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Aviation History
2004
2004-09 - 1628.PDF
ULL LIST OF READER SERVICES ADVERTISER CONTACTS - PS2 EDITORIAL + 44 (20) 8652 3842 Quadrant House, The Quadrant, Sutton, Surrey SM2 5AS, UK Fax <-44 (20) 8652 3840 email fligtit.international@rbi.co.uk Editor Murdo Morrison +44 (20) 8652 4395 mijrdo.morrison@rbi.co.uk Editorial Assistant Andrew Costerton +44 (20) 8652 3835 andrew.costerton@rbi.co.uk News Editor Andrew Doyle +44 (20) 8652 3096 andrew.doyle@rbi.co.uk Commercial Aviation Editor Max Kingsley-Jones +44 (20) 8652 3825 max.kingsley.jones@rbi.co.uk Defence Editor Craig Hoyle +44 (20) 8652 3834 craig.boyte@rbi.co.uk Operations/Safety Editor David Learmount +44 (20) 8652 3845 david.learmount@rbi.co.uk Business & General Aviation Editor Kate Sarsf ield +44 (20) 8652 3885 kate.sarsfield@rbi.co.uk Senior Reporter Justin Wastnage +44 (20) 8652 3863 justin.wastnage@rbi.co.uk Technical Reporter Rob Coppinger +44 (20) 8652 3843 rob.coppinger@rbi.co.uk Spaceflight Correspondent Tim Furniss +44 (1237) 477883 tim@spaceport.co.uk Business Reporter +44 (20) 8652 3990 Senior Technical Artist Giuseppe Picarella +44 (20) 8652 8054joe.picarella@rbi.co.uk Editorial Artist Tim Brown +44 (20) 8652 8043 tim.brown@rbi.co.uk EUROPE/MIDDLE EAST Israel Correspondent Arie Egozi +972 (3) 9413132 Middle East Correspondent Gerald Butt Russia Correspondent Vladimir Karnozov mr00079@east.ru AMERICAS Washington DC Office Fax +1 (703) 836 8344 Americas Editor Graham Warwick +1 (703) 836 3448 grabam.warmck@rbi.co.uk East Coast Editor Stephen Trimble +1 (703) 836 3084 stepben.trimble@rbi.co.uk West Coast Editor Guy Norris +1(949)2528971 Fax+1 (949) 252 8972 guy.norris@rbi.co.uk Brazil Correspondent Jackson Flores Jr +55 212439-6062 Fax +55 212349-6090 fubar@uot.com.br Canada Correspondent Brian Dunn ASIA/PACIFIC Singapore Office Fax +65 6789 7575 Regional Managing Editor Nicholas lonides +65 6780 4311 nicbotas.ionides@rbi.co.uk Deputy Asia Editor Brendan Sobie +65 6780 4309 brendan.sobie@rbi.co.uk Regional Reporter Leithen Francis +65 6780 4314 leitben.francis@rbi.co.uk Australia Civil Aviation Correspondent Emma Kelly +61 (8) 9454 4987 emmajkelty@bigpond.com Associate Editor (Defence) Peter La Franctii +61419 246 620 Fax +61 (2) 62312795 nulka@ozemait.com.au EDITORIAL PRODUCTION Group Production Editor Graeme Osborn +44 (20) 8652 3828 Group Art Editor James Mason +44 (20) 8652 4994 Chief Sub-Editor Chris Thornton +44 (20) 8652 4997 Deputy Production Editor +44 (20) 8652 3850 Sub Editor Simon Rees +44 (20) 8652 3848 Photographer Mark Wagner +44 (20) 8944 5225 WWW.FLIGHTINTERNATIONAL.COM Webmaster Sheena Buchanan +44 (20) 8652 4432 webmaster@fiigbtinternational.com SUBSCRIPTIONS +44 (1444) 445454 rbi.subscriptions@rbi.co.uk THE FLIGHT COLLECTION kim.hearn@rbi.co.uk © and Database Rights 2004 Reed Business Information Ltd. All rights reserved. No part of ttiis publication may be reproduced, stored in a retrieval system or transmitted in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without the prior permission in writing of the publishers / ffl\ f Air Transport Intelligence (ATI), Flight International's sister online service at www.rati.com, contains the full text of Flight i International'and Airline Businesssma 1996. Full text of the magazines can also be found online with Lexis-Nexis, Dialogue, FT Profile, IAC and Reuters. Editor Kieran Daly +44 (20) 8652 3837 Reed Business Information COMMENT Holes in the cheese Sometimes an accident warrants examining because it is extraordinary. The Girona report needs study because it is ordinary If Professor James Reason was looking for the ideal real-life example to demonstrate his famous "Swiss cheeses" model of what enables accidents to happen in a basically safe system, the just-published report on the September 1999 Boeing 757 accident at Girona in Spain has it all. Now the investigators reveal a web of inter acting forces, circumstances and influences, even including what secular insurers still call an act of God. Gamblers would call it a wild card. It is worth using an event like Girona to examine whether, just sometimes, things like this are bound to happen and we have to accept it, or whether something could - or should - have been done that might have blocked the chain of events. Although this 757, with 245 people on board, careered off the run way at high speed with almost all its controls disabled or malfunctioning, only one person died as a result. Even the low toll in human life Investigators reveal a web of interacting forces, including an act of God could be considered a matter of luck. This aircraft set off from the UK for Girona, knowing its destination and all its alternates were affected by a band of stormy, frontal weather - but it was the type that might delay a landing until a storm cell passed rather than prevent it. The captain loaded an additional 15min of fuel above standard company diver sionary minima to allow for this. On calling Girona it was clear that a storm cell was close to the airfield, but it was dark and its precise location was not communicated. The wind - not strong - had shifted from southerly to northerly, so the captain decided on a runway 02 non-pre cision approach rather than a precision approach on to 20 with a tailwind. The trouble with 20 is that it has a strong downslope -just above the International Civil Aviation Organisation recommended maximum. And the runway - adequate but not generously long at 2,400m (7,900ft) - was going to be wet, so the captain opted for the risk of a non-precision approach rather than the alternative risk of a tailwind landing on runway 20. He also took over as the pilot flying at that point. But the VOR/DME approach did not go well, the tower/approach controller advised during it that the storm cell was now over the airfield, and the captain carried out a go-around. Meanwhile, the wind was shifting again to southerly, making an ILS to runway 20 plausible for the second attempt. Then the aircraft flight management system advised the crew they were approach ing company fuel minima, so the captain was under pressure to make a decision whether to divert or not. It was dark, turbulent and the rain over the airfield was "torrential", but had they diverted to any of the alternates it might have been the same. As they established on the ILS for runway 20, the "must land" mindset would have been a tempting one to adopt. The approach was turbulent and not stable relative to the glideslope, but the runway lights were vis ible before decision height and, despite a sink-rate warning from the ground proximity warning system on short final, the captain clearly thought the landing could be safe. Then fate played the wild card. The runway lights went out for 11 s just as the captain needed them to judge the final descent and flare. The report says a contributory factor in the very hard, nose-down landing that fol lowed was "the effect of shock or mental incapacitation on the pilot flying at the failure of the runway lights, which may have inhibited him from making a decision to go-around". Most pilots have experienced an unexpected loss of visual contact with runway lights at the last moment - usually due to a patch of fog caused by a local micro-climate effect - but by the time the pilot has registered the loss of contact the lights usually reappear again. A pilot is "the system's goalkeeper", and this one got past the 757's crew. So where else did the defences fail? Girona, with its steeply slop ing runway, is scarcely perfect, but that was a known part of the risk management calcula tion. With hindsight, 15min of extra fuel was not enough. A recommendation that go- around manoeuvres below decision height should be a mandatory part of recurrent train ing seems useful because it would help pilots override a "must land" mindset. Another rec ommendation - that more precise real-time weather information should be immediately available to controllers - would have helped the captain with decision making. There's plenty else - the report is a gift for nitpickers. The Girona report should be required read ing for airline and airport safety committees, because there is no "silver bullet" solution for this one. It was an ordinary situation that got out of hand, and all operators can face chal lenges like these at any time. SEE AIR TRANSPORT P10 www.flightinternational.com FLIGHT INTERNATIONAL 7-13 SEPTEMBER 2004 5
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