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Third Freedom from Inept Civil Servants

Comment 4th September 2010

From: "Jim Quinn"
To:  "The Cabinet Office UK" <pscorrespondence@cabinet-office.x.gsi.gov.uk>
Cc:
Subject: UNSAFE AAIB report 4-2010
Date: 04 September 2010 21:30

The UK AAIB have done it again with their report on a Boeing 777 incident at St Kitts, West Indies (airport ref SKB) on 26th September 2009. See:
http://www.aaib.gov.uk/sites/aaib/publications/formal_reports.cfm

Their report AAIB 4-2010 dated 2sept10 is the fourth poor one this year (and thus every one this year has been poor!) that I have commented upon, and it again has insufficient safety recommendations.

The UK AAIB report says at para 1.18.1.1:
"Also the low sun was directly over the western end of the ramp."
According to the following website, http://www.sunrisesunsetmap.com/ , sunset was at 1802 hours Bolivia time, and the 777 aircrew started to talk to ATC (Air Traffic Control) about taxi at 2059:57 hours (three hours later, and Boliva is on the same longitude as SKB, but there may be an hour time zone difference of course), so the sun was well below the horizon. Since St Kitts is only 17 degrees North of the Equator, I would have thought the Sun would set at about 1800 hours for days are as long as nights on the equator at almost all times of the year, so I also mindfully conclude that the Sun was actually set for some long time previous to taxi out, and thus it was dark. Thus my safety recommendation ON THE UK AAIB, that they always check local time, and quote local sunset time in this case, for their reports.

So, it was dark, yet the UK AAIB report mentions no lights on the taxiway. Were there none, and thus why the co-pilot taxied blindly? Or was it his fault for not having a recce of the taxiway map before flight? Do SKB have big maps at aircrew lounge departure doors? Two more safety recommendations.

If the taxiway lights had been on, the co-pilot would have seen alpha taxiway to A departing to his left as he approached B. So importantly, were there no taxiway lights? Because the co-pilot was only following his own head lamps it seems. A safety recommendation to fit taxiway lights.

The UK AAIB mention the British Airways NDA, but do not show it. Why not, since it seems to me to indicate that BA should have their St Kitts flight clearance withdrawn – useless NDA still not corrected? A safety recommendation.

Why is there no ATC sound recorder? The UK AAIB report did not even mention it, even though they recognised difficulties in memory recall from the staff in the ATC room. I agree with the UK AAIB report 4-2010, that SKB is obviously not performing as it should, for they were lazy in their approach to safety. So they should be more stringently scrutinised before flights are allowed there again – but no UK AAIB recommendation anywhere near strong enough. Suspension hurts the whole island, so pressure to improve much better if flights were suspended. Two more safety recommendations.

If the departure via beta (B) was so regular, why was there no woman standing at the junction to ensure the 777 aircraft went down alpha to A? There are not that many flights into or out of SKB, so it should be easily setup. A safety recommendation.

The UK AAIB mention June 2010 as the date for work to be completed at the airport. Their report is September 2010. Was it done? Why publish the lazy report, if they do not know? Similarly for the training necessary for ATC crew. Another safety recommendation UPON the UK AAIB.

Count those safety recommendations up, and I think the UK AAIB will find they should be up to about number 2010-056 by now (not just their 2010-049), with an additonal two from ME onto THEM, which obviously EASA/CAA will have to think about.

Thus the UK AAIB are again quality audited. The UK AAIB should send many senior managers back to school (or sack them), and make sure those left know how to conduct an investigation in future. A safety recommendation on the UK AAIB, for our skys are only safer, if they report well.

NOW please.
IMMEDIATELY, for our future flight safety depends upon these people.

The UK Cabinet Office to follow up actions please.

Jim Quinn FIMechE

Why does this matter?

Thus the UK AAIB are again quality audited. The UK AAIB should send many senior managers back to school (or sack them), and make sure those left know how to conduct an investigation in future. A safety recommendation on the UK AAIB, for our skys are only safer, if they report well.

NOW please.
IMMEDIATELY, for our future flight safety depends upon these people.

The UK Cabinet Office to follow up actions please.

Jim Quinn FIMechE

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