anatomy of a runway incursion

F E D E R A L A V I A T I O N A D M I N I S T R A T I O N • I R T R A F F I C O R G A N I Z A T I O N

Anatomy of a Runway Incursion

Or What Went Wrong?

F E D E R A L A V I A T I O N A D M I N I S T R A T I O N • I R T R A F F I C O R G A N I Z A T I O N 6

SO WHAT WENT WRONG?

Day/IFR

Weather - Light Rain

Visibility - Restricted; Fog & Low Clouds

583 Passengers & Crew

Los Rodeos Airport Tenerife, Canary Islands, March 27, 1977

Taipei’s Chang Kai Shek International Airport, October 31, 2000

Night/IFR

Weather - Heavy Rain

Visibility - 600 meters

Typhoon in area


83 Fatalities Aircraft impacted equipment

on closed runway during takeoff

Linate Airport, Milan, Italy October 8, 2001

Day/IFR

Visibility - Restricted; Fog


114 Fatalities

Citation strayed onto runway during MD-80’s takeoff roll


WHAT WENT WRONG?

RUNWAY INCURSIONFAA Order 7210.58

Any occurrence at an airport involving an aircraft, vehicle,

person, or object on the ground that creates a collision hazard or

results in a loss of separation with an aircraft taking off,

intending to takeoff, landing, or intending to land.

RunwayIncursion

Sev

erit

y C

ateg

ori

es

A

B

C

D

Severity Categories

14

Severity Categories

ABC

D

Animated Illustration

9

Little or no risk of

collision

Ample time and distance to avoid collision

Significant

potential

for collision

Barely

avoid

collision

Above scenarios are all classified as runway incursions, but with different severity codes.

•In each case the taxiing aircraft penetrated the runway safety area (hold position) AND

•A collision hazard or loss of separation occurred with the landing aircraft.


Surface Incident

An unauthorized movement within the

area

An occurrence in a movement area affecting safety of flight

Examples: VPD’s, taxiway incursion, animal on runway, operational deviation, etc.


Pilot DeviationsPilot Deviations

Actions that violate a

Federal Air Regulation


Operational Errors

Occurrences that result in:

1) less than applicable separation, or

2) authorization for aircraft to land or depart closed runway


Vehicle or Pedestrian Deviations Occur when a vehicle operator, pedestrian, non-pilot operator or aircraft enters a movement area without ATC authorization.


SO WHAT WENT WRONG?

Let’s Review


Conditions at Time of Runway Incursions

Airport Diagram Not Used

Unfamiliar with Airport Signage

Not Familiar with Airport

Failed to Follow Instructions

Inexperienced at Towered Airports (Phraseology)

Unfavorable Environmental Conditions

Clearance Not Read back

HUMAN ERROR


Major Runway Incursion Causes

•Spatial Disorientation

•Loss of Situational Awareness

•Unclear/Ineffective CRM

•Misunderstanding ATC

•Disorientation

•Lapse in short term memory

HUMAN ERROR


HUMAN

FACTORS

Human FactorsFatigue (double shifts)

Employee turnover

Stress (job related)

Distractions in Cockpit- down head time, attention to squawked items

NO CELL PHONES

Complacency

Language

5 Hazardous Attitudes

Anti-Authority

Impulsitivity

Invulnerability

Macho

Resignation

Responsibility

Trust… no one to come behind to check if you do it wrong

Poor Judgement

Case Study: December 6, 1999Approximately 8:35 PM

Theodore Francis Green State AirportProvidence, Rhode Island

Click to Continue

On 12/6/99, at about 8:35 p.m., United Airlines Flight 1448, a Boeing 757, was involved in a runway incursion on Runway 5R at Theodore Francis Green State Airport, near Providence, Rhode Island.

Click to Continue

At the time of the incident, it was dark and the reported visibility was 1/4 mile in dense fog.

Tower and Ground Control positions were combined.

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Click Here to Begin

The following slides contain the actual ATC recording of the runway incursion incident.

Transcription of the audio will appear in this area.

Aircraft movement and position will appear in the diagram to the right.

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United 1448, what’s your position?

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We’re clear of the runway, on November by Bravo, United 1448.

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United 1448, Thank you, Taxi to ramp, via taxiways November and Tango, report crossing Runway 16.

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OK, November, Tango, will report crossing Runway 16, United 1448.

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Ground, USAir 2998 is holding short behind FEDEX.

USAir 2998, Thank You.

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Ground, UPS 27, Taxi.

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UPS 27, Providence Ground, good evening, Runway 5R, taxi, use taxiway Victor and Runway 23R, hold short Runway 16, advise holding short.

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OK, We can’t take Victor this time, we’re facing the wrong way, any chance Alpha, Mike, and November ?

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UPS 27, you can expect that taxi route, hold the position for now, remain clear of all taxiways.

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OK, We’ll hold our position here on the ramp, over, UPS 27.

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USAir 1020, turn left taxiway November or Alpha, and report clear of the runway please.

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Roger, it looks like we’ve got November here, USAir 1020.

