I have read the report and very thorough it is.
I note in the "interview with flight crew" section,the Captain
says he thinks the 05R edge lights were illuminated (but couldn't be
sure). Conversely, the F/O and relief pilot both think the edge lights
were NOT illuminated. However, all 3 pilots testify to being confronted
by the "correct picture" when they lined up...The inability
to determine whether the runway edge lights were on or not might appear
to undermine the report's ability to establish probable cause...although
it never in fact tries to do this anyway.
If the runway edge lights were NOT illuminated (and hence they didnt
have the "correct picture"), then it was a gross oversight
on the part of the crew. If they were illuminated, what we are
left with is still "pilot error" but with strong mitigating
circumstances. Reminds me a little of the Erebus disaster...in that
a web of unfortunate circumstances conspired against the crew. But however
entangled that web is, it never relieves the pilot-in-command of his/her
duty to fulfill that most basic of tenets...to know where the hell you
are at all times.
If all 05R´s lights were ablaze and 05L was in absolute darkness,the
fact remains that all it takes is one cursory glance at the taxi chart
to see that 05L is the second right after turning off the end of NP
and NOT the first. Talk about lights on 05R that shouldn't have been
on relates to the setting of the trap that any of us might fall into,
but it doesn't relate to probable cause.
I know that some will counter this with:
"How did the crew know that they hadn´t indeed
passed the first turn (ie 05R), and that the green
lights were leading them onto 05L?After all, they couldn't
see out of the side windows (no wipers),and they
couldn't be expected to make out the runway
designator/markers in those conditions,and they were
quite rightly expecting 05R to be unlit or red-barred?"
This argument does represent the crew´s best chance for an "escape
clause" but the turn from NP onto 05R must really be considered
an almost continuous 180, which cannot in all honesty be confused with
proceeding to the end of N1 before making a 90 degree turn onto 05L.
Additionally, the Captains decision to ignore the fact that the PVD
was trying to tell him something was certainly most unfortunate.
There is no denying that the crew was aware of the NOTAMed closure
of 05R. There is also no denying that they suffered a loss of SA(situational
awareness) which eventually led to that wrong turn while still believing
they were on 05L as cleared. No one - not even SIA or the Singapore
government - denies this.
However, as has been pointed out by many before me, the events that
have contributed to this loss of SA need to be identified and given
their due weight in the matter. My personal take on this is that since
the Taiwanese had intended to continue using 05R as a taxiway despite
the runway closure, the NOTAM should more correctly have been worded
something to the effect of "Runway 05R not
operational but still available for taxiing. Runway edge and centreline
lights remain illuminated." That would have at least alerted
the crew to a potential catch-22 of an unservicable runway appearing
still open. I don't know about others, but as for me, when I read that
a runway is closed, that is what I expect : total closure, including
de-activation of the lights. You may not agree with me on this, but
if a NOTAM indicates a runway is closed without specifying further
that things like the lights are gonna be left ON, then when you taxi
out there, the very fact that you see some runway lights WILL ACTUALLY
RE-INFORCE your belief that you are now on the correct runway and CONTRIBUTE
TO LOSS OF SA - especially so in conditions of marginal/reduced viz.
That 05R was a non-instrument runway while 05L WAS an instrument runway
does certainly provide clues to the crew, but only if they can see the
runway all the way down. The viz that night was 400-600 mtr in driving
rain - unlikely to have revealed the 05L barrettes at all.
There is no doubt to me that the crew goofed big time, but as others
have pointed out, there does seem to be many other links in this error
chain that have gone un-noticed or swept under the carpet. It would
be a shame if it takes another crash involving Taiwanese before it is
recognised that attitudes all round really need to change.
My initial reaction on hearing about this tragic
accident was to ask myself one simple question. I still believe this
is the central question. (I understand
that 05R was in partial use as a taxiway during the construction period,
which is why it was not blocked off entirely - also explains the type
of lighting used).
But if aircraft were not supposed to use runway
05R for departure, because it was covered in heavy plant & equipment,
why were effective measures not taken to close the runway thresholds
at each end to prevent aircraft entering and starting to roll?
All it needed was a line of illuminated barriers
or a few parked vehicles down each threshold side with amber beacons
on at each end and with a big sign saying "Runway 05R is Closed".
Clearly a ground radar system monitored by ATC might also have made
a big difference.
Any pilot attempting to turn onto the wrong runway
would have seen the barriers or vehicles and realised he was in the
wrong place. It is usually the simplest and most obvious precautions
that are the most effective.
Taiwan Airport and all other airport authorities
should examine their ground movements control, especially during runway/taxiway
maintenance, and it is about time ground radar was installed and used
at all international airports.
What is required is an ICAO Deputy Commissar with a roving commission
to visit all international airports and physically ascertain that national
deficiencies aren't creating accident potentials. His pronouncements
should be a heads up to National Aviation Authorities that, if an accident
happens, the fact that they were warned (but have yet
failed to act) will be in his Safety Hazard Report - and will be made