Zooker, very true. And - in the US particularly - the use of only blue sideline taxiway lights, and only rare use of green centreline lights, is awful. You're faced with a sea of blue - blackness - blue - blackness - blue.... Some of the blackness is taxiway but most is not. But try distinguishing which bit of blackness is the taxi bit & which is not at a strange airport bloody difficult.

Centerline greens, however, are a much better way of marking the way. You have a clear line of breadcrumbs to follow.

One lesson to come out from this for airports is that runway / movement area inspections by ARFF are no good for electrical or pavement inspections - IMHO.

This is not to detract from the valuable job that ARFF do in emergency responses, nor the value of their routine inspections. But this accident has shown, like other accidents I know of, that such "drive-by" inspections are limited. Their frame of reference is to detect gross deficiencies such as wheels, flaps, cargo doors, etc., lying on the runway, or other obstacles such as dead animals. That is as far as the ARFF are trained to do, and as much as can be expected from their inspection.

They cannot detect pavement problems such as ruts, failures or slab breakage, and nor do they detect electrical/lighting problems. The report makes it clear that at JNB they missed the unserviceable sign and the many non-functioning taxiway lights – in section 1.11.5.2. I contend that for an airport to rely on ARFF to do the inspection tasks of pavement engineers or airport electricians is delusional, because ARFF are not trained in those tasks. What an airport must have is a routine inspection programme by the senior groundsman / technical officer for pavements, and by the electrician for lighting, signs, PAPIs etc. That is the ONLY way that pavement and lighting deficiencies can be assured of being detected.

Section 1.17.3.4 of the report outlines the ACSA Runway and Taxiway Inspections Procedures, which looks good on paper (and I am not being sarcastic). This includes a “Maintenance or Engineering representative to be in the inspection team”; and at ACSA International Airports “the electrician on duty is required to complete an inspection focusing on the serviceability of lights during the course of the day or night”. But it didn’t work; report section 2.1.21.4 refers to “daily runway and taxiway daily inspection sheets and maintenance checklists as proof of actions taken”. It looks good. But the reality is all that got generated were bits of paper with ticks on them. The defective lighting and signage still existed and they were a significant factor in this accident.

I don’t want to single out JNB or ACSA here; I have seen exactly the same problem at other airports in South Africa and I have seen it in other countries. It is a system-wide problem, and the only solution is separate out the routine “drive the runway” inspection from the pavement + electrical technical inspections.

After several tries I managed to download the report and read it. An extremely thorough report but perhaps overly detailed in places.

I know this has been mentioned before, but what I found staggering was that this was an exact repeat, with a more unfortunate outcome, of an earlier mistake at the Bravo/Mike intersection, by the same airline!

How come that one fell through the cracks at BA?

No problems with that in my airline... been doing it for a few years now. Works very nicely.

Can I ask whether I've misunderstood a point in the body of the report?

I thought that what it was trying to say was that Mike had been described on paper as a taxilane. But physically it didn't look like a taxilane, and had all the visual characteristics of a taxiway. Therefore, even if you were aware from your paperwork that Mike was approaching, you wouldn't be expecting to see it look like a taxiway; and therefore, if you saw a taxiway ahead of you, you might mistakenly think that it was still Bravo and continue along it.

If I've got that right, it's a relatively subtle point, and I wouldn't be surprised if the summary writer didn't manage to grasp or convey that.

I24, who is to say that ONLY BA had had the problem previously?

You might find that it was BECAUSE of the comprehensive nature of BA's ASR system that they were able to search for previous issues at JNB and found it.

iirc from reading report, the JNB authorities had no trace of it.

If the local authorities had no trace of the previous BA incident, how many other previous incidents at that intersection have they 'conveniently' 'no recollection' of from other airlines?

Remember also that local operators in and out all the time have much better local knowledge, the true test of an airport layout and procedures and deficiencies is gained from irregular users.

Just a countering view ....

"Just a countering view ...."

Which has conveniently ignored the point of the question.........any interest declared, perchance (when not on the golf course)?

The fact that the SA CAA publish a clear warning on their AIP Ground Movement Chart for JNB, indicates that taxiing down Mike in error, was and is a known threat. Normally published 'Hot Spots' and warnings for taxying are normally derived from past errors that have been made. I would be very surprised if BA was the only operator that has had aircraft involved in entering Mike in error.

The SA CAA obviously felt that the threat was worthy of mention on the AIP taxi chart itself and not confined to the text portion of the aerodrome entry. If Navtech had done the same and published the warning on the chart itself, then perhaps there would have been more likelihood of the crew spotting this and perhaps even briefing it before hand?

Exactly my point. I doubted that BA were the only ones EVER to make that mistake and hence questioned HOW and IF any previous instances were reviewed for severity and repeated occurrences by the authorities.

My interest is in finding out the facts and them being accurately and impartially analysed to prevent any future event. If (at least 2) crews have made the same mistake at the same point in recent years (I suspect more), shouldn't that sound a warning bell saying that more diligence and less sweeping under the carpet is required?

