Features
An analysis of a deadly runway overrun
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.
by Dr Gotabhya Ranasinghe
Senior Consultant Cardiologist
National Hospital Sri Lanka
When we sought a meeting with Hon Dr. Ramesh Pathirana, Minister of Health, he graciously cleared his busy schedule to accommodate us. Renowned for his attentive listening and deep understanding, Minister Pathirana is dedicated to advancing the health sector. His openness and transparency exemplify the qualities of an exemplary politician and minister.
Dr. Palitha Mahipala, the current Health Secretary, demonstrates both commendable enthusiasm and unwavering support. This combination of attributes makes him a highly compatible colleague for the esteemed Minister of Health.
Our discussion centered on a project that has been in the works for the past 30 years, one that no other minister had managed to advance.
Minister Pathirana, however, recognized the project’s significance and its potential to revolutionize care for heart patients.
The project involves the construction of a state-of-the-art facility at the premises of the National Hospital Colombo. The project’s location within the premises of the National Hospital underscores its importance and relevance to the healthcare infrastructure of the nation.
This facility will include a cardiology building and a tertiary care center, equipped with the latest technology to handle and treat all types of heart-related conditions and surgeries.
Securing funding was a major milestone for this initiative. Minister Pathirana successfully obtained approval for a $40 billion loan from the Asian Development Bank. With the funding in place, the foundation stone is scheduled to be laid in September this year, and construction will begin in January 2025.
This project guarantees a consistent and uninterrupted supply of stents and related medications for heart patients. As a result, patients will have timely access to essential medical supplies during their treatment and recovery. By securing these critical resources, the project aims to enhance patient outcomes, minimize treatment delays, and maintain the highest standards of cardiac care.
Upon its fruition, this monumental building will serve as a beacon of hope and healing, symbolizing the unwavering dedication to improving patient outcomes and fostering a healthier society.We anticipate a future marked by significant progress and positive outcomes in Sri Lanka’s cardiovascular treatment landscape within the foreseeable timeframe.
by Fr. Emmanuel Fernando, OMI
Jesuit Fr. Aloysius Pieris (affectionately called Fr. Aloy) celebrated his 90th birthday on April 9, 2024 and I, as the editor of our Oblate Journal, THE MISSIONARY OBLATE had gone to press by that time. Immediately I decided to publish an article, appreciating the untiring selfless services he continues to offer for inter-Faith dialogue, the renewal of the Catholic Church, his concern for the poor and the suffering Sri Lankan masses and to me, the present writer.
It was in 1988, when I was appointed Director of the Oblate Scholastics at Ampitiya by the then Oblate Provincial Fr. Anselm Silva, that I came to know Fr. Aloy more closely. Knowing well his expertise in matters spiritual, theological, Indological and pastoral, and with the collaborative spirit of my companion-formators, our Oblate Scholastics were sent to Tulana, the Research and Encounter Centre, Kelaniya, of which he is the Founder-Director, for ‘exposure-programmes’ on matters spiritual, biblical, theological and pastoral. Some of these dimensions according to my view and that of my companion-formators, were not available at the National Seminary, Ampitiya.
Ever since that time, our Oblate formators/ accompaniers at the Oblate Scholasticate, Ampitiya , have continued to send our Oblate Scholastics to Tulana Centre for deepening their insights and convictions regarding matters needed to serve the people in today’s context. Fr. Aloy also had tried very enthusiastically with the Oblate team headed by Frs. Oswald Firth and Clement Waidyasekara to begin a Theologate, directed by the Religious Congregations in Sri Lanka, for the contextual formation/ accompaniment of their members. It should very well be a desired goal of the Leaders / Provincials of the Religious Congregations.
