PROGRESS HAS BEEN MADE IN REDUCING 

RUNWAY INCURSIONS, BUT RECENT 

INCIDENTS UNDERSCORE THE NEED FOR 

FURTHER PROACTIVE EFFORTS 

Federal Aviation Administration 

Report Number: AV-2007-050 

Date Issued: May 24, 2007 
U.S. Department of 

Memorandum

Transportation 

Office of the Secretary 

of Transportation 

Office of Inspector General 

Subject: ACTION: Report on Runway Incursions: 

Progress Has Been Made in Reducing Runway 

Incursions, but Recent Incidents Underscore the 

Need for Further Proactive Efforts 

Federal Aviation Administration 

Date: May 24, 2007 

Report Number AV-2007-050 

From: David A. Dobbs

Principal Assistant Inspector General 

 for Auditing and Evaluation 

Reply to 

Attn. of: JA-10 

To: Federal Aviation Administrator 

This report provides the results of our review of the Federal Aviation 

Administration’s (FAA) actions to address runway incursions at Boston Logan, 

Chicago O’Hare, Philadelphia, and Los Angeles International Airports. Our 

objectives were to assess the actions taken by FAA to (1) identify and correct the 

causes of recent runway incursions at those airports and (2) address those issues 

that could affect safety system-wide. We added Los Angeles International Airport 

to our review in October 2006 as a result of several serious incidents that occurred 

at that location between July and September of 2006 and in response to concerns 

expressed by Senator Barbara Boxer to our office regarding those incidents. 

Our review, conducted between May 2006 and April 2007, included site visits to 

those four locations and FAA Headquarters. Exhibit A details our review scope 

and methodology. Exhibit B lists the specific organizations that we contacted or 

visited during the audit. Exhibit C provides a summary of our prior reports 

pertaining to runway incursions. 

We focused on FAA programs for reducing runway incursions; this audit did not 

evaluate the status of runway safety technologies. Our office is reviewing those 

issues as part of two ongoing audits on the status of FAA’s Airport Surface 

Detection Equipment-Model X Program and FAA’s air traffic modernization 

efforts (which will also include a review of the Automatic Dependent 

i
Surveillance-Broadcast Program). We will issue the results of those audits later 

this year. 

FAA defines a runway incursion as any incident at an airport involving an aircraft, 

a vehicle, person, or an object on the ground that creates a potential collision 

hazard or results in a loss of separation with an aircraft taking off, intending to 

take off, landing, or intending to land. Runway incursions are classified into three 

types of operational categories: 

• Operational Errors—when the actions of a controller cause an incident, 

• Pilot Deviations—when the actions of a pilot cause an incident, and 

• Vehicle/Pedestrian Deviations—when the actions of a vehicle operator or 

pedestrian cause an incident. 

Runway incursions are also graded by severity of the incident (A through D). 

Category A runway incursions represent incidents in which a collision was barely 

avoided, whereas Category D runway incursions represent incidents where there 

was little or no chance of a collision. 

Because runway incursions can be caused by different groups, responsibility for 

their prevention falls on all users of the National Airspace System—FAA, airlines, 

and airport operators. Within FAA, its lines of business; including the Air Traffic 

Organization, Aviation Safety, and Airports Division; share the responsibility for 

preventing and correcting the root causes of runway incursions. 

From 1998 to 2001, we reported1

 that 

runway incursions were increasing at 

alarming rates. To its credit, FAA took 

decisive action, and the total number of 

runway incursions decreased from a high of 

407 in fiscal year (FY) 2001 to a low of 323 

in FY 2003 (see figure 1). The most serious 

incidents have decreased from a high of 69 

in FY 1999 to a low of 28 in FY 2004. 

However, since 2003, the number of runway 

incursions has leveled off, and very serious 

runway incursions continue to occur.2

 

Figure 1. Runway Incursions

FY 1999 to FY 2006

327

326

323

339

407

405

329

330

0 100 200 300 400 500

FY 2006

FY 2004

FY 2002

FY 2000

Source: FAA

Recently, there has been an increase in the 

 

1

 OIG reports can be found on our website at www.oig.dot.gov. Our prior reports regarding runway incursions are 

also listed at exhibit C. 2

 The rate of runway incursions per 1,000,000,000 operations has also remained relatively constant since FY 2003—

from 5.22 in FY 2003 to 5.40 in FY 2006. 

ii
number and severity of runway incursions at four major airports—Boston Logan, 

Chicago O’Hare, Philadelphia, and Los Angeles International. During the period 

of FY 2005 through FY 2006, Boston Logan had 22 incidents (1 severe), Chicago 

O’Hare had 15 incidents (5 severe), Philadelphia International had 16 incidents 

(1 severe involving a collision), and Los Angeles International had 16 incidents 

(2 severe). Those were the highest number of runway incursions among the 

Nation’s large commercial airports. In several instances, a fatal collision was 

barely avoided. For example: 

• On March 21, 2006, at Chicago O’Hare, a controller (during on-the-job 

training) mistakenly cleared two commercial aircraft for take off on 

intersecting runways. Another controller spotted the error and ordered both 

aircraft to abort their take-off rolls. However, before stopping, the 2 aircraft 

came within 100 feet of one another at the runway intersection. 

• On September 30, 2006, at Los Angeles International, a collision was barely 

avoided when a Skywest aircraft aborted a take-off roll after the pilot of a 

British business jet mistakenly crossed the active runway, deviating from a 

controller’s instructions to hold short3

 at the taxiway. The 2 aircraft were less 

than 100 feet from one another when the Skywest aircraft managed to stop. 

Several serious airport surface incidents have recently occurred at other airports as 

well. For example: 

• On August 27, 2006, 49 people lost their lives and 1 was critically injured 

when Comair flight 5191 crashed while attempting to take off from the wrong 

runway at Lexington, Kentucky. 

• On October 28, 2006, Continental flight 1883 (with 152 passengers on board) 

mistakenly landed on an active taxiway at Newark International airport. 

Fortunately, there were no other aircraft or vehicles occupying the taxiway at 

the time of the incident, and no one was injured. 

Although these two incidents are not classified as runway incursions under FAA’s 

current definition, the Lexington accident would be considered a runway incursion 

under the International Civil Aviation Organization’s definition; FAA plans to 

adopt this definition in FY 2008. 

 

3

 “Hold short” is terminology used by controllers when instructing pilots to stop and not enter onto or cross a runway. 

iii
RESULTS IN BRIEF 

At the Boston, Chicago, Philadelphia, and Los Angeles airports, we found that 

FAA, airlines, and airport operators had taken concerted actions in response to an 

increase in the number and severity of runway incursions occurring at those 

locations. For example: 

• At Boston, where pilot deviations were the primary cause of runway 

incursions, FAA revised its local air traffic procedures to change or eliminate 

certain operations and runway configurations. Airport managers were also 

making structural improvements to the airport itself to help prevent runway 

incursions. Those improvements include new airport lighting, signage, and 

markings on the airfield and construction of a new center-field taxiway to 

reduce runway crossings and airfield congestion. 

• At Philadelphia, where controller operational errors were the primary causes of 

runway incursions, FAA has taken actions to improve management oversight 

of air traffic operations, including hiring a new air traffic manager and more 

supervisors and operational managers to provide additional oversight in the 

tower cab. Air Traffic management at the tower also took steps to improve 

controller performance, including establishing an operational position 

responsible for coordinating runway crossings, providing controllers with 

refresher training and team briefings on air traffic procedures, and establishing 

new procedures to minimize runway crossings. 

However, at all four locations, the actions were taken only after an increase in the 

number and severity of incidents at those airports. For example, at Boston, 

significant actions did not occur until after a Category A runway incursion 

happened on June 9, 2005, when 2 aircraft came within 171 feet of a collision. 

That marked the ninth runway incursion in FY 2005—a significant increase over 

the previous year when only one runway incursion occurred during the entire year. 

This incident and six subsequent runway incursions that occurred in FY 2005 

sparked reviews by the National Transportation Safety Board and FAA’s Air 

Traffic Terminal Services and eventually led to the creation of a special team 

(consisting of FAA and airport officials) to identify solutions to Boston’s runway 

incursion problems. 

Compared to 5 years ago, FAA has made significant progress in reducing runway 

incursion incidents. However, the serious risks associated with runway incursions 

underscore the need for maintaining vigilant oversight and a proactive approach 

for preventing severe incidents. During our review at the four locations, we 

identified the following three areas where FAA could take additional proactive 

actions at the national level to help prevent runway incursions system-wide. 

iv
Better information sharing is needed to identify root causes of pilot deviations 

and to communicate best practices that have effectively reduced runway 

incursions. It is important that FAA and users have mechanisms in place to 

identify trends and root causes of runway incursions caused by pilot deviations so 

that appropriate actions can be taken to mitigate risks. FAA has two programs that 

obtain detailed information that could help to identify root causes of pilot 

deviations—the Runway Incursion Information and Evaluation Program (RIIEP) 

and the Aviation Safety Action Program (ASAP). Both programs provide a 

mechanism to obtain information that may not otherwise be reported. However, 

we found the data obtained by these programs were either ineffectively utilized or 

inaccessible to users. 

