[Peetwo]

O&O report AO-2016-166

The following is an Oz Aviation summary article of this - AO-2016-166 - ATSB FR released three days ago   

ATSB calls for centreline lighting on wider runways after 2016 incident

written by australianaviation.com.au May 15, 2019

The impact of the Virgin Australia runway excursion at Darwin Airport. (ATSB)

The Australian Transport Safety Bureau (ATSB) is renewing calls for centreline lighting to be installed on wider than usual runways following a 2016 incident where a Virgin Australia flight destroyed six runway lights when it landed 21m off the centre of the runway.

The incident occurred on December 6 2016, when the Virgin Australia Boeing 737-800 VH-VUI flying from Melbourne to Darwin was on approach to Runway 29. There was thunderstorm activity in the area and the flight was due to land at about 2300 local time.

The ATSB final report into the incident published on Wednesday said the flight crew had established and maintained clear visual reference to the runway and surrounds “until they encountered heavy rain shortly before reaching the runway threshold”.

“Under the influence of a light but increasing crosswind, the aircraft drifted right without the flight crew being able to discern the extent of the drift,” the final report said.

“The aircraft landed 21m to the right of the runway centreline and, shortly after touchdown, the right landing gear departed the sealed surface of the runway, destroying six runway lights before the aircraft returned to the runway.

“The aircraft incurred minor damage from ground debris and there were no injuries.”

In addition to the six runway lights being destroyed, the ATSB final report said debris from the lights and ground impacted the aircraft, resulting in minor damage to areas of the right aft fuselage and right horizontal stabiliser, and littered the edge of the runway surface.
There was also a large quantity of grass accumulated in the vicinity of the right wheel well, landing gear and wing flaps.


Wheel tracks where VH-VUI departed the runway 29 sealed surface and destroyed runway edge lights. (ATSB)


The tyre damage on VH-VUI. (ATSB)


The fuselage damage, marked with green tape, on VH-VUI. (ATSB)

Runway 29 at Darwin Airport measures about 60m wide and 3,350m long. The ATSB report noted the runway was about 15m wider than “almost all the other runways used by air transport aircraft in Australia”. It does not have centreline lighting.

As a result, the ATSB said the two rows of lights alongside Runway 29 were further apart than what a flight crew would normally encounter.
The ATSB said the absence of centreline lighting meant there were “very limited visual cues for maintaining runway alignment during night landings in reduced visibility”.

Darwin Airport is a shared civil and military facility. The Department of Defence owns the runway and other airport infrastructure, while Darwin International Airport runs the civilian operation.

The ATSB noted that while international guidelines recommended the use of centreline lighting on wider runways, there was no mandate from the International Civil Aviation Organisation (ICAO) to do so.


The final approach and landing roll of VH-VUI. (ATSB)

Further, its accident investigation records from 1997 to 2007 showed there had been two other incidents at Darwin Airport where the absence of centreline lighting may have been a factor.

The first was in 2003, when the right landing gear of a Boeing 737 veered off Runway 29 after landing 590m from the threshold, followed by the left landing gear about 760m from the threshold.

Another occurred in 2008, when a Boeing 717 made a “hard landing” at night. The ATSB investigation at the time said the lack of runway centreline lighting had reduced the available visual cues during the latter stages of the approach and landing on Runway 29.

The ATSB had recommended the installation of centreline lighting at Darwin Airport following the 2003 incident.

However, Darwin International Airport responded at the time that “a standard runway centerline system would be prohibitively expensive and is not currently a standard for our runway category”.

The ATSB also raised concerns following the 2008 landing. While the ATSB did not issue recommendation, it did seek a response from the Department of Defence, which said the installation, upgrade and maintenance costs for centreline lighting did not represent value for money.

“A wide runway without centreline lighting, such as at Darwin, poses a particular challenge for aircraft making approaches in darkness and heavy rain,” ATSB executive director for transport safety Nat Nagy said in a statement.

“In these circumstances centreline lighting greatly helps flight crews align the aircraft with the runway.”

The ATSB has issued a safety recommendation to ICAO to review the runway lighting standards in light of the new evidence available.

“The Australian Transport Safety Bureau recommends that the International Civil Aviation Organization review the effectiveness of Annex 14, recommendation 5.3.12.2 (for the installation of runway centreline lighting on Category I runways that are wider than 50 m), given that Category I runways that are wider than 50 m and without centreline lighting are over-represented in veer-off occurrences involving transport category aircraft landing in low visibility conditions,” the ATSB said.

The ATSB said both Darwin Airport and the Department of Defence had advised it that the installation of centreline lighting would be considered during any future runway works.

Meanwhile, the ATSB final report said Virgin Australia had introduced additional guidance to flight crews for approach to Darwin airport, including notes about runway surface, slope, width, lighting, and ambient light.

The carrier had also initiated specific training to pilots for loss of visibility in heavy rain, investigated enhancements to simulator modelling of degraded visibility at low levels, reviewed risk profiles for each airport including Darwin, commenced a program to investigate the potential to install hydrophobic windshield coatings on its 737 fleet, initiated a review of callouts for loss of visibility and reviewed the use of autopilot in poor weather, the ATSB said.

The full report can be read on the ATSB website.

On the face of it the report seems reasonable, however once you start to dissect, push, probe and compare IMO this is just another in a long..long series of top cover reports by the Hooded Canary and his not so merry team...

To begin why on earth did this investigation take 2 years, 5 months and 10 days (or 616 working days) to complete?

