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An analysis of a deadly runway overrun

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by Capt. G A Fernando, MBA

gafplane@sltnet.lk

 

RCyAF, Air Ceylon, AirLanka, Singapore Airlines and SriLankan Airlines
President Aircraft Owners and Operators Association, Sri Lanka

Former Chief Pilot Boeing 737
Former Deputy Chief Pilot Lockheed L 1011, Tri Star

Former Member Accident Investigation Team CAASL.
Former Crew Resource Management Facilitator SIA

On the night of 1st June 1999, an American Airlines Flight 1420, a MD 82 aircraft, was approaching Little Rock Airport, Arkansas, USA, carrying 139 passengers, with thunderstorms in the vicinity. They were over two hours late and the pilots were trying to beat the onset of weather ,which was already moving in creating intense precipitation (rain), reducing visibility and causing strong cross winds at speeds well beyond the limits imposed by the Company Operations Manual which the pilots had to follow. Little Rock is subjected to frontal weather. In the USA, cold air masses moves in from the north, literally ploughing under warm moist air from the south (Gulf of Mexico) and pushing upwards to create violent thunderstorms.

The resulting rain brings about down draughts of air which manifest themselves as wind after hitting the ground and spreading out. (Microbursts) causing a phenomenon known as low level ‘Wind Shear’ that can be extremely dangerous to aircraft approaching to land. It manifests itself as a sudden change of wind speed at low level which may make the aircraft fall out of the sky with insufficient height to recover!

 

Microburst

The pilots of American Airlines Flight 1420, had been awake for a long time and they were at the tail end of their fight duty period, after a long day. They were attempting to fly, looking for visual clues outside the aircraft, (they could see the lights of the airport occasionally), when it was really instrument flight conditions. Basically, there are two rules to fly by. Visual Flight Rules (VFR) or Instrument Flight Rules (IFR). After a mid-air collision over the Grand Canyon, USA, in 1956, where both aircraft involved were flying visually, it was required that all commercial airlines will file their Flight Plans in accordance to IFR until such time the pilots declare that they have the destination airport in sight. At this time, their flight is automatically considered a flight operating, in accordance with VFR. Trying to ‘eyeball’ known traffic even today is worse than looking for a needle in a haystack.

The two pilots of flight AA1420 had been aware of the forecast weather for Little Rock, before they departed on their short flight from Dallas-Fort Worth, Texas. Taking into consideration the speed of the moving weather fronts, it is relatively easier to forecast, accurately, expected weather at the time of arrival, in that part of the world, than in the weather in the Tropics. From the Cockpit Voice Recorder (CVR) the Crew were observed by the accident investigators, to be calm and collected till the actual weather at the airport was communicated to them by the Air Traffic Controller at Little Rock. They were fully expecting to get to their destination before the weather moved in. It looked as if the weather was closing in fast.

Then the ‘human condition’ kicked in and things happened fast. Through the years, while aviation technology improved and aircraft were more and more reliable, the human has remained basically in the Stone Age, fallible, unimproved and unreliable. (Essentially not supermen but of muscle, blood, skin and bone) and subject to fear and emotion. In reality, no flight is error free. Some observers, on safety audits, have detected over 300 errors made by a single crew on routine flights even in the best of airlines. Most individual crew errors are detected or are inconsequential. The few that filter through, gets picked up by the second crew member. If a serious error that gets through undetected, and results in an undesirable situation, that, too, could be corrected, even at the last moment. Thus saving the day. “To err was human” as said by Cicero. Through intense training and continuous evaluation, It is the role of the crew to avoid and trap errors, manage threats to air safety and mitigate their effects when necessary. Pilots don’t have control over threats, such as weather. That is how the system should work. As the aircraft gets closer and closer to the destination, the tolerance limits also narrows down. For instance, airlines fly along airways that are 10 miles wide at 30,000 feet and are expected to land on a Runway strip 150 feet wide, demanding greater flying accuracy from the crew resulting in greater stress. Greater the stress, greater the chances of making errors which are classified by the behavioural scientists as ‘Slips, Lapses, Mistakes and Violations’.