For example, ASAP is a program in which air carrier employees can report 

potential safety issues without fear of enforcement action from FAA. An intended 

benefit of ASAP is that the information obtained may not otherwise be reported. 

We are currently reviewing ASAP as part of a separate audit to determine the 

appropriateness of including certain incidents or accidents that by their nature 

would be known and reported to FAA, such as runway incursions. As part of this 

review, however, we found that existing ASAP data could be beneficial in 

identifying root causes and corresponding solutions related to commercial pilot 

deviations. However, detailed information related to many of these incidents is 

kept by the individual air carriers participating in the program and is protected 

from disclosure. This is the case even if the runway incursion is serious. 

For instance, on July 18, 2006, a serious pilot deviation occurred at Chicago 

O’Hare when an American Eagle regional jet turned onto the wrong taxiway and 

conflicted with an arriving US Airways Boeing 737. The 2 aircraft came within 

100 feet of a collision; yet, the final report on the incident provides no details 

about why the American Eagle pilot was on the wrong taxiway. It simply states 

that the investigation is being handled under ASAP and that the airline failed to 

respond to a request for additional information concerning the pilot deviation. 

Key stakeholder personnel we interviewed (Regional Runway Safety Program 

Managers, Flight Standards personnel, and pilot representatives) agreed that 

ASAP information could help in identifying effective mechanisms to reduce 

runway incursions. Given that our audit of ASAP is not yet complete, FAA needs 

to work with the pilot and airline communities to develop a process whereby 

Regional Runway Safety Program Managers can request site-specific, redacted 

ASAP information on runway incursions and surface incidents to identify trends 

and root causes of runway incursions. 

v
At all four locations, we also found that comparable actions were taken to prevent 

runway incursions. These included increasing management oversight of tower 

operations; improving controls over airport driver certification and training; 

highlighting potentially dangerous intersections; and improving airport signage, 

lighting, and markings. However, other than informal networking, there were no 

formal mechanisms for users to share effective actions taken at individual 

locations with other users of the National Airspace System. 

Sharing local actions taken, such as changes in airport signage or local air traffic 

procedures, could be an effective means of enhancing runway safety at other 

airports with similar layouts. Regional Runway Safety Program Managers in 

particular expressed frustration at their inability to share best practices through a 

formal channel, such as an internet posting site specifically dedicated to runway 

safety issues. FAA should develop such a means for users to share best practices 

for reducing runway incursions. 

Additional focus is needed on controller human factors issues and training to 

improve individual, team, and facility performance. In its last National Plan 

for Runway Safety (2002), FAA cited human factors and lack of controller 

teamwork as significant contributing factors of runway incursions caused by 

controller operational errors. The report also stated that those types of errors could 

be mitigated through training and procedural interventions. However, we found 

that FAA has made little progress in addressing human factors training to help 

reduce the risk of runway incursions caused by controllers. 

For example, the National Air Traffic Professional Program (NATPRO) is a 

human factors initiative that we reviewed in 2003.4

 NATPRO training is designed 

to sharpen and maintain controllers’ mental skills most closely associated with 

visual attention and scanning. Participants thus gain personal insight into how 

performance can be influenced (e.g., by distraction, fatigue, and boredom) and 

how those factors increase the opportunity for operational errors. 

The program was tested in FY 2003, and FAA provided this training at its en route 

centers and plans to implement it at its large terminal radar approach control 

facilities in FY 2007. However, it has not been implemented at towers where 

visual attention and scanning are key factors in preventing runway incursions. 

The managers at all four facilities we visited expressed an interest in this training, 

but FAA has not yet established milestone dates for implementing NATPRO at air 

traffic control towers. 

Another tool with a high potential for improving facility performance is safety risk 

analysis. Safety risk analyses consist of a methodology to identify all hazards 

 

4

 OIG Report Number AV-2003-040, “Report on Operational Errors and Runway Incursions,” April 3, 2003. 

vi
associated with a specific operation or change in operation so that risks can be 

mitigated to an acceptable level prior to the change being made. At Boston, such 

an analysis was key in preventing future runway incursions. 

For example, after serious runway incursions occurred on June 9, 2005, and 

October 4, 2005, a procedure involving aircraft departing on a non-standard 

runway configuration was discontinued. The facility conducted a safety risk 

analysis of the operation and found that the operation could resume only if certain 

precautionary procedures were instituted. After these procedures were instituted, 

the operation resumed in July 2006; since then, there have been no additional 

runway incursions involving the use of this departure runway operation at Boston. 

The use of safety risk analysis is required for any changes to the National Airspace 

System. Because safety risk analyses are effective in identifying potential runway 

safety risks of existing operations (such as what occurred in Boston), FAA needs 

to determine if they should also be required for evaluating existing operational 

procedures at airports where potential runway safety risks have been identified. 

Greater authority and accountability at the national level is needed to ensure 

that runway safety remains a priority for all lines of business. We found that 

several Agency-wide efforts, initiated in 2001, have subsequently waned as the 

number of incidents declined and FAA met its goals for reducing runway 

incursions. For example, FAA’s Runway Safety Office was established in 2001 to 

provide central oversight and accountability for implementing runway safety 

initiatives throughout the Agency. However, that office has not had a permanent 

Director for over 2 years. In addition, the office was re-organized and realigned 

twice since the establishment of the Air Traffic Organization in February 2004 and 

was reduced in size by 50 percent (from 18 to 9 staff members), including the 

elimination of branch offices. 

Another example is FAA’s National Plan for Runway Safety. This plan defined 

FAA’s strategy and prioritized its efforts to reduce runway incursions by including 

specific activities, milestones, and the organization responsible for those activities. 

FAA believed that this plan, along with quarterly status briefings to the 

Administrator, would improve program accountability by ensuring that initiatives 

were completed in a timely manner. However, we found that this plan is no longer 

prepared, and the last time FAA prepared one was in 2002. 

FAA officials we spoke with told us that the FAA Flight Plan took the place of the 

National Plan for Runway Safety and that each line of business is responsible for 

including runway incursion initiatives in their own annual business plans. The 

individual business plans, however, do not have the same national focus and 

emphasis that the National Plan for Runway Safety provided. 

vii
For instance, FAA does not require each line of business to include goals in its 

business plan that are specific to its oversight responsibility, and this may diminish 

accountability for achieving results within each line of business. For example, 

while FAA met its FY 2006 overall goal of no more than 34 serious runway 

incursions, pilot deviations (the responsibility of the Aviation Safety line of 

business) experienced a 100-percent increase—rising from 9 in FY 2005 to 18 in 

FY 2006. 

SUMMARY OF RECOMMENDATIONS 

Our recommendations focus on programmatic actions that could help FAA to 

reduce runway incursions system-wide. They include the following: 

• Providing managers with access to critical data on pilot deviations for specific 

airports to aid in identifying trends, root causes, and possible local solutions; 

• Developing an automated means to share local best practices that successfully 

reduced runway incursions; 

• Implementing human factors training initiatives for controllers at air traffic 

control towers; 

• Requiring the use of safety risk analyses for existing operational procedures at 

airports where potential runway safety risks have been identified; and 

• Requiring each line of business to include goals for reducing runway 

incursions in its annual business plans that are specific to its responsibilities. 

A complete list of our recommendations can be found on page 17 of this report. 

SUMMARY OF MANAGEMENT COMMENTS AND OFFICE OF 

INSPECTOR GENERAL RESPONSE 

We provided FAA with a draft copy of this report on April 6, 2007, for comment. 

On April 30, 2007, FAA gave us its formal response, which is contained in its 

entirety in the appendix to this report. While FAA senior officials verbally agreed 

with our recommendations when we briefed them on our audit findings and 

recommendations, FAA’s formal response does not explicitly state whether the 

Agency concurs or non-concurs. In addition, the actions proposed by FAA were 

unspecific as to how or when the Agency would address the intent of our 

recommendations. 

viii
For example, FAA’s response states that an airman involved in a runway incursion 

will be given an opportunity to participate in FAA’s Runway Incursion 

Information and Evaluation Program but does not state what specific initiatives 

will be established to promote increased pilot participation, as we recommended. 

In another example, FAA’s response states that it plans to implement human 

factors training for controllers but fails to provide milestones beyond FY 2007, 

which was the basis for our recommendation. 

Accordingly, we are requesting that FAA provide us with additional information 

regarding the specific actions that it plans to take to implement each of our 

recommendations along with timeframes for completion. A complete summary of 

FAA’s comments and our response can be found on pages 18 through 21 of this 

report. 

ACTIONS REQUIRED 

In accordance with Department of Transportation Order 8000.1C, please provide 

us with additional information regarding the specific actions that FAA plans to 

take to implement our recommendations along with timeframes for completion 

within 30 calendar days. We will consider the recommendations unresolved until 

we receive the requested information. 

