FLIGHT SAFETY BLOG
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Tuesday, March 29, 2011
Tuesday, March 22, 2011
Tuesday, March 8, 2011
Tuesday, January 18, 2011
THE BLACKBIRD STORY : CROSSCHECK YOUR INSTRUMENTS
What was the slowest you ever flew the Blackbird?"
Brian Shul, Retired SR-71 Pilot, via Plane and Pilot Magazine
Brian Shul, Retired SR-71 Pilot, via Plane and Pilot Magazine
As a former SR-71 pilot, and a professional keynote speaker, the question I'm most often asked is "How fast would that SR-71 fly?" I can be assured of hearing that question several times at any event I attend.
It's an interesting question, given the aircraft's proclivity for speed,but there really isn't one number to give, as the jet would always give you a little more speed if you wanted it to. It was common to see 35 miles a minute. Because we flew a programmed Mach number on most missions, and never wanted to harm the plane in any way, we never let it run out to any limits of temperature or speed. Thus, each SR-71 pilot had his own individual high speed that he saw at some point on some mission. I saw mine over Libya when Khadafy fired two missiles my way, and max power was in order. Let's just say that the plane truly loved speed, and effortlessly took us to Mach numbers we hadn't previously seen.
So it was with great surprise, when, at the end of one of my presentations, someone asked: What was the slowest you ever flew the Blackbird? This was a first. After giving it some thought, I was reminded of a story I had never shared before, and relayed the following:
I was flying the SR-71 out of RAF Mildenhall, England, with my back-seater, Walt Watson; we were returning from a mission over Europe and the Iron Curtain, when we received a radio transmission from home
base. As we scooted across Denmark in three minutes, we learned that a small RAF base in the English countryside had requested an SR-71 fly-past. The air cadet commander there was a former Blackbird pilot,
and thought it would be a motivating moment for the young lads to see the mighty SR-71 perform a low approach. No problem; we were happy to do it. After a quick aerial refueling over the North Sea, we proceeded to find the small airfield.
Walter had a myriad of sophisticated navigation equipment in the back seat, and began to vector me toward the field. Descending to subsonic speeds, we found ourselves over a densely wooded area in a slight haze.
Like most former WWII British airfields, the one we were looking for had a small tower and little surrounding infrastructure. Walter told me we were close, and that I should be able to see the field, but I saw nothing. Nothing but trees as far as I could see in the haze. We got a little lower, and I pulled the throttles back from the 325 knots we were at. With the gear up, anything under 275 was just uncomfortable. Walt said we were practically over the field, yet there was nothing in my windscreen. I banked the jet and started a gentle circling maneuver in hopes of picking up anything that looked like a field. Meanwhile, below, the cadet commander had taken the cadets up on the catwalk of the tower, in order to get a prime view of the fly-past. It was a quiet, still day, with no wind and partial gray overcast. Walter continued to give me indications that the field should be below us, but, in the overcast and haze, I couldn't see it. The longer we continued to peer out the window and circle, the slower we got. With our power back, the awaiting cadets heard nothing. I must have had good instructors in my flying career, as something told me I better cross-check the gauges. As I noticed the airspeed indicator slide below 160 knots, my heart stopped, and my adrenalin-filled left hand pushed two throttles full forward. At this point, we weren't really flying, but were falling in a slight bank. Just at the moment, both afterburners lit with a thunderous roar of flame (and what a joyous feeling that was), and the
aircraft fell into full view of the shocked observers on the tower. Shattering the still quiet of that morning, they now had 107 feet of fire-breathing titanium in their face, as the plane leveled and accelerated, in full burner, on the tower side of the infield, closer than expected, maintaining what could only be described as some sort of
ultimate knife-edge pass.
Quickly reaching the field boundary, we proceeded back to Mildenhall without incident. We didn't say a word for those next 14 minutes. After landing, our commander greeted us, and we were both certain he was
reaching for our wings. Instead, he heartily shook our hands and said the commander had told him it was the greatest SR-71 fly-past he had ever seen, especially how we had surprised them with such a precise
maneuver that could only be described as breathtaking. He said that some of the cadets' hats were blown off, and the sight of the plan form of the plane in full afterburner, dropping right in front of them, was unbelievable. Walt and I both understood the concept of breathtaking very well, that morning, and sheepishly replied that they were just excited to see our low approach.
