[Peetwo]

No.19 completed with Popinjay to the rescue - yet AGAIN??  

Bored and maybe miffed by not having to appear at Estimates, Popinjay took up the role as this week's talking head Director Transport Safety with comments on defined investigation AO-2022-007:

King Air lands off runway surface during visual approach to Lord Howe Island during a rain shower



A King Air aircraft with a pilot and six passengers on board touched down on the grass strip to the left of the runway at Lord Howe Island after conducting an approach and landing during a heavy rain shower, an ATSB investigation report details.

The aircraft, being operated by Eastern Air Link, was conducting a scheduled passenger flight from Port Macquarie to Lord Howe Island on the morning of 18 February 2022. Approaching Lord Howe at about 0800, the pilot commenced a DME (distance measuring equipment) instrument arrival procedure conducted under instrument flight rules.

Early in the DME approach the pilot established visual meteorological conditions and transitioned to a visual approach. The pilot then descended the aircraft visually below cloud while over the water to an altitude below 1,000 ft, while also positioning for a straight-in approach to runway 10. During the approach, the aircraft entered an area of reduced visibility in rain and then touched down to the left of the runway.

“At the time of the aircraft's final approach and landing, the Lord Howe Island aerodrome was experiencing a heavy rain shower with limited visibility, conditions that were marginal for visual flight,” said ATSB Chief Commissioner Angus Mitchell.

“While the pilot commenced a visual approach to the runway with the required visual cues, it was highly unlikely that the required visual contact with the runway was retained throughout the approach.”

The ATSB investigation found that, with the loss of visual cues, the pilot did not commence a go around, which was contrary to the missed approach requirements, and instead continued towards the runway. This resulted in an increasing displacement from the runway centreline.

“Late in the approach with the aircraft close to the runway but with a significant displacement from the runway centreline, visual contact with the runway was reacquired,” Mr Mitchell said.

“Considerable manoeuvring with significant heading changes were required to realign the aircraft with the runway, resulting in an unstable approach, and, ultimately, the aircraft touching down off and to the left of the runway, on the runway strip.”

The pilot was aware that the aircraft had touched down to the side of the runway, but at the time thought that only the left main tyre was displaced at or around the edge of the runway. They elected to therefore continue the landing, manoeuvring the aircraft onto the runway and completing the landing roll without further incident.

A postflight inspection of the aircraft did not identify any damage, however an inspection of the runway by the aerodrome operator identified ground marks from an aircraft’s tyres along the left section of the runway strip, and a broken runway edge light on the left side of the runway, about 1,000 ft (300 m) from the runway threshold.

The ground markings indicated that the aircraft had touched down on the runway strip, with the closest main landing gear to the sealed runway surface about 2 m from the edge, and that the aircraft had quickly regained the runway shortly after touchdown.

In addition, the investigation also identified several flights conducted by the operator that followed a similar approach profile as that used by the occurrence flight, which were also conducted in marginal weather conditions for visual approach operations.

This practice significantly increased the risk of reduced obstacle clearance assurance for both an approach and a potential missed approach. 

“Adherence to operational procedures ensures consistency of pilot action and aircraft operation during the approach and landing phases of flight. This, along with careful monitoring of aircraft and approach parameters, ensures approaches are conducted safely,” Mr Mitchell said.

The ATSB has issued a safety recommendation to the operator that it provides guidance and training to flight crew concerning the safest option in the selection of an approach method when weather conditions are marginal for the conduct of a visual approach.

“Operators should encourage the use of the most appropriate and safe approach available,” Mr Mitchell said.

“When conditions are marginal, the use of an instrument approach that provides obstacle clearance assurance minimises the risks resultant from any unforeseen deterioration in conditions,” he continued.

“These approach types provide a protected flight path for any missed approach and have been shown to be significantly safer than a visual approach when weather conditions are marginal."