We appreciate the courtesies and cooperation of FAA representatives during this 

audit. If you have any questions concerning this report, please contact me at 

(202) 366-0500 or Dan Raville, Program Director, at (202) 366-1405. 

# 

cc: FAA Deputy Administrator 

Anthony Williams, ABU-100 

ix
TABLE OF CONTENTS 

FINDINGS................................................................................................. 1

FAA, Airlines, and Airport Operators Had Taken 

Concerted Actions at Boston, Chicago, 

Philadelphia, and Los Angeles in Response to an 

Increase in the Number and Severity of Runway 

Incursions at Those Locations ...................................................... 1

Additional Proactive Measures Could Be Taken by 

FAA at the National Level To Help Prevent Runway 

Incursions System-Wide................................................................. 6

Better Information Sharing Is Needed To Identify Root 

Causes of Pilot Deviations and To Communicate Best 

Practices That Have Effectively Reduced Runway 

Incursions........................................................................................ 6

Additional Focus on Controller Human Factors Issues 

and Training Is Needed To Improve Individual, Team, 

and Facility Performance .............................................................. 11

Greater Authority and Accountability Is Needed at the 

National Level To Ensure That Runway Safety 

Remains a Priority for All Lines of Business................................. 14

RECOMMENDATIONS .......................................................................... 17

AGENCY COMMENTS AND OFFICE OF INSPECTOR 

GENERAL RESPONSE ......................................................................... 18

EXHIBIT A. SCOPE AND METHODOLOGY........................................ 22

EXHIBIT B. ORGANIZATIONS VISITED OR CONTACTED................ 24

EXHIBIT C. PRIOR OIG REPORTS...................................................... 25

EXHIBIT D. MAJOR CONTRIBUTORS TO THIS REPORT................. 27

APPENDIX. AGENCY COMMENTS ..................................................... 28
1

FINDINGS 

At the Boston, Chicago, Philadelphia, and Los Angeles airports, we found that 

FAA, airlines, and airport operators had taken actions to address runway 

incursions. However, those actions were taken only after an increase in the 

number and severity of incidents that occurred at those airports. Preventing 

runway incursions throughout the National Airspace System requires continuous 

vigilance on the part of FAA and users. Compared to 5 years ago, FAA has made 

significant progress in reducing those incidents. However, the serious risks 

associated with runway incursions underscore the need for maintaining a proactive 

approach for preventing serious incidents. 

We identified three areas where FAA needs to take additional measures to further 

reduce serious runway incursions. Specifically, we found that (1) better 

information sharing is needed to identify root causes of pilot deviations and to 

communicate best practices that have effectively reduced runway incursions; 

(2) additional focus on controller human factors issues and training is needed to 

improve individual, team, and facility performance; and (3) greater authority and 

accountability is needed at the national level to ensure that runway safety remains 

a priority for all lines of business. 

FAA, Airlines, and Airport Operators Had Taken Concerted Actions at 

Boston, Chicago, Philadelphia, and Los Angeles in Response to an 

Increase in the Number and Severity of Runway Incursions at Those 

Locations 

Boston Logan: At Boston Logan International Airport, where pilot deviations 

were the primary cause of runway incursions, numerous actions were undertaken 

during FY 2005 and FY 2006 to reverse the increase in runway incursions. 

However, significant actions did not occur until after a Category A runway 

incursion occurred on June 9, 2005, when 2 aircraft came within 171 feet of a 

collision. This marked the ninth runway incursion in FY 2005 (a significant 

increase over the previous year when only one runway incursion occurred during 

the entire year) and sparked a June 2005 review by the National Transportation 

Safety Board.5

 

In October 2005, after 16 runway incursions had occurred within a 12-month 

period at the airport, FAA’s Air Traffic Terminal Services conducted an 

operational assessment, and the FAA Regional Administrator formed a special 

team (consisting of FAA and airport officials) to identify solutions to Boston 

 

5

 The National Transportation Safety Board transmitted the results of its review to the Boston Air Traffic Manager in a 

June 30, 2005, letter that included four suggested actions to assist in preventing runway incursions. 

Findings
2

Logan’s runway incursion problems. Actions taken at Boston Logan in FY 2005 

and FY 2006 to reduce runway incursions include the following: 

• Increasing management oversight of air traffic operations (including hiring 

additional supervisors); 

• Revising air traffic procedures to change or eliminate certain operations; 

• Publishing a high-alert intersection brochure to warn pilots of problem areas; 

• Providing training to mechanics who taxi aircraft across runways; and 

• Improving airport lighting, signage, and markings on the airfield (see figures 2 

and 3). 

Figure 2. Example of Improved Airfield Lighting: Picture of an 

Elevated Runway Guard Light at Boston Logan 

Source: OIG 

Source: Office of Inspector General 

The actions taken by FAA, airlines, and the airport operator have been successful 

in reducing runway incursions at Boston. The total number of incursions have 

declined from 15 (1 serious) in FY 2005 to 7 (0 serious) in FY 2006. Additional 

airport improvements are planned in 2007 and 2008 that should further reduce the 

risk of runway incursions. These include constructing a new center-field taxiway 

to reduce runway crossings and airfield congestion and redesigning the southwest 

corner of the airfield to eliminate the intersection of three taxiways, where many 

of the runway incursions occurred. 

Findings
3

Figure 3. Picture of Enhanced Runway Markings 

at Boston Logan 

Source: Office of Inspector General 

Chicago O’Hare: At Chicago O’Hare International Airport, actions to address 

runway incursions were initiated in March 2006 after several incursions occurred, 

including one very serious incident. Those actions were still underway when we 

visited the facility, and we were unable to assess their effectiveness at the time of 

our review. Most of those actions focused on improving air traffic operations, 

since historically 76 percent of runway incursions at Chicago O’Hare have been 

the result of controller errors. Actions taken to reduce runway incursions include 

the following: 

• Increasing management oversight of air traffic operations (including hiring 

additional supervisors and operational managers to oversee operations in the 

tower cab), 

• Providing controller training and team briefings on air traffic procedures, 

• Removing potential distractions from the air traffic control tower, 

• Hiring additional staff to train controllers, 

• Establishing a local air traffic work group to evaluate procedures, 

• Developing a “hot-spots” map (which depicts where runway incursions have 

occurred at the airport) for all users at the airport and including the hot spots 

on airport diagrams used by pilots, 

• Improving airport signage and markings on the airfield, and 

• Closing a potentially hazardous intersection (see figure 4). 

Findings
4

Figure 4. Picture of Taxiway at Chicago O’Hare Closed Because 

of Repeated Incidents at That Intersection 

Source: Office of Inspector General 

Since initiating actions after the March 2006 incidents, Chicago O’Hare 

experienced seven more incursions (two serious) through February 2007 

(including four controller errors). 

Philadelphia: At Philadelphia International Airport, during FY 2005 and 

FY 2006, actions to reduce runway incursions caused by controller errors appear 

to have been effective. At the time of our field work, however, actions to prevent 

vehicle/pedestrian deviations, which constituted the majority of runway incursions 

in FY 2006, had just been initiated. Actions taken to reduce runway incursions 

include the following: 

• Increasing management oversight of air traffic operations (including hiring a 

new air traffic manager and additional supervisors and operational managers to 

become more actively engaged in managing the operations of the tower cab); 

• Establishing an air traffic operational position responsible for coordinating 

runway crossings; 

• Providing controllers with training and team briefings on air traffic procedures; 

• Establishing new procedures to minimize runway crossings; 

• Developing a hot-spots map for all users at the airport; 

• Implementing new training requirements and disciplinary actions for airfield 

vehicle drivers; and 

• Improving airport signage, lighting, and markings on the airfield. 

Findings
5

The number of runway incursions caused by controllers decreased from six in 

FY 2005 to three in FY 2006. However, the number of incursions caused by 

vehicle drivers increased from two in FY 2005 to four in FY 2006. Because the 

airport’s new training program for drivers was not implemented until June 2006, it 

was too early to determine if it had been effective at the time of our field work. 

Since June 2006, Philadelphia experienced one additional vehicle deviation (not 

serious) that caused a runway incursion. 

Los Angeles: At Los Angeles International Airport, most of the actions were 

geared toward preventing pilot deviations because historically over 80 percent of 

the runway incursions at that location were caused by pilots. Actions taken to 

reduce runway incursions include the following: 

• Revising controller staffing requirements to ensure adequate coverage during 

the night shift; 

• Revising controller phraseology to ensure that pilots hold short when 

instructed; 

• Developing hot-spot maps and training materials on the complexity of the 

airport for pilots; and 

• Improving airport signage, lighting, and markings on airfield. 

Since February 2006, the Los Angeles airport has not had any runway incursions 

caused by controller errors, but pilot deviations continue to occur—two such 

incidents (neither were serious) occurred in February 2007. However, the airport 

is in the process of moving 1 runway 55 feet farther away from a parallel runway 

so that a center-field taxiway can be added. This action has the most potential for 

preventing runway incursions because the majority of pilot deviations occurred 

when aircraft were exiting one runway but, due to the close proximity of the 

parallel runway, were unable to hold short of the second runway as instructed. 