As we retired to the equipment room to change from space suits to flight suits, we just sat there: We hadn't spoken a word since the pass. Finally, Walter looked at me and said, "One hundred fifty-six knots.
What did you see?" Trying to find my voice, I stammered, "One hundred fifty-two." We sat in silence for a moment. Then Walt said, "Don't ever do that to me again!" And I never did.
A year later, Walter and I were having lunch in the Mildenhall Officers' club, and overheard an officer talking to some cadets about an SR-71 fly-past that he had seen, one day. Of course, by now the story included kids falling off the tower, and screaming as the heat of the jet singed their eyebrows. Noticing our Habu patches, as we stood there with lunch trays in our hands, he asked us to verify to the cadets that such
a thing had occurred. Walt just shook his head and said, "It was probably just a routine low approach; they're pretty impressive in that plane". Impressive indeed.
Little did I realize, after relaying this experience to my audience that day, that it would become one of the most popular and most requested stories. It's ironic that people are interested in how slow the world's fastest jet can fly. Regardless of your speed, however, it's always a good idea to keep that cross-check up -- and keep your Mach up, too.
Sunday, December 26, 2010
Thursday, November 25, 2010
Tuesday, November 16, 2010
Wednesday, November 10, 2010
Monday, November 1, 2010
Friday, October 29, 2010
EMIRATES 419 INCIDENT AT AUCKLAND
Factual Information
History of the flight
On Thursday 22 March 2007 at 1554, the
crew of A6-EBC, an Emirates Boeing 777-300ER, call sign Emirates 419, were
carrying out their final preparations for a scheduled flight from Auckland
International Airport to Sydney. The aircraft was parked at the international
terminal and on board for the flight were 357 passengers, 16 cabin crew and 2
pilots.
The first officer on Emirates 419,
whose first language was English, contacted the air traffic delivery controller
and received a route clearance for the aircraft. The pilots said that they had
listened to the current automatic terminal information service (ATIS)
broadcast, Romeo, and had a digital printout of the previous ATIS, Quebec, from
an aircraft on-board system. After checking that this information did not
differ significantly from Romeo, they used the ATIS Quebec weather information
for the aircraft operational performance tool software program of the
electronic flight bag2 to
calculate the take-off performance.
Included near the beginning of the
verbal ATIS broadcast were the words, “active runway mode normal operations…”
and advice that the active runway was 05 Right (05R). Near the middle of the
ATIS were the words, “reduced runway length eastern end refer NOTAM B/1203”.
The first officer did not acknowledge that the pilots had received ATIS Romeo,
nor did the controller ask whether the pilots had done so, as was normal
practice. The first officer did not request the western extension3 to runway 05R for the take-off.
The first officer contacted the
aerodrome apron control and
requested push-back and start-up clearance. The apron controller issued the
appropriate instructions and, because it was not a requirement of apron control,
did not confirm whether the pilots had received other relevant information such
as ATIS or knew that the runway length had been reduced.
About 2 hours earlier, the pilots had
flown the aircraft from Sydney to Auckland as Emirates 418. The captain advised
that their normal procedure was to use digital ATIS printouts if they were
available, and where possible to listen to the first part of the voice ATIS
broadcast for any updates before requesting a printout. They had the then
current ATIS Papa, which advised that runway 05R was in use, and near the
middle of the ATIS were the words, “reduced runway length eastern end refer
NOTAM B/1203”.
The pilots had NOTAM B/1203 (see NOTAM at the end), and at Sydney during their pre-departure stage they had planned for a
reduced length landing at Auckland. In the meantime the full length of the
runway had been made available temporarily to a departing long-haul flight to
Singapore5.
For traffic sequencing, the aerodrome controller held the Singapore-bound
aircraft at the runway holding point and cleared the Emirates pilots to land
their aircraft first. Because the full length of the runway was temporarily
available, the aerodrome controller advised the pilots that the full length of
the runway was available for their landing. The pilots landed the Boeing 777
with an automatic brake setting appropriate for a long landing rollout and
taxied normally to the gate.
At 1609 the first officer contacted the
aerodrome ground controller for taxi instructions for Emirates 419’s return
flight to Sydney. The controller gave the pilots instructions to taxi for
runway 05R and to hold at taxiway A10 (see figure above). The first officer
read back the instructions correctly and the controller responded, “That’s
correct, and confirm you will depart from alpha ten [A10] reduced length?”. The
first officer replied, “That’s correct.”
