SQ006 final report out 26/4/02
Join Date: Dec 1998
Location: U.S.A
Posts: 61
Likes: 0
Received 0 Likes
on
0 Posts
To some of us Singapore's reply is not a surprise.
The word on the street is that SIA "may" be making a serious attempt to give "safety" serious thought. This includes taking human factors seriously.
There are plenty of information in PPRuNe archives leaving no doubt that safety came last at SIA. It was always money first, safety last.
As for the government of Singapore and misinformation, amongst other things, through years of brain washing and lack of freedom of speech, they have managed to actually make the Singaporeans believe, 'Singapore and Singaporeans are perfect'.
The word on the street is that SIA "may" be making a serious attempt to give "safety" serious thought. This includes taking human factors seriously.
There are plenty of information in PPRuNe archives leaving no doubt that safety came last at SIA. It was always money first, safety last.
As for the government of Singapore and misinformation, amongst other things, through years of brain washing and lack of freedom of speech, they have managed to actually make the Singaporeans believe, 'Singapore and Singaporeans are perfect'.
Guest
Posts: n/a
Gladiator - that is your personal and, I think, subjective view. How long did you actually work for SIA? The archives contain meggabytes of stuff that represents the views of some disenchanted ex pilots but not the views of any recognised safety authority.
I worked for SIA for over ten years and as a professional I find your remarks quite insulting. I certainly never felt that commercial pressure overcame safety, nor do I think that anyone else did either. Obviously it would have come to the surface occasionally - it does in all airlines but pilots discretion is always the last word.
You obviously didn't enjoy your time with SIA, possibly left under a cloud and have a very juandiced view of how things work there.
I worked for SIA for over ten years and as a professional I find your remarks quite insulting. I certainly never felt that commercial pressure overcame safety, nor do I think that anyone else did either. Obviously it would have come to the surface occasionally - it does in all airlines but pilots discretion is always the last word.
You obviously didn't enjoy your time with SIA, possibly left under a cloud and have a very juandiced view of how things work there.
Join Date: Aug 2001
Location: At home
Posts: 144
Likes: 0
Received 0 Likes
on
0 Posts
My initial reaction on hearing about this tragic accident was to ask myself one simple question. I still believe this is the central question.
If aircraft were not supposed to use runway 05R, because it was covered in heavy plant & equipment, why the hell were effective measures not taken to close the runway thresholds at each end to prevent aircraft entering and starting to roll?
All it needed was a line of illuminated barriers or a few parked vehicles with amber beacons on at each end with a big sign saying "Runway Closed". A ground radar system monitored by ATC would also have made a big difference, clearly.
Any pilot attempting to turn onto the wrong runway would have seen the barriers or vehicles and realised he was in the wrong place. It is usually the simplest and most obvious precautions that are the most effective.
Taiwan Airport and all other airport authorities should examine there ground movements control, especially during runway/taxiway maintenance, and it is about time ground radar was installed and used at all international airports.
If aircraft were not supposed to use runway 05R, because it was covered in heavy plant & equipment, why the hell were effective measures not taken to close the runway thresholds at each end to prevent aircraft entering and starting to roll?
All it needed was a line of illuminated barriers or a few parked vehicles with amber beacons on at each end with a big sign saying "Runway Closed". A ground radar system monitored by ATC would also have made a big difference, clearly.
Any pilot attempting to turn onto the wrong runway would have seen the barriers or vehicles and realised he was in the wrong place. It is usually the simplest and most obvious precautions that are the most effective.
Taiwan Airport and all other airport authorities should examine there ground movements control, especially during runway/taxiway maintenance, and it is about time ground radar was installed and used at all international airports.
Join Date: Oct 2000
Location: Infinity.... and beyond.
Posts: 354
Likes: 0
Received 0 Likes
on
0 Posts
Alpha Leader
It seems that our disagreement revolves around the word 'blame'. I take 'blame' to denote culpability, guilt or similar concepts. I agree that '(Y)ou can't blame it on "the system" and leave it there.' (There's that word again!) Certainly we achieve nothing if we 'leave it there.' The investigation must go further than that.
I just hope that we can fix the 'system' without destroying lives in the process. Too many 'investigations' in the past have led to criminal charges, sackings or other punitive actions.
All that is achieved in this manner is to ensure that those particular individuals -sacked, jailed or dead - will never have the same accident again. Nothing is achieved for the rest of us.
Once we move away from 'blame' and look for real solutions, we will start making some progress.
It seems that our disagreement revolves around the word 'blame'. I take 'blame' to denote culpability, guilt or similar concepts. I agree that '(Y)ou can't blame it on "the system" and leave it there.' (There's that word again!) Certainly we achieve nothing if we 'leave it there.' The investigation must go further than that.