Besides being a formator/accompanier at the Oblate Scholasticate, I was entrusted also with the task of editing and publishing our Oblate journal, ‘The Missionary Oblate’. To maintain the quality of the journal I continue to depend on Fr. Aloy for his thought-provoking and stimulating articles on Biblical Spirituality, Biblical Theology and Ecclesiology. I am very grateful to him for his generous assistance. Of late, his writings on renewal of the Church, initiated by Pope St. John XX111 and continued by Pope Francis through the Synodal path, published in our Oblate journal, enable our readers to focus their attention also on the needed renewal in the Catholic Church in Sri Lanka. Fr. Aloy appreciated very much the Synodal path adopted by the Jesuit Pope Francis for the renewal of the Church, rooted very much on prayerful discernment. In my Religious and presbyteral life, Fr.Aloy continues to be my spiritual animator / guide and ongoing formator / acccompanier.
Fr. Aloysius Pieris, BA Hons (Lond), LPh (SHC, India), STL (PFT, Naples), PhD (SLU/VC), ThD (Tilburg), D.Ltt (KU), has been one of the eminent Asian theologians well recognized internationally and one who has lectured and held visiting chairs in many universities both in the West and in the East. Many members of Religious Congregations from Asian countries have benefited from his lectures and guidance in the East Asian Pastoral Institute (EAPI) in Manila, Philippines. He had been a Theologian consulted by the Federation of Asian Bishops’ Conferences for many years. During his professorship at the Gregorian University in Rome, he was called to be a member of a special group of advisers on other religions consulted by Pope Paul VI.
Fr. Aloy is the author of more than 30 books and well over 500 Research Papers. Some of his books and articles have been translated and published in several countries. Among those books, one can find the following: 1) The Genesis of an Asian Theology of Liberation (An Autobiographical Excursus on the Art of Theologising in Asia, 2) An Asian Theology of Liberation, 3) Providential Timeliness of Vatican 11 (a long-overdue halt to a scandalous millennium, 4) Give Vatican 11 a chance, 5) Leadership in the Church, 6) Relishing our faith in working for justice (Themes for study and discussion), 7) A Message meant mainly, not exclusively for Jesuits (Background information necessary for helping Francis renew the Church), 8) Lent in Lanka (Reflections and Resolutions, 9) Love meets wisdom (A Christian Experience of Buddhism, 10) Fire and Water 11) God’s Reign for God’s poor, 12) Our Unhiddden Agenda (How we Jesuits work, pray and form our men). He is also the Editor of two journals, Vagdevi, Journal of Religious Reflection and Dialogue, New Series.
Fr. Aloy has a BA in Pali and Sanskrit from the University of London and a Ph.D in Buddhist Philosophy from the University of Sri Lankan, Vidyodaya Campus. On Nov. 23, 2019, he was awarded the prestigious honorary Doctorate of Literature (D.Litt) by the Chancellor of the University of Kelaniya, the Most Venerable Welamitiyawe Dharmakirthi Sri Kusala Dhamma Thera.
Fr. Aloy continues to be a promoter of Gospel values and virtues. Justice as a constitutive dimension of love and social concern for the downtrodden masses are very much noted in his life and work. He had very much appreciated the commitment of the late Fr. Joseph (Joe) Fernando, the National Director of the Social and Economic Centre (SEDEC) for the poor.
In Sri Lanka, a few religious Congregations – the Good Shepherd Sisters, the Christian Brothers, the Marist Brothers and the Oblates – have invited him to animate their members especially during their Provincial Congresses, Chapters and International Conferences. The mainline Christian Churches also have sought his advice and followed his seminars. I, for one, regret very much, that the Sri Lankan authorities of the Catholic Church –today’s Hierarchy—- have not sought Fr.
Aloy’s expertise for the renewal of the Catholic Church in Sri Lanka and thus have not benefited from the immense store of wisdom and insight that he can offer to our local Church while the Sri Lankan bishops who governed the Catholic church in the immediate aftermath of the Second Vatican Council (Edmund Fernando OMI, Anthony de Saram, Leo Nanayakkara OSB, Frank Marcus Fernando, Paul Perera,) visited him and consulted him on many matters. Among the Tamil Bishops, Bishop Rayappu Joseph was keeping close contact with him and Bishop J. Deogupillai hosted him and his team visiting him after the horrible Black July massacre of Tamils.
