# Presentation: 414356

## Presentation to the

**of Canada**

**Bureau de la sécurité des transports**
**du Canada**

- National Transportation Safety Board

- Runway Incursion Forum
- 27 March 2007

**Notes:**
Notes de présentation.

## Transportation Safety Board of CanadaLothar HoppSenior Investigator/Air Traffic Services Specialist

## Object of the TSB of Canada

**The object* of the Board is to advance transportation safety by**
- conducting independent investigations, including, when necessary, public inquiries, into selected transportation occurrences in order to make findings as to their causes and contributing factors;
- identifying safety deficiencies as evidenced by transportation occurrences;
- making recommendations designed to eliminate or reduce any such safety deficiencies; and
- reporting publicly on its investigations and on the findings in relation thereto.
- *Canadian Transportation Accident Investigation
-  and Safety Board (CTAISB) Act

## However ...

**In making its findings as to the causes and contributing factors of a transportation occurrence, it is not the function of the Board to assign fault or determine civil or criminal liability, but the Board shall not refrain from fully reporting on the causes and contributing factors merely because fault or liability might be inferred from the Board's findings.**

## TSB Investigations

- Since 1997, the TSB has conducted 13 investigation involving runway incursion at Canadian airports.
- Some of the more significant findings that resulted from those investigations were...

- http://www.tsb.gc.ca/en/air/

## Slide 6

## TSB Report Findings

**Situational Awareness**
- The airport controller _assumed_ that runway 25 had been transferred to the control of the airport controller when the ground controller advised that the Cessna was released. (A99H0004)
- _No active warning system to serve as a reminder_ for the FSS specialist that a vehicle is operating on a runway is in place at the Terrace FSS. (A98H0004)
-  The Cessna 172 took off _without clearance_ from Runway 30, causing a risk of collision with the Airbus A320. (A04Q0089)

## TSB Report Findings (con’t)

**Phraseology**
- A review of taped ATC communications revealed a number of instances of _non-standard_ and casual R/T communications ... (A97O0037)
- The expression "runway available", from a local order, caused _confusion_... (A97Q0005)
- The air controller _did not use the phraseology recommended_ in ATC manuals for situations in which an aircraft is cleared to position on an intersecting runway, but is not number one for take-off. (A99W0036)

## TSB Report Findings (con’t)

**Equipment/Procedures**
- There is _no automated runway incursion warning system_, such as inductive loop or similar technology, that warns pilots directly of incursions; the runway incursion monitor/collision avoidance system may not provide sufficient warning to prevent an accident.(A01O0299)
-  The aircraft and the vehicle were _operating on different radio frequencies_, which was in accordance with established procedures (uncontrolled airport). (A98H0004)
- ...There is _no requirement_ for a pilot _to immediately advise_ the tower _when unable to comply_ with the (acknowledged runway) exit instructions.(A04P0047)

## TSB Report – Safety Action Taken

- The new radios will allow vehicle operators to _hear communication from and to aircraft_ flying into or out of Terrace Airport, thereby increasing their situational awareness.(A98H0004)
- The ... Airport Authority is in the process of instituting a _refresher training program_, in addition to the regular annual program held in the fall of each year, that will include a re-emphasis of proper radio procedures by its drivers. (A97O0037)
-  (Reaction to) Non-compliance situations by a pilot are _taught_ (to controllers) in the classroom, and are _practised_ in a number of exercises in the dynamic 360-degree airport simulator throughout the course. (A04Q0089)

## Runway Incursion Incidents

- From 1997 to 1999, there was a significant increase in the number of reported runway incursion incidents in Canada
- The regulator, Transport Canada, and the ATS service provider, NAV CANADA,  both launched studies as a result of this trend
- Both agencies produced their own reports with recommendations

**Notes:**
NAV CANADA is the private sector, non-share capital corporation that owns and operates
Canada's civil air navigation system (ANS). We provide air traffic control, flight information,
weather briefings, aeronautical information, airport advisory services and electronic aids to
navigation. Our revenue comes from our customers, who operate aircraft in Canada and in
international airspace where we provide service.
NAV CANADA is the private sector, non-share capital corporation that owns and operates
Canada's civil air navigation system (ANS). We provide air traffic control, flight information,
weather briefings, aeronautical information, airport advisory services and electronic aids to
navigation. Our revenue comes from our customers, who operate aircraft in Canada and in
international airspace where we provide service.