To illustrate the point, using the analogy of driving a car, if one is expected to drive at 100 kph in a freeway and the speed slowly creeps up to 110 kph, before one recognises the error it is considered to be a ‘slip’. If one forgets to wear one’s seat belt, the error is considered to be a ‘lapse’. If one attempts to overtake on a dual lane road, based on one’s judgement and then realises that there is a car coming in the opposite direction and one is forced not to overtake, that type of error is called a ‘mistake’. If one is aware that one is breaking the law and one continues to do so regardless, that becomes a ‘violation’. (Like crossing double white lines, when overtaking.)

With AA1420 the presence of thunderstorms in the immediate vicinity and associated lightning, turbulence, air speed fluctuations of the aircraft, provided distractions, there is a possibility of self-induced stress. This is exactly what happened. While attempting to align the aircraft on the runway, in strong cross wind condition, they landed a bit deep. Being too busy (task overloaded) on the final approach, both crew members forgot to arm the automatic Ground Spoilers, resulting in an overrun of the wet runway. The Ground Spoilers are the devices on the top surface of the wing that pop out and literally spoils the lift of the wings a few seconds after touch down. The spoilers operate automatically when armed, pressing the wheels to the ground to improve braking action. If that didn’t happen either crew member could, reach across and physically pull a handle that can deploy the spoilers manually.

There was another human consideration known in the industry as ‘Intra Cockpit Authority Level’, between the Captain and the First Officer. The Captain, in this case, was a 10,000-hour, former US Air Force Veteran and Management Pilot, while the First Officer was a new hire with low experience, who may not have wanted to suggest that the Captain aborts the landing approach and goes around or interfere with the controls, as it would be misconstrued as ‘mutiny’. The million dollar question is, why he keep quiet when it also involved preservation of his own life?

Usually, it is left for the Captain (the team leader), at the initial briefing, to set the tone, by saying something like “if you see me do something unacceptable or dangerous, please sing it out loud even at the risk of being embarrassed”, because the Captain may sometimes give a logical explanation for his actions afterwards. Unfortunately, from what we could gather from the Cockpit Voice Recorder (CVR) that didn’t happen. There wasn’t time for even a proper briefing which should have been done before the top of descent, covering all options including a possible diversion to an alternate airport with better weather, or to their departure airport, which was Dallas-Fort Worth where the weather was good. That could have been a far safer option than landing on a wet runway with high cross winds. While continuing the landing in high winds was a ‘violation’, in certain countries, the Captain and Crew are allowed to proceed down to a minimum altitude and ‘take a look’ and abort (go around) the landing, if the situation is deemed to be unsafe. To some airports, like London, England, it is illegal for the crew to even commence an approach if the landing conditions are unacceptable. This regulation was imposed after an Ariana Afghan Airlines approached in bad weather, with 62 people on board, to London Gatwick, England, 51 years ago, and crashed.

Anyway the final result with flight AA 1420 was that the aircraft couldn’t stop, skidded sideways, overran the runway and hit a man-made obstacle that was not frangible (Breaking on impact), destroying the aircraft, killing the Captain instantly and 10 other passengers. The wreck caught fire. The crash was avoidable if the pilots delayed their approach to land or diverted to another airport and if that killer obstacle had been removed by the airport authorities. After the accident, the Captain’s wife took the Airport Authorities to court and was awarded damages of 2 million US Dollars, against the authorities, for not having frangible obstacles in the Runway End Safety Area (RESA). A long day, Pilot fatigue and a behavioural phenomenon called ‘get -there-a–ritis’ (also known as get-home-a-titis) where the pilots were intent at landing at any cost, under self-imposed pressure may have been contributing factors. In the opinion of the Accident Investigating team, the thunderstorms were far too close to the airport and recommended that aircraft should not commence an approach for landing, if the thunderstorms were closer than five miles from the airport. It was also recommended that arming of the Ground Spoilers be included in the ‘Before Landing Checklist’ The Accident Investigation team took over two years (in the comfort of quiet, air conditioned command centre) to analyse the case of American Airlines 1420 and quite rightly stated that it would be unfair to solely blame the crew who had less than two minutes, in demanding conditions, to make crucial decisions between life and death. Their objective was to find the cause behind the cause