According to the safety issue addressed to Virgin the airline's SMS team had their identified safety issue(s) addressed inside of 2 months:

Aviation safety issues and actions
Operator guidance to flight crews
Issue number: AO-2016-166-SI-03
Who it affects: Virgin Australia Airlines flight crews operating into Darwin airport
Issue owner: Virgin Australia Airlines
Operation affected: Aviation: Air transport
Background: Investigation Report AO-2016-166
Date: 15 May 2019
Safety issue description
Virgin Australia did not have formal guidance for flight crews regarding the limited visual cues for maintaining alignment to runway 11/29 at Darwin during night landings in reduced visibility.

Proactive Action
Action organisation: Virgin Australia Airlines
Action number: AO-2016-166-NSA-012
Date: 20 January 2018
Action status: Closed
On 20 January 2017, the operator introduced additional guidance to flight crews for approach to Darwin airport, including notes about runway surface, slope, width, lighting, and ambient light.

Current issue status: Adequately addressed
Status justification:
The operator’s action, in conjunction with other safety actions, should provide crews with adequate guidance to enable them to assess risk and prepare for approaches in low visibility conditions at Darwin Airport.


Last update 15 May 2019

One has to ask how is it possible for an ATSB identified safety issue (above) be proactively addressed by the addressee a year before the safety issue was identified? And why wasn't the safety issue once identified then disseminated across the international aviation/airline industry? Surely if this was a deficiency in one airline this could also have a been a deficiency in other airlines?

Extract from the ATSB report:

Runway design standards and guidance

The International Civil Aviation Organization (ICAO) specifies standards and recommended practices (SARPS) for international aviation operations in a series of Annexes. ICAO Annex 14 (Aerodromes, Volume 1 Aerodrome Design and Operations, 7th edition July 2016) stated that runway centreline lights and touchdown zone lights shall be provided for runways with a category II or III[19] precision approach. It also stated:

5.3.12.2 Recommendation— Runway centre line lights should be provided on a precision approach runway category I, particularly when the runway is used by aircraft with high landing speeds or where the width between the runway edge lights is greater than 50 m.

Annex 14 had included the same or similar recommendation since 1966. There was no recommendation for touchdown zone lights for category I runways.

ICAO also published other guidance about aerodrome lighting. For example, ICAO document 9157 (Aerodrome Design Manual, Part 4 Visual Aids) stated:

The function of the centre line lighting is to provide the pilot with lateral guidance during the flare and landing ground roll or during a take-off. In normal circumstances, a pilot can maintain the track of the aircraft within approximately 1 to 2 m of the runway centre line with the aid of this lighting cue. The guidance information from the centreline is more sensitive than that provided from the pilot’s assessment of the degree of asymmetry between the runway edge lighting. In low visibility conditions, the use of the centre line is also the best means of providing an adequate segment of lighting for the pilot to use. The greater distances involved in viewing the runway edge lighting together with the need for the pilot to look immediately ahead of the aircraft during the ground roll also contribute to the requirements for a well-lit runway centre line.

Another section of the manual stated:

…Some of the most difficult tasks when flying an aircraft visually are judging the approach to a runway and the subsequent landing manoeuvre. During the approach, not only must the speed be carefully controlled, but continuous simultaneous corrections in all three dimensions are necessary in order to follow the correct flight path.


…There are two reasons why approach and runway lighting systems are provided with patterns that emphasize the centre line. One obvious reason is that the ideal landing position is along the centre of the runway. The other is that the fovea of the eye, the region of sharp vision, is only about 1.5 degrees in width…

Studies have shown that the average time required for a pilot to switch from outside visual cues to instruments and back to outside cues is about 2.5 seconds. Since high performance aircraft will travel at least 150 m in this time period, it is apparent that in so far as possible the visual aids should provide the utmost in guidance and information, enabling the pilot to proceed without the necessity of cross-checking the instruments…

Consistent with Annex 14, the MOS for CASR Part 139 required centreline and touchdown zone lighting for runways with category II or II approaches and recommended centreline lighting for category I runways with a width of more than 50 m.

Next from under 'other factors that increase risk' the ATSB report addressed a SR to ICAO:

Standards for installation of runway centreline lighting on wider runways 

Safety issue number:  AO-2016-166-SI-01
Safety issue: Category I runways that are wider than 50 m and without centreline lighting are over-represented in veer-off occurrences involving transport category aircraft landing in low visibility conditions. The installation of centreline lighting on wider category I runways is recommended but not mandated by the International Civil Aviation Organization Annex 14.

Safety recommendation to the International Civil Aviation Organization

The Australian Transport Safety Bureau recommends that the International Civil Aviation Organization review the effectiveness of Annex 14, recommendation 5.3.12.2 (for the installation of runway centreline lighting on Category I runways that are wider than 50 m), given that Category I runways that are wider than 50 m and without centreline lighting are over-represented in veer-off occurrences involving transport category aircraft landing in low visibility conditions.

"..recommended but not mandated.." - Hmm...I thought everyone knew that ICAO only 'recommends'? After all the ICAO Annexes (SARPs) are exactly 'Standards And Recommended Practices' and a country which wishes to have a difference to those SARPs simply notifies that difference. Mandating is something the ICAO doesn't have the power to do but mandating is something that a signatory State's NAA (National Aviation Authority) is ultimately responsible for. This begs the question to why it is that the Hooded Canary team have not addressed a similar SR to CASA?

...Consistent with Annex 14, the MOS for CASR Part 139 required centreline and touchdown zone lighting for runways with category II or III approaches and recommended centreline lighting for category I runways with a width of more than 50 m...

Hmm...MTF? - Definitely...P2  

ps Although there is no notified difference from Australia for Annex 14 Ch 5 para 5.3.12.2 there is one for 5.3.12.3 which is listed as a rare 'More exacting or exceeds' ND:

Runway centreline lights must be provided on the following: (a) a Cat II or III precision approach runway; (b) a runway intended for take-offs with an operating minimum below an RVR of 350 m.

 
Hmm...as usual 'nothing to see here, move along' -