# Presentation: 221804

## Southwest Region
Paul S. Erway 
Runway Safety Program Manager 
October 11, 2003

**Paul S. Erway**** **
**Runway Safety Program Manager**** **
**October 11, 2003**

## Presentation Topics

**1.  Definitions**
**Severity Level**
**Safety Culture and System Safety**
**Safe Ground Operations **
**Human Factors**
**What Have We Learned**
**7.  Questions**

## Runway IncursionDefinition

- “Any occurrence at an airport involving an *aircraft, vehicle, person or object on the ground* that creates a _collision hazard_ or results in *loss of separation* with an *aircraft taking off, intending to takeoff, landing, or intending to land”*

**Notes:**
In determining whether a collision hazard exists, one or more of the following occurs:
The aircraft intending to land was within 1 mile of the landing threshold of the incurred runway or landing
The controller took an unplanned action to avoid an aircraft, vehicle, object, or person on the runway (I.e., unplanned go around within 1 mile of landing threshold)
A pilot took an unplanned or evasive action to avoid an aircraft, vehicle, object or person on the runway (I.e., pilot initiated go around, aborted takeoff or landing, aggressive evasive maneuver)

##       Types of Runway Incursions

- Operational Errors

- Action of an Air Traffic Controller  that results in:
- Less than required minimum separation between 2 or more aircraft, or between an aircraft and obstacles, (vehicles, equipment, personnel on runways)     or
- Clearing an aircraft to take off or land on a closed runway

- Pilot Deviations

- Action of a pilot that violates any Federal Aviation Regulation Example: a pilot crosses a  runway without a clearance while enroute to an airport gate

- Vehicle/Pedestrian Deviation

- Pedestrians or vehicles entering  any portion of the airport movement areas (runways/taxiways) without authorization from air traffic control

**Notes:**
More than one runway incursion occurs everyday with an extremely close call occurring on average about one each week.
There are 65 million operations a year.
Prior to 9/11 there were 68 million.
It seems like a small number of incursions each year, but they can be and are deadly!

##    Not all runway incursions are “created equal”

- Case 2

- This is a severe situation where the margin of safety is so low that a collision is barely avoided.

- Potential for a collision is high
- Typifies the common perception of a runway incursion
- More severe but less frequent

- Case 1

- This incident meets the definition of a runway incursion, but there is little or no chance of collision.

- The potential for a collision is low
- Most frequently  reported incursion

**Notes:**
These examples demonstrate why more descriptive runway incursion categorization were necessary to capture the different potential for collision associated with each incursion. 

##     Runway Incursion Severity

**The two simple cases illustrate that a variety of dimensions can dramatically impact the severity of a runway incursion.**

**Notes:**
Note the criteria that is used to identify the level of severity.

## Location of all Runway Collisions at Towered Airports Since 1990 in USA

**10,000 x150**

- xx

- xx

**ATL**
**1/90**

**DTW**
**12/90**

**LAX**
**2/91**

**STL**
**11/94**

**SRQ**
**3/00**

**VNY**
**10/01**

**Traffic Flow**

**Location of all Runway Collisions at Towered Airports Since 1990 in USA**

**Notes:**
Note the traffic flow.
Location covers approximately the 1st half of the runway.
Last example is where 2 general aviation aircraft collided and burned in  Van Nuys, CA.

## Location of Runway Fatalities at Towered Airports since 1990 in USA, with CY 2000 and 2001 Category A and B Runway Incursions

**10,000 x150**

- xx

- xx

**Traffic Flow**

**Collisions**

**2001 A Events**

**2000 A Events**

**2001 B Events**

**2000 B Events**

**DTW**
**12/90**

**LAX**
**2/91**

**SRQ**
**3/00**

**ATL**
**1/90**

**STL**
**11/94**

- 2/3 of runway

**Location of Runway Fatalities at Towered Airports since 1990 in USA, with CY 2000 and 2001 Category A and B Runway Incursions**

**Notes:**
Most A’s and B’s occurred on the first 2/3 of the runway or the first 60% of the runway.
Avoid crossing the runway on the first 2/3 of the runway.  
Don’t let the tower put you into position and hold and keep you there more than a minute or so – they can forget you are there.  Call the tower if that happens to you.

