Runway Incursion A Strategic Approach Antonio Travaglione ICAO European Runway Safety and Air Traffic Services Management Seminar Moscow, Russian Federation, 12 - 15 September 2005 Runway Incursion A Strategic Approach Antonio Travaglione IFATCA Aerodrome Safety Representative

Highway Intersection Concept ICAO European Runway Safety and Air Traffic Services Safety Management Seminar Moscow, Russian Federation, 12 - 15 September 2005 Highway Intersection Concept Evolution of the ICAO Model Analysis Models & Results Intrinsic Safety

CROSSROADS VS HIGHWAY INTERSECTIONS ICAO European Runway Safety and Air Traffic Services Safety Management Seminar Moscow, Russian Federation, 12 - 15 September 2005 CROSSROADS VS HIGHWAY INTERSECTIONS

IDEAL LAY-OUT Single runway ICAO European Runway Safety and Air Traffic Services Safety Management Seminar Moscow, Russian Federation, 12 - 15 September 2005 IDEAL LAY-OUT APRON Single runway

IDEAL LAY-OUT Single runway ICAO European Runway Safety and Air Traffic Services Safety Management Seminar Moscow, Russian Federation, 12 - 15 September 2005 IDEAL LAY-OUT APRON Single runway

IDEAL LAY-OUT Two parallels ICAO European Runway Safety and Air Traffic Services Safety Management Seminar Moscow, Russian Federation, 12 - 15 September 2005 IDEAL LAY-OUT APRON Two parallels

THE REAL WORLD Charles de Gaulle, Malpensa, Manchester... ICAO European Runway Safety and Air Traffic Services Safety Management Seminar Moscow, Russian Federation, 12 - 15 September 2005 THE REAL WORLD TWR APRON Charles de Gaulle, Malpensa, Manchester...

!!! CROSSROAD !!! ICAO European Runway Safety and Air Traffic Services Safety Management Seminar Moscow, Russian Federation, 12 - 15 September 2005 !!! CROSSROAD !!!

LIMITATIONS ICAO European Runway Safety and Air Traffic Services Safety Management Seminar Moscow, Russian Federation, 12 - 15 September 2005 LIMITATIONS

LIMITATIONS Poor system descripting Model, ICAO European Runway Safety and Air Traffic Services Safety Management Seminar Moscow, Russian Federation, 12 - 15 September 2005 LIMITATIONS Poor system descripting Model, Q More focused to Human Errors than Human Factors, Lack of strategic vision

System Descripting Model PPE MODEL ICAO European Runway Safety and Air Traffic Services Safety Management Seminar Moscow, Russian Federation, 12 - 15 September 2005 System Descripting Model PPE MODEL PEOPLE PROCEDURE EQUIPMENT

ICAO European Runway Safety and Air Traffic Services Safety Management Seminar Moscow, Russian Federation, 12 - 15 September 2005 SHELL MODEL EQUIPMENT PEOPLE PROCEDURE H S L E L Software (S) = Procedures (P) + laws, rules, regulations, Hardware (H) = Equipment (E) + infrastructures, Environment (E) = ? Liveware (L) = People (P), producing HE core of the system, HF to be considered

REASON’S MODEL !!! ACCIDENT !!! INCIDENT ICAO European Runway Safety and Air Traffic Services Safety Management Seminar Moscow, Russian Federation, 12 - 15 September 2005 REASON’S MODEL FAILURES LATENT DECISION MAKERS LATENT LINE MANAGEMENT LATENT PRECONDITIONS INCIDENT ACTIVE PRODUCTIVE ACTIVITIES ACTIVE LATENT DEFENCES !!! ACCIDENT !!!

THREE DIMENSIONS ICAO European Runway Safety and Air Traffic Services Safety Management Seminar Moscow, Russian Federation, 12 - 15 September 2005 THREE DIMENSIONS

S Software Decision Makers Q FAA educated Captain ICAO European Runway Safety and Air Traffic Services Safety Management Seminar Moscow, Russian Federation, 12 - 15 September 2005 Software Decision Makers S FAA educated Captain “taxi to holding position, runway…” (ICAO) “taxi into position and hold, runway…” (FAA) Q

S Software Decision Makers Q Q FAA educated Captain ICAO European Runway Safety and Air Traffic Services Safety Management Seminar Moscow, Russian Federation, 12 - 15 September 2005 Software Decision Makers S FAA educated Captain “taxi to holding position, runway…” (ICAO) “taxi into position and hold, runway…” (FAA) Lined-up in front of an acft on final that, having acft in sight, went around ICAO has understood that it is necessary to change phraseology again and sent a State Letter for it. EAPPRI only warns controllers and, worse, pilots on final, that this is the phraseology, but an aircraft may line-up while YOU are on final! As a member of the working group, this embarrass me very much. Q Q

H Hardware Infrastructures Decision Makers Q ICAO European Runway Safety and Air Traffic Services Safety Management Seminar Moscow, Russian Federation, 12 - 15 September 2005 Hardware Infrastructures Decision Makers H Acft, after landing, was taxiing to the apron that is beyond another runway. RWY crossing procedures are traps for pilots and controllers. Perimeter taxiways are a need. IFATCA is aware that this is a costly and long-period change, and is not urging “sorcery-stick” solutions. We require that new airports are well designed and old ones re-master-planned (i.e. building new perimeter taxiways), in order to get a solution in a planned future. Q

