Investigation into Runway 09 ILS Damage

Transcription

1 Investigation into Runway 09 ILS Damage An internal investigation into the damage caused late last summer 2012 to the Runway 09 westerly approach Instrument Landing System (ILS) at Jersey Airport has determined that the incident happened due to a failure to follow laid down procedures. 1.0 Cause of damage The investigation has concluded that the damage was caused by pellet holes from a discharged shotgun, a firearm used as part of Jersey Airport s wildlife control measures. This resulted in water seeping into the cable allowing moisture to interfere with the equipment, causing this component of the system to become unstable. Jersey Airport management took the system offline as soon as the damage was identified and it was out of service between 25 September 2012 and 27 October An independent firearms expert was brought in to assist with the investigation and determined that in his professional opinion the gun was accidently discharged. Having loaded the cartridge/s it is believed that the individual was shutting the breach and had his hand on the trigger and not, as is the standard practice, on the wooden stock. Therefore, in the act of loading the firearm the individual accidently discharged the gun, which, although resulting in damage to the ILS fortunately did not involve injury to any persons. 2.0 Decision to take ILS out of service The loss of the ILS did not, at any stage compromise the safety of any aircraft in-flight as there are established regulatory safeguards in place, ensuring at no times were aircrew or passengers in any danger. Furthermore, at no time did the equipment suffer complete failure because if this had happened, the fault would have been picked up from the airport s remote monitoring equipment. It is understood that the damage to the ILS was caused sometime between 29 August 2012 and 24 September 2012 when it was discovered during a routine monthly check of the equipment. Unable to fully guarantee its continuing safe operation and on the advice of the manufacturer Jersey Airport immediately took the equipment out of service. The decision to do so was further influenced following a review of previous October monthly Met Office weather data to determine the low percentage chance of easterly fog. Thus, the decision to take the ILS out of service and the reasons for doing so were communicated to airline business partners. 3.0 Repair and re-commission of equipment A certified engineer from the manufacturer, supported by the airport s own air traffic engineers undertook an initial inspection and determined that the damaged cable would need to be replaced. Each cable for an ILS is made specific to that unit and therefore has to be custom produced. Due to length of the cable, which measured one kilometre the production took two weeks to complete and was followed by a further week for installation, certification and flight check validation before the ILS came back into service in the early morning of Saturday 27 October 2012.

2 Timeline of Events Date Activity 29/08/12 Outline inspection of 09 ILS all clear 24/09/12 Routine inspection of 09 ILS damage identified 25/09/12 ILS taken out of action 01/10/12 Manufacturer engineer assesses damage & parts ordered wc 15/10/12 Parts arrive in Jersey and installation commences wc 22/10/12 System testing 25/10/12 & 26/10/12 Flight calibration 27/10/12 09 ILS returned to service 4.0 Flight disruption Unfortunately, inclement weather did affect local flying at Jersey Airport for a period of six days in October 2012 during which time approximately 350 flights were due to arrive. As part of the investigation all flight meteorologist data and visibility figures were identified for every flight and evaluated. Of these expected numbers, 93 arrival flights were cancelled due to poor weather conditions and only eight of these cancelled flights are believed to be as a direct result of the ILS out of service. Out of the 93 cancelled arrival flights: Reason Visibility lower than operating minima on both 09 and 27 runways Cancellations 19 20% Aircraft/Airline decision to cancel - unrelated to 09 ILS Runway 09 in use with visibility within limits for the available equipment (i.e. even though 09ILS was out of 11 12% service) Runway 27 in use with visibility within limits of 27 ILS 37 40% Reasons for cancellation not communicated to Airport 2 2% Aircraft/Airline decision to cancel - potentially related to 09 ILS Aircraft offered alternative approaches on Runway 27 as conditions were within operating limits, but chose not 16 17% to accept Aircraft were not offered alternative approaches 8 9% Total % In summary, 20% of the cancellations would have occurred anyway due to poor weather conditions. 54% of the cancellations were airline or aircraft decision and unrelated to the 09 ILS being out of service. Of the remaining 26%, only eight cancellations are believed to have been caused by the 09ILS out of service although we have not had confirmation from the airlines involved.

