How Did That Happen? Analyzing Prevention Resources Available

Line-Oriented Safety Audit 23% of errors23% of errors 38% of threats38% of threats Occur before leaving the ground

March Taiwan. A TransAsia Airbus landed on Runway 36 at Taiwan Airport and hit a maintenance vehicle on the runway. There were no injuries to the passengers and crew. The flight was late and AT cleared the aircraft to land on the runway shortly after it was closed for maintenance activity.

The two people in the maintenance vehicle were only slightly injured.

Heads up!

Best Practice: TIMELY AND ACCURATE NOTAMS

SO WHAT WENT WRONG? QUE PASO?

Conditions at Time of Runway Incursions Airport Diagram Not Used Failed to Follow Instructions Not Familiar with Airport Unfamiliar With Airport Signage Inexperienced at Towered Airports (Phraseology) Unfavorable Environmental Conditions Clearance Not Read back HUMAN ERROR

ABX 50 DC85 Over flew Israir 102 by less than 100 feet. Israir 102 B767 Entered RWY.

N525VV C525 Entered RWY EJA 377 C550 At taxi speed. 2,000 feet horizontal MIA

NATIONAL SURVEY – Types of errors caused by: Pilots Pilot enters/crosses a runway after acknowledging “hold short” Pilot crosses the hold line after acknowledging “hold short” Pilot enters/crosses a runway without authorization, “hold short” not required Pilot crosses the hold line with authorization, “hold short” not required Pilot departs without communication or authorization

NATIONAL SURVEY – Types of errors caused by: Controllers Failure to provide required Arrival/Departure separation for the same or intersecting runway(s) Authorizing a crossing or a holding within the safety area then clearing an aircraft to land/takeoff Cleared an aircraft for takeoff on a closed/occupied runway Did not correct an incorrect readback

USA 1170 B737 EIN 132 A333 Airborne USA 1170 is 171 feet from intersection as EIN 132 is just through intersection climbing.

NATIONAL SURVEY – Types of errors caused by: Vehicles/Pedestrians An unauthorized POV or pedestrian on the airfield that entered or crossed an active runway Airport personnel entered a runway without communications or authorization Airport personnel instructed to hold short/remain clear of a runway. Readback correct but crossed the hold line or entered the runway.

Cause of errors…numerous human factors Inaccurate Position Awareness Expectation Bias Preoccupation Forgetfulness Task Saturation Confusion Incomplete Training Poor Judgment

HUMAN FACTORS

Human Factors Fatigue (double shifts) Employee turnover Inadequate initial and recurrent training Stress (job related - home related) Distractions in Cockpit- down head time, attention to squawked items NO CELL PHONES Complacency

Language Responsibility Trust… no one to come behind to check if you do it wrong Poor Judgement

A Few Common Mistakes No clearance obtained to push-back No contact made with ATC when repositioning Wrongfully accept an ATC clearance as your own Misinterpret an ATC clearance Don’t want to look “stupid” by contacting ATC again Wrong ATC instruction given Unfamiliar with airfield layout In a big rush to stay on schedule (everyone)

Changing Our Behaviors

Resources

The agents for improving airport safety Airport Management and Staff Air Traffic Control Airline Station Managers Fixed Base Operators Tenants Pilots Everyone at this meeting

Runway Safety is Everyone’s Responsibility Runway Safety is Everyone’s Responsibility Be a part of the SOLUTION!