##  Safe Ground Operations

**1.  Review airport layouts as ****-part of preflight planning ****-during cruise****-before descent****-while taxiing**
**2.   Review NOTAM’s for runway/taxiway **
**      ****closures and construction areas ****(Is the airport diagram correct?)**
**3.  Write down taxi instructions**

**Notes:**
May have to call the airport or local FSS

##  Safe Ground Operations, Cont.

**4.  Check actual instructions against expectations**
**5.  Read back all runway crossing and /or hold short instructions **_**verbatim**_** with the call sign**
**6.  Know and understand airport signage**
**7. Request progressive taxi instructions if unsure or**
**    ****confused about the taxi route**

## Entering ? Or Exiting? The Runway

**Entering ? Or Exiting? The Runway**

## Safe Ground Operations, Cont.

**8.  Always check for traffic before entering any**
**     ****runway or taxiway**
**9.   Check with ATC if waiting on the runway**
**      ****longer than anticipated**
**10. Turn on aircraft lights while taxiing **
**11. Clear the active runway on rollout as quickly**
**      ****as possible, then **_**wait for taxi instructions**_
**      **_**before further movement**_

**Notes:**
AFTER LANDING
Stress is reduced, guard drops
  Flight crew alertness and situational      awareness is lower
  Familiarity, repetition and expectation      can be hazardous!
  Pilots respond to what is familiar

## ARE YOU CROSSING A RUNWAY ? 

_**ARE YOU CROSSING A RUNWAY**_** ?**** **
_***HOLD***_*** – THEN READ BACK THE HOLD***
_***LOOK***_*** ******– THEN LOOK AGAIN***
_***LISTEN***_*** FOR THE CLEARANCE***
_***ACKNOWLEDGE***_*** THE CLEARANCE ***
_***THEN LOOK AGAIN***_

## Safe Ground Operations, Cont.

**12.  Wait until you have cleared all runways before **
**        ****attending to other details **
**13. Study and use proper phraseology found in**
**      ****the Aeronautical Information Manual**
**14.  Remain alert even in familiar locations ****       through continued surveillance **
**       ****FAMILIARITY can be a HAZARD**

**Notes:**

BEFORE TAKE -OFF
Situational awareness outside is not always      at the highest level during taxi

  Flight crews are busy preparing the aircraft     for the departure

  Situational awareness peaks at the takeoff phase

## System Safety and Safety Culture

- What do we mean by _SYSTEM_ in System Safety?
- The Aviation System is People, Hardware, Software, Rules, Procedures, Airports, Tools, Facilities, etc.
- What is _SAFETY CULTURE_?
- Culture is the Values, Beliefs, and Behaviors that we share with other members of groups
- Culture binds us together as a group
- Culture provides cues and clues on how to behave in normal and novel situations
**	****	****Short definition of culture: The way we do things here!**
**	****	****Culture is a factor in accidents and incidents in aviation**

## New Technology can Change the System and Present Challenges

## So We Try Newer Technology but That Might Not Eliminate Human Error

## Even Newer Technology Has No Guarantees Eliminate Human Error 

## Culture is Also Attitude and Judgment

**But I’m wearing eye protection**

**That’s funny, it doesn’t smell that bad!**

## Slide 20

## Slide 21

##   “I Know This Airport Like        the Back of My Hand!”

**Of the Current Filed Incursions**
**61% were familiar with the airport**
**65% had the airport diagram available**
**Ambiguity ? **
**Distraction or expectation ?**
**Complacency ?**
**NOTAM’s ?**

## Pilots and Physicians are Very Confident by Nature and by Culture

**I’m a professional!**
**I’ve trained hard and long for this!**
**I’ve done it thousands of times!**
**I’m current and very proficient!**
**What could possibly go wrong???**

## Slide 24

## WHY?

**Taxiing over the hold line and/or**
**Taxiing onto the runway without**
**	****proper clearance**
**Pilot reads back instructions, but**
**	****executes incorrectly**
**WHY?**

**Most Common  Pilot Deviations**

**Notes:**
July 2002 Runway Incursions:  7 OE’s, 8 PD’s, 8 VPD’s. 
 OE’s included 1 loss of separation, 5 local control and ground control miscommunications on taxi route, release of runway and crossing runways and not verifying position prior to crossing and 1 incursion where the ATC did not verify the readback.
PD’s included 5 a/c that acknowledged hold short then entered the runway at the intersection or approach end. 1 a/c crossed the hold line after acknowledging hold short, but did not enter the runway, 1 a/c taxied into position hold, acknowledged and then departed.  1 a/c landed on taxiway, then crossed onto active runway with an a/c departing.
VPD’s included privately operated vehicles crossing a runway, airport vehicle crossing the runway and had acknowledge hold, aircraft maintenance taxi entered the runway after acknowledging hold short, construction vehicles crossing the runway or hold line and a pedestrian crossing the runway.  