## Runway Incursion Reports

## Incursion Prevention Action Team(IPAT)

- Incursion Prevention Action Team(IPAT)

- In 2001, decision to establish a joint implementation team to address the recommendations of the aforementioned two reports in a coordinated manner
- Under the leadership of Transport Canada and NAV CANADA, along with other stakeholder and observers, the IPAT was formed
- The recommendations from the two reports were combined, and over the next four years, the IPAT met regularly to address them

## IPAT Results

- Common definition for what is a runway incursion
- Better statistical data
- Airport diagrams available on the internet (free of charge)
- Changes in ATC procedures such as -
- Clearances include intersection name when take-off being conducted from an intersection
- Specific clearance across all runways when taxiing to the departure runway
- Taxi to position procedures and phraseology
- Establishing standard taxi routes at some airports
- Focus on education and procedures

## IPAT Results (con’t)

- Awareness posters for aircrew, vehicle operators and ATS personnel

- http://www.tc.gc.ca/civilaviation/systemsafety/posters/menu.htm

## Runway Incursion Reports

## Runway Safety and Incursion Prevention Panel

- The Next Initiative (2005)
- Identify interested stakeholders
- Form discussion panel
- Follow-up on panel discussions and recommendations
- Result – formation of the Runway Safety and Incursion Prevention Panel (RSIPP)

## RSIPP

- Scope
- ... the panel is to _provide a forum_ for the exchange of safety related information pertaining to the movement of aircraft and vehicles in the vicinity of the runway with the aim of promoting runway safety and with _a primary focus on the reduction in the risk of runway incursions_.  The panel should _identify findings and make recommendations_ to improve safety and prevent runway incursions.

## RSIPP

**Organization**
- This _multi-disciplinary group_ is composed of:
- NAV CANADA,
- Canadian Airports Council (CAC);
- Canadian Owners and Pilot's Association (COPA);
- Airline Pilot's Association (ALPA);
- Canadian Air Traffic Controller Association (CATCA);
- Air Traffic Specialists Association of Canada (ATSAC);
- Air Transportation Association of Canada (ATAC);
- other aviation stakeholders as identified by the panel; and
- observers with a direct interest in runway safety (such as Transport Canada, the Transportation Safety Board of Canada or technical specialists from stakeholder organizations).

## RSIPP

**The duties of the panel were agreed to as follows:**
- Review the current runway incursion prevention activities applicable to operations at Canadian aerodromes;
- Review  international runway incursion prevention activities with the objective of identifying and promoting proven best practices where feasible;
- Recommend methods for sharing safety information within the aviation community  and suggest runway incursion strategies/initiatives;
- Share available runway incursion data to identify and analyze potential runway incursion safety issues or trends;
- Make recommendations for runway safety and incursion prevention to supporting agencies.

## RSIPP

- However –
- It will not be the mission of this panel to assign fault or determine liability.
- This panel in no way replaces local runway safety committees (that is at airports, ATS units, operators etc)
- And –
- Recommendations of the panel will be based on consensus, and although not binding on any of the parties shall be given full consideration by the affected supporting agencies.

## CASS explores emerging safety issues with a view to creating awareness thereof and offering strategies to eliminate hazards or manage their effects. 

- CASS explores emerging safety issues with a view to creating awareness thereof and offering strategies to eliminate hazards or manage their effects.

- http://www.tc.gc.ca/CivilAviation/SystemSafety/CASS/2007/menu.htm

## Where to from here?

## Transportation Safety Board

**of Canada**

**Bureau de la sécurité des transports**
**du Canada**