# Presentation: 814264

## Safety 

**Safety**** **

**Runway**

**Initiative**

**NTSB Runway Safety Meeting**
- March 27, 2007
**Earl Weener, PhD**
- Foundation Fellow
**Flight Safety Foundation**

**Notes:**
Welcome

We are all here to address the Runway safety challenge.  

Runway accidents are normally very high visibility accidents – since by definition they happen on or by a runway, which means on or by an airport, where there are lots of people.

## Participants

**  ****EASA**
**  ****CANSO**
**  ****IFALPA**
**  ****FAA**
**  ****LVNL**
**  ****Boeing**
**  ****Flight Safety Foundation**

-   **Airbus**
**  ****Embraer**
**  ****ACI**
**  ****IATA**
**  ****ERA**
**  ****Eurocontrol**
**  ****AAPA**

**Notes:**
The Flight Safety Fondation is an independent, non-profit,  international aviation safety organization
We were founded 60 years ago by the aviation industry.

FSF deals with all professionally flown aircraft 

FSF is a unique organization that has no counterpart in any other industry

This is our goal...................................

## What is the Flight Safety Foundation ?

** ****Non-Profit**

** ****International**
**Founded in 1947 by Aviation Industry**

** ****Independent**

**Notes:**
We’re a independent, non-profit,  international aviation safety organization
We were founded 60 years ago by the aviation industry.

FSF deals with all professionally flown aircraft 

FSF is a unique organization that has no counterpart in any other industry

This is our goal...................................

## FSF Goal:

**Make  Aviation  Safer  by  Reducing the  Risk  of  an  Accident **

**Notes:**
Runway safety issues are important to achieving this goal 

Here is a definition of runway safety........

## Definition:

**A Runway safety issue is any safety issue that deals with the runway environment (or any surface being used as a runway) and the areas immediately adjacent to it (e.g. overruns, high speed taxiways).  Runway Safety issues include runway incursions, runway excursions, and inappropriate use of runways.**

## Runway  Safety  Issues

_**Runway  Safety  Issues**_

**   ****Runway  Excursions**

**   ****Runway  Confusion**

## Data  Availability

_**Data  Availability**_

**   ****Runway  Excursions****     - ****Good for Accidents and Incidents****          with Damage**

**   ****Runway  Confusion****     -  ****Limited (normally no damage, no ****          injury, no loss of separation)**

## 1977 - KLM / Pan Am

**Los Rodeos Airport -Tenerife  Canary Islands**

**Notes:**
March 1977 -  583 fatalities

We all know that runway incursion is the cause of the largest single air disaster ever

## US Airways Runway Incursion Accident – Los Angeles:  Controller cleared aircraftto land with other aircraft on the runway.

**February 1991**

**US Airways Runway Incursion Accident – Los Angeles:  Controller cleared aircraft****to land with other aircraft on the runway.**

**Notes:**
Flight 149  2 Feb 1991  34  Fatalities

This is the worst runway incursion accident in the US

## SASOctober 2001

**SAS****October 2001**

**Milan, Italy**

## Runway  Incursions

**Runway  Incursions**

** ****Part of the new breed of safety issues****   -  Not a lot of accidents****   -  Numerous Incidents**

**  ****Basic Risk Management:****   Risk = (Probability) X (Severity)**

## Slide 12

**Notes:**
Transbrasil flight TBA 202 (Guarulhos - Porto Alegre), went off Runway 29 at 23:19 UTC, in heavy rainfall at Porto Alegre.

Excursions includes veer offs, which is going off the side of the runway.  

Excursions also includes...............

## Slide 13

**Notes:**
Overruns – or going off the end of the runway.

## Slide 14

**Notes:**

Many excursions will incur minimal damage.  

Many have no damage or injury – and are not reported 

## Slide 15

**Notes:**
View of forward fuselage area retrieval effort from Subic Bay
Freighter flight to Subic Bay
Night flight in cloudy, rainy weather 
Flight crew, senior PIC, junior F/O
Airspeed disagreement (30kt) and air data anomalies noted during flight prior to arrival due to CADC problem
Crew did not discuss airspeed difference or execute ‘Flight with Unreliable Airspeed” checklist
Crew chose to fly approach using the higher airspeed which was incorrect
During approach and landing numerous GPWS warnings sounded
Aircraft overran  Rwy07 (9,000 ́runway), and went into Subic Bay

And just to broaden our sample group, let me show you some numbers from corporate aviation................... 