## Where is the hold short line?

**Where is the hold short line****?**

## Repeat Successful Efforts

**Crew Resource Management (CRM)**
**Windshear**
**Controlled Flight Into Terrain (CFIT)**

**Notes:**
Training programs in these areas have proven to be effective.

## Controlled Flight Into Terrain Example:

**First half of 1990s**
**2000 fatalities and 28 lost aircraft hulls per year**
**With training and technology**
**1 hull loss every 2 years**
**Over 90% reduction**

## New Technology

**Improved  or new surface radar**
**Loop sensors**
**Surface markers to inform pilots of their location**
**Moving map displays**
**Improved signs and markings**
**On airport voice locator beacons**

## Most common factors:

**Memory**
**Attention**
**Communication**
**Fatigue**
**Teamwork**

- Data Source:
- _Runway Safety: It’s Everybody’s Business _(July 2001)
- U.S. Department of Transportation, Federal Aviation Administration

## Memory factors

- Most people can remember about  7 unrelated items
- Stress reduces the amount of information  we can hold in memory

- Data Source:
- _Runway Safety: It’s Everybody’s Business _(July 2001)
- U.S. Department of Transportation, Federal Aviation Administration

## Memory factors ...

**Memory can be “constructed” – **** ****we remember what we wanted to hear**
**Remembering to do something ****in the future**** is very difficult.**

- Data Source:
- _Runway Safety: It’s Everybody’s Business _(July 2001)
- U.S. Department of Transportation, Federal Aviation Administration

## Attention Factors

**Focused attention allows us to filter out irrelevant information while concentrating on what is important**
**Too much attention on one thing, however, can lead**** to error (****Tunnel Vision****)**

- Data Source:
- _Runway Safety: It’s Everybody’s Business _(July 2001)
- U.S. Department of Transportation, Federal Aviation Administration

## Attention Demonstration 

## Communication Tips...

**Use standard phraseology**
**Readback all clearances to takeoff, land, cross and hold short with call sign and runway designator**
**Inform ATC immediately if unable to comply with “take next exit” after landing or “land and hold short of ...” instructions**

- Data Source:
- _Runway Safety: It’s Everybody’s Business _(July 2001)
- U.S. Department of Transportation, Federal Aviation Administration

## Communication Tips...

**When acknowledging taxi instructions after landing, do so while at taxi speed**
**If you need to go off the ATC frequency, notify a crewmember or ATC**
**Watch out for traps like similar call signs, unfamiliar accents, and  expectations**

- Data Source:
- _Runway Safety: It’s Everybody’s Business _(July 2001)
- U.S. Department of Transportation, Federal Aviation Administration

## End the “Blame Game”

** ****Recognize the fact that this is a systems problem, ****  not a pilot or a controller problem.**
** ****Even the most well-trained, professional, and conscientious ****  pilot and controller  can have a Runway Incursion.**
** ****Human error can’t be eliminated, but it can be managed!**

- Data Source:  The Human Factor portion of the presentation is from
- Daniel J. Hannon, Ph.D, Volpe National Transportation
- Systems Center.

**We can only improve Runway Safety through the constructive collaboration of the entire aviation community.**

** **

***Runway Safety - Not a New Problem***

## What Have We Learned.....The Consequences Are Clear

**Notes:**
This was a Boeing 747 Dutch Airliner at Tenerife (largest of the Canary Islands).  It collided with another 747, burned and killed 583 people.  This was the worst aviation disaster in aviation history.

The Dutch Captain ignored his 1st officer and took an IFR clearance as a take-off clearance.  He was a revered pilot – and they even had pictures of him on travel posters.

##      Airport complexity greatly influences the number and     rate of runway incursions

- LAX

- STL

- IAD

- 33 Incursions

- 29 Incursions

- 4 Incursions

**Notes:**
Airport geometry plays a major role as to the number of incursions.  LAX has closely spaced parallel runways. There is no room for perimeter taxiways.  Exiting onto a high speed taxiway can put you right back on the parallel active runway.
St. Louis has bad geometry!
Dulles is the only airport designed by the federal government (FAA).

## B727 on landing roll hit King Air taxiing on runway. (OE) 1 Fatality.

**B727 on landing roll hit King Air taxiing on runway. (OE) 1 Fatality.**

**Notes:**
Notice the location on the runway where this incident happened – about 1/3 of the way down.

## Departing B727 hit lost DC9 on runway. (PD)

**Departing B727 hit lost DC9 on runway. (PD)**
**8 Fatalities.**

**Notes:**
This incident happened in low visibility and early morning.  The DC9 was confused and stopped on the runway and set the brakes.
Notice the direction and the location on the runway – this accumulated data will show a pattern.

## Landing B737 hit SA227

**Landing B737 hit SA227**
**given position and hold. (OE)**
**34 Fatalities.**

**Notes:**
A Boeing 737 hit a Sweringen Metroliner and skidded off the runway and hit an abandoned fire station and burst into flames.  Notice the location on the runway.

## Regional:  www.faarsp.org/asw

**Regional:  **_[www.faarsp.org/asw](http://www.faarsp.org/asw)_
**National:  www.faarsp.org**

**Notes:**
The website offers valuable information – and provides links to the national website and AOPA.
You can take the AOPA Safety Test.
You can download information, airport diagrams, hot spot brochures and even take a signs and marking quiz.

## RUNWAY SAFETY PROGRAM

- QUESTIONS

**RUNWAY SAFETY PROGRAM**

## THANK YOU

**the end**

***THANK YOU***