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G-BNLL report published

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G-BNLL report published

Old 19th Jun 2015, 21:39
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G-BNLL report published

The original thread about this BA 744 colliding with a building at JNB was moved from here to the African Aviation forum after it eventually decended into triviality.

The accident report has now been published by SACAA and it contains lessons for all of us, so maybe the moderators will allow discussion to return here rather than remain quietly hidden in the Africa forum.

http://www.caa.co.za/Accidents%20and...ports/9257.pdf
It has taken a long time but this is an excellent report well worth reading.

My quick summary : the crew were suckered into a mistake by faulty taxiway lighting, as usual there were many contributing factors.
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Old 20th Jun 2015, 06:52
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Very interesting reading. Two points.

To those who mutter about the time taken to see the official reports - take one hour to read this report- all 130 pages- and see the detail involved for a relatively minor incident. Well done SACAA.

Secondly, as expected, a chain of errors,
Personally I find the signage/lighting deficit slightly more significant than the briefing error. (Not well done Acasa.)
But my experience of ORT is now more than 15 years old. I recollect it being quite hard work at night.

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Old 20th Jun 2015, 16:48
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Couple quibbles with the report

Engine position mis-identification on Page 23
1.6.5 Engine: No. #4 (Port L/H – Inboard)
If you don't know how 744 engines are numbered, ask someone.

Communications description on Page 27

1.9.1.2 With the VHF radio equipment installed, the crew could communicate with ATC by
means of microphone, with cabin crew by means of passenger assist (PA) and the
passengers by means of the aircraft’s intercom system.
And my browser shows a date at the bottom of each page which is 5 months and 12 days prior to the accident.

CA 12-12a 11 JULY 2013 Page 1 of 130
Something's lost in translation here.
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Old 20th Jun 2015, 19:28
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And my browser shows a date at the bottom of each page which is 5 months and 12 days prior to the accident.
That's simply the date corresponding to the latest version of the proforma, nothing to do with the contents.

Here's another example with exactly the same footer: http://www.caa.co.za/Accidents%20and...ports/9315.pdf

The PDF containing the BA report is datestamped 19 June 2015.
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Old 20th Jun 2015, 19:30
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Failure to NOTAM maintenance work that resulted in lighting being unserviceable (report para 2.1.21.4) - that's gotta be high up the list of causal factors, hasn't it?
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Old 20th Jun 2015, 20:51
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I have ploughed through it. The oddly written introduction/Executive summary was clearly written by somebody different to the main report which is by and large well written and incredibly thorough. It would have benefited from some additional proofreading and tech review but the typos don't in any way alter the conclusions which are as succinctly summarized by the Ancient Geek.

The tensions between ACSA and SACAA are evident and there is some finger pointing in a way you wouldn't find in an AAIB report. Its slightly odd that the dual role of SACAA involves it mentioning itself in the context of the incident which it is investigating but you'd be hard pushed to find fault with the particular instances where that occurs.

The conclusions of OverRun in the PPrune thread at the time that "M" was constructed as a Taxiway were vindicated, as was the decision by BA to return the flight crew to flying duties soon after the incident.. the picture indicating the failed centerline lighting and signage onto Bravo was pretty damning. Jury is out in my mind on whose fault it was that the lessons were not learned or engineered out from the carbon copy incident of a previous BA 744 incident in the same location.

Worth the wait.
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Old 21st Jun 2015, 02:55
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I am not saying that it would have ended differently with me there, but one has to admit that it doesn't look to good to have written off a 747 due to a couple of burned out taxiway lights and a sign not lit. This is in Africa.

First 45 degree turn to the left. There were further green lights on that taxiway and a yellow line. What about the blue lights.

Apparently there was a briefing page 10-P6 with a caution about this area being confusing that was not read. That doesn't help.

Frequently there tends to be a hint that something is going wrong prior to the actual damage happening. It was noted that the taxiway was narrower than expected all of a sudden and a nearby building that looked too close. You have to do something at that point. it just shows how you really do have to be ready as PNF to jump on the brakes even at a major airport.

After this accident and reading about others, I like to look at the taxi chart for the briefing and mention if the taxiway goes beyond the end of the runway or similar and brief it.