I just hope that we can fix the 'system' without destroying lives in the process. Too many 'investigations' in the past have led to criminal charges, sackings or other punitive actions.
All that is achieved in this manner is to ensure that those particular individuals -sacked, jailed or dead - will never have the same accident again. Nothing is achieved for the rest of us.
Once we move away from 'blame' and look for real solutions, we will start making some progress.
Thread Starter
Join Date: Dec 1999
Location: Ottawa, Ontario, Canada
Posts: 330
Likes: 0
Received 0 Likes
on
0 Posts
Alpha Leader,
There's no denying the SQ006 crew took a wrong turn and that they knew 05R was closed but it seems to me phd makes an excellent point: 05R was not clearly marked as being closed. Here in N America, at least, at any road works, a lane that is closed to traffic is clearly marked as such along its entire length (with barrels or other objects along the sides), even though there may be no barrier at either end. Surely 05R should have been unambiguously indicated as being a taxiway only (or even just prominently identified as 05R) and there should be no shadow of a doubt that the edge lights were off. I don't necessarily lay the blame on the CKS airport authorities. Perhaps ICAO regulations are not sufficiently stringent when it comes to runway markings.
Rockhound
There's no denying the SQ006 crew took a wrong turn and that they knew 05R was closed but it seems to me phd makes an excellent point: 05R was not clearly marked as being closed. Here in N America, at least, at any road works, a lane that is closed to traffic is clearly marked as such along its entire length (with barrels or other objects along the sides), even though there may be no barrier at either end. Surely 05R should have been unambiguously indicated as being a taxiway only (or even just prominently identified as 05R) and there should be no shadow of a doubt that the edge lights were off. I don't necessarily lay the blame on the CKS airport authorities. Perhaps ICAO regulations are not sufficiently stringent when it comes to runway markings.
Rockhound
Join Date: Jun 2001
Location: Above 30,000 ft
Posts: 215
Likes: 0
Received 0 Likes
on
0 Posts
There is no denying that the crew was aware of the NOTAMed closure of 05R. There is also no denying that they suffered a loss of SA which eventually led to that wrong turn while still believing they were on 05L as cleared. No one - not even SIA or the Singapore government - denies this.
However, as has been pointed out by many before me, the events that have contributed to this loss of SA need to be identified and given their due weight in the matter. My personal take on this is that since the Taiwanese had intended to continue using 05R as a taxiway despite the runway closure, the NOTAM should more correctly have been worded something to the effect of "Runway 05R not operational but still available for taxiing. Runway edge and centreline lights remain illuminated." That would have at least alerted the crew to a potential catch-22 of an unservicable runway appearing still open. I don't know about any of you, but as for me, when I read that a runway is closed, that is what I expect : total closure, including de-activation of the lights. You may not agree with me on this, but if a NOTAM indicates a runway is closed without specifying further that things like the lights are gonna be left ON, then when you taxi out there, the very fact that you see some runway lights WILL ACTUALLY RE-INFORCE your belief that you are now on the correct runway and CONTRIBUTE TO LOSS OF SA - especially so in conditions of marginal/reduced viz. That 05R was a non-instrument runway while 05L WAS an instrument runway does certainly provide clues to the crew, but only if they can see the runway all the way down. The viz that night was 400-600 mtr in driving rain - unlikely to have revealed the 05L barrettes at all.
There is no doubt to me that the crew goofed big time, but as others have pointed out, there does seem to be many other links in this error chain that have gone un-noticed or swept under the carpet. It would be a shame if it takes another crash involving Taiwanese before it is recognised that attitudes all round really need to change.
However, as has been pointed out by many before me, the events that have contributed to this loss of SA need to be identified and given their due weight in the matter. My personal take on this is that since the Taiwanese had intended to continue using 05R as a taxiway despite the runway closure, the NOTAM should more correctly have been worded something to the effect of "Runway 05R not operational but still available for taxiing. Runway edge and centreline lights remain illuminated." That would have at least alerted the crew to a potential catch-22 of an unservicable runway appearing still open. I don't know about any of you, but as for me, when I read that a runway is closed, that is what I expect : total closure, including de-activation of the lights. You may not agree with me on this, but if a NOTAM indicates a runway is closed without specifying further that things like the lights are gonna be left ON, then when you taxi out there, the very fact that you see some runway lights WILL ACTUALLY RE-INFORCE your belief that you are now on the correct runway and CONTRIBUTE TO LOSS OF SA - especially so in conditions of marginal/reduced viz. That 05R was a non-instrument runway while 05L WAS an instrument runway does certainly provide clues to the crew, but only if they can see the runway all the way down. The viz that night was 400-600 mtr in driving rain - unlikely to have revealed the 05L barrettes at all.