Read the report: Touchdown off the runway surface involving Raytheon B200, VH-MVP, at Lord Howe Island Airport, NSW, on 18 February 2022 | ATSB

Publication Date
24/05/2023

Got to wonder why Popinjay insists on making these media statements when it is a very profile incident? Why not let the report speak for itself? I also wonder what the annual cost would be for producing such word weasel waffle? Surely those resources would be better put to completing investigations in a more timely manner and in compliance with ICAO Annex 13? 

The investigation took an acceptable 15 months and 7 days. Although being a defined investigation, there was no prelim report published within 30 days (IE breach of ICAO Annex 13).

The intriguing aspects of this investigation are how this incident, without any injuries or damage to the aircraft, became the subject of a full blown defined investigation??

The answer I believe is contained in the identified safety issue: https://www.atsb.gov.au/safety-issues/AO-2022-007-SI-01

This safety issue has led to the ATSB issuing a very rare safety recommendation.. :

Action description

The ATSB recommends that Eastern Air Link address the safety issue, through provision of guidance and training to flight crew concerning the safest option in the selection of an approach method when weather conditions are marginal for the conduct of a visual approach.

Hmm...this bit reads more like the observations and actions that should fall inside the remit of the regulator (IE issuing of an RCA)?

ATSB comment

The ATSB acknowledges Eastern Air Link’s changes to the 3 NM limit for manoeuvring for a straight-in approach, but notes these were actioned through notice only with no supported training. Consequently, the ATSB examined flight crew actions during approaches into Lord Howe Island during a period of potential marginal weather conditions on 3 February 2023. While the weather conditions at that time did not qualify as being marginal for a visual approach, the data was mixed, with 2 of the 4 arrivals positioning for a straight-in approach while within the 3 NM manoeuvring limit. This prompted a request for further clarity on how the proposed changes were being implemented as the non‑adherence to the operational change indicates that, without any attached guidance or training component to emphasise and support the change, its implementation had been ineffective.

The changes to the stabilised approach criteria, and the later advice on the intention of this change, also required closer examination. In guidance on the appropriate response to deviation from stabilised approach criteria, the Flight Safety Foundation recommends that:

If the approach is not stabilized before reaching the minimum stabilization height, or if any flight parameter exceeds deviation limits (other than transiently) when below the minimum stabilization height, a go-around must be conducted immediately.

Transient deviations from stabilised approach criteria are generally accepted when turbulent conditions exist, whether the result of weather or the effects of local terrain, although should conditions result in serious deviation, the safest option is to go around. A transient deviation acceptance could be read into the content of 2C6.6.2, with the statement that ‘only minor corrections to speed and flight path, to maintain a stable approach, should be required…’ however, both this text, and the new note raised the question of what is required where more serious deviation results. The note gives no indication of transient exceedances being the issue but permits intentional exceedance of stabilised approach criteria should conditions necessitate, if that exceedance was foreseen through a special briefing. However, the ATSB notes that:

• The stated ‘self-briefing’ component is not apparent from the text.
  
• There is no guidance on what is considered a safe deviation from these criteria. As stated, the text permits an unrestricted authorisation to deviate from the standards.
  
• The operator has not introduced a monitoring or reporting component to this authorised deviation.
  

The stabilised approach method, and the well-established limits therein, has resulted in a significant reduction in loss of control and collision with terrain accidents during approach and landing. This method and the associated limits are recognised and followed globally and operate successfully in environments that present the possibility of conditions more extreme than that presented by Lord Howe Island, and without the need for acceptance of deviation. Further, this modification to the note following the stabilised approach criteria has the potential to validate the manoeuvring conducted during the occurrence event, as well as introducing the potential to significantly increase risk where meteorological conditions exist to justify extreme breaches of stabilised approach criteria.

In summary, the ATSB considered that Eastern Air Link’s initial response and the associated safety action did not address the safety issue. Therefore additional information was sought from the operator.

MTF...P2