An airport moving map(AMM) installation would have given the crew the tools to overcome any situational awareness issues. But that involves money and a commitment to spending money to prevent incidents like this. An example of an accident that likely would have been avoided if this company had that commitment.

Last edited by JammedStab; 21st Jun 2015 at 10:19.
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Old 21st Jun 2015, 06:58
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My hat off to Accident and Incident Investigations Division (of SACAA). Well done, and as Pinkman says - incredibly thorough.

The delay in the release of the report speaks volumes about the pressures that must have been applied. It is a pity that the summary forgot to adequately mention the missing taxiway lighting and darkened sign, and still gets confused about the difference between a taxilane and a taxiway. But the body of the report does a good job and has lessons for all of us to ponder.

Originally Posted by Pinkman
I have ploughed through it. The oddly written introduction/Executive summary was clearly written by somebody different to the main report which is by and large well written and incredibly thorough. It would have benefited from some additional proofreading and tech review but the typos don't in any way alter the conclusions which are as succinctly summarized by the Ancient Geek.

The tensions between ACSA and SACAA are evident and there is some finger pointing in a way you wouldn't find in an AAIB report. Its slightly odd that the dual role of SACAA involves it mentioning itself in the context of the incident which it is investigating but you'd be hard pushed to find fault with the particular instances where that occurs.

The conclusions of OverRun in the PPrune thread at the time that "M" was constructed as a Taxiway were vindicated, as was the decision by BA to return the flight crew to flying duties soon after the incident.. the picture indicating the failed centerline lighting and signage onto Bravo was pretty damning. Jury is out in my mind on whose fault it was that the lessons were not learned or engineered out from the carbon copy incident of a previous BA 744 incident in the same location.

Worth the wait.
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Old 21st Jun 2015, 07:12
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Exec summary / Briefing

OverRun makes a good point: the executive summary is at odds with the main report. I was being kind in my comments.

JammedStab: your point about the briefing is well made; the crew had carried out a thorough briefing and hazard analysis for the route that they had expected to take and were clearly surprised by the initial instruction to "start, push, and face South". Would the expectation be that they then stopped and re-briefed for a new route (which had not been given to them in its entirety at that point)? What happens if the route is given piecemeal? Not being defensive, just trying to understand what is considered "practicable". The crew thought they were on a taxiway and it would be interesting to do some human factors analysis.. when the report says "lack of situational awareness" what it really means is that a combination of high workload, visual miscues (lights and taxiway construction), and probably confirmation bias, led them to continue.

Last edited by Pinkman; 21st Jun 2015 at 07:24.
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Old 21st Jun 2015, 07:28
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...crossing the intersection/junction of Bravo and Mike instead of following Bravo where it turns off to the right and leads to the Category 2 holding point.
Which way does Bravo turn?
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Old 21st Jun 2015, 08:36
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It turns Left
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Old 21st Jun 2015, 09:45
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Never been able to turn up the airport and board the aircraft in 5 minutes at JNB.
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Old 21st Jun 2015, 10:03
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Originally Posted by Pinkman
JammedStab: your point about the briefing is well made; the crew had carried out a thorough briefing and hazard analysis for the route that they had expected to take and were clearly surprised by the initial instruction to "start, push, and face South". Would the expectation be that they then stopped and re-briefed for a new route (which had not been given to them in its entirety at that point)? What happens if the route is given piecemeal?
I would think that while at the gate during the briefing, one can brief the expected route and when there are parallel taxiways, look to see if there are any unusual features. If not then specific detailed mention may not be necessary. If there are unusual features such as this one and then brief...." if we happen to get a taxi clearance on taxiway B, we have to be careful to make sure that we make the 45 degree left turn which is located not very far after exiting the ramp. Otherwise we will be in an area that we can't exit. Bravo is the first left turn after the end of the ramp". Takes 10 seconds. If something comes up as you stated when cleared to push back, a convenient time to re-brief can be during the push prior to start. Or stop and brief. I find it difficult to taxi properly and try to figure stuff out, especially at night in unfamiliar places.
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Old 21st Jun 2015, 19:19
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from a practical perspective, sometimes having the info for an aerodrome printed on many pages doesn't help. here mention is made of a warning note on pg 6 about this.

Let's be realistic, time constraints, workload issues and cockpit ergonomics, especially older airliners, are not conducive to a making a comprehensive briefing covering reams and reams of paperwork.