Sri Lanka-Singapore Free Trade Agreement
By Gomi Senadhira
senadhiragomi@gmail.com
“You might tell fairy tales, but the progress of a country cannot be achieved through such narratives. A country cannot be developed by making false promises. The country moved backward because of the electoral promises made by political parties throughout time. We have witnessed that the ultimate result of this is the country becoming bankrupt. Unfortunately, many segments of the population have not come to realize this yet.” – President Ranil Wickremesinghe, 2024 Budget speech
Any Sri Lankan would agree with the above words of President Wickremesinghe on the false promises our politicians and officials make and the fairy tales they narrate which bankrupted this country. So, to understand this, let’s look at one such fairy tale with lots of false promises; Ranil Wickremesinghe’s greatest achievement in the area of international trade and investment promotion during the Yahapalana period, Sri Lanka-Singapore Free Trade Agreement (SLSFTA).
It is appropriate and timely to do it now as Finance Minister Wickremesinghe has just presented to parliament a bill on the National Policy on Economic Transformation which includes the establishment of an Office for International Trade and the Sri Lanka Institute of Economics and International Trade.
Was SLSFTA a “Cleverly negotiated Free Trade Agreement” as stated by the (former) Minister of Development Strategies and International Trade Malik Samarawickrama during the Parliamentary Debate on the SLSFTA in July 2018, or a colossal blunder covered up with lies, false promises, and fairy tales? After SLSFTA was signed there were a number of fairy tales published on this agreement by the Ministry of Development Strategies and International, Institute of Policy Studies, and others.
However, for this article, I would like to limit my comments to the speech by Minister Samarawickrama during the Parliamentary Debate, and the two most important areas in the agreement which were covered up with lies, fairy tales, and false promises, namely: revenue loss for Sri Lanka and Investment from Singapore. On the other important area, “Waste products dumping” I do not want to comment here as I have written extensively on the issue.
1. The revenue loss
During the Parliamentary Debate in July 2018, Minister Samarawickrama stated “…. let me reiterate that this FTA with Singapore has been very cleverly negotiated by us…. The liberalisation programme under this FTA has been carefully designed to have the least impact on domestic industry and revenue collection. We have included all revenue sensitive items in the negative list of items which will not be subject to removal of tariff. Therefore, 97.8% revenue from Customs duty is protected. Our tariff liberalisation will take place over a period of 12-15 years! In fact, the revenue earned through tariffs on goods imported from Singapore last year was Rs. 35 billion.
The revenue loss for over the next 15 years due to the FTA is only Rs. 733 million– which when annualised, on average, is just Rs. 51 million. That is just 0.14% per year! So anyone who claims the Singapore FTA causes revenue loss to the Government cannot do basic arithmetic! Mr. Speaker, in conclusion, I call on my fellow members of this House – don’t mislead the public with baseless criticism that is not grounded in facts. Don’t look at petty politics and use these issues for your own political survival.”
I was surprised to read the minister’s speech because an article published in January 2018 in “The Straits Times“, based on information released by the Singaporean Negotiators stated, “…. With the FTA, tariff savings for Singapore exports are estimated to hit $10 million annually“.
As the annual tariff savings (that is the revenue loss for Sri Lanka) calculated by the Singaporean Negotiators, Singaporean $ 10 million (Sri Lankan rupees 1,200 million in 2018) was way above the rupees’ 733 million revenue loss for 15 years estimated by the Sri Lankan negotiators, it was clear to any observer that one of the parties to the agreement had not done the basic arithmetic!
Six years later, according to a report published by “The Morning” newspaper, speaking at the Committee on Public Finance (COPF) on 7th May 2024, Mr Samarawickrama’s chief trade negotiator K.J. Weerasinghehad had admitted “…. that forecasted revenue loss for the Government of Sri Lanka through the Singapore FTA is Rs. 450 million in 2023 and Rs. 1.3 billion in 2024.”