The center-field taxiway will be completed in 2008 (see figure 5).6

 

 

6

 We also provided this information to Senator Boxer in a March 22, 2007, letter from the Inspector General (CC2007-07). The letter can be found on our website at www.oig.dot.gov. 

Findings
6

Figure 5. Runway Construction at Los Angeles International 

Source: Los Angeles Airport Authority 

Additional Proactive Measures Could Be Taken by FAA at the 

National Level To Help Prevent Runway Incursions System-Wide 

The serious risks associated with runway incursions underscore the need for 

maintaining a proactive approach for preventing these incidents. During our 

review, we identified opportunities that could help FAA to further reduce runway 

incursions. Specifically, we found the following: 

• Better information sharing is needed to identify root causes of pilot deviations 

and to communicate best practices that have effectively reduced runway 

incursions; 

• Additional focus on controller human factors issues and training is needed to 

improve individual, team, and facility performance; and 

• Greater authority and accountability is needed at the national level to ensure 

that runway safety remains a priority for all lines of business. 

Better Information Sharing Is Needed To Identify Root Causes of Pilot 

Deviations and To Communicate Best Practices That Have Effectively 

Reduced Runway Incursions 

Pilot deviations have historically been the cause of 50 percent or more of all 

runway incursions. In FY 2006, both the total and the most serious runway 

incursions caused by pilots increased to their highest levels since FY 2002 (see 

figure 6). Given those statistics, it is important that FAA have mechanisms in 

Findings
7

place to share information about pilot deviations that could be used to identify 

trends and potential causal factors. 

Figure 6. History of Pilot Deviation Runway Incursions 

FY 2001 to FY 2006 

191 190

174 173

233

169

0

50

100

150

200

250

FY 2001 FY 2002 FY 2003 FY 2004 FY 2005 FY 2006

32

Cat 

A/B

20

Cat 

A/B

14

Cat A/B

14

Cat 

A/B

9

Cat 

A/B

18

Cat 

A/B

Source: FAA data 

FAA has two programs that obtain detailed information that could help to identify 

root causes of pilot deviations—the Runway Incursion Information and Evaluation 

Program (RIIEP) and the Aviation Safety Action Program (ASAP). Both 

programs provide a mechanism to obtain information that may not otherwise be 

reported. However, we found that the data contained in these programs were 

either ineffectively utilized or inaccessible to users. 

RIIEP: RIIEP was designed to provide additional human factors data on runway 

incursions and surface incidents caused by pilot deviations. The RIIEP 

questionnaire gathers human factors information from pilots involved in a runway 

incursion about activity in the cockpit, pilots’ comprehension of air traffic 

instructions, and physiological conditions of the pilots. For example, a RIIEP 

report filed for a recent Los Angeles pilot deviation provided valuable insight that 

was not provided in the investigation report, including crew communication 

information, the impact of fatigue, and a suggestion on how to prevent the 

reoccurrence of a similar pilot deviation. 

The program (which is voluntary) was originally tested in FY 2000 for a 1-year 

period. Based on the results of that test, FAA believed that the program could 

provide valuable safety information that would help determine root causes and 

develop effective corrective actions to reduce runway incursions caused by pilot 

deviations. As a result, FAA renewed the program for a 2-year period in July 

2004. However, we found that the program was not being utilized effectively. 

Findings
8

For example, only 19 percent of all runway incursions and surface incidents that 

occurred during that 2-year period had a completed program questionnaire. In 

addition, FAA was unable to provide us with evidence that any data analyses were 

performed on the information that was collected. 

FAA has subsequently initiated efforts to revitalize RIIEP. In October 2006, FAA 

renewed RIIEP for another 2 years. FAA also established goals to increase pilot 

participation by 10 percent annually over the next 2 years. In addition, FAA plans 

to provide all regional and field inspectors with training on the program to 

increase its utilization. The program manager for RIIEP stated that given these 

improvements, he believes the program will be more successful at identifying root 

causes and solutions to reduce runway incursions. 

Renewing RIIEP is, in our opinion, a step in the right direction. In order to meet 

its participation goals, we recommend that FAA establish initiatives to promote 

increased voluntary pilot participation in RIIEP so that the necessary data can be 

accumulated and appropriately analyzed to identify and mitigate runway incursion 

causal factors. 

ASAP: ASAP is a program in which air carrier employees can report potential 

safety issues without fear of enforcement action from FAA. An intended benefit 

of ASAP is that the information obtained may not otherwise be reported. We are 

currently reviewing ASAP as part of a separate audit to determine the 

appropriateness of including certain incidents or accidents that by their nature 

would be known and reported to FAA, such as runway incursions. As part of this 

review, however, we found that existing ASAP data could be beneficial in 

identifying root causes and corresponding solutions related to commercial pilot 

deviations. However, detailed information related to many of these incidents is 

kept by the individual air carriers participating in the program and is protected 

from disclosure. This is the case even if the runway incursion is serious. 

For example, on July 18, 2006, a serious pilot deviation occurred at Chicago 

O’Hare when an American Eagle regional jet made a wrong turn onto Taxiway Q 

and conflicted with an arriving US Airways Boeing 737 on a short final to 

Runway 27L. The 2 aircraft came within 100 feet of a collision. The final report 

on the incident, however, provides no details about why the American Eagle pilot 

was on the incorrect taxiway. It simply states the investigation is being handled 

under ASAP and that the airline failed to respond to a request for additional 

information concerning the pilot deviation. 

Obtaining detailed information contained in ASAP reports could identify possible 

common causes that may exist among different air carries, which each air carrier 

by itself may not see as a trend. 

Findings
9

For example, at Boston Logan, where pilot deviations represent the largest 

percentage of runway incursions, stakeholders recognized and acted upon the need 

for pilot deviation information to be shared. As a result, a team of pilot and air 

traffic representatives meet regularly to review tapes of local pilot deviations and 

develop solutions specific to Boston Logan. However, the amount of information 

available to the team is limited since any pilot deviation reported under ASAP is 

restricted and kept by the individual participating air carriers. 

Key stakeholder personnel we interviewed (Regional Runway Safety Program 

Managers, Flight Standards personnel, and pilot representatives) agreed that 

ASAP information could help in identifying effective mechanisms to reduce 

runway incursions. Given that our audit of ASAP is not yet complete, FAA needs 

to work with the pilot and airline communities to develop a process whereby 

Regional Runway Safety Program Managers can request site-specific, redacted 

ASAP information on runway incursions and surface incidents to identify trends 

and root causes of runway incursions. 

Best Practices: At all four locations, we found several comparable actions that 

were taken to prevent runway incursions. However, other than informal 

networking, there were no formal mechanisms for users to share effective actions 

taken at individual locations with other users of the National Airspace System. 

Examples of effective actions at all four airports include the following: 

• Air Traffic managers adopted tools for tracking controller performance. At 

Boston, managers implemented the use of an automated software program for 

performance oversight, while the other facilities adopted the use of other tools 

or forms to better track employee performance until automated software is 

available. 

• Air Traffic managers also increased the minimum required time for 

management to work in the operational area. At Chicago O’Hare, managers 

implemented a requirement for operational managers to spend at least 

80 percent of their time in the operational area. 

• Airport operators tightly controlled the testing of drivers in the airfield driver 

certification process. Each airport operator imposed punitive action for noncompliance of driver rules, some resulting in revocation of driver privileges or 

enforcement of fines. 

• Airport operators and the FAA Runway Safety Office created maps or 

brochures to highlight potentially hazardous intersections (known as hot spots) 

on the airport movement area. At Philadelphia, the airport operator created 

user-specific hot-spot maps, which identified different hot spots for vehicle 

drivers and for pilots. At Boston, Regional Runway Safety Program Managers 

Findings
10

developed a high-alert intersection brochure that identified hot spots and 

distributed it to airport users. 

• All airport operators improved airport lighting, signage, and markings in 

response to runway incursions. For instance, the airports upgraded surfacepainted, hold-short surface markings in advance of FAA’s mandatory 

implementation date of June 2008. The airports also added unique signage to 

prevent runway incursions. For example, to prevent general aviation pilots 

from inadvertently taxiing onto an active runway at Chicago, the airport 

operator added above-ground signage near the general aviation ramp that 

instructs general aviation aircraft to hold and contact the ground controller 

before continuing (see figure 7). 

Figure 7. Picture of Ground Signage at Chicago O’Hare 

Instructing General Aviation Pilots To Hold 

and Contact Ground Control Before Proceeding 

Source: Office of Inspector General 

While the implementation of these actions varied among the airports, they all had 

common threads that have the potential to reduce runway incursions system-wide. 

However, other than informal networking, there were no formal means for the 

various users to share actions with other users that had been effective at reducing 

or preventing runway incursions at their locations. Regional Runway Safety 

Managers in particular expressed frustration at their inability to share best 

practices through a formal channel, such as an intranet posting site specifically 

dedicated to runway safety issues. 

