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Runway at BRS was unsafe.

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Runway at BRS was unsafe.

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Old 12th Jan 2009, 08:19
  #21 (permalink)  
 
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Helen 49 - Excellent Post

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

Last edited by Pinkman; 12th Jan 2009 at 19:44.
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Old 12th Jan 2009, 18:20
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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

BBC NEWS | England | Bristol | Bristol runway shut in safety row
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Old 13th Jan 2009, 06:04
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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.
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Old 13th Jan 2009, 12:52
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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
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Old 13th Jan 2009, 15:53
  #25 (permalink)  
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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.
 
Old 13th Jan 2009, 19:11
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And just like magic the CAA produced this doc last summer...

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

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Old 13th Jan 2009, 19:45
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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.
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Old 14th Jan 2009, 11:45
  #28 (permalink)  
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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.
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Old 14th Jan 2009, 12:55
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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.......

P.S Again, credit to the ezy pilots who were a shining example of proffesionalism!!
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Old 14th Jan 2009, 13:28
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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

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?
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Old 14th Jan 2009, 14:59
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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.
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Old 14th Jan 2009, 15:03
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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?
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Old 14th Jan 2009, 16:25
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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.
 
Old 16th Jan 2009, 18:32
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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
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Old 17th Jan 2009, 00:19
  #35 (permalink)  
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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.
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Old 17th Jan 2009, 01:29
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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?

Last edited by OverRun; 17th Jan 2009 at 04:55. Reason: Poor grammar
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Old 17th Jan 2009, 02:21
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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.
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Old 17th Jan 2009, 11:41
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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

Last edited by Pinkman; 17th Jan 2009 at 12:04.
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Old 17th Jan 2009, 12:07
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I think the graph is here
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Old 17th Jan 2009, 17:43
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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.
 


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