Aerodromes have become waaay too complicated, my base is Narita, have a look at the taxiway layout there, it's a set up already.

Singapore has a brilliant system at night, "follow the greens". This should be standard worldwide. it would prevent a lot of problems.
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Old 21st Jun 2015, 20:07
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Singapore has a brilliant system at night, "follow the greens". This should be standard worldwide. it would prevent a lot of problems.
Copied, I believe, from the system pioneered at Heathrow (and subsequently Gatwick).
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Old 21st Jun 2015, 20:31
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Singapore has a brilliant system at night, "follow the greens". This should be standard worldwide. it would prevent a lot of problems.
Or convince CAAs that iPad with GPS receiver in connection with JeppFD displaying precise aircraft location on taxiway chart present greater benefit than risk of any possible EM interference...

Much cheaper alternative that works everywhere where airport chart is georeferenced.
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Old 21st Jun 2015, 21:06
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Originally Posted by gtseraf
from a practical perspective, sometimes having the info for an aerodrome printed on many pages doesn't help. here mention is made of a warning note on pg 6 about this.

Let's be realistic, time constraints, workload issues and cockpit ergonomics, especially older airliners, are not conducive to a making a comprehensive briefing covering reams and reams of paperwork.
Correct, but it is not really a valid excuse as we have to just deal with the way things are. In order to mitigate this, I have notes for every airport I fly to commercially. They are on my laptop and I have them printed out on paper in a small pile in my room. When I am going somewhere, the paper copy gets brought with me for quick reference. It is just a single page of notes divided up into arrival, arrival taxi, departure taxi, and departure and whatever other random notes I might feel is important. Some airports have only a few notes, others are quite extensive.

Much of the information has come from pre-reading the Jeppesens and the many briefing pages, in advance of going into the airport the first time. That way, I don't have to worry about sorting through reams of Jeppesen pages on the ground while in a rush or in flight, especially a short flight. I can just look at my cheat sheet for quick reference. It gets updated on occasion as required with computer updated and a new page printout that goes into the pile.

Bottom line, I am just not nearly as sharp as some of those smart guys who really seem to know their stuff, so I write it down and review.

It can have out of date info and it is my responsibility to check and see if the Jepp pages have been updated since I was last at an airport.

Last edited by JammedStab; 21st Jun 2015 at 21:44.
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Old 21st Jun 2015, 21:41
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Don't ever be afraid to slow down and ask the GMC ATCO for help folks.
It always amazed me, on the cockpit trips I did, (after sitting 9 floors up in the tower for many years), how different it all looks at night, in the rain, at pilot eye-level, especially taxying towards the terminal buildings. It seemed to become a 2 dimensional mass of lights. This is a classic example of lots of little cheese-holes lining-up.
Safe taxying y'all.
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Old 21st Jun 2015, 22:28
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"Correct, but it is not really a valid excuse as we have to just deal with the way things are. In order to mitigate this, I have notes for every airport I fly to commercially. They are on my laptop and I have them printed out on paper in a small pile in my room. When I am going somewhere, the paper copy gets brought with me for quick reference. It is just a single page of notes divided up into arrival, arrival taxi, departure taxi, and departure and whatever other random notes I might feel is important."

Proof positive, if ever it was needed, that the very expensive aero info supplied to our profession is not and never has been up to the required standard.

Neither the content nor the delivery, in graphical design terms, is user friendly and the same trap awaits in other locations for those in our profession.

I recall in the last decade complaining to my airline management and training departments about the standard of the notams and their presentation but alas in the absence of a "Tombstone Imperative" neither interest nor action was taken.

There will be more BNLL type accidents/incidents before the nettle is grasped by the xAAs, if ever. And certainly any solution which costs (more) money will have a hard time being implemented.

"To those who mutter about the time taken to see the official reports...."
Rest assured I have not and will not mutter about delayed reports, my highlighting the delay to the LHR Airbus cowlings accident will be continued at a higher volume until we are all able to learn the lessons currently being obscured.

Or do you want aircraft accident reports to follow the example of the UKs much delayed Chilcott Enquiry?!
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Old 22nd Jun 2015, 01:52
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Airport qualifications for air carrier operators are important, but local familiarity with the airport makes or breaks the deal, so to speak.

I cannot download the report but I hope the station manager was held accountable.
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