H Hardware Infrastructures Decision Makers Q Q ICAO European Runway Safety and Air Traffic Services Safety Management Seminar Moscow, Russian Federation, 12 - 15 September 2005 Hardware Infrastructures Decision Makers H Acft, after landing, was taxiing to the apron that is beyond another runway. The other runway is used for departures Due to a mistake (pilot? – controller?) crossing happened while a take-off was in progress Q Q

E Environment Line Managers Q Acft was taxiing for departure. ICAO European Runway Safety and Air Traffic Services Safety Management Seminar Moscow, Russian Federation, 12 - 15 September 2005 Environment Line Managers E Acft was taxiing for departure. Q

E Environment Line Managers Q B737 was taxiing for departure. ICAO European Runway Safety and Air Traffic Services Safety Management Seminar Moscow, Russian Federation, 12 - 15 September 2005 Environment Line Managers E B737 was taxiing for departure. While taxiing, departure runway and taxi route was changed CAA Environment protection procedure (noise abatement), that impose a rotation in the use of runways. Q

E Environment Line Managers Q Q B737 was taxiing for departure. ICAO European Runway Safety and Air Traffic Services Safety Management Seminar Moscow, Russian Federation, 12 - 15 September 2005 Environment Line Managers E B737 was taxiing for departure. While taxiing, departure runway and taxi route was changed Crew lost its Situation Awareness and entered the runway while a take-off was in progress. Q Q

E Environment Line Managers Q Q ICAO European Runway Safety and Air Traffic Services Safety Management Seminar Moscow, Russian Federation, 12 - 15 September 2005 Environment Line Managers E Two acft were holding positions at opposite heads of the same runway. CAA Environment protection procedure. Arrivals RWY 24 and departures RWY 06 to reduce overfly of the city, that is west. But it is not mandatory, and pilots can request to depart into the wind. Q Q

E Environment Line Managers Q Q ICAO European Runway Safety and Air Traffic Services Safety Management Seminar Moscow, Russian Federation, 12 - 15 September 2005 Environment Line Managers E Two acft were holding positions at opposite heads of the same runway. No. 1 was instructed to line-up. Q Q

E Environment Line Managers Q Q ICAO European Runway Safety and Air Traffic Services Safety Management Seminar Moscow, Russian Federation, 12 - 15 September 2005 Environment Line Managers E Two acft were holding positions at opposite heads of the same runway. No. 1 was instructed to line-up. Few seconds later take-off clearance was issued. No. 2 misunderstood the clearance, Q Q

E Environment Line Managers Q Q Q Q Q Q Q Q Q Q ICAO European Runway Safety and Air Traffic Services Safety Management Seminar Moscow, Russian Federation, 12 - 15 September 2005 Environment Line Managers E Two acft were holding positions at opposite heads of the same runway. No. 1 was instructed to line-up. Few seconds later take-off clearance was issued. No. 2 misunderstood the clearance, entered the runway and gave thrust. Q Q Q Q Q Q Q Q Q Q

L Liveware Human Errors vs Human Factors Prof. Sydney Decker ICAO European Runway Safety and Air Traffic Services Safety Management Seminar Moscow, Russian Federation, 12 - 15 September 2005 Liveware The Human Element of the System L Human Errors vs Human Factors Prof. Sydney Decker In all preceding examples you can find a human operator to blame. This is common management behaviour, since they have to state that “the system is perfect, we only have to take the bad-apple away from the basket”. This also is what the public want to hear. But is not the truth and is not what can prevent next occurrence.

ICAO European Runway Safety and Air Traffic Services Safety Management Seminar Moscow, Russian Federation, 12 - 15 September 2005 Liveware The Human Element of the System L Q Humans (OP) make mistakes, Q Regulators and Service Providers provide OP with awareness campaigns and/or modify proc. Q After an awareness campaign has been held, Regulators and Service Providers are relieved from their responsibility; OP retains his responsibility, since he has been informed about the risks. In all preceding examples you can find a human operator to blame. This is common management behaviour, since they have to state that “the system is perfect, we only have to take the bad-apple away from the basket”. This also is what the public want to hear. But is not the truth and is not what can prevent next occurrence.

ICAO European Runway Safety and Air Traffic Services Safety Management Seminar Moscow, Russian Federation, 12 - 15 September 2005 Liveware The Human Element of the System L A physiological amount of actions producing results different from intended cannot be avoided, Awareness campaigns and/or new procedures are: short term and relatively cheap actions, NOT A PANACEA In all preceding examples you can find a human operator to blame. This is common management behaviour, since they have to state that “the system is perfect, we only have to take the bad-apple away from the basket”. This also is what the public want to hear. But is not the truth and is not what can prevent next occurrence.

L Liveware Different approach to Human Factors: ICAO European Runway Safety and Air Traffic Services Safety Management Seminar Moscow, Russian Federation, 12 - 15 September 2005 Liveware The Human Element of the System L Different approach to Human Factors: NOT ONLY when academically studying them, BUT endorsing and implementing HF principles into SARPs, Guidelines, Action Plans, Procedures, Infrastructure Design, AS WELL In all preceding examples you can find a human operator to blame. This is common management behaviour, since they have to state that “the system is perfect, we only have to take the bad-apple away from the basket”. This also is what the public want to hear. But is not the truth and is not what can prevent next occurrence.

L Liveware SUGGESTED WAYS remove hazards: ICAO European Runway Safety and Air Traffic Services Safety Management