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USAir 1020, Thank you, Taxi to ramp, via taxiways November and Tango, report crossing Runway 16.

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November, Tango to the ramp, report crossing 16, and we are clear of 5 at this time, USAir 1020.

USAir 1020, Thank you.

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FedEx 1662, Runway 5R, fly Runway heading, cleared for takeoff.

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Runway heading, cleared for takeoff, 5R, FedEx 1662.

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1448 is on November by the runways here, we don’t see the, uh, are we cleared across straight ahead on November?

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United 1448, affirmative, cross Runway 16, join taxiway November, Tango on the other side.

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November, Tango on the other side, United 1448.

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USAir 1020 exercise caution, 757 ahead, just coming up on Runway 16 at November, taxi to the ramp.

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OK, we’re looking for the other airplane . . . we’re crossing November at Bravo, did you want us to taxi Alpha to the ramp?

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USAir 1020, negative, that was just if you missed November on the rollout, taxi to the ramp via taxiways November and Tango.

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Report entering Taxiway Tango, please.

Thank you, November, Tango, USAir 1020.

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And uh, United 1448, we’re approaching Kilo here, uh, ah,

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And uh, United 1448, we’re approaching Kilo here, uh, ah,

Somebody just took off.

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United 1448, you shouldn’t be anywhere near Kilo, hold your position please, just stop.

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Ah, this is United 1448, we are currently on a runway, I am looking out to the right with a Kilo, ah, we need to go on the Kilo taxiway.

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United 1448, you were supposed to taxi November and Tango, I need to know what runway you’re on, I can’t see anything from the tower.

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We . . .

Uh, Ma'am we are on 23 Right intersection of 16 and we did not connect on November, we are . . .

We . . .

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We are by Kilo to our right and we just overshot Kilo, we did not see it.

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FedEx 1662, contact Departure, good day.

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FedEx 1662, contact Departure, good day.

FedEx 1662, over to Departure, so long.

. . . runway on 23, ah, Left, here.

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(clutter)

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United, stand by please.

USAir 2998, Runway 5R, fly runway heading, cleared for takeoff.

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Ma’am, I’m trying to advise you, we’re on an active runway, United 1448.

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23 Right is not an active runway, it’s a taxiway when we’re IFR or in the dark.

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Clutter . . .

(??) stand clear of all runways until he, we figure this out.

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Everybody standby please, radio silence until I talk to you.

. . runway . .

Everybody stand by.

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USAir 1020, hold your position please, I don’t know exactly where the United is, I’ll figure it out in a minute.

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We’re on Tango, for 1020.

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United 1448, we’re on 23 Right, we’re looking at Kilo straight ahead, if we can go straight we can can get on Kilo and get off the runway.

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United 1448, standby please, don’t talk, I have other things I need to do.

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Roger, Ma’am.

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USAir 2998, Runway 5R, fly runway heading, cleared for takeoff.

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Uh, Tower, USAir 2998, 'til we figure out what’s going on down there, we’re just going to stay clear of all runways.

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USAir 2998, roger, hold short of Runway 5R, he’s not anywhere near the runway, but you can hold short.

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OK.

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1662, climb and maintain 10 thousand.

. . . he doesn’t even know where he is.

10, ten thousand, FedEx 1662.

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Tower, USAir 2998 isn’t going yet because I have a United who doesn’t know where the hell he is, I’ll take him back and flash you when he’s ready.

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USAir 1020, are you at your gate?

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We’re stopped as requested on Tango.

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USAir 1020, Thank you.

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United 1448, understand you’re on Runway 23 Right, have you gone past taxiway Kilo and Tango 1 ?

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Ma’am, we’re on 23 Left and 16, and we’re, I’m facing into Kilo, at this point, the nose is, ah just, over 23 Left.

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Are you facing northwest or southeast?

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We are facing, we are heading, for United 1448, right now we are facing approximately 200 degrees on the heading.

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I am looking out the window and I am seeing a sign that says 23L to my right and a sign that says 16 to my left.

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And I have yellow signs that say Kilo to my right and to my left. We are on a current runway, heading 200.

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Stop all traffic until advised please, United has no idea where they are. Thank you.

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United 1448, just taxi straight ahead, let me know when you get to the next sign please.

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Ok, we’re gonna go straight ahead, we’re gonna go up to Kilo here.

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United 1448, are you just turning on to Runway 23 Left right now?

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Yes we are, and we’re gonna go over, we’re on 23 Left, we’re currently exiting and we are coming up on Kilo now.

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United 1448, roger, turn right at Kilo and then a slight left turn taxiway Charlie, hold short Runway 23 Right.

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We’re on Kilo, we are clear of the runway, and we are approaching Kilo 1, and we’re on Kilo.

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WHAT WENT WRONG?