As a standard practice, the aviation industry learns from crashes that occur in any part of the world. Pilots in our part of the world are as human as anywhere else. It is very easy to imagine that a similar scenario could happen in Sri Lanka, where similar weather patterns are encountered during the Inter-monsoon seasons (evening thunder showers). I am sure we have all seen the mighty power and devastating effects of the wind just before the onset of a storm. They blow down trees and damage roofs. Doppler Radar, capable of spotting wind shear is still a dream. Obstacles at the end of the runway should be identified and removed because aircraft can be at the wrong place at the wrong time. It is a case of evaluating the risks, by the operating crew.

That is what Safety Management is about. According to the International Civil Aviation Organisation (ICAO), being proactive, predictive and preventive is the name of the game. Unfortunately, many want to be in the spotlight as ‘movers and shakers’ of the a Aviation Industry but wouldn’t give two hoots to make the system safer. We have seen in the past that It is difficult to hold anyone accountable after an accident. The easy way out is to blame the pilots.

Perhaps. as Anton Jones in his popular ‘Baila’ about the Martinair crash at Maskeliya, says “Kageda warada notherai” (We don’t know whose fault it is).

That is the stark reality.


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Islamophobia and the threat to democratic development

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There’s an ill more dangerous and pervasive than the Coronavirus that’s currently sweeping Sri Lanka. That is the fear to express one’s convictions. Across the public sector of the country in particular many persons holding high office are stringently regulating and controlling the voices of their consciences and this bodes ill for all and the country.

The corrupting impact of fear was discussed in this column a couple of weeks ago when dealing with the military coup in Myanmar. It stands to the enduring credit of ousted Myanmarese Head of Government Aung San Suu Kyi that she, perhaps for the first time in the history of modern political thought, singled out fear, and not power, as the principal cause of corruption within the individual; powerful or otherwise.

To be sure, power corrupts but the corrupting impact of fear is graver and more devastating. For instance, the fear in a person holding ministerial office or in a senior public sector official, that he would lose position and power as a result of speaking out his convictions and sincere beliefs on matters of the first importance, would lead to a country’s ills going unaddressed and uncorrected.

Besides, the individual concerned would be devaluing himself in the eyes of all irrevocably and revealing himself to be a person who would be willing to compromise his moral integrity for petty worldly gain or a ‘mess of pottage’. This happens all the while in Lankan public life. Some of those who have wielded and are wielding immense power in Sri Lanka leave very much to be desired from these standards.

It could be said that fear has prevented Sri Lanka from growing in every vital respect over the decades and has earned for itself the notoriety of being a directionless country.

All these ills and more are contained in the current controversy in Sri Lanka over the disposal of the bodies of Covid victims, for example. The Sri Lankan polity has no choice but to abide by scientific advice on this question. Since authorities of the standing of even the WHO have declared that the burial of the bodies of those dying of Covid could not prove to be injurious to the wider public, the Sri Lankan health authorities could go ahead and sanction the burying of the bodies concerned. What’s preventing the local authorities from taking this course since they claim to be on the side of science? Who or what are they fearing? This is the issue that’s crying out to be probed and answered.

Considering the need for absolute truthfulness and honesty on the part of all relevant persons and quarters in matters such as these, the latter have no choice but to resign from their positions if they are prevented from following the dictates of their consciences. If they are firmly convinced that burials could bring no harm, they are obliged to take up the position that burials should be allowed.