At 1613 the first officer advised the
aerodrome controller that Emirates 419 was approaching taxiway A10 and was
ready for take-off. The controller instructed the pilots to hold the aircraft
at A10. A short time later the controller cleared Emirates 419 for line-up on
runway 05R, and at 1615 cleared the aircraft for take-off.
The first officer was the pilot flying
and the pilots set the thrust that they had determined was necessary for an
assumed temperature-reduced thrust departure using the full length of the runway
from intersection A10. The aircraft began its take-off and accelerated
normally.
The pilots said that when the aircraft was nearly halfway
down the runway they saw vehicles ahead in the distance on the eastern end of
the runway, so the captain immediately applied take-off go-around (TOGA)
thrust.
According to data from the aircraft
quick access recorder, and separate runway position information, TOGA was
applied when the aircraft had travelled approximately 1327 metres (m); i.e.
about 41% of the length of the full runway or 61% of the length of the reduced
runway. The recorded airspeed at the time was 149 knots. Within 4 seconds the
aircraft accelerated to the pilots’ predetermined take-off decision speed (V1) of 161 knots. The first officer later
said that immediately after reaching V1
the captain called “rotate” when the
rotation speed (VR)
of 163 knots was achieved. The aircraft became airborne approximately 190 m
before the end of the reduced runway and climbed away steeply.
The vehicles on the closed eastern
portion of the runway were an airport safety officer’s utility vehicle and a 3
m high rubber-removal truck, about 460 m beyond the end of the reduced length of
the runway. The vehicles were authorised to be on the closed portion of the
runway for programmed work.
The airport safety officer had put his
vehicle between the truck and the aircraft and watched Emirates 419 accelerate
towards him. When the aircraft was closer than usual to the end of the available
runway and still not airborne compared with other similar-sized aircraft, he
drove his vehicle to the side of the runway as a precaution. The work crew on
the runway also moved to the side but the truck remained on the runway.
The aerodrome controller said that he
became concerned when the aircraft was still on the runway past the usual
take-off point, and when it got close to the truck after take-off. A report from
the safety officer suggested the aircraft might have passed some 20 m above the
truck.
Calculations using quick access
recorder data and vehicle position information showed that the aircraft wheels
were about 103 feet (31 m) above the runway as the aircraft flew over the vehicles,
or about 93 feet (28 m) clear of the truck. The aircraft climb rate was 2040
feet (622 m) per minute and increased to 5608 feet (1710 m) per minute 14
seconds later, before it reduced.
After contacting Auckland Control the
pilots reviewed the ATIS and NOTAM information and saw the text in the ATIS
about the reduced runway length, along with information about aircraft go-around
ability after entering the aerodrome circuit.
The first officer asked the controller
about the work vehicles and their distance from the end of the runway. The
controller advised the NOTAM take-off distance available from the A10
intersection. The pilots then notified the operator of the incident. The aircraft
continued to Sydney where the pilots landed it safely about 3 hours later. The
operator stood the pilots down from duty and returned them to its headquarters
in Dubai.
No one was injured in the incident and
no damage occurred.
Pilot information
The captain
was aged 40 years and used English as his first language. He held an Airline
Transport Pilot Licence valid until 10 August 2007. His associated medical
certificate was valid until 30 June 2007. He had flown approximately 14 000
hours.
The captain
had been a Boeing 777 pilot with the operator for about 3.5 years. He had been
a captain on the Boeing 777 for the previous 18 months. He had previous captain
and first officer experience flying Boeing 737, 757 and 767 aircraft. His last
pilot proficiency check had been completed on 4 March 2007.
A review of
the results of the previous 2 proficiency checks found there were no
significant concerns, and included a comment on the most recent check that it
had been completed to a very good standard.
At the time
of the incident on 22 March 2007, the captain had been on duty for
approximately 6 hours and had flown about 3 hours. On 21 March he had been off
duty on a layover in Sydney. On 20 March he had been on duty for approximately
11.5 hours and had flown 9 hours. On 19 March he had been off duty on a layover
in Bangkok.
The captain
said he had flown to and out of Auckland more than 30 times in the previous 3.5
years, and that he had flown all modes of approach and departure using the
different coloured pages in the airport approach and landing publications.