## Causes  of  Approach and Landing AccidentsCorporate Aircraft1991 - 2002

**Notes:**
This breaks down the causes of 132 approach and landing accidents

In General aviation, the major causes of fatal accidents are the same as for the big commercial aircraft. 
 In the US (and Australia), the most common causes of fatal accidents are LOC and CFIT –
Just like commercial aviation  

What we are interested in is that, as you can see, excursions account for almost half of the ALA for corporate aviation 

## Lion Air, Solo Airport, Indonesia

**Notes:**
 Lion Air – Indonesia – 30 Nov 2004
Have proven several times each year that if you land long and fast with a tailwind on a contaminated runway, the consequences are predictable

An excursion is normally not like CFIT, which by definition is “...without prior knowledge of the crew”
- An excursion is normally not a total surprise to the crew.

Runway safety also includes inappropriate use of a runway.........

## Slide 18

**Notes:**
Singapore airlines – Taipei

So Runway safety includes a lot of areas – and accounts for a lot of accidents.

Who is responsible to reduce the risk of runway accidents ?  Who are the stakeholders ?

I think we have all of them represented here in this room – we are the people who need to address this challenge

These players include.............

## The Players

**  ****Airports**

**  ****ATC**

**  ****Regulators**

**  ****Operators****   -  ****Aircrews****   -   Management**

## Operators

**  ****Stabilized Approach Criteria**

**  ****True No-Fault Go Around Policy**

**  ****Decision making**** **
**    ****-  ****On approach****   -  On the runway**

**  ****Training**

**Notes:**

Stabilized Criteria – 1. Do the crews follow it  (FOQA)                                  2. Does one exist ?

Is the go-around policy truly “no fault” ?

What type of training is provided by management ?Not only do the crews practice good decision making, but
Do the aircrews have the information to make the correct decision ?

This is by no means an all inclusive list – just some highlights

## Air France 358, Toronto, Canada

**Notes:**
What role did the crew play in this accident ?
   How about management ?
   The Airport ?
   ATC ?

## Slide 22

**Notes:**
Flight from Mexico City to Reynosa; 83 Pax; 5 crew.  Minor injuries 4 reported fatalities
Landed fast and long (1000m; RW is 1900m long)

How could this accident have been prevented ?

## Slide 23

**Notes:**
SAS accident in New Yorkl
Date of Accident: 28 February 1984Airline: Scandinavian Airlines (SAS)Aircraft: McDonnell Douglas DC-10-10Location: New York, New York, USA (JFK Airport)Registration: LN-RKBFlight Number: 901Fatalities: 0:177MSN: 46871Line Number: 219Year of Delivery: 1976Accident Description: The aircraft landed 4,700 beyond the threshold of runway 22L at Kennedy Airport. Unable to stop in the remaining 3,300 feet, the crew steered the plane off the right side of the runway to avoid a seawall. The aircraft came to rest in shallow water.
Or this one ?
We all know that aircrews may be the final link in the chain of runway safety, but finding the crew made an error should be the beginning of the investigation, not the end 
What role did the airport, ATC, the regulator – even management play 

## Airports

**  ****Airport Design**

**  ****Lighting**

**  ****Approach Aids (e.g. VASI, PAPI)**

**  ****Runway Design (crown, grooved)**

**  ****Runway markings and signage**

**  ****Runway clearing/cleaning**

**  ****Runway condition measurement**

**  ****Runway Safety Areas**

**Notes:**
There is a lot listed here, and I am sure our airport experts will be the first to tell you that this list is not all inclusive – there is more than just what is listed here

## Slide 25

**Notes:**
What role did the airport play in this accident ?

## ,

**Notes:**
Or in this one

We also need to look at other organizations, ones like.....