There is no doubt to me that the crew goofed big time, but as others have pointed out, there does seem to be many other links in this error chain that have gone un-noticed or swept under the carpet. It would be a shame if it takes another crash involving Taiwanese before it is recognised that attitudes all round really need to change.
Last edited by gengis; 29th Apr 2002 at 14:51.
Join Date: Apr 2002
Location: Undecided
Posts: 30
Likes: 0
Received 0 Likes
on
0 Posts
A slide presentation by the Singaporean MOT on the signage, marking and lighting leading to CKS 05 R/L on that faithful nite!!
http://www.sq006.gov.sg/ppt/SQ6_Runw...Simplified.pps
(Right click on slide to advance to the next slide )
I would have been a easy sucker as well under those weather condition!
http://www.sq006.gov.sg/ppt/SQ6_Runw...Simplified.pps
(Right click on slide to advance to the next slide )
I would have been a easy sucker as well under those weather condition!
Last edited by hawkeye18; 29th Apr 2002 at 17:30.
Join Date: Oct 2000
Location: Wellington
Posts: 84
Likes: 0
Received 0 Likes
on
0 Posts
I always feel that discussions like this (where 'blame', 'responsibility', etc. become the focus of the debate) are more to do with retribution than with capturing learnings and trying to avoid repetition in the future.
I feel it is far more useful to think in terms of probabilities. We can use past data to figure out the probability that any given flight will be involved in an accident, and by looking at the circumstances we can quite accurately assign increased probabilities to the presence or absence of particular factors.
There were a whole raft of probability increasing factors present here (night, visibility, familiarity, quality of lighting, etc.). The useful question to ask is - given the vastly increased probability of an accident created by this heavy assembly of negative factors, was there any compensatory set of procedures, training, equipment, etc. that might have reduced the probability that SQ 006 would have done what it did?
We can include in such calculations operational culture, level of individual experience and other human factors.
For me considerations of blame or negligence come into the mix only if anybody (or any body) involved failed to do something they were specifically expected to do, or did something they were specifically expected not to do, or failed to adopt compensatory procedures for a reasonably predictable set of probability increasing circumstances. Only then does punishment, liability or retribution become an issue. For me mistaken perception is not negligence, but a manifestation of the presence of negative environmental factors that cause misperception.
In this case those questions concern whether the airport authorities and flight crew could reasonably have predicted the misperceptions that led to the fatal actions and, if so, whether they took adequate mitigating operational measures. Misperceptions, or signals that in the event turned out to be inadequate, are not of themselves reasons to apportion blame.
I feel it is far more useful to think in terms of probabilities. We can use past data to figure out the probability that any given flight will be involved in an accident, and by looking at the circumstances we can quite accurately assign increased probabilities to the presence or absence of particular factors.
There were a whole raft of probability increasing factors present here (night, visibility, familiarity, quality of lighting, etc.). The useful question to ask is - given the vastly increased probability of an accident created by this heavy assembly of negative factors, was there any compensatory set of procedures, training, equipment, etc. that might have reduced the probability that SQ 006 would have done what it did?
We can include in such calculations operational culture, level of individual experience and other human factors.
For me considerations of blame or negligence come into the mix only if anybody (or any body) involved failed to do something they were specifically expected to do, or did something they were specifically expected not to do, or failed to adopt compensatory procedures for a reasonably predictable set of probability increasing circumstances. Only then does punishment, liability or retribution become an issue. For me mistaken perception is not negligence, but a manifestation of the presence of negative environmental factors that cause misperception.
In this case those questions concern whether the airport authorities and flight crew could reasonably have predicted the misperceptions that led to the fatal actions and, if so, whether they took adequate mitigating operational measures. Misperceptions, or signals that in the event turned out to be inadequate, are not of themselves reasons to apportion blame.
Join Date: Apr 2002
Location: Undecided
Posts: 30
Likes: 0
Received 0 Likes
on
0 Posts
Alpha Leader,
I just tried it ...... and it is working!
Alternatively you can acsess it at the site itself ... it is at the bottom of the page at
http://www.sq006.gov.sg/final_draft/fr_final_draft.htm
"To view the simulation of the line of vision of the pilots on the night of the accident,click here."]
I just tried it ...... and it is working!
Alternatively you can acsess it at the site itself ... it is at the bottom of the page at
http://www.sq006.gov.sg/final_draft/fr_final_draft.htm
"To view the simulation of the line of vision of the pilots on the night of the accident,click here."]
Last edited by hawkeye18; 30th Apr 2002 at 06:08.
