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Runway Incursion Causal Analysis

Section 3

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PILOTS and VEHICLE OPERATORS must taxi and maneuver their aircraft/vehicles on taxiways and runways in accordance with ATC instructions.

CONTROLLERS must monitor the location and progression of the aircraft and vehicles operating on the airport surface, in accordance with instructions issued, to provide separation assurance.

A safety hazard/ runway incursion is likely to occur when the exact location of an aircraft or vehicle on the airport surface in

relation to a specific ATC clearance is unknown.

Genesis of a Incursion

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Runway Incursion Causal Categories

OPERATIONAL ERROR (OE) - A human error caused by a tower controller. There are over 8000 tower controllers in the U.S.

PILOT DEVIATION (PD) - A human error caused by a pilot. There are over 675,000 licensed pilots in the U.S.

VEHICLE/PEDESTRIAN DEVIATION (V/PD) - A human error caused by a vehicle operator or pedestrian which results in an entry onto the movement area that has not been authorized by ATC.

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V/PD21%OE/D

23%

PD56%

Runway Incursion History

Comparison by Error Distribution(data as of July 2002)

- Office of Runway Safety

Operational Error

Pilot Deviation

Vehicle/Pedestrian

Deviation

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Operational Error (OE)

CONTROLLERS are at risk of being a party to an incursion when they are unable to correlate their

visual observations of the aircraft/vehicle location with previously issued ATC instructions.

Some contributing factors include:-FAILURE TO FOLLOW ESTABLISHED STANDARDIZED PROCEDURES

-FAILURE TO UNDERSTAND THE IMPLICATIONS OF THEIR ACTIONS OR INACTIONS

-LACK OF TRAINING & PRACTICE TO INTERNALIZE PROCEDURES

-LOSS OF SITUATIONAL AWARENESS

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Primary Performance Factors of Operational Error Runway Incursions (1997-2001)There were 430 Operational Error Runway Incursions

398 of these Operational Errors were analyzed

55 involved a simultaneous runway crossing with an aircraft landing or departing with coordination

186 loss of arrival/departure separation on same/intersecting runways

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Primary Performance Factors of Operational Error Runway Incursions (Continued)

54 other operational errors included: mistaking the location of aircraft or vehicle on/near runway, clearing aircraft to

land/depart from closed runway, and errors involving taxi into position and hold (TIPH).

52 simultaneous runway crossings with an aircraft landing or departing with lack of coordination

51 “hear back/read back” involving entries or crossings

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Primary Performance Factors of Operational Error Runway Incursions (1997-2001)

186

158

55

52

51

0

20

40

60

80

100

120

140

160

180

200

Lack of Coordination between Ground and Local with Crossing

“Read Back/ Hear Back”

Loss of Separation on the Runway

Simultaneous Runway Crossing with Arrival and Departure

Other OEs included mistaken traffic location, usage of closed runway, and misuse of TIPH clearance.

Crossing

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Causal Factors Operational Errors (OE)(data from category A & B incursions between 1997-2000)

0

5

10

15

20

25

30

35

40

45

50

Lost SituationalAwareness

Improper Procedures Poor Judgement Faulty CrewCoordination

Poor Communications

Perc

enta

ge

- FAA Report on Runway Incursion Information Evaluation Program, 10/12/01

for the period of March 17, 2000 through March 16, 2001.

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Pilot Deviation (PD)

PILOTS are at risk of being a party to an incursion when they are unable to correlate their visual observations of airport signs,

markings and lighting and other physical features on the airport with the specific ATC taxi instructions.

Contributing Factors:-FAILURE TO ASK FOR HELP WHEN CONFUSED

-FAILURE TO USE THE AIRPORT DIAGRAM

-LACK OF TRAINING

-NOT FAMILIAR WITH THE AIRPORT

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Primary Performance Factors of Pilot Deviation Runway Incursions (1997-2001)

There were 972 Pilot Deviation Runway Incursions 719 of these Pilot Deviations were analyzed

87 other pilot deviations included: landing over aircraft in position and landing/departing on closed/wrong runways, taxiways, etc.

537 pilots entered the runway or crossed the hold short line after acknowledging hold short instructions

95 pilots took off without clearance after acknowledging “taxi into position and hold” (TIPH) instructions

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Primary Performance Factors of Pilot Deviation Runway Incursions (1997-2001)

537

95 90

0

100

200

300

400

500

600

Violated Hold Line after Acknowledging

Hold Short

Departed without Clearance after Acknowledging

TIPH Instructions

Landed over Traffic in Position or Used

Incorrect Surface for Departure / Landing

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Causal Factors Pilot Deviations (PD)

Pilot Interviews(data from category A & B incursions between 1997-2000)

Conditions at Time of Runway Incursions

0

10

20

30

40

50

60

Not Familiar withAirport Signage

Not Familiar withAirport

UnfavorableEnvironmental

Conditions

Clearance wasNot Readback

Inexperienced atTowered Airports

Airport DiagramNot Used

Failed to FollowInstructions

Per

cent

age

- FAA Report on Runway Incursion Information Evaluation Program

March 17, 2000 through March 16, 2001

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Distribution of Pilot Deviations(approximate percentages)

OE

PD

VPD

Other2%

Commercial21%

General Aviation77%

- Office of Runway Safety

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Pedestrian Deviation (V/PD)

VEHICLE OPERATORS and PEDESTRIANS are at risk of being a party to an incursion

when they are unable to correlate their visual observations of airport signs, markings and lighting and other physical features on the

airport with the specific ATC taxi instructions.

Some contributing factors include:-FAILURE TO ASK FOR HELP WHEN CONFUSED

-FAILURE TO USE THE AIRPORT DIAGRAM

-LACK OF TRAINING

-NOT FAMILIAR WITH AIRPORT

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Primary Performance Factors of Vehicle/Pedestrian Runway Incursions.

All 350 Vehicle/Pedestrian Runway Incursions were analyzed

217 entered the runway without communications or authorization

133 instructed to hold short and read back but still entered the runway

157 POVs and pedestrians60 airport vehicles

109 airport vehicles24 by a non-pilot maintenance taxiing an aircraft

End of Section 3