3 5.0 Identification of responsible individual/s Despite staff interviews, a comprehensive review of the available data and an analysis of the operational manual and electronic tags, it has not been possible to formally identify the person/s responsible for the incident. The investigation did identify our documented procedures surrounding the logging and tracking of the firearm used for lethal control had not been consistently followed. In light of the serious nature of the incident appropriate action is being taken with those responsible for the management of these procedures to ensure that new processes introduced as a result are adhered to at all times. 6.0 Wildlife control requirements Due to Jersey Airport s coastal location it is a natural habitat for attracting birds and wildlife and its subsequent policy is that such lethal measures are introduced only as a last resort when all other methods have been exhausted. Jersey Airport s lethal control measures are carried out under licence from the Island s Environment Department who are also consulted on both habitat and wildlife management. Bird strikes cause 1.2billion in damage across the industry each year and if unmanaged can lead to tragic consequences such as the 2012 crash in Nepal, which killed 19 people on board a Dornier 228 aircraft. Therefore, airport authorities proactively manage these threats to minimise any damage or injury as a result of bird strikes on the airfield. Common measures used by Jersey Airport as part of the Wildlife Control measures, include: Removing seed-bearing plants and use insecticides or pesticides to eliminate food sources for insect-eating birds; Covering nearby ponds with netting to prevent birds from landing; Removing brush and trees that serve as attractive nesting sites for birds; Implementing a long grass policy, which makes it difficult for birds and animals to dwell; Using sonic cannons, recorded predator calls and other noise generators to disrupt birds with lasers at dawn and dusk to simulate predators and scare birds away. In line with other UK airports, Jersey introduced its own in-house Lethal Bird/Wildlife Control measures on the recommendation of the Food & Environment Research Agency (FERA) following an audit in Recommendations of the investigation As a result of the investigation, other procedures and processes, which airport authorities have or are in the process of implementing include: The number of officers attached to the Wildlife Control team has been reduced, with one identified accountable manager to assume overall responsibility for the team; Critical spares for the ILS will be sourced and kept on site should they be required in future; Other critical navigational equipment such as the glidepath will be assessed and identified risks protected; An improvement in terms with suppliers to guarantee faster responses by them to future incidents. Table of recommendations

4 No Recommendation Target Date Current Status R1 A decision as to whether Bird/Wildlife Lethal Control 29 October Positive decision reached. measures are reintroduced needs to be made Bird/Wildlife Lethal Control Measures reintroduced R2 A decision as to whether existing Bird/Wildlife Lethal Control measures, procedures and processes are reintroduced needs to be made 29 October Agreed that existing measures not acceptable. Revised Bird/Wildlife Lethal Control measures developed and implemented R3 R4 R5 R6 R7 R8 A decision as to whether revised Bird/Wildlife Lethal Control measures, procedures and processes as an interim are reintroduced needs to be made A decision as to whether a detailed review of all procedures, processes and operations followed by revisions as appropriate needs to be made A decision as to whether the investigation should be continued with a view to identifying persons/s concerned needs to be made The privately owned.22 rifle to be removed from airport premises An independent external expert is to be approached to provide his expertise in helping to pinpoint as closely as possible the location the shotgun was discharged from A review of the FERA report on the control of rabbits to be undertaken between Airport Fire Fighting Service (ARFFS) and Airport Engineering. This will involve a review of procedures, lethal control measures and method as well as means of implementation 9 November Revised measures developed and implemented A review of procedures, processes and operations carried out Investigation complete. Person/s not identified Airport Operations Officer to write to Airfield Ops Officer concerned and give notice to remove the weapon. Weapon now removed from airport property Group Operations Director instruction to proceed was received and investigation concluded It has been agreed that the rabbits in the worst affected areas of the airfield, at the eastern end of the runway, will be eradicated by gassing method, which will remove the need for continuous lethal shooting. The continuing rabbit control methods will need to include fence proofing and some liaison with the airport s neighbours to minimise any future migration of rabbits to the airport s property

5 No Recommendation Target Date Current Status R9 R10 R11 R12 R13 R14 It is recommend that competency assessments, theoretical and practical, under controlled conditions are conducted at quarterly intervals on authorised Lethal Control Measures Operatives It is recommended that the airport reviews the provision of the regulatory requirement and delivery of control measures while evaluating the most efficient way of servicing them in terms of organisational and departmental structure It is recommended that the airport holds three Ultima touch tablets to ensure no data loss. The software should also be able to combine seamlessly the data from all three units It is recommended that the airport implements a system that allows each weapon to be individually tagged and tracked It is recommended that the provision of non-precision satellite approaches is accelerated and that provision of precision satellite approaches is evaluated with a view to providing enhanced redundancy in terms of landing aids It is recommended that Air Traffic Engineering survey and risk assess the critical infrastructure on the airfield to identify how and if these installations can be further protected against damage ARFFS will undertake Training Decay Analysis (TDA) to determine the time periods for retraining and assessing competence for this task and return to Group Operations Director with results. TDAs are an accepted way of determining periods of recency in other areas of Fire service training and take into account a number of key criteria relating to the specific task. Schedule of training to be implemented. Jan Discussed at a meeting of Bird Control Management Group, who interprets this as being a wider ranging review of how bid control measures are conducted and if the organisational structures are best suited to the provision. Deadline May 2013 upon delivery a new Ultima tablet will be fitted to the vehicle, releasing the old one as spare. Deadline March 2013 Investigations still underway to ascertain best way to track weapons automatically. Global Navigation Satellite System (GNSS) satellite approaches will be in service by 4 April Deadline March 2013 Sites being risk assessed.

6 No Recommendation Target Date Current Status R15 R8 It is recommended that Air Traffic Engineering keep signal cable and other spares on site where this is both cost effective and time critical. Contact suppliers to ascertain costs involved in improving response times for equipment replacements and flight calibration. February 2013 Deadline 2013 Parts being identified and will be ordered where possible. November 2012 Costs obtained for fast tracking calibration.