In addition, the special team established at Boston experienced a similar problem 

in obtaining information on industry best practices. The team identified a need to 

distribute site-specific training material, including industry best practices, to its 

local users. However, it was unable to accomplish this initiative because there 

Findings
11

was no central source to turn to for gathering examples of best practices used at 

other locations. 

We are recommending that FAA develop an automated means, such as 

establishing an intranet site through the Regional Runway Safety Offices, to share 

best practices for reducing runway incursions with all users of the National 

Airspace System. 

Additional Focus on Controller Human Factors Issues and Training Is 

Needed To Improve Individual, Team, and Facility Performance 

In its 2002 National Plan for Runway Safety, FAA cited human factors (such as 

memory lapses) and lack of controller teamwork as significant contributing factors 

of runway incursions caused by controller operational errors. The report also 

stated that those types of errors could be mitigated through training and procedural 

interventions. However, we found that FAA has made little progress in 

implementing initiatives to address human factors training to help reduce the risk 

of runway incursions caused by controllers. Some of these initiatives were 

identified over 6 years ago but have not been implemented. 

Based on our review of the four airports and FAA documentation, we have 

identified several initiatives that have significant potential to reduce runway 

incursions by improving (1) individual performance through human factors 

training, (2) team performance through team effectiveness training, and (3) facility 

performance through the use of simulators and safety risk analyses. 

Improving Individual Performance: In April 2003, we reported that since 

almost 90 percent of controller errors were due to human factors issues rather than 

procedural or equipment deficiencies, it was important that FAA develop 

initiatives to prevent theses types of errors. In FY 2002, FAA initiated two key 

human factors studies to improve controller performance—JANUS and National 

Air Traffic Professional Program (NATPRO). 

• JANUS is a technique designed to improve the data collection process for 

operational errors by applying human factors principles so that interventions 

can be developed to enhance performance. The overall purpose is to 

understand the role of the individual, situation, and work-related factors as they 

influence air traffic controllers’ operational performance. The objectives are to 

develop an improved understanding of the human factors relating to individual 

performance and the occurrence of operational errors and to broaden the role of 

cognitive factors as they influence the performance of air traffic controllers. 

FAA began testing JANUS in FY 2002 but has not implemented this program. 

Findings
12

• NATPRO (i.e., memory enhancement training) is designed to sharpen and 

maintain controllers’ mental skills most closely associated with visual attention 

and scanning. Participants thus gain personal insight into how performance 

can be influenced (e.g., by distraction, fatigue, and boredom) and how those 

factors increase the opportunity for performance errors. 

NATPRO was tested in FY 2003, and FAA provided this training at its en 

route centers and plans to implement it at its large terminal radar approach 

control facilities in FY 2007. However, it has not been implemented at towers 

where visual attention and scanning are key factors in preventing runway 

incursions. The managers at all four facilities we visited expressed an interest 

in having this training for controllers at their locations. 

Improving Team Performance: Crew Resource Management (CRM) training 

focuses on teamwork in the tower with an emphasis on operations. Therefore, it 

has the potential to reduce runway incursions through improved team 

performance. This initiative was originally included in FAA’s 2000 National Plan 

for Runway Safety, yet only three facilities have completed this training through 

FY 2006. 

At Philadelphia, which is one of the three air traffic control towers to complete 

this training nationwide, CRM training was used as a tool to reduce runway 

incursions. The CRM training at Philadelphia was site-specific and geared toward 

open discussions that would improve teamwork, improve individual performance, 

and manage operational errors. According to managers at Philadelphia, CRM was 

extremely effective at improving overall team performance and a contributing 

factor in reducing controller errors. 

FAA needs to keep this valuable training on target. During the first 5 months of 

FY 2007, three additional tower facilities have completed CRM training (Chicago, 

Boston, and Miami); FAA plans to complete CRM at one additional tower (Los 

Angeles) before the end of the year. However, FAA officials could not provide us 

with implementation milestones for FY 2008 and beyond. 

Improving Facility Performance: Tower simulators have the potential to 

improve overall facility performance by reducing runway incursions through 

enhanced initial and proficiency training. They provide controllers with a virtual 

replica of the tower environment, which can be used to train controllers using reallife scenarios such as day-versus-night operations, varying weather conditions, 

different runway configurations, or emergency situations (see figure 8). 

Simulators are currently being tested at Miami, Ontario, Phoenix Sky Harbor, and 

Chicago O’Hare and have been used by other facilities to mitigate safety risks of 

proposed and existing operations and to improve runway safety. 

Findings
13

For example, Boston Logan used a tower simulator to aid in establishing necessary 

safety procedures in conjunction with the use of a newly constructed runway. 

Likewise, the National Aeronautics and Space Administration used a tower 

simulator to study several alternatives for improving runway safety at Los Angeles 

International Airport and to evaluate the effectiveness of adding a center-field 

taxiway between its parallel runways. 

Figure 8. Picture of a Tower Cab Simulator 

Source: FAA 

Utilizing a tower simulator has also been identified as an effective tool for training 

new controllers and providing proficiency training for experienced controllers. In 

doing so, simulator training can aid in reducing the risk of runway incursions that 

occur while training new controllers (such as the March 21, 2006, incursion at 

Chicago O’Hare) and those caused by more experienced controllers. 

For example, at Philadelphia, we found that 70 percent (14 of the 20) runway 

incursions caused by controllers over a 4-year period occurred during periods 

when an infrequently used runway configuration was in use. We found that this 

particular configuration was used only 30 percent of the time at Philadelphia. 

Therefore, it was difficult for controllers to maintain their proficiency on that 

particular configuration. According to Air Traffic officials, proficiency training 

using a simulator has a high potential for eliminating such errors. 

The need for tower simulators for controller training was originally identified in 

FAA’s 2000 National Plan for Runway Safety; yet, over 6 years later, only four 

towers have simulators installed. While FAA is still in the testing phase of this 

initiative, it must stay on track and implement simulators in a timely manner. This 

is especially important in light of the fact that FAA will be hiring over 11,800 new 

controllers (many of which will be for tower facilities) to replace those expected to 

leave over the next 10 years. 

Findings
14

Another tool with a high potential for improving facility performance is safety risk 

analysis, which is required for any changes to the National Airspace System. 

Safety risk analyses are used to identify all hazards associated with a specific 

operation or change in operation so that all associated safety risks can be mitigated 

to an acceptable level prior to implementing a change. 

At Boston Logan, safety risk analysis was used to develop procedures to prevent 

runway incursions during use of an existing non-standard departure operation after 

two runway incursions occurred during this operation on June 9 and October 4, 

2005 (rated as Category A and C runway incursions, respectively). The operation 

involved aircraft departing on a runway that was not normally used for 

departures.7

 

As a result of those incidents, the use of this non-standard operation was 

discontinued in December 2005. The facility conducted a safety risk assessment 

analysis of the operation and found that the operation could resume if certain 

precautionary procedures were instituted. After these procedures were instituted, 

the operation resumed in July 2006; since then, there have been no additional 

runway incursions involving the use of this runway operation at Boston. 

In our opinion, the use of a safety risk analysis at airports where potential runway 

safety risks exist could improve facility performance by ensuring that appropriate 

control mechanisms are in place to reduce the risk of runway incursions. FAA 

should require the use of safety risk analyses to evaluate existing operational 

procedures when potential runway safety risks exist and train appropriate 

personnel in conducting such analyses. 

Greater Authority and Accountability Is Needed at the National Level To 

Ensure That Runway Safety Remains a Priority for All Lines of Business 

We found that several national initiatives (some established as early as 2000) that 

could promote runway safety have subsequently waned as the number of incidents 

declined and FAA met its goals for reducing runway incursions. At the national 

level, FAA’s Runway Safety Office is responsible for overseeing FAA’s runway 

safety program. The original purpose of establishing this office was to have one 

central office responsible for overseeing actions taken by all of the lines of 

business involved in runway safety. However, we found that the Runway Safety 

Office has been in a state of flux since 2003. 

For example, from 2003 to 2006, the office incurred a 50-percent reduction in staff 

(from 18 to 9 staff members), including the elimination of branch offices. The 

 

7

 The runway configuration was not normally used at Boston, but pilots on international flights sometimes requested it 

if weather permitted because the runway heading provided more direct routing for trans-Atlantic departures. 

Findings
15

office has not had a permanent Director for over 2 years and has been re-organized 

and realigned twice since the establishment of the Air Traffic Organization. 

We found that several efforts previously performed by the Runway Safety Office 

are no longer accomplished. For instance, the Runway Safety Office no longer 

prepares an annual report detailing runway incursion trends and ongoing 

initiatives, conducts periodic program evaluations of regional runway safety 

efforts, or prepares a National Plan for Runway Safety. 

FAA’s National Plan for Runway Safety, a proactive, Agency-wide effort, was last 

prepared in 2002. The plan defined FAA’s strategy and prioritized its efforts to 

reduce runway incursions from 2002 through 2004. The plan included specific 

activities and objectives that FAA was to undertake to improve runway safety, 

included the organization responsible for completing specific tasks, and required 

that milestones be established for completion of the tasks. 