Join Date: Apr 2001
Location: New York
Posts: 45
Likes: 0
Received 0 Likes
on
0 Posts
It seems that a loss of situational awareness was a major contributary factor, and this was partly brought on by the spurious lighting/weather/markings, etc.However, what do you do in aviation if you have ANY element of doubt. Well of course, the best answer is stop and reconfirm if operationally possible, even if that doubt is 1%.
I have many a time seen crew come off high speed taxiways and shoot off into a maze of taxiways, often making a mistake, or even had awareness problems taxiing from parking bays. Sitting and seeing this whilst operating, or observing from a jumpseat, highlights an issue which many are guilty of in many situations.
Let everyone learn once and for all if you are in doubt about anything STOP (if you can), ask, and re-orientate.
If we don't, people will continue to taxi to the wrong bays, turn into the wrong taxiways, line up to land on the wrong runways, bust flight levels, and very occasionally try to take off on the wrong runway.
Join Date: Mar 2002
Location: India
Posts: 346
Likes: 0
Received 0 Likes
on
0 Posts
hawkeye 18:
Good slideshow and very informative.
Beggers the question, though, as to how many flights SQ had operated out of CKS prior to the SQ006 crash without having raised any complaints to the airport operator about the non-ICAO-compliant situation.
:o
Good slideshow and very informative.
Beggers the question, though, as to how many flights SQ had operated out of CKS prior to the SQ006 crash without having raised any complaints to the airport operator about the non-ICAO-compliant situation.
:o
Join Date: Apr 2002
Location: Undecided
Posts: 30
Likes: 0
Received 0 Likes
on
0 Posts
Hi Apha Leader,
From what I gathered SQ operates mainly on the eastern side of the field hence their preference in using Runway 06/24.
They rarely if not never ( correct me if I am wrong) use Runway 05/23 for takeoff operation.
On that faithful nite, Captain of SQ006 elected to use the longer 05L due to the marginal weather condition.
During the investigation, 2 pilots came forward voluntarily and related their experiences at 05 R... one of them was from Fed EX whom nearly mistook 05R as 05L but managed to pullback at the last instance from committing.... ....this captain use 05L close to 200 instances during the last year of operation out of CKS!
However, these instances of confusion at the said 05R were only reported to their company and not the airport authority!!!
(all these are buried somewhere in the 2 reports, I am commiting them to writing from memory)
Cheers!
From what I gathered SQ operates mainly on the eastern side of the field hence their preference in using Runway 06/24.
They rarely if not never ( correct me if I am wrong) use Runway 05/23 for takeoff operation.
On that faithful nite, Captain of SQ006 elected to use the longer 05L due to the marginal weather condition.
During the investigation, 2 pilots came forward voluntarily and related their experiences at 05 R... one of them was from Fed EX whom nearly mistook 05R as 05L but managed to pullback at the last instance from committing.... ....this captain use 05L close to 200 instances during the last year of operation out of CKS!
However, these instances of confusion at the said 05R were only reported to their company and not the airport authority!!!
(all these are buried somewhere in the 2 reports, I am commiting them to writing from memory)
Cheers!
Last edited by hawkeye18; 30th Apr 2002 at 15:55.
Thread Starter
Join Date: Dec 1999
Location: Ottawa, Ontario, Canada
Posts: 330
Likes: 0
Received 0 Likes
on
0 Posts
In the Slot,
What you say is all well and good but I believe you are missing the point here. I would maintain there was no doubt in the SQ006 pilots' mind that they were properly aligned for takeoff from the correct runway, just as in Tenerife in 1977, the KLM 747 commander was convinced he had been cleared for takeoff. (The PVD issue, which was debated at length in this forum last year, is a red herring. It is not meant as a tool with which to identify a runway). Surely the crucial question is, what circumstances led to this mindset? Why were the pilots satisfied that no error had been committed and all was in order?
Rockhound
What you say is all well and good but I believe you are missing the point here. I would maintain there was no doubt in the SQ006 pilots' mind that they were properly aligned for takeoff from the correct runway, just as in Tenerife in 1977, the KLM 747 commander was convinced he had been cleared for takeoff. (The PVD issue, which was debated at length in this forum last year, is a red herring. It is not meant as a tool with which to identify a runway). Surely the crucial question is, what circumstances led to this mindset? Why were the pilots satisfied that no error had been committed and all was in order?
Rockhound
Join Date: Dec 2000
Location: USA
Posts: 11
Likes: 0
Received 0 Likes
on
0 Posts
Perhaps there is hope for Singapore yet. Take a look at the following for the 'real' story of SIA006 - humour at its blackest.
http://www.talkingcock.com/html/sect...ticle&artid=17
http://www.talkingcock.com/html/sect...ticle&artid=17