfort of an armchair.

43 inches, you’re dead right the PIC is 100% responsible. But we can all understand and sympathise with him/her. Some days, you’re just plumb out of luck and that’s all there is to this.

Nevertheless, I’m enormously relieved to note that no one brought up Swiss Cheese.

[Lookleft]

Tried taxiing off onto J1 from 03 in Perth recently 43"? Eventually Perth airport assessed the risk of a potential catastrophic runway incursion and closed it because the environment gave pilots the impression that the taxiway took them straight to the apron. The photo at post #36 says it all really. Why that small patch of grass hadn't been filled in years ago says a lot about aviation in Australia. Yes the PIC is responsible for the operation but just once it would be nice if the various corporate entities took responsibility for helping the PIC meet their legal obligations instead of dumping it in their lap. If the marshaller had any sort of competence and seen that the aircraft was going to taxi over the grass then they should have crossed the wands and signaled for them to stop. Years ago a QLink -8 nearly reversed into Gate 57R (the opposite end was 57A) at Sydney because the crew thought the marshaller was indicating a reverse manouvre and the marshaller thought the crew were reversing on the bay deliberately. It was only the action of an experienced marshaller, who was having lunch watching the whole debacle, run out and show the crew a crossed arms signal that prevented a potential disaster. Everyone thought that the R stood for reverse and that it was permitted on that bay. PIC? Marshaller? ambiguous ground markings? or a combination of all 3? Too easy to blame the pilot when there are multiple factors at play taxiing onto a Bay. BTW SAC renamed 57R to 57B to avoid any ambiguity.

https://www.atsb.gov.au/publications...aair200500778/

[RickNRoll]

TOGA won't budge it?

[43Inches]

At night in rain, with confusing advice from the RHS, it makes it a very difficult task; all too easy to criticise from the comfort of an armchair.

And at night in rain is when you know to slow down and stick to those basic principles of following the lines, and making sure the nosewheel doesn't slide on the painted areas or smooth concrete, etc etc. On the ground you have the leisure of coming to a halt and reassessing your decisions. I've seen fog so thick that you could not see the taxiway from the flight deck, what do you do? stop and get a ground vehicle to guide you. Having problems seeing with the nosewheel light? turn on the landing lights... many things that the experience of a professional crew can do to stop this from happening. Basic environmental factors like rain and shiny taxiiways are not excuses for professional pilots to make mistakes that lead to off road adventures, this is the daily operating environment we live in. I have a sneaking suspicion that maybe in this case the taxi/landing lights were turned off early to avoid blinding the ground crew, no illumination of the ground taxi route, then an assumption that the lines visible under apron lights continued to their position with guidance from the marshaller (just my thoughts on what happened), its a trap, but all stems from the crews assumptions, not any sinister placements of hazards. I won't turn off the taxi light until I'm under the apron lights for the reason I'm following that line until the apron lighted area joins with my lines.

BTW I've seen a number of jets cross the stop bars at the major ports when they havn't got clearances, has reduced recently as the system auto reports any transgressions now. If you can't even get pilots to follow a bright row of red lights what chance have you got.

Tried taxiing off onto J1 from 03 in Perth recently 43"?

I've operated at almost every Australian major port and some internationals, Never had an issue in Perth on the ground, a few odd taxiway intersections but the runway entries are clearly marked. The only reason pilots transgress these lines is being distracted at the wrong time and not paying enough attention to the path. J2 is the one that has caused the issues over time, but seriously some orientation like you would in the air would solve most of these issues. Never had a runway incursion in my time, but I'm very cautious that ground operations is one of the easiest areas to do something silly, the margins are narrow for some types so you need to be aware of your path and surroundings.

[Paragraph377]

43, you are too rigid on the ‘had to be the PIC’s fault’ in regards to this incident. I don’t disagree with you in regards to the PIC being, for all intents and purposes, the accountable person, but rarely is there one causal factor.

As has happened a lot lately (very scary), I agree with Lookleft. There could be a number of reasons at play with this one. Then again, it could be all the fault of the PIC. The investigation report might find there was an engineering issue. Who knows…

[43Inches]

Of course the point has always been in the absence of any engineering or other unforeseen complication. We are just talking about if this was a perfectly serviceable aircraft that has been intentionally steered into this position, and I never have referred to the Captain as at fault, the steering pilot was at fault. I don't know if both pilots have a tiller in the 717, so who was steering and who was supposed to be monitoring is completely outside my knowledge.

[morno]

Glad you’re not a safety investigator 43”, you arse

[SHVC]

Why would you refer to someone as being a donkey! Why can’t it ever just be one persons fault? Why does it have to be multiple factors all the time? It’s clear the taxi line was NOT followed from the over head picture, there is limited reasons why this would happen! Mechanical failure, incapacitation, loss of situation awareness because they were not paying attention or they were talking non operational like how awesome their landing was not paying attention. Attributing some fault to someone with red sticks is not one of them, they can put their hands up soon as you touch down will you turn straight toward them, no you wouldn’t. I’ve been at aerodromes at night pouring rain and the line is hard to see that’s telling me to slow down, be sure of where we are take it easy.

[chickenman]

Originally Posted by Paragraph377

43, you are too rigid on the ‘had to be the PIC’s fault’ in regards to this incident. I don’t disagree with you in regards to the PIC being, for all intents and purposes, the accountable person, but rarely is there one causal factor.

As has happened a lot lately (very scary), I agree with Lookleft. There could be a number of reasons at play with this one. Then again, it could be all the fault of the PIC. The investigation report might find there was an engineering issue. Who knows…

Yes, the ‘investigation report’. It’s one thing for us all to speculate here on how this could have happened, ( and that’s not a bad thing because it opens our eyes to threats we may not have considered), but within hours of this incident, a statement had been made by the company squarely blaming the pilot.
’the pilot inadvertently guided the aircraft across soft ground’. This statement was seemingly sent to everyone ( I was shown this by an FA with another subsidiary who received it on their company email) and then it was repeated to the media in a press release.