The captain
advised that the turnaround at Auckland was unrushed, and he and the first
officer had gone through the briefing package for the return flight and prepared
the cockpit in accordance with standard procedures.
The captain
said he and the first officer had received the ATIS broadcast Romeo for
departure, which he said was presented in the same way as when they had arrived
from Sydney. He said they had the previous printed copy of the digital ATIS but
did not “pick” the line that referred to reduced runway length. After reviewing
the ATIS they used the operational performance tool software program of the
electronic flight bag to calculate the aircraft take-off performance and thrust
required for the full length of runway 05R from the A10 intersection. He said
they did not see any vehicles on the end of the runway until after the aircraft
had begun its take-off roll.
The captain
said that after seeing the vehicles on the runway and applying TOGA, the first officer
rotated the aircraft at the proper speed and that clearing the vehicles was not
a problem.
The first
officer was aged 48 years. He held an Airline Transport Pilot License valid
until 23 June 2010. His associated medical certificate was valid until 1
September 2007. He had flown 12 664 hours.
The first
officer had been with the operator since May 2006, flying the Boeing 777. His
other flying experience included captaincy and first officer experience on
Boeing 737, McDonnell Douglas MD 82 and MD 83 aircraft. His last pilot
proficiency check had been completed on 19 January 2007. A review of the
results of the previous 2 proficiency checks found they were unremarkable.
At the time
of the incident on 22 March 2007, the first officer had been on duty for approximately
6 hours and had flown about 3 hours. On 21 March he had been off duty on a layover
in Sydney. On 20 March he had been on duty for approximately 11.5 hours and had
flown 9 hours. On 19 March he had been off duty on a layover in Bangkok.
The first
officer had previously flown to and out of Auckland on 12 August 2006, 9
February 2007 and 7 March 2007.
The first
officer said that during the turnaround at Auckland he had had some food before
returning to the flight deck and preparing the aircraft for the flight to
Sydney. He said that he and the captain had checked the current verbal ATIS
broadcast.
The first
officer said that it was not until after the aircraft had begun to accelerate
down the runway during departure that his and the captain’s attention had been
drawn to the far end of the runway. At that point they realised there was
something on the runway but still some distance away, so the captain applied
TOGA thrust. He said they made a normal take-off and “handily” cleared the
vehicles.
The pilots
advised that because the full runway length had been available when they
landed, they shared a belief that it would also be available for their
departure. They said that the ATIS words “normal operations” near the start of
the verbal broadcast Romeo helped to reinforce that belief and they said they
subsequently overlooked some information near the middle of the ATIS. The
captain said that the same words in the earlier verbal ATIS to which the pilots
had listened before they landed at Auckland caused them to think that NOTAM
B/1203 was not active, and that their belief was confirmed when the aerodrome
controller told them the full length of the runway was available for landing.
They commented that the non-applicable information about the ability of a
certain category of aircraft to enter the circuit in the event of a go-around
had cluttered the information in the ATIS.
The aircraft
operator advised that crews often requested the digital ATIS printout some time
before departure in order to begin calculating the take-off performance data.
As long as the ATIS information immediately prior to departure did not differ
significantly from the earlier ATIS, no change to the data was required. The
pilots had a digital printout of the previous ATIS Quebec, and the captain said
he had used its information for the calculation of the take-off performance
figures once they had the aircraft’s actual zero fuel weight, which was
obtained about 30 minutes before departure. After listening to the first part
of ATIS Romeo and hearing the words “normal operations” in the runway mode
information, and confirming that the information for calculating take-off
performance had not altered, they had not requested a digital printout. The
pilots commented that because the digital ATIS printout from the aircraft ran
lines together, it made text interpretation difficult.
The pilots
said that when the ground controller asked, “… and confirm you will depart from
alpha ten reduced length?” they thought she was referring to the western
extension to the runway that they had elected not to use.
Meteorological information
At the time of the
incident: the runway was dry; visibility was 50 kilometres; there were a few clouds
at 1800 feet (550 m) and some scattered cloud at 2500 feet (762 m); the
temperature was 22° Celsius and the dew point 15° Celsius; the surface wind was
variable at 5 knots (9 kilometres per hour); and the QNH was 1022 hecto-pascals.