For completeness, I am no longer employed by BA but was until retirement a BA 747-400 Captain who operated in/out of Jo'berg between 1997 and 2009 and think I know the place fairly well (for a foreign operator - about 20 times between 2006-2009).

Remote monitoring of physical surfaces is difficult, but checking individual lights is within the compass of existing technology. If my car can check the functioning of each of its light bulbs, or LEDs, every time I swich on the ignition, surely a similar system can be devised for all functional lights at an airport.

A simple-minded scheme based on current drawn by a long string of lights may not be sufficiently sensitive, but including sufficient intelligence at the socket, with reporting back along the ower cables, should not cost more than a few pence per light. In total, less than a superannuable B747.

Too late for this particular horse, but such a scheme might be an effective bolt on future stable doors. If it worked, of course, we would never knoe because there would be no unknown missing lights to lead flight crew astray.

I have my doubts about the fixes for this problem.
Lights will fail, inspections will at times be less than diligent, crews will get distracted etc etc and it is likely to happen again.

A better fix would be to put a dogleg in Mike so that it joins Bravo at a right angle after the bend. The current straight on junction is an accident waiting to happen.

A distinction has to be drawn between the regulator and the airport operator. There is no denying that there were shortcomings that were attributed to the airport operator. The regulator on the other hand obviously accepted that there was a threat and highlighted this in a unambiguous way in the AIP for the benefit of the end user i.e. the pilot. For this to happen then I suspect that previous occurrences were not hidden from a wider audience, otherwise nothing would be published.

Another interesting question is how many BA pilots would have been aware of the previous incident at JNB? Not that one expects a pilot to trawl through years of ASR information prior to each flight. However previous errors made by colleagues can prove to be truly invaluable in preventing a similar occurrence. What is key is making such relevant information accessible and not hidden in amongst safety databases.

Doesn't BA have an airport briefing package for each destination giving general info and cautions.

Sorry for being stupid, but could someone please explain to a simpleton what the picture on page 4 is supposed to convey?

There are two markings, one long red dotted line and one shorter white dotted line. From what I know the crew followed the shorter, white, dotted line and ended up in a building. The picture description appears to say that the crew expected to taxi along the red dotted line, completely opposite to the white one.

But reading the following pages it is, to me, somewhat vague if they really expected that. Anyone care to help me out here?

The crews' expectations are explained BEFORE the photograph - on page 3

Section 1.1.4.1, item (ii)

"The expected taxi route, which was based on previous experience, was discussed and agreed on by the crew. They expected the taxi route to be facing tail south, with the intention to use taxiway Echo, turning onto taxiway Alfa for a "full length taxi" and "to keep going the extra 200m straight to the end of Runway 03L". i.e. - the red path.

Items (iii) and (iv) cover further expectations about problems along the red expected route.

To me the critical evidence is the picture of theintersection with the missing lights - unless you were really on the ball the curve of the Bravo taxiway beyond the intersection is very hard to pick up

Mike isn't brilliant either but when you have pre-briefed "straight on to the end" you can see how it happened

The only other thing that concerns me is that even though the CC reported dripping fuel the flight crew kept the engines running and then started the APU - that could have turned an incident into a full on disaster

HH,

You weren't there, you didn't see the leak size or location. After an incident like this it would be so easy for a crew succumb to the 'oh **** what have we done' aspect and lose control of the situation. They remained calm and rational and made sensible decisions with the information they had and are to be commended for that.

Out of interest have you ever tried to set fire to Jet A1? It's harder than you think. People get very badly hurt evacuating from a 747, it's not a decision to take lightly.

Lad

Funily enough I HAVE tried to set fire to JetA and you are correct - its much better to use Vodka as a fire-starter

I just think that knowing you've hit something and then getting a report of a leak you'd shut down - no reason to evacuate but you aren't going anywhere until someone outside has had a look. They had no idea how much they'd lost, or where it was leaking from. It was pretty dark out there.............

Thankyou very much, pattern_is_full!

I guess I didn't grasp the subtleties of "facing tail south" and "facing south" (as in "facing face south"), to me it was unclear, but I guess for you natives it is piece of cake.

I would agree with the person who noted the marked difference in the summary and the report conclusions. The summary looks hurried, as if they ran out of paper or something...

"didn,t discuss.." I may suggest anyone to try to stop an airliner after pushback,to discuss the taxi routing. Try it at CDG or AMS and you will be missing much more than your slot. The whole thing is based on that You know every airport by heart,so every instruction of taxi clearance is clear in your mind,including every work in progress. Loophole lies in there,because taxiing is always full with preparations,so everyone is supposed to know the routing. Understanding those instructions is left for the person who hears them,so... We were once the first to taxy at BRU morning cargo flight , all departing at the same time... Barely visible taxiing,i missed one sign for my captain,so we turned to the inner one too soon. The whole convoy of about twelve of us,followed wthout a question asked... Follow the one who seems know-syndrome.