FAA believed that the National Plan for Runway Safety would be the key for 

improving program accountability by ensuring that initiatives were completed in a 

timely manner. FAA assigned responsibility to the Runway Safety Office for 

providing quarterly briefings to the Administrator on the status of activities 

included in the National Plan for Runway Safety. However, during this review, 

we found that a National Plan for Runway Safety is no longer prepared and 

quarterly meetings are no longer conducted. 

FAA officials indicated that the National Plan for Runway Safety was replaced by 

the FAA Flight Plan and that each line of business is responsible for including 

runway incursion initiatives in its own annual business plan. However, we found 

that the individual business plans do not provide the same level of detail as the 

National Plan for Runway Safety. 

For example, the 2002-2004 National Plan for Runway Safety included 

11 initiatives assigned to FAA’s Flight Standards Office to help reduce pilot 

deviations. However, the FY 2005 through FY 2007 business plans for Aviation 

Safety (the line of business that includes Flight Standards) did not include any 

initiatives specific to runway incursions. This was despite the fact that runway 

incursions caused by pilot deviations continue to account for over 50 percent of all 

runway incursions and were at their highest levels in FY 2006 since FY 2002. 

FAA does not require each line of business to include goals in its business plan 

specific to its oversight responsibility (e.g., Aviation Safety for reducing runway 

incursions caused by pilots or Air Traffic for reducing runway incursions caused 

by controllers) and does not hold each organization accountable for reducing 

runway incursions in its area of responsibility. While FAA experienced success in 

meeting its FY 2006 overall goal of no more than 34 serious runway incursions, 

Findings
16

pilot deviations (the responsibility of the Aviation Safety line of business) 

experienced a 100-percent increase, rising from 9 in FY 2005 to 18 in FY 2006. 

We found that only one line of business (Airports) included goals specific to its 

direct oversight responsibilities (reducing vehicle/pedestrian deviations) in its 

annual business plan. In our opinion, to improve accountability, FAA should 

require each line of business to establish quantitative runway incursion goals 

specific to its oversight responsibility. In addition, FAA should designate the 

Runway Safety Office as the authority to review and approve all runway safety 

initiatives included in each annual business plan submitted by the lines of 

business. 

Findings
17

RECOMMENDATIONS 

We recommend that FAA: 

1. Establish initiatives to promote increased voluntary pilot participation in 

RIIEP and ensure that the data collected are analyzed to identify and mitigate 

runway incursion causal factors. 

2. Work with the pilot and airline communities to establish a process whereby 

Regional Runway Safety Program Managers can request site-specific, 

redacted ASAP information on runway incursions and surface incidents to 

aid in identifying trends, root causes, and possible local solutions. 

3. Develop an automated means to share local best practices that were 

successful in reducing runway incursions. One such mechanism would be 

establishing an intranet site through the Regional Runway Safety Offices. 

4. Establish milestones for implementing JANUS, NATPRO, and CRM training 

and tower simulator training technologies at air traffic control towers that 

have a history of a high number of runway incursions caused by controller 

operational errors. 

5. Require the use of safety risk analyses to evaluate existing operational 

procedures at airports where potential runway safety risks have been 

identified and train appropriate personnel in conducting such analyses. 

6. Require each line of business to include quantitative goals in its annual 

business plans for reducing runway incursion risks that are specific to its 

oversight responsibilities and designate the Runway Safety Office as the 

authority to review and approve all runway safety initiatives submitted by all 

lines of business. 

 

Recommendations
18

AGENCY COMMENTS AND OFFICE OF INSPECTOR GENERAL 

RESPONSE 

We provided FAA with a draft copy of this report on April 6, 2007, for comment. 

On April 30, 2007, FAA gave us its formal response (see appendix). While FAA 

management officials verbally agreed with our recommendations when we briefed 

them on our audit findings and recommendations, FAA’s formal response does not 

explicitly state whether it concurs or non-concurs. In addition, the actions 

proposed by FAA were unspecific as to how or when the Agency would address 

the intent of our recommendations. Accordingly, we consider all six 

recommendations unresolved. FAA’s comments, our response, and the specific 

information needed to resolve each recommendation are listed below. 

Recommendation 1: Establish initiatives to promote increased voluntary pilot 

participation in RIIEP and ensure that the data collected are analyzed to identify 

and mitigate runway incursion causal factors. 

FAA’s Response: FAA states that it has established goals for RIIEP participation 

and that an airman involved in a runway incursion will be offered an opportunity 

to participate in the RIIEP program. It also states that additional aviation 

inspectors have been trained for administering the RIIEP questionnaire and that 

the information collected is being analyzed and reported to management. 

OIG’s Response: FAA’s response does not address the intent of our 

recommendation—to establish initiatives to increase voluntary pilot participation 

in RIIEP and ensure that data collected are analyzed. Instead, FAA’s response 

simply states the current program requirements and guidelines. FAA needs to 

elaborate on the specific initiatives it has established (or plans to establish) to 

encourage pilots to participate in the program. We are requesting that FAA clarify 

its position regarding this issue. We are also requesting that FAA provide us with 

a list of the management controls that it has established (or plans to establish) to 

ensure that data collected are being analyzed. Additionally, we are requesting that 

FAA provide us with target dates for completion. 

Recommendation 2: Work with the pilot and airline communities to establish a 

process whereby Regional Runway Safety Program Managers can request sitespecific, redacted ASAP information on runway incursions and surface incidents 

to aid in identifying trends, root causes, and possible local solutions.

FAA’s Response: FAA states that it is expanding the data collected through the 

Voluntary Safety Information Sharing (VSIS) program with both the domestic and 

international aviation community. FAA states that this program allows 

Agency Comments and Office of Inspector General Response 
19

participants to share archived voluntary redacted safety data, including ASAP 

reports. FAA also states that the VSIS working group includes a representative 

from the Runway Safety Office. 

OIG’s Response: While FAA’s plans to include ASAP reports in the VSIS 

program appear to meet part of our recommendation’s intent (to use ASAP data in 

conjunction with efforts to reduce runway incursions), it is unclear how these data 

will be made available to Regional Runway Safety Program Managers to aid them 

in identifying trends, root causes, and possible local solutions. Therefore, we are 

requesting that FAA explain to us how VSIS information will be made available to 

Regional Runway Safety Program Managers. We are also requesting that FAA 

provide us with target dates for implementation of the VSIS expansion. 

Recommendation 3: Develop an automated means to share local best practices 

that were successful in reducing runway incursions. One such mechanism would 

be establishing an intranet site through the Regional Runway Safety Offices.

FAA’s Response: FAA states that it is in the process of consolidating all of its 

regional runway safety web pages into one main website. As part of this effort, 

FAA states that it plans to include an area for sharing best practices. 

OIG’s Response: FAA’s proposed action meets the intent of our 

recommendation for sharing best practices. However, we are requesting that FAA 

provide us with a target date for completing this effort. 

Recommendation 4: Establish milestones for implementing JANUS, NATPRO, 

and CRM training and tower simulator training technologies at air traffic control 

towers that have a history of a high number of runway incursions caused by 

controller operational errors. 

FAA’s Response: FAA states that it has identified 33 facilities for the initial 

phase of NATPRO training and will have a cadre of instructors for these facilities 

ready by the end of FY 2007. FAA also indicated that for CRM training, six 

additional facilities will be included in this training by the end of FY 2007 and a 

CRM course is being developed to support training on a larger scale. In addition, 

FAA stated that the Joint Resource Counsel has approved the initial investment for 

field tower simulators and that the first simulators could be deployed as early as 

January 2008. Finally, FAA states that target dates associated with these training 

programs will be included in future business plans 

OIG Response: FAA’s response is, for the most part, responsive to our 

recommendation’s intent but does not provide sufficient details. First, FAA’s 

Agency Comments and Office of Inspector General Response 
20

response does not address milestones for JANUS, and we are requesting that FAA 

clarify whether it intends to implement this training. Second, it is not clear 

whether the 33 facilities FAA has identified for NATPRO training include only 

towers or if terminal radar approach control facilities are also included in this 

number. Third, while the response addresses near-term milestones for NATPRO, 

CRM, and tower simulators, it does not provide milestones beyond FY 2007 or FY 

2008. We recognize that outside factors (such as shifting Agency priorities or 

budget constraints) may affect FAA’s ability to complete training according to a 

strict schedule; however, in our opinion, a long-term strategic approach should be 

taken to ensure that the training remains a priority and implementation delays are 

limited. We are requesting that FAA provide us with additional details on 

estimated long-term milestones for completing the implementation of these 

training programs. 

Recommendation 5: Require the use of safety risk analyses to evaluate existing 

operational procedures at airports where potential runway safety risks have been 

identified and train appropriate personnel in conducting such analyses.