Analysis
The event
The flight
was a routine scheduled service between Auckland and Sydney. The pilots were qualified,
experienced international pilots, who were familiar with Auckland International
Airport. There was no evidence that the pilots were under any undue pressure or
suffering from fatigue or stress-related issues. There were no transceiver
issues, and the radio communications were clear and coherent. The weather was
not considered to have been a factor because the flight was during the
afternoon in good visibility.
Despite the
above and the fact the correct information about the reduced runway length was accessible
by normal means and the pilots had that information, they did not fully
scrutinise the ATIS information and made an error in that they believed the
full runway length was available for their take-off. Consequently, they began
their take-off with a larger reduced-thrust setting and different optimum flap
setting on the aircraft than were required for the available runway length,
which was about 1060 m less than the full length of the runway.
Because of
the length of the runway, the pilots did not see the vehicles on the end of the
runway until the take-off was well advanced. Once they saw the vehicles, they
immediately recognised that something was amiss, and the captain’s quick action
in applying full thrust ensured the aircraft became airborne about 190 m before
the end of the available runway, and cleared the work vehicles by about 28 m.
At no stage
did the aircraft fly below the obstacle clearance fan at the end of the runway
and endanger the work crew. However, the airport safety officer’s concern and
his actions are understandable because there was uncertainty over whether the
aircraft would be airborne before the end of the available runway. The
controller’s worry that the aircraft had not rotated at the expected point on
the available runway also demonstrated that the take-off appeared to be irregular.
Large
reduced-thrust take-offs could appear unusual to the observer because the
aircraft may use a significant portion of the runway. The evidence in this case
showed that had the captain not increased thrust, the aircraft would have taken
approximately 2 further seconds to reach its planned rotation speed, and been
about 30 m from the end of the available runway when it got airborne. If the
full-length runway had been available, the take-off would have been normal. Had
the pilots planned for a reduced-length take-off, the aircraft would have
become airborne some distance earlier than it did.
The most
significant threat to the safety of the aircraft related to the pilots
rejecting the take-off before achieving the planned V1 of 161 knots, which was more hazardous than
continuing the take-off. They had not determined the correct V1 of 143 knots because of their error in believing a
longer runway distance was available. After they saw the work vehicles, the
pilots had no ability to recalculate V1 and reconfigure the aircraft. Even if they had been able to determine
the proper V1 speed, it would have been invalid
because of the aircraft configuration and because more runway had been used in
accelerating to that speed with the reduced thrust. Had they rejected the
take-off between the point on the runway where the correct V1 was achieved until the planned V1 of 161 knots, the aircraft would have overrun the
end of the available runway and entered the closed portion of the runway where
work vehicles and personnel were present.
Given the
situation in which the pilots found themselves after recognising their error,
with less available runway than planned and the speed of the aircraft
approaching the planned VR, the captain had little choice
but to take the action he did by applying full thrust, continuing the takeoff and
having the first officer rotate the aircraft at the planned VR of 163 knots. The relative light weight of the
aircraft and its surplus engine thrust ensured that the aircraft climbed away quickly
from the runway.
Theoretically,
there was also a risk of the aircraft encroaching into the obstacle clearance
safety fan at the end of the available runway had an engine failure occurred
between the predetermined V1 and when the
aircraft was safely above the runway. However, because the aircraft was rotated
only seconds after full thrust was selected, and did safely clear the work
zone, that risk was slight.
Understanding the pilots’ error
What needs
to be understood is why the 2 experienced pilots made the
information-processing error they did, which then compromised the safety of the
aircraft, its occupants and the ground personnel.
The pilots
had the correct flight information, including the relevant charts, ATIS and
NOTAM information. They had studied NOTAM B/1203 for their flight earlier that
day from Sydney to Auckland, were familiar with its contents and knew that the
available runway length at Auckland could be reduced. Accordingly they expected
a reduced-length landing on runway 05R. An updated ATIS when Emirates 418 was
en route to Auckland advised that the NOTAM was active, but the words “normal
operations” at the start of the verbal ATIS caused the pilots to think there
were no runway restrictions.
Before
Emirates 418 landed, the airport operator had returned the runway to its full
length temporarily in response to a request by the crew of a departing
long-haul aircraft. For traffic sequencing ATS held the departing aircraft so
that Emirates 418 could land first. Because there was a temporary change to the
information contained in the current ATIS broadcast that could have affected
Emirates 418, the controller advised the pilots of the change, i.e. that the
full runway length was available for their landing.