If these numbers are correct, as tariff liberalisation under the SLSFTA has just started, we will pass Rs 2 billion very soon. Then, the question is how Sri Lanka’s trade negotiators made such a colossal blunder. Didn’t they do their basic arithmetic? If they didn’t know how to do basic arithmetic they should have at least done their basic readings. For example, the headline of the article published in The Straits Times in January 2018 was “Singapore, Sri Lanka sign FTA, annual savings of $10m expected”.
Anyway, as Sri Lanka’s chief negotiator reiterated at the COPF meeting that “…. since 99% of the tariffs in Singapore have zero rates of duty, Sri Lanka has agreed on 80% tariff liberalisation over a period of 15 years while expecting Singapore investments to address the imbalance in trade,” let’s turn towards investment.
Investment from Singapore
In July 2018, speaking during the Parliamentary Debate on the FTA this is what Minister Malik Samarawickrama stated on investment from Singapore, “Already, thanks to this FTA, in just the past two-and-a-half months since the agreement came into effect we have received a proposal from Singapore for investment amounting to $ 14.8 billion in an oil refinery for export of petroleum products. In addition, we have proposals for a steel manufacturing plant for exports ($ 1 billion investment), flour milling plant ($ 50 million), sugar refinery ($ 200 million). This adds up to more than $ 16.05 billion in the pipeline on these projects alone.
And all of these projects will create thousands of more jobs for our people. In principle approval has already been granted by the BOI and the investors are awaiting the release of land the environmental approvals to commence the project.
I request the Opposition and those with vested interests to change their narrow-minded thinking and join us to develop our country. We must always look at what is best for the whole community, not just the few who may oppose. We owe it to our people to courageously take decisions that will change their lives for the better.”
According to the media report I quoted earlier, speaking at the Committee on Public Finance (COPF) Chief Negotiator Weerasinghe has admitted that Sri Lanka was not happy with overall Singapore investments that have come in the past few years in return for the trade liberalisation under the Singapore-Sri Lanka Free Trade Agreement. He has added that between 2021 and 2023 the total investment from Singapore had been around $162 million!
What happened to those projects worth $16 billion negotiated, thanks to the SLSFTA, in just the two-and-a-half months after the agreement came into effect and approved by the BOI? I do not know about the steel manufacturing plant for exports ($ 1 billion investment), flour milling plant ($ 50 million) and sugar refinery ($ 200 million).
However, story of the multibillion-dollar investment in the Petroleum Refinery unfolded in a manner that would qualify it as the best fairy tale with false promises presented by our politicians and the officials, prior to 2019 elections.
Though many Sri Lankans got to know, through the media which repeatedly highlighted a plethora of issues surrounding the project and the questionable credentials of the Singaporean investor, the construction work on the Mirrijiwela Oil Refinery along with the cement factory began on the24th of March 2019 with a bang and Minister Ranil Wickremesinghe and his ministers along with the foreign and local dignitaries laid the foundation stones.
That was few months before the 2019 Presidential elections. Inaugurating the construction work Prime Minister Ranil Wickremesinghe said the projects will create thousands of job opportunities in the area and surrounding districts.
The oil refinery, which was to be built over 200 acres of land, with the capacity to refine 200,000 barrels of crude oil per day, was to generate US$7 billion of exports and create 1,500 direct and 3,000 indirect jobs. The construction of the refinery was to be completed in 44 months. Four years later, in August 2023 the Cabinet of Ministers approved the proposal presented by President Ranil Wickremesinghe to cancel the agreement with the investors of the refinery as the project has not been implemented! Can they explain to the country how much money was wasted to produce that fairy tale?
It is obvious that the President, ministers, and officials had made huge blunders and had deliberately misled the public and the parliament on the revenue loss and potential investment from SLSFTA with fairy tales and false promises.
As the president himself said, a country cannot be developed by making false promises or with fairy tales and these false promises and fairy tales had bankrupted the country. “Unfortunately, many segments of the population have not come to realize this yet”.
(The writer, a specialist and an activist on trade and development issues . )
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