I’ve been told ( this is a rumour network after all) that the crew were being marshalled by the contractor. Why so quick to publicly blame ‘the pilot’ well before any investigation has taken place? All that was required in a press release was that the aircraft had left the taxiway and become bogged, investigation to follow.

The manual states ‘ taxy lines are to be followed unless under the guidance of a marshaller’, a statement I’m told was reiterated in a safety bulletin to crew after this event.
We all understand that the buck stops with us.
We have all had marshallers giving erroneous instructions. ( I had one throw his bats on the ground when I didn’t follow his turn commands onto a parking bay. He was marshalling to keep the nose wheel on the line on a 90 degree turn with parked aircraft either side. In the 717 if you do that, you will find both main wheels on the inside of the taxi line)

What if the pilots misread where they were? ( We’re all capable of that). It’s been said they should have stopped, but if you don’t know you have misread where you are ? Looking at the photo of where the aircraft ended up, they possibly had a taxi line visible in front of them ( due to the angle of vision from the cockpit). What if the contract marshaller frantically gave a turn right signal when turn left was required? What if the crew were blinded by baggage vehicle lights pointed straight at them ( a frequent occurrence).

So, why publicly blame the pilot 100% ‘straight out of the gate when there are any number of contributing factors? To prevent the unions pointing to another accident that may not have occurred with a stable experienced labour force of ground crew? Or is this part of a new policy that sees pilots publicly shamed by their company and by the time the real ‘investigation’ is published the mud has stuck and that pilot will forever be considered as the ‘cause’ by colleagues and public alike?

[morno]

Originally Posted by SHVC

Why would you refer to someone as being a donkey! Why can’t it ever just be one persons fault? Why does it have to be multiple factors all the time? It’s clear the taxi line was NOT followed from the over head picture, there is limited reasons why this would happen! Mechanical failure, incapacitation, loss of situation awareness because they were not paying attention or they were talking non operational like how awesome their landing was not paying attention. Attributing some fault to someone with red sticks is not one of them, they can put their hands up soon as you touch down will you turn straight toward them, no you wouldn’t. I’ve been at aerodromes at night pouring rain and the line is hard to see that’s telling me to slow down, be sure of where we are take it easy.

Because isn’t that what we’re taught these days about threat and error management? Unless it’s a clear violation, accidents and incidents aren’t always a single point of failure.

43” approach is to just chastise the PIC for apparently not being as good as he is. Looking forward to the day that we’re reading about him effing it up, because I will laugh and point fingers.

I’ve worked in a country where the first thing they did was fine the pilots and not look at the root causes, all that does is create a negative safety environment where people cover things up that can one day lead to a serious accident or incident.

Stop being assholes and like I said at the start, understand that this crew wouldn’t have gone out to do it intentionally. Somewhere along the line something has happened where the eventual undesired state was them ending up where they are.

[tossbag]

He called him an arse, not an ass. No worries.

[43Inches]

I never have said the PIC is to blame, the aircraft has two pilots, the one who was steering is responsible for putting it where it is. Morno you sound like you are getting defensive for no reason, I've been in a situation similar and have owned my faults. While there were factors that led to my situation I recognize that I was 100% responsible for my own actions, everything else was just a factor. This crew stuffed up, trying to say a commercial airline crew just happened to drive across the fairway because it was raining, ffs, it just makes it look like a half arsed cover up.

[lucille]

43 inches, No one disagrees that it’s the PICs responsibility. He has the tiller, the brakes and the power levers. It’s his ship.

Easy to say, from a warm cosy armchair that he had to stop or slow down in the event of confusion or doubt but first you have to recognise that doubt or confusion. Sometimes there are mitigating circumstances: eg fatigue or strident and assertive advice coming from an “expert” in the RHS or simply just not seeing what would be obvious on a clear day.

To paraphrase Donald Rumsfeld… “ Sometimes you just don’t see what you don’t see”.😜

[43Inches]

43” approach is to just chastise the PIC for apparently not being as good as he is. Looking forward to the day that we’re reading about him effing it up, because I will laugh and point fingers.

You probably already have read about my antics in an ATSB report. I'm actually quite happy to talk about it because I feel others can learn from my mistake that I'm 100% responsible for even though there were several other factors that led me to that action, I still made the fateful action that led to x problem. The issue is how a crew is treated after making a mistake, not whether they are nominated responsible for it. Being responsible does not mean its intentional or that they need to be removed from duty or hung drawn and quartered, but it sure as hell makes it easier to move on when you accept what you did and own it and can laugh at it yourself.

[neville_nobody]

Why can’t it ever just be one persons fault? Why does it have to be multiple factors all the time? It’s clear the taxi line was NOT followed from the over head picture, there is limited reasons why this would happen! Mechanical failure, incapacitation, loss of situation awareness because they were not paying attention or they were talking non operational like how awesome their landing was not paying attention.

Because it usually isn't just one cause. In this example it is quite possible that they were slightly disoriented and mentally had themselves on Twy J entering the apron rather than B and then say hypothetically the marshaller raises their hands and voila you have the perfect one in a million star alignment that causes an accident. If any one of those things don't happen, ie the captain get's slightly disoriented but the marshaller keeps their arms down then nothing happens. Or if in the reverse the marshaller raises his hands but the captain knows where his is, then again nothing happens. From my experience its is usually two or more random events aligning that causes problems, very rarely will one person's error, cause a problem in an airline environment.