The pilots
subsequently completed a normal full-runway-length landing using sufficient
brake for a long roll-out. Because of the words in the verbal ATIS and the
change to full runway length, the pilots formed a mindset that the runway
restrictions had been removed for the day, and that the full runway length
would be available for their return flight to Sydney about 2 hours later.
The pilots’
turnaround at Auckland was routine, but during that time the available runway length
was again reduced. The ATIS broadcast was updated during that time, but it
continued to advise that the available length of runway 05R was reduced at its
eastern end and to refer to NOTAM B/1203. Because of the pilots’ mindset, they
might have subconsciously believed the ATIS was updated to reflect a removal of
the runway length restriction, following the controller’s advice that the full
runway length was available for landing.
The words “active
runway mode normal operations…” at the start of the current verbal ATIS broadcast
reinforced the pilots’ mistaken belief that the full runway length was
available. This misled the pilots into thinking that operations were normal and
inadvertently to overlook the information in the middle of the ATIS that
advised reduced runway length was in effect. Consequently, they believed they
had no reason to apply the NOTAM information about reduced runway length.
Airways
believed that in this situation it was restricted by the word choice in the AIP
arrival and departure information about Auckland International Airport to use “normal
operations” in the ATIS broadcast, because the instrument approaches and
landing threshold were unaltered, therefore operations were “normal”. This was
a matter of interpretation, because the AIP did imply that reduced runway lengths
were sometimes “special operations”. The difficulty was that if “special
operations” was referred to, pilots could use incorrect approach charts for landing
on runway 05R because its threshold was not displaced.
Although the
situation may have seemed normal to ATS, clearly the situation facing the
pilots for their take-off was non-normal. What the pilots needed to break their
mindset was some early confirmation that things were “not normal”, rather than
the unintentional reinforcement the ATIS provided that they were “normal”.
The ATIS
also contained about 11 seconds of permanent information about an aircraft
category that was not relevant to the pilots’ flight. This information, which
appeared immediately before the critical information about the reduced length
at the eastern end of the runway, helped to clutter an already busy ATIS and to
obscure the critical runway length information. While the printed copy of the
ATIS broadcast did not contain the runway mode “normal operations” reference,
its word order and presentation, with no punctuation or line separation, made
it potentially misleading and difficult to read, and thus obscured the critical
runway length
information.
Because the verbal ATIS broadcast was about twice as long as the 30 seconds recommended
by ICAO, it created the potential for pilots to filter information, which
appeared to be the case with the Emirates 419 pilots.
When the
pilots did not diligently follow standard checking procedures and listen to and
read all of the ATIS information as they prepared the aircraft and planned for
the return flight, they circumvented a defence against error. Had they properly
scrutinised the ATIS, the error could have been avoided. Instead they shared a
mistaken view about the runway length and prepared the aircraft for departure
on the basis of that flawed view.
The action
the aircraft operator took with the pilots following the incident should have heightened
their awareness regarding their pre-flight responsibilities for their
identification of potential threats, and helped them to avoid similar errors.
Although the
pilots had a responsibility to follow all procedures and ensure they received, understood
and applied the relevant ATIS information, from a human factors perspective
their error was understandable. The ATIS broadcast was the usual means of
alerting the pilots to the critical piece of information that runway
restrictions were in effect, but it was not robust enough in its word choice
and construction to break their mindset to ensure they understood that critical
information. Instead, the verbal ATIS broadcast inadvertently reinforced their
mistaken belief that things were normal.
Because the
pilots had not identified any runway threats, they were denied the opportunity
to apply the principles of threat and error management and manage correctly the
threat posed by a reduced-length-runway departure.
To help
reduce the potential for similar errors, ATS should ensure that ATIS information,
regardless of the means of transmission, has a clear word and sentence
structure, is unambiguous, contains only information that is of a critical and
non-permanent nature and complies as closely as possible with the
ICAO-recommended length. When operations are non-normal, the ATIS broadcasts
should not contain information that suggests, or encourages pilots to believe,
they are normal.
Because
Airways published the AIP information that it believed restricted its word
choice for an ATIS broadcast at Auckland International Airport, it could
enhance the AIP information so that the
words “normal operations” are not selected for use in ATIS broadcasts when any non-normal
operations are in effect.