## ATC

**  ****Stabilized Approach Assistance**

**  ****Pertinent and timely Information**
**    ****-   Weather****    -   Runway Condition**

**Notes:**
ATC.  They play a big role in any issues dealing with the runway and runway safety

Late runway changes
“Slam Dunk approaches”

As the pilots in here know, ATC can destablize any approach 

But does ATC know ?  A good example is the one from our ALAR work of US Air and ATC at Charlotte.
That’s why we have all the players here

## Slide 28

**Notes:**
This is sometimes a predictable result if all the players don’t work together

## Regulator

**  ****Provide appropriate and   ****   professional oversight**

**  ****Approaches with vertical guidance**

**Notes:**
Finally, the regulator.  They oversee all the players, and play a major role in reducing the risk in this critical area.

## Slide 30

## Purpose of Initiative:  

**To identify issues, gaps, and opportunities that lead to solutions in addressing runway safety challenges.**

**Notes:**
This was the purpose for our first meeting. 

From the meeting, we generated a catalog of runway safety products...................

## Runway  Safety  Products  Catalog

_**Runway Incursion:**_
_**Product Title**_**                                        **_**Originator**_**              **_**Type Product**_**            **_**Audience**_
**ICAO Runway Safety Toolkit              ICAO                         CD and web           Aircrew, Airports, ATM, **
**                                                                                                                                ****Management**
**Runway and Surface Safety               FAA                           CD and web            Flight Instructors**
**                                                                                                                                ****Pilot Examiners**
**Taxi 101                                                FAA                          CD and web             Maintenance personnel**
**Runway Incursion Prevention            FAA, ACI,                CD and web             Aircrew, Airports, ATM**
**Program                                                IATA, PAAST**
**European Action Plan for the              Eurocontrol et al   CD and web              Aircrews, Airports, ATM**
**Prevention of Runway Incursions                                                                        Vehicle drivers**
**Runway Incursion Joint Safety           FAA (CAST)            CD                             Aircrews, Airports, ATM**
**Analysis and Implementation  **
**Team Reports**
**FAA Runway Safety Website               FAA                         Web site                   Aircrews, ATM, Vehicle **
**                                                                                                                                 ****Drivers**
**Enhanced Taxiway Centerline             FAA                        CD and web             Aircrews, ATM, Airports**
**AOPA Runway Safety Course              FAA, AOPA             Web site                   General Aviation Pilots**
**ALPA Runway Safety Course               FAA, ALPA              Web site                  Aircrews**
**Sporty’s Pilot Guide to Runway Safety  Sporty’s              CD                            General Aviation Pilots**

_**Runway Excursion:**_
**ALAR Tool Kit                                Flight Safety Foundation     CD                       Aircrews, ATM, Airports**
**Managing Threats and Errors      Flight Safety Foundation     Web                    Aircrews**
**During Approach and Landing:**
**How to avoid a Runway Overrun**
**Takeoff Safety Training Aid               FAA                                  CD and web       Aircrews **

_**Runway Confusion:**_**     ???????????**

## Runway  Safety  Data Availability

_**Runway  Safety  Data Availability**_

**   **_**Runway  Excursions**_**:****    -  Many are documented **_***if***_** damage ****        or injury result**

**   **_**Runway  Confusion**_**:****    -  Documented only if damage or****        injury occur.  Incidents not ****        required to be documented.**

## Preliminary  Data

_**1995 – 2006**_
**1,237 Total Accidents**

**                         **_**Number**_**       **_**Percent of Total**_
**Incursions:          10                       ****.8%****               **

**Excursions:        363                  ****29.4%**

**Confusion:              4                      ****.3%**

**Notes:**
This data includes12 years of data for:

   All Western and Eastern built commercial jet and turboprop aircraft

   All substantial damage and higher accidents

## Preliminary  Data2002 – 2006

**                      **_**Number (Fatalities)**_**   **_**Percent of Total Acc**_
**Incursions:      3    ****(17)****             .6%               **

**512 Total Accidents**

**Excursions:    13  ****(283)****      ****    ****2.5%**

**Confusion:       1   ****(49)****             .2%**

**Notes:**
This data includes 5 years of data for 512 total accidents that include:

   All Western and Eastern built commercial jet and turboprop aircraft involved in substantial or higher damage accidents. 

## FSF Goal:

**Make  Aviation  Safer  by  Reducing the  Risk  of  an  Accident **

**Notes:**
As you have seen
Runway safety plays a big part of reducing the risk of an accident and achieving this goal.