FAA’s Response: In its response, FAA states that Safety Risk Management 

analyses have been used to address operational procedures where runway safety 

risk had been identified and that it will continue to use this process to address risk 

identified with operational procedures. 

OIG Response: FAA’s response does not address the intent of our 

recommendation—to require the use of safety risk analyses to evaluate existing 

operational procedures at airports where potential runway safety risks have been 

identified. FAA’s response states that it will continue to use Safety Risk 

Management analysis to address risk identified with operational procedures; 

however, it is unclear whether FAA plans to require the use of safety risk analyses 

to evaluate existing operational procedures where potential runway safety risks 

exist, as we recommended. We are requesting that FAA clarify this issue and 

provide us with target dates for implementation. 

Recommendation 6: Require each line of business to include quantitative goals 

in its annual business plans for reducing runway incursion risks that are specific to 

its oversight responsibilities and designate the Runway Safety Office as the 

authority to review and approve all runway safety initiatives submitted by all lines 

of business. 

FAA’s Response: FAA states that it includes quantitative goals on reducing 

runway incursions within the Agency’s FY 2007-2011 Flight Plan, which contains 

FAA’s corporate strategy and plan for reducing the risk of runway incursions. 

Each line of business develops an annual business plan with initiatives and goals 

Agency Comments and Office of Inspector General Response 
21

that support this strategy. Many of these initiatives require support from and 

collaboration with the other lines of business to be successful. 

OIG Response: FAA’s response does not address the intent our 

recommendation—to require each line of business to establish quantitative goals 

in its annual business plan for reducing runway incursion that are specific to its 

area of responsibility. FAA’s response also does not address whether it will 

provide the Runway Safety Office with the authority to review and approve 

runway safety initiatives submitted by the lines of business. Instead, FAA’s 

response only reiterates the current process, which does not hold individual lines 

of business accountable for reducing incidents specific to their oversight 

responsibility. FAA’s response is unclear as to whether FAA intends to require 

each line of business to establish quantitative goals for its own area of 

responsibility. Accordingly, we are requesting that FAA clarify its response to 

this recommendation. 

In accordance with Department of Transportation Order 8000.1C, please provide 

us with the information requested above within 30 calendar days. We will 

consider the recommendations open and unresolved until we receive the requested 

information. 

Agency Comments and Office of Inspector General Response 
22

EXHIBIT A. SCOPE AND METHODOLOGY 

This performance audit was conducted in accordance with generally accepted

Government Auditing Standards prescribed by the Comptroller General of the 

United States and included such tests as we considered necessary to provide 

reasonable assurance of detecting abuse or illegal acts. We conducted this review 

between May 2006 and April 2007 using the following methodology. 

We selected the initial three airports (at Boston, Chicago, and Philadelphia) for 

review because these three airports led the Nation in the number of runway 

incursions for large commercial airports during the 19-month period from 

October 1, 2004, through April 30, 2006. We added the fourth airport (Los 

Angeles) to our review in October 2006 after two serious runway incursions 

occurred in July and September 2006 and in response to concerns expressed by 

Senator Barbara Boxer to our office concerning those incidents. 

To evaluate runway incursion trends at each of the four airports included in our 

review, we analyzed runway incursion data for the 4-year period from FY 2003 

through FY 2006 using the national runway incursion database and individual 

investigation reports. We also obtained trend analysis information performed by 

Regional Runway Safety Program Managers and air traffic control facilities. 

To evaluate the actions taken to reduce runway incursions at each airport, we: 

• Interviewed FAA representatives from Air Traffic, Airport, and Flight 

Standards regional and local offices. 

• Interviewed Airport Operators and Airline personnel (such as pilots, air traffic 

liaisons, safety officials, and maintenance representatives). 

• Interviewed controller, pilot, and mechanic union representatives. 

• Verified the status of recommended actions contained in Runway Safety 

Action Team, TIGER team, air traffic facility evaluations, or National 

Transportation Safety Board reports. 

• Reviewed any additional actions taken or planned that were designed to reduce 

runway incursions. 

• Observed air traffic operations and toured the airport movement area. 

• Analyzed whether actions taken were effective at reducing runway incursions. 

Exhibit A. Scope and Methodology 
23

To assess actions taken or planned to address runway incursions at the national 

level, we: 

• Interviewed FAA Headquarters representatives from Air Traffic, Airport, and 

Flight Standards offices. 

• Reviewed FY 2005 through FY 2007 business plans for FAA’s lines of 

business, i.e., Air Traffic Organization, Airports Division, and Aviation Safety 

(we also reviewed business plans from Flight Standards for the same period). 

• Reviewed FAA’s National Plan for Runway Safety, dated October 2000 and 

July 2002. 

• Reviewed FAA’s Runway Safety Report, dated August 2005. 

We also evaluated changes made to the structure and operation of the Runway 

Safety Office since FY 2001, including staffing and budget changes. 

To determine the accuracy and completeness of the national runway incursion 

database, we judgmentally sampled runway incursion investigation reports for 

pilot deviations, operational errors, and vehicle/pedestrian deviations and 

compared these reports to the runway incursions listed on the national runway 

incursion database.

Exhibit A. Scope and Methodology 
24

EXHIBIT B. ORGANIZATIONS VISITED OR CONTACTED 

Federal Aviation Administration 

• FAA Headquarters, Washington DC 

• Philadelphia Air Traffic Control Tower, Philadelphia, PA 

• Boston Logan Air Traffic Control Tower, Boston, MA 

• Chicago O’Hare Air Traffic Control Tower, Chicago, IL 

• Los Angeles Air Traffic Control Tower, Los Angeles, CA 

• Eastern Region Headquarters, Jamaica, NY 

• New England Region Headquarters, Burlington, MA 

• Great Lakes Region Headquarters, Des Plaines, IL 

• Western-Pacific Region Headquarters, Lawndale, CA 

• Central Terminal Service Area, Fort Worth, TX 

• Eastern Terminal Service Area, Jamaica, NY 

• Los Angeles Flight Standards District Office, El Segundo, CA 

• Boston Flight Standards District Office, Lexington, MA 

• Philadelphia Flight Standards District Office, Philadelphia, PA 

Airport Operators 

• City of Philadelphia, Philadelphia International Airport 

• Massachusetts Port Authority, Boston Logan International Airport 

• Department of Aviation, Chicago O’Hare International Airport 

• Los Angeles World Airports, Los Angeles International Airport 

Airlines, Industry Associations, and Other Federal Agencies 

• Air Wisconsin 

• American 

• Cape Air 

• JetBlue 

• Piedmont 

• Skywest 

• Southwest 

• United 

• US Airways 

• Air Line Pilots Association 

• National Air Traffic Controllers Association 

• Aircraft Mechanics Fraternal Association 

• National Transportation Safety Board

Exhibit B. Organizations Visited or Contacted 
25

EXHIBIT C. PRIOR OIG REPORTS 

Since 1998, we have issued four audit reports on FAA’s efforts to reduce runway 

incursions. 

• OIG Report Number AV-1998-075, “Runway Incursion Program,” 

February 9, 1998. 

• OIG Report Number AV-1999-114, “Follow-Up Review of FAA’s Runway 

Safety Program,” July 21, 1999. 

• OIG Report Number AV-2001-066, “Despite Significant Management 

Focus, Further Actions Are Needed To Reduce Runway Incursions,” 

June 26, 2001. 

• OIG Report Number AV-2003-040, “Report on Operational Errors and 

Runway Incursions: Progress Made, but the Number of Incidents Is Still 

High and Presents Serious Safety Risks,” April 3, 2003. 

FAA actions taken as a result of the two most recent audit reports are described 

below. 

In April 2003, we reported that FAA had made progress in reducing runway 

incursions during FY 2002 due in part to a reduction in air traffic operations but 

also because of site-specific improvements at airports. Despite this progress, 

further actions were still needed. We recommended that FAA (1) implement 

recommendations in its Runway Incursion Airport Assessment Report published 

in January 2003 and (2) conduct reviews at 4 airports that had 10 or more runway 

incursions over a 4-year period to determine whether technological solutions were 

needed. FAA has completed actions to implement these recommendations. 

In our April 2003 report, we also emphasized the need for FAA to complete 

actions on recommendations made in our June 2001 report. At that time, FAA had 

not taken actions on our recommendations to (1) advance low-cost technologies to 

high-risk airports, (2) expedite technologies (such as in-cockpit surface moving 

map displays) to aid pilots, and (3) improve program accountability. 

FAA subsequently completed its evaluation of three low-cost technologies and 

found one (the Final Approach Runway Occupancy Signal)8

 to be viable. An 

operational evaluation of this technology is being conducted and is expected to be 

completed this year. FAA has not taken actions concerning in-cockpit surface 

moving maps because the full use of this equipment, according to FAA, depends 

 

8

 Final Approach Runway Occupancy Signal provides a visual alert to pilots on approach that it is unsafe to land due 

to an aircraft or vehicle occupying a critical position on the runway. 