While the
pilots’ omission to acknowledge that they had indeed received ATIS Romeo, and
the delivery controller’s oversight in not questioning them to ensure they had
received it, did not contribute to the incident, these omissions meant that the
normal closed communications loop concerning receipt of the ATIS was not
achieved as it should have been before the pilots proceeded. Because the ATIS
was an internationally used method of improving controller effectiveness and
relieving frequency congestion, it contained essential information and needed verification
that it had been received.
Although the
ground controller used her initiative in an attempt to ensure the pilots knew
the runway length was reduced, the pilots misunderstood the controller’s
question and thought the reference was to the runway extension behind them. As
a result, the additional defence the controller provided was frustrated. To
help prevent similar occurrences, ATS should introduce standardised procedures
that require controllers, as a back-up to the ATIS information, to always warn
pilots when runway restrictions are in effect, using phraseology that ensures
there can be no misunderstanding. This action will aid controllers and help
pilots to avoid similar
errors.
The runway
works in place at the time were correctly documented, notified and programmed
in accordance with normal processes. Although the airport operator fitted in as
much runway work as practicable during the less busy air traffic periods, some
work such as the work at the end of the runway could be carried out only during
the day and the operator needed the flexibility to achieve this. Runway rubber
removal was an ongoing process, and although the rubber removal at the time of
the incident was in addition to the work at the end of the runway, the operator’s
decision to use the opportunity to do this work was understandable.
The airport
operator could help to reduce the likelihood of similar occurrences by reducing
the opportunities for error by ensuring runway work is kept to only essential
items during normal heavy air traffic periods. Whether a curfew period for
heavier periods of maintenance could be introduced is something the airport
operator should continue to explore as a means of enhancing safety.
The airport
operator’s safety action (see 4.2) in having the apron tower personnel advise
pilots whenever there are runway works or reduced runway length in effect will
provide an additional defence for international flights against similar
occurrences at Auckland.
Findings
- Findings are listed in order of development and not in order of priority.
- The pilots were appropriately qualified, rested, authorised and fit for the flight.
- The aircraft was serviceable and its records indicated that it had been maintained in accordance with its schedules.
- An information processing error by the pilots led them to believe the full runway length was available for departure when it had been reduced, so they began their take-off with less thrust than required for the available length of runway.
- The pilots’ error stemmed from a mindset they had developed from their landing a few hours earlier that the runway length restrictions had been removed, and their insufficiently thorough pre-flight checking process.
- The captain’s prompt application of full thrust after the pilots saw the obstruction on the end of the runway ensured a safe outcome to the take-off.
- The pilots’ error compromised their ability to reject the take-off or maintain obstacle clearance safely in the event of a loss of engine thrust, and exposed the flight and ground personnel to unnecessary risk.
- The current ATIS broadcast did not properly fulfil its intended purpose of conveying essential but routine information to the pilots because:
•
it was about
twice as long as that recommended by ICAO
•
it contained
permanent information
•
its words “normal
operations” contradicted the reference later in the ATIS that advised“reduced
runway length”.
- Although the ATIS broadcast contained the correct information about the runway length restrictions, its word choice helped to reinforce the pilots’ mindset that the runway length was normal when it was not, and its construction was not robust enough to break that mindset.
- The Auckland AIP arrival and departure information inadvertently restricted ATS’s word choice for ATIS broadcasts so that it implied that operations were normal when a non-normal runway restriction was in effect.
- The format of the printed version of the ATIS broadcast made it confusing to read, and some interpretation was required to determine the length and content of each sentence. This format contributed to the pilots’ information-processing error.
- ATIS broadcasts were the only normal means used to alert pilots to critical runway information, such as when length restrictions were in effect. Had another defensive layer been established that required controllers to use standardised, unambiguous phraseology to warn pilots whenever runway restrictions were in effect, the pilots’ mindset would likely have been broken.
- While it did not contribute to this incident, the pilots and the controller inadvertently removed a defence against error when they did not confirm the pilots had received the current ATIS broadcast. Confirmation of receipt of the current ATIS was necessary to ensure that pilots had correct aerodrome information to plan safely for a departure or landing.
- Although the runway works and their scheduling did not directly contribute to this incident, any unnecessary works during normal traffic periods at major airports increase the opportunities for errors and the potential for an occurrence.