Statistics and Trends

Recent Incidents

Distribution by Type of Runway IncursionsDistribution by Type of Runway Incursions

FY 2004 YTD (03/12/04)

V/PD15%

PD61%

OE/D 22%

OE/D23%

PD57%

V/PD20%

FY 2000-2003

DATA ARE PRELIMINARY AND SUBJECT TO CHANGE

Changing Our BehaviorsChanging Our Behaviors

Culture

The customs, skills, and other interrelated learned behavior patterns that set them apart as a distinct group of people

Cultural ChangeCultural Change

Cultural Change is a form of organizational transformation that involves changing the basic values, norms, beliefs, etc., among members of the group/organization, in order to improve organizational performance.

WHAT CAN YOU DO?

Training…

Training…

And More ^ TrainingStan

dardized


Does your Training Manual includeRunway Safety Training?

Let’s Talk

About Your Training

Things to Consider

•Testing required for all Areas of Training

• Only Standardized Training at all facilities –reduces human error

• Less desired shifts…Less seniority…Less experienced

• Providing enough instruction time and keeping to prescribed time

• Lack of instructors

• Contract Maintenance Facilities – training requirements


•Required Qualification Level

Left Seat, Right Seat, Aircraft Type

Aircraft Training – Who, When, How, Where, by Whom

Law of Primacy-even bad instruction can stick

Aircraft taxi at contract facilities? (limited to flight crew?)

•Medical Requirements

• What safeguard/control is in position for scheduling only people that are current & qualified?


• Develop a Maintenance Pre-Flight Checklist (all items should be readily available to AMT)

• Fill out NASA Forms as required!

• Weather Conditions: low visibility, adverse weather How to get current

weather? Go No Go criteria during adverse weather

• Airport Diagrams – Jeppesen subscription, Local High Alert Area Diagrams

•Establish taxi routes based on Airport charts

•Avoidance of taxi during peak times


• Airport Notams

• SMGCS Airports

• Aircraft Checklists Use

•Braking action for different aircraft

• Copying Clearances

• Additional training for each local airport


Additional Considerations

Financial problems of company and its effect on training.

Radio communication training often overlooked – train and do routine practice before actual use.

Airport Driver Training – reinforce within company training


Resources


ATORUNWAY SAFETY PROGRAM


www.ato.faa.gov


Reporting in Old Organization

FreeFlight

FAA Administrator&

Deputy Administrator

Air Traffic ServicesSubcommittee

ATO ChiefOperating Officer

Aviation Research

BusinessManagement

CompetitiveSourcing

William J HughesTechnical Center

AcquisitionManagement

Operational Evolution Plan

AT SystemsDevelopment

Communication,Navigation &

Surveillance Systems

System Architecture& Investment

Analysis

Air Traffic SystemRequirements

Service

TerminalBusiness UnitSystem Capacity

Independent Operational Test

& Evaluation

Airway FacilitiesServiceRunway Safety

Air Traffic Service

Research &Acquisitions

Air TrafficServices


Air Traffic ServicesSubcommittee

FAA Administrator&

Deputy Administrator

Reporting in New Organization

ATO Transition

ATO ChiefOperating Officer

TerminalFlight

ServicesTechnical

OperationsSystem

Operations

FinanceOperationsPlanning

Acquisition & Business Services

Safety Communications

En Route& Oceanic


Technical OperationsVICE PRESIDENT

ATO Transition*SENIOR VICE PRESIDENT

OperationsPlanning

VICE PRESIDENT

Acquisition & Business Services

VICE PRESIDENT Federal Acquisition Exec.

SafetyVICE PRESIDENT

CommunicationsVICE PRESIDENT

Assistant Administrator for Financial Services/ Chief Financial Officer

Associate Administrator for Airports

Associate Administrator for Commercial Space

Transportation

Agency Liaisons

Assistant Administrator for Aviation Policy,

Planning & Environment

Assistant Administrator for International Aviation

FAA Liaisons

Office of the Chief Counsel

Assistant Administrator for Civil Rights

Assistant Administrator for Human Resource

Management

Assistant Administrator for Information Services/ Chief Information Officer

FinanceVICE PRESIDENT

System OperationsVICE PRESIDENT

*temporary

ChiefOperating Officer

(COO)

Office of Government& Industry Affairs

Agency Liaisons

Assistant Administrator forSecurity & Hazardous Mtls.

Office ofSystem Safety

Assistant Administrator for Region & Center Operations

Joint Planning & Development Office

(JPDO)

Office ofPublic Affairs

TerminalVICE PRESIDENT

En Route & OceanicVICE PRESIDENT

Flight ServicesVICE PRESIDENT

Associate Administrator for Regulation & Certification

Administrator&

Deputy AdministratorNational leadership & policy


OWNERSU.S. citizens *Traveling public *Taxpayers * * As represented by CongressOffice of Management and BudgetSecretary of Department of TransportationInspector General

EMPLOYEESATO Individual Federal EmployeesLabor Unions

CUSTOMERS Commercial Aviation• Airlines• Cargo

Business AviationPrivate AviationDHS (and other Govt. agencies)Military (DOD)* * Partner with ATO

ATO: “Back to the Basics”

Success requires meeting the needs of all • Transparency is the key

anatomy of a runway incursion

Documents