Exhibit C. Prior OIG Reports 
26

upon implementation of other new technology, such as the Automatic Dependent 

Surveillance-Broadcast Program.9

 

Finally, FAA took actions to improve program accountability by implementing a 

National Plan in 2002 that required each line of business to establish initiatives 

and milestones addressing runway safety and by providing the Administrator with 

quarterly status briefings on these initiatives. As we discuss further in this report, 

however, we found that some of the Agency-wide emphasis on reducing runway 

incursions has subsided as the number and severity of incidents declined. 

 

9

 Automatic Dependent Surveillance-Broadcast will provide pilots with a moving map display that shows where other 

aircraft are located on the runways and taxiways. 

Exhibit C. Prior OIG Reports 
27

EXHIBIT D. MAJOR CONTRIBUTORS TO THIS REPORT 

THE FOLLOWING INDIVIDUALS CONTRIBUTED TO THIS REPORT.

Name Title 

Daniel Raville Program Director 

Mary (Liz) Hanson Project Manager 

Annie Glenn Bungo Senior Analyst 

Kimberly Leading Senior Auditor 

Mark Gonzales Analyst 

Kevin Montgomery Analyst 

Andrea Nossaman Writer-Editor 

Exhibit D. Major Contributors to This Report 
28

APPENDIX. AGENCY COMMENTS 

Federal Aviation 

Administration 

Memorandum 

Date: April 30 2007 

To: Robin Hunt, Acting Assistant Inspector General for Aviation and Special 

Program Audits 

From: Ramesh K. Punwani, Assistant Administrator for Financial Services/CFO 

 Prepared by: Anthony Williams, x79000 

Subject: “Draft Report: Progress Has Been Made in Reducing Runway Incursions, but 

Recent Incidents Underscore the Need for Further Proactive Efforts “ 

As requested in your memorandum dated April 6, I have reviewed the subject draft report. 

Attached is FAA’s position to the six recommendations contained in the report. 

Thank you for allowing the FAA the opportunity to review the report and provide the specific 

action taken or planned for each recommendation. If you have any questions, please contact 

Anthony Williams, Budget Policy Division, at (202 267-9000). 

Attachment 

Appendix. Agency Comments 
29

Federal Aviation Administration’s (FAA) Response to the 

Office of Inspector General’s (OIG) Draft Report on 

Progress Has Been Made in Reducing Runway Incursions,

But Recent Incidents Underscore The Need For 

Further Proactive Efforts

Recommendation 1: 

Establish initiatives to promote increased voluntary pilot participation in RlIEP and 

ensure that the data collected are analyzed to identify and mitigate runway incursion 

causal factors. 

Response: 

The FAA has established goals for RIIEP participation. An airman involved in a runway 

incursion will be offered an opportunity to participate in the RIIEP program. Additional 

aviation inspectors have been trained for administering the RIIEP questionnaire and 

addressing the pilot’s questions about the program. The information collected is being 

analyzed and reported to management. 

Recommendation 2: 

Work with the pilot and airline communities to establish a process whereby Regional 

Runway Safety Program Managers can request site-specific, redacted ASAP information 

on runway incursions and surface incidents to aid in identifying trends, root causes, and 

possible local solutions. 

Response: 

The FAA is currently participating in the process of expanding the data collected through 

the Voluntary Safety Information Sharing (VSIS) program with both the domestic and 

international aviation community. This archive of voluntary aviation safety data allows 

participants to share redacted data. The airline Aviation Safety Action Plan (ASAP) 

reports will be one of the data sources being shared though this program. The FAA and 

aviation industry participate in the VSIS working group which includes a representative 

from the Runway Safety Office. 

Recommendation 3: 

Develop an automated means to share local best practices that were successful in 

reducing runway incursions. One such mechanism would be establishing an intranet site 

through the Regional Runway Safety Offices. 

Response: 

The FAA is in the process of updating the Runway Safety webpage by consolidating the 

regional pages into areas within the main website. By reducing the duplication of 

multiple websites, the relevant information becomes easily discernable. The updated 

website will contain an area for sharing best practices. 

Appendix. Agency Comments 
30

Recommendation 4: 

Establish milestones for implementing JANUS, NATPRO, CRM training, and tower 

simulator training technologies at air traffic control towers that have a history of a high 

number of runway incursions caused by controller operational errors. 

Response: 

The FAA has identified 33 facilities for the initial phase of NATPRO training. The goal 

is to have the cadre of trainers for these facilities trained by the end of FY 2007. The 

FAA has recently completed CRM training at three facilities with six additional facilities 

identified for training by the end of FY 2007. A CRM Cadre course is being developed 

to support training on a larger scale. The JRC has approved the initial investment for the 

deployment and initial operation of field tower simulators. The first simulators could be 

deployed as early as January 2008. Initiative targets associated with these training 

programs will be included within future business plans. 

Recommendation 5: 

Require the use of safety risk analyses to evaluate existing operational procedures at 

airports where potential runway safety risks have been identified and train appropriate 

personnel in conducting such analyses. 

Response: 

The FAA is currently providing training to air traffic control facilities on the application 

of Safety Risk Management (SRM) as part of the Safety Management System (SMS). 

This process has been used to address operational procedures where runway safety risk 

had been identified. The agency will continue to use this process to address risk 

identified with operational procedures. We suggest the recommendation be clarified to 

read as follows: 

“Require the use of safety risk management analyses to evaluate existing air traffic 

control operational procedures at airports where potential runway safety risks have been 

identified, and train appropriate personnel in conducting such analyses.” 

Recommendation 6: 

Require each line of business to include quantitative goals in their annual business plans 

for reducing runway incursion risks that are specific to their oversight responsibilities and 

designate the Runway Safety Office the authority to review and approve all runway 

safety initiatives submitted by all lines of business. 

Response: 

The FAA includes quantitative goals on reducing runway incursions within the agencies 

FY 2007-2011 Flight Plan. The Flight Plan contains the FAA’s corporate strategy and 

plan for reducing the risk of runway incursions. Each line of business develops an annual 

business plan with initiatives and goals that support this strategy. Many of these 

initiatives require support from and collaboration with the other lines of business to be 

successful. 

Appendix. Agency Comments 
The following pages contain textual versions of the graphs and charts found in this 

document. These pages were not in the original document but have been added 

here to accommodate assistive technology. 
Progress Has Been Made in Reducing Runway Incursions, but Recent 

Incidents Underscore the Need for Further Proactive Efforts 

Section 508 Compliant Presentation 

Figure 1. Runway Incursions Fiscal Year 1999 to Fiscal Year 2006 

• In fiscal year 1999, there were 329 runway incursions. 

• In fiscal year 2000, there were 405 runway incursions. 

• In fiscal year 2001, there were 407 runway incursions. 

• In fiscal year 2002, there were 339 runway incursions. 

• In fiscal year 2003, there were 323 runway incursions. 

• In fiscal year 2004, there were 326 runway incursions. 

• In fiscal year 2005, there were 327 runway incursions. 

• In fiscal year 2006, there were 330 runway incursions. 

Source: Federal Aviation Administration 

Figure 2. Example of Improved Airfield Lighting: Picture of an Elevated 

Runway Guard Light at Boston Logan 

Photograph shows guard light elevated from the runway. 

Source: OIG 

Figure 3. Picture of Enhanced Runway Markings at Boston Logan 

Photograph shows new runway markings painted on the runway surface. 

Source: OIG 

Figure 4. Picture of Taxiway at Chicago O’Hare Closed Because of Repeated 

Incidents at That Intersection 

Photograph shows blocking devices placed to demarcate the closed taxiway. 

Source: OIG 
Figure 5. Runway Construction at Los Angeles International 

Photograph of runway area and construction diagram show plans to complete the 

center-field taxi runway. 

Source: Los Angeles Airport Authority 

Figure 6. History of Pilot Deviation Runway Incursions Fiscal Year 2001 to 

Fiscal Year 2006 

• In fiscal year 2001, there were 233 pilot deviation runway incursions. Thirtytwo of these were rated as Category A or B incidents. 

• In fiscal year 2002, there were 191 pilot deviation runway incursions. Twenty 

of these were rated as Category A or B incidents. 

• In fiscal year 2003, there were 174 pilot deviation runway incursions. 

Fourteen of these were rated as Category A or B incidents. 

• In fiscal year 2004, there were 173 pilot deviation runway incursions. 

Fourteen of these were rated as Category A or B incidents. 

• In fiscal year 2005, there were 169 pilot deviation runway incursions. Nine of 

these were rated as Category A or B incidents. 

• In fiscal year 2006, there were 190 pilot deviation runway incursions. 

Eighteen of these were rated as Category A or B incidents. 

Source: FAA data 

Figure 7. Picture of Ground Signage at Chicago O’Hare Instructing General 

Aviation Pilots To Hold and Contact Ground Control Before Proceeding 

Photograph shows a large sign on the ground near runway. The sign message is, 

“HOLD HERE CONTACT GROUND.” 

Source: OIG 

Figure 8. Picture of a Tower Cab Simulator 

Photograph shows the screens and other equipment used for tower cab simulation. 

Source: FAA