The Civil Aviation Advisory Publication for Aeroplane Landing Areas (92-1(1)) did not have guidance for the inclusion of a safe runway overrun area.
The ATSB notes the response from the Civil Aviation Safety Authority indicating they will not be including any guidance on the inclusion of a safe runway overrun area for aeroplane landing areas as Civil Aviation Advisory Publication 92-1(1) has been superseded. The subsequent guidance on the use of aerodromes puts the onus of responsibility on the pilot to determine if the landing area and length is operationally suitable.
It is noted that CASA has justified not providing guidance to owners of ALAs to include runway overrun areas because ICAO standards do not mandate these for aerodromes not available to the public. As the ATSB has identified this lack of guidance as an ongoing area of risk for operations into ALAs, the lack of an ICAO standard does not restrict CASA from providing such guidance. As no further guidance regarding runway overrun areas is to be provided for aeroplane landing areas, this safety issue has been closed not addressed.
The ATSB recommends the Civil Aviation Safety Authority include guidance for the inclusion of a safe runway overrun area in their regulatory guidance for Aeroplane Landing Areas.
In relation to the ATSB safety recommendation AO-2018-025-SR-012 regarding CASA's Aeroplane Landing Areas (ALA) guidance on runway overrun areas, CASA does not accept the ATSB recommendation.
The guidance on runway landing areas in Civil Aviation Advisory Publication (CAAP) 92-1 is predicated on the pilot in command having sound piloting skills and displaying sound airmanship. The ATSB found that;
"the aircraft touched down at a high speed and at a point on the runway that reduced the available stopping distance and there were no indications of an attempt at a go-around'.
It is clear from your report that the pilot did not have enough runway to stop the aircraft after landing well beyond the planned touchdown point and subsequently overran the runway. The risk of runway overrun was increased significantly due to the decision to land once it was apparent that the landing distance was no longer sufficient.
The ALA owner indicates in the report;
"that 30 to 50 m before the final stopping point of OAJ had been considered clearway area by the operators at Somersby and not used for take-off or landing"
Effectively therefore, there already was a safe runway overrun area at Somersby as proposed by the safety recommendation.
CASA considers that the unnecessary ATSB recommendation dilutes the key safety message being;
"the importance of pilot preparedness to conduct a go-around if the landing criteria are not met or if there are indications of an unstable landing"
CASA offers guidance on 'go arounds' in CAAP 166-01 Operations in the vicinity of non-controlled aerodromes.
CASA has previously noted that the cost and impact may be difficult for ALA owners to add 30-meter runway strip ends or a potential Runway End Safety Area (RESA).
The practical effect of the ATSB's recommendation may simply be that ALA owners will shorten their runways at either end rather than clearing obstacles after the runway, effectively reducing the length of the runway by 60 meters.
Nevertheless, CASA is currently reviewing the Civil Aviation Advisory Publication (CAAP) 92-1(1), titled Guidelines for aeroplane landing areas. This CAAP was written prior to the introduction of Part 139 of the CASR's and associated manual of standards and therefore requires incorporation and alignment with the CASR framework.
CASA plans to:
• Review CAAP 92-1 and republishing as a Part 139 AC with guidance on RESA for certified aerodromes.
• Update AC 91-02 for operators of small aircraft to provide operational guidance for pilots, including pilot operational guidance contained within CAAP 92-1.
The publication of the above planned ACs updates are scheduled for mid-2020.
CASA's response indicated that the safety recommendation had been considered and rejected, and that CASA will not include guidance for a runway end safety area (RESA), although you had plans to revise the Civil Aviation Advisory Publication (CAAP) 92-1 and other advisory publications in mid-2020.
CASA's main consideration in rejecting this safety recommendation appears to be linked to the fact that in this accident, the pilot's long touchdown at a faster speed led to the runway the overrun. While education and training efforts may reduce such actions in the future, other pilots will make the same errors. The ATSB considers pilot actions that contributed to the accident do not remove the risk associated with the safety issue identified in the investigation and led to the safety recommendation.
CASA also indicated that the area beyond the accident runway was considered to be a clearway area by the owner. However, the ATSB investigation report identified undulating terrain and a small watercourse immediately at the end of the runway that increased the likelihood and severity of occupant injury in the case of a runway excursion. That is, a clearway is not an obstacle-free flat area consistent with the concepts of a runway strip or runway end safety area.
The ATSB notes that CASA have also indicated that guidance for the inclusion of a safe runway overrun area could potentially lead ALA owners to reduce their runway length by 60 m, which could be costly and impact operations.
The ATSB also acknowledges there will be challenges for some ALA owners to implement a runway end safe area. However, in the interest of reducing the consequences of future runway overrun accidents at ALAs, the ATSB still believes CASA guidance for ALA owners' consideration, similar to the guidance about obstacles lateral to the runway and in the take-off approach area, is warranted.
As CASA is currently reviewing the Civil Aviation Advisory Publication (CAAP) 92-1(1) 'Guidelines for aeroplane landing areas', the ATSB encourages CASA to re-consider this safety recommendation so that current and future ALA owners have guidance and education about the safety benefits of a safe runway overrun areas.