If any ‘higher authority’ is preventing them from allowing burials, our ministers and officials are conscience-bound to renounce their positions in protest, rather than behave compromisingly and engage in ‘double think’ and ‘double talk’. By adopting the latter course they are helping none but keeping the country in a state of chronic uncertainty, which is a handy recipe for social instabiliy and division.

In the Sri Lankan context, the failure on the part of the quarters that matter to follow scientific advice on the burials question could result in the aggravation of Islamophobia, or hatred of the practitioners of Islam, in the country. Sri Lanka could do without this latter phobia and hatred on account of its implications for national stability and development. The 30 year war against separatist forces was all about the prevention by military means of ‘nation-breaking’. The disastrous results for Sri Lanka from this war are continuing to weigh it down and are part of the international offensive against Sri Lanka in the UNHCR.

However, Islamophobia is an almost world wide phenomenon. It was greatly strengthened during Donald Trump’s presidential tenure in the US. While in office Trump resorted to the divisive ruling strategy of quite a few populist authoritarian rulers of the South. Essentially, the manoeuvre is to divide and rule by pandering to the racial prejudices of majority communities.

It has happened continually in Sri Lanka. In the initial post-independence years and for several decades after, it was a case of some populist politicians of the South whipping-up anti-Tamil sentiments. Some Tamil politicians did likewise in respect of the majority community. No doubt, both such quarters have done Sri Lanka immeasurable harm. By failing to follow scientific advice on the burial question and by not doing what is right, Sri Lanka’s current authorities are opening themselves to the charge that they are pandering to religious extremists among the majority community.

The murderous, destructive course of action adopted by some extremist sections among Muslim communities world wide, including of course Sri Lanka, has not earned the condemnation it deserves from moderate Muslims who make-up the preponderant majority in the Muslim community. It is up to moderate opinion in the latter collectivity to come out more strongly and persuasively against religious extremists in their midst. It will prove to have a cementing and unifying impact among communities.

It is not sufficiently appreciated by governments in the global South in particular that by voicing for religious and racial unity and by working consistently towards it, they would be strengthening democratic development, which is an essential condition for a country’s growth in all senses.

A ‘divided house’ is doomed to fall; this is the lesson of history. ‘National security’ cannot be had without human security and peaceful living among communities is central to the latter. There cannot be any ‘double talk’ or ‘politically correct’ opinions on this question. Truth and falsehood are the only valid categories of thought and speech.

Those in authority everywhere claiming to be democratic need to adopt a scientific outlook on this issue as well. Studies conducted on plural societies in South Asia, for example, reveal that the promotion of friendly, cordial ties among communities invariably brings about healing among estranged groups and produces social peace. This is the truth that is waiting to be acted upon.

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Pakistan’s love of Sri Lanka

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By Sanjeewa Jayaweera

It was on 3rd January 1972 that our family arrived in Karachi from Moscow. Our departure from Moscow had been delayed for a few weeks due to the military confrontation between Pakistan and India. It ended on 16th December 1971. After that, international flights were not permitted for some time.

The contrast between Moscow and Karachi was unbelievable. First and foremost, Moscow’s temperature was near minus 40 degrees centigrade, while in Karachi, it was sunny and a warm 28 degrees centigrade. However, what struck us most was the extreme warmth with which the airport authorities greeted our family. As my father was a diplomat, we were quickly ushered to the airport’s VIP Lounge. We were in transit on our way to Rawalpindi, the airport serving the capital of Islamabad.

We quickly realized that the word “we are from Sri Lanka” opened all doors just as saying “open sesame” gained entry to Aladdin’s cave! The broad smile, extreme courtesy, and genuine warmth we received from the Pakistani people were unbelievable.