NOTAM B1203
(B1203/07
NOTAM)
A)NZAA
B)0703181900 C)0704080500
D)DAILY
1900 TO 0500
E)RWY
05R/23L WIP EAST OF RWY 23L THR. REDUCED LEN FOR TKOF AND LDG
WILL
APPLY. FULL LEN LDG NOT AVBL. RESTRICTIONS NOT ACTIVATED WHEN RWY WET.
ACTIVATION
OF RESTRICTIONS WILL BE BY ATIS OR RTF. AIP NZAA AD 2-31.6,
AUCKLAND
ARRIVAL/DEPARTURE (5) - RWY 05R/23L DISPLACED THR INFO REFERS.
PUBLISHED
ZULU AND VULCAN YELLOW CHARTS APPLY FOR DTHR. RWY 23L. THR
DISPLACED
1100M. PAPI AVBL S SIDE OF RWY GIVING 73FT THR XNG HGT. ALL LDG
ACFT
USE PAPI TO AVOID WORKS AREA. INSET THR MARKED BY ILLUMINATED HIGH INTST
GREEN
WING MARKERS BOTH SIDES OF RWY. HIGH INTST ALS, LOW INTST ALS AND RCLL
NOT
AVBL. DEP ACFT SHOULD APCH RWY FM TWY A3. IF REQUIRED BY ACFT PERFORMANCE
TWY
A2 AND CLSD PORTION OF RWY 23L BTN TWY A2 AND DTHR ARE AVBL FOR TKOF WITH
30
MIN PRIOR NOTICE. FULL LENGTH TKOF AVBL TO APPROVED LONG HAUL INTL ACFT
WITH
45 MIN PRIOR NOTICE. EFFECTIVE DIST AVBL RWY 23L:
LDA
2535M
LDA
EXIT TWY A10 2170M
TORA/ASDA
2535M
TODA
2735M
TORA/ASDA
FROM TWY A2 3235M
TODA
FROM TWY A2 3435M
RWY
05R. DEP ACFT SHOULD APCH RWY FM TWY A10, RCLL NOT AVBL. LDG ACFT PLAN TO
VACATE
RWY NO LATER THAN TWY A3. CLSD PORTION OF RWY 05R WEST OF TWY A3 IS
AVBL
FOR LDG. EFFECTIVE DISTANCES AVBL RWY 05R:
LDA
2190M
LDA
EXIT TWY A3 2320M
TORA/ASDA
FM TWY A10 2170M
TODA
FM TWY A10 2320M
TORA/ASDA
FM WESTERN EXTENSION 2520M
TODA
FROM WESTERN EXTENSION 2670M
CAUTION,
REVISED FULL LEN DISTANCES APPLY TO APPROVED LONG HAUL INTL ACFT
REQUIRING
FULL LEN RWY 05R TKOF, 45 MIN PRIOR NOTICE IS REQUIRED. RWY LEN IS
REDUCED
BY 20M. REVISED FULL LEN ASDA/TORA FM WESTERN EXTENSION 3615M
REVISED
FULL LEN TODA FROM WESTERN EXTENSION 3828M
REVISED
FULL LEN ASDA/TORA FROM TWY A10 3210M
REVISED
FULL LEN TODA FROM TWY A10 3423M
MEN
AND EQPT WILL VACATE WORK SITE FOR FULL LEN OPS)
END
Friday, October 22, 2010
BOEING 787 UPDATE: STAY OFF MY BACK!!!
The first Boeing 787
delivery is still months away, but the new plane is already threatening to cause
flight delays.
The Federal Aviation
Administration has been thinking about the new jet, and they’re a little
concerned that it might just be too fast and powerful. They’ve put out new guidelines regarding how closely other aircraft can
follow the new plane, as they’re concerned that the big wings and big
engines of the 787 will shake up the air in front of the planes waiting on the
runway.
Right now planes like
the 747-400 have a four-mile separation requirement, but the new 787 is getting a ten-mile rule.
It’s not just one plane either, as Boeing’s latest version of the 747 — the
747-8 — is also subject to the new rules.
The FAA just wants to
ensure that the new airplanes aren’t bullying smaller jets and older aircraft
on the runway. Right now it’s just an interim thing while the planes go through
testing, but if the restriction sticks
it could be an issue as planes are forced to lineup on the runway.
The
FAA might just be taking a conservative approach at this point, as even the Airbus A380 doesn’t require a
ten-mile spacing. Boeing is already chatting with the FAA about this new
guideline, as they realize this spacing could cause some of their customers to
be not so happy.
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