The ATSB will continue to monitor the CASA's progress addressing this safety recommendation.
On 4 May 2020, CASA advised that they are reviewing Civil Aviation Advisory Publication (CAAP) 92-1(1) - Guidelines for aeroplane landing areas as part of their ongoing review of safety documentation. They further indicated that this work did not change CASA's position on safety recommendation AO-2018-025-SR-012. However, they acknowledge that the result of this review may go towards satisfying the ATSB that this recommendation has been adequately addressed.
CASA will provide a copy of the updated CAAP to the ATSB once finalised. The review is not expected to be finalised until late 2020.
When providing an update of CASA's safety action in response to this recommendation, on 30 July 2023, they advised that:
1. When CAAP 92-1 was published it was to support the existing regulatory framework for licensed aerodromes and aircraft landing areas (ALAs). Standards for ALAs were included in Chapter 8 of the Rules and Practices for Aerodromes in 2000. Even back then the responsibility for use of an ALA fell on the pilot and the CAAP was to determine suitability of an ALA by the pilot:
2. The regulatory framework was superseded in 2004 when CASR Part 139 and its MOS were created and certified and registered aerodromes were established.
3. The regulatory framework was updated in 2019 to reflect a risk-based approach to aerodrome regulations. A single category of certified aerodromes was established with regulatory requirements increasing as passenger numbers and aircraft movements increased or for international aerodromes.
4. At the same time the flight operations regulatory suite was being finalised. Part 91 would be the relevant regulation for the pilot of the RV-6A and the aerodrome must be ‘a place that is suitable for the landing and taking-off of aircraft’.
5. Both the Part 139 MOS and ICAO Annex 14 do not require a runway end safety area (RESA) for Code 1 and 2 non-instrument runways which would be the case for Somersby.
6. As CASA stated in its initial response to ATSB, this single accident was a result of gross pilot error. A safety recommendation affecting all ALAs based on one accident caused by pilot error is not a risk-based, data-driven and evidence-based decision.
7. AC 91-02 ‘Guidelines For Aeroplanes With MTOW Not Exceeding 5 700 Kg - Suitable Places To Take Off And Land’ is the appropriate document to provide guidance on suitable places to land. Section 2.2 of the AC provides the relevant guidance on ‘use of aerodromes’.
8. CASA is no longer proposing to recommend or provide guidance to all ALAs to establish runway overrun areas as it is the pilot’s responsibility for determining if the landing area and length is operationally suitable.
The ATSB acknowledges CASA's response to the safety recommendation. However, the ATSB sought clarification about point 5 regarding ICAO Annex 14 not requiring a runway end safety area as the document states that:
'A strip shall extend before the threshold and beyond the end of the runway or stopway for a distance of at least:
— 60 m where the code number is 2, 3 or 4;
— 60 m where the code number is 1 and the runway is an instrument one; and
— 30 m where the code number is 1 and the runway is a non-instrument one.
Runway end safety areas
A runway end safety area should, as far as practicable, extend from the end of a runway strip to a distance of at least:
— 240 m where the code number is 3 or 4; or a reduced length when an arresting system is installed;
— 120 m where the code number is 1 or 2 and the runway is an instrument one; or a reduced length when an arresting system is installed; and
— 30 m where the code number is 1 or 2 and the runway is a non-instrument one.
On 28 August 2023, CASA provided the following in response to the ATSB's question dated 25 August 2023:
1. The applicability of Annex 14 Vol I is based on Articles 15 and 68 of the Convention, which is intended for international operations. Contracting States should adopt these for domestic aerodromes if appropriate:
Annex 14 Vol I
1.2.2 The specifications, unless otherwise indicated in a particular context, shall apply to all aerodromes open to public use in accordance with the requirements of Article 15 of the Convention. The specifications of Annex 14, Volume I, Chapter 3, shall apply only to land aerodromes. The specifications in this volume shall apply, where appropriate, to heliports but shall not apply to stolports.
Article 15 of Doc 7300
Every airport in a contracting State which is open to public use by its national aircraft shall likewise, subject to the provisions of Article 68, be open under uniform conditions to the aircraft of all other contracting States. The like uniform conditions shall apply to the use, by aircraft of every contracting state, of all air navigation facilities, including radio and meteorological services, which may be provided for public use for the safety and expedition of air navigation.
[Article 15 continues with charges information ....]
Article 68 of Doc 7300
Each contracting State may, subject to the provisions of this Convention, designate the route to be followed within its territory by any international air service and the airports which any such service may use.
2. A Recommended Practice is not mandatory but is desirable, if in the interests of safety.
3. ICAO does not require or expect States to apply the international provisions of the Annexes to aerodromes that do not hold an aerodrome certificate issued by a Contracting State.
The ATSB acknowledges CASA's response and that the recommendations in ICAO Annex 14 are not mandatory. However, the ATSB notes that there is guidance available for the provision of a runway strip and runway end safety area.