This was all to do with Mrs Sirima Bandaranaike’s decision to allow Pakistani aircraft to land in Colombo to refuel on the way to Dhaka in East Pakistan during the military confrontation between Pakistan and India. It was a brave decision by Mrs Bandaranaike (Mrs B), and the successive governments and Sri Lanka people are still enjoying the fruits of it. Pakistan has been a steadfast and loyal supporter of our country. They have come to our assistance time and again in times of great need when many have turned their back on us. They have indeed been an “all-weather” friend of our country.

Getting back to 1972, I was an early beneficiary of Pakistani people’s love for Sri Lankans. I failed the entrance exam to gain entry to the only English medium school in Islamabad! However, when I met the Principal, along with my father, he said, “Sanjeewa, although you failed the entrance exam, I will this time make an exception as Sri Lankans are our dear friends.” After that, the joke around the family dinner table was that I owed my education in Pakistan to Mrs B!

At school, my brother and I were extended a warm welcome and always greeted “our good friends from Sri Lanka.” I felt when playing cricket for our college; our runs were cheered more loudly than of others.

One particular incident that I remember well was when the Embassy received a telex from the Foreign inistry. It requested that our High Commissioner seek an immediate meeting with the Prime Minister of Pakistan, Mr Zulifikar Ali Bhutto (ZB), and convey a message from Mrs B. The message requested that an urgent shipment of rice be dispatched to Sri Lanka as there would be an imminent rice shortage. As the Ambassador was not in the station, the responsibility devolved on my father.

It usually takes about a week or more to get an audience with the Prime Minister (PM) of a foreign country due to their busy schedule. However, given the urgency, my father spoke to the Foreign Ministry’s Permanent Sectary, who fortunately was our neighbour and sought an urgent appointment. My father received a call from the PM’s secretary around 10 P.M asking him to come over to the PM’s residence. My father met ZB around midnight. ZB was about to retire to bed and, as such, was in his pyjamas and gown enjoying a cigar! He had greeted my father and had asked, “Mr Jayaweera, what can we do for great friend Madam Bandaranaike?. My father conveyed the message from Colombo and quietly mentioned that there would be riots in the country if there is no rice!

ZB had immediately got the Food Commissioner of Pakistan on the line and said, “I want a shipload of rice to be in Colombo within the next 72 hours!” The Food Commissioner reverted within a few minutes, saying that nothing was available and the last export shipment had left the port only a few hours ago to another country. ZB had instructed to turn the ship around and send it to Colombo. This despite protests from the Food Commissioner about terms and conditions of the Letter of Credit prohibiting non-delivery. Sri Lanka got its delivery of rice!

The next was the visit of Mrs B to Pakistan. On arrival in Rawalpindi airport, she was given a hero’s welcome, which Pakistan had previously only offered to President Gaddafi of Libya, who financially backed Pakistan with his oil money. That day, I missed school and accompanied my parents to the airport. On our way, we witnessed thousands of people had gathered by the roadside to welcome Mrs B.

When we walked to the airport’s tarmac, thousands of people were standing in temporary stands waving Sri Lanka and Pakistan flags and chanting “Sri Lanka Pakistan Zindabad.” The noise emanating from the crowd was as loud and passionate as the cheering that the Pakistani cricket team received during a test match. It was electric!

I believe she was only the second head of state given the privilege of addressing both assemblies of Parliament. The other being Gaddafi. There was genuine affection from Mrs B amongst the people of Pakistan.

I always remember the indefatigable efforts of Mr Abdul Haffez Kardar, a cabinet minister and the President of the Pakistan Cricket Board. From around 1973 onwards, he passionately championed Sri Lanka’s cause to be admitted as a full member of the International Cricket Council (ICC) and granted test status. Every year, he would propose at the ICC’s annual meeting, but England and Australia’s veto kept us out until 1981.

I always felt that our Cricket Board made a mistake by not inviting Pakistan to play our inaugural test match. We should have appreciated Mr Kardar and Pakistan’s efforts. In 1974 the Pakistan board invited our team for a tour involving three test matches and a few first-class games. Most of those who played in our first test match was part of that tour, and no doubt gained significant exposure playing against a highly talented Pakistani team.

Several Pakistani greats were part of the Pakistan and India team that played a match soon after the Central Bank bomb in Colombo to prove that it was safe to play cricket in Colombo. It was a magnificent gesture by both Pakistan and India. Our greatest cricket triumph was in Pakistan when we won the World Cup in 1996. I am sure the players and those who watched the match on TV will remember the passionate support our team received that night from the Pakistani crowd. It was like playing at home!

I also recall reading about how the Pakistani government air freighted several Multi Barrell artillery guns and ammunition to Sri Lanka when the A rmy camp in Jaffna was under severe threat from the LTTE. This was even more important than the shipload of rice that ZB sent. This was crucial as most other countries refused to sell arms to our country during the war.

Time and again, Pakistan has steadfastly supported our country’s cause at the UNHCR. No doubt this year, too, their diplomats will work tirelessly to assist our country.

We extend a warm welcome to Mr Imran Khan, the Prime Minister of Pakistan. He is a truly inspirational individual who was undoubtedly an excellent cricketer. Since retirement from cricket, he has decided to get involved in politics, and after several years of patiently building up his support base, he won the last parliamentary elections. I hope that just as much as he galvanized Sri Lankan cricketers, his political journey would act as a catalyst for people like Kumar Sangakkara and Mahela Jayawardene to get involved in politics. Cricket has been called a “gentleman’s game.” Whilst politics is far from it!.

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Covid-19 health rules disregarded at entertainment venues?

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Believe me, seeing certain videos, on social media, depicting action, on the dance floor, at some of these entertainment venues, got me wondering whether this Coronavirus pandemic is REAL!

To those having a good time, at these particular venues, and, I guess, the management, as well, what the world is experiencing now doesn’t seem to be their concerned.

Obviously, such irresponsible behaviour could create more problems for those who are battling to halt the spread of Covid-19, and the new viriant of Covid, in our part of the world.

The videos, on display, on social media, show certain venues, packed to capacity – with hardly anyone wearing a mask, and social distancing…only a dream..

How can one think of social distancing while gyrating, on a dance floor, that is over crowded!

If this trend continues, it wouldn’t be a surprise if Coronavirus makes its presence felt…at such venues.

And, then, what happens to the entertainment scene, and those involved in this field, especially the musicians? No work, whatsoever!

Lots of countries have closed nightclubs, and venues, where people gather, in order to curtail the spread of this deadly virus that has already claimed the lives of thousands.

Thailand did it and the country is still having lots of restrictions, where entertainment is concerned, and that is probably the reason why Thailand has been able to control the spread of the Coronavirus.

With a population of over 69 million, they have had (so far), a little over 25,000 cases, and 83 deaths, while we, with a population of around 21 million, have over 80,000 cases, and more than 450 deaths.

I’m not saying we should do away with entertainment – totally – but we need to follow a format, connected with the ‘new normal,’ where masks and social distancing are mandatory requirements at these venues. And, dancing, I believe, should be banned, at least temporarily, as one can’t maintain the required social distance, while on the dance floor, especially after drinks.

Police spokesman DIG Ajith Rohana keeps emphasising, on TV, radio, and in the newspapers, the need to adhere to the health regulations, now in force, and that those who fail to do so would be penalised.

He has also stated that plainclothes officers would move around to apprehend such offenders.

Perhaps, he should instruct his officers to pay surprise visits to some of these entertainment venues.

He would certainly have more than a bus load of offenders to be whisked off for PCR/Rapid Antigen tests!

I need to quote what Dr. H.T. Wickremasinghe said in his article, published in The Island of Tuesday, February 16th, 2021:

“…let me conclude, while emphasising the need to continue our general public health measures, such as wearing masks, social distancing, and avoiding crowded gatherings, to reduce the risk of contact with an infected person.

“There is no science to beat common sense.”

But…do some of our folks have this thing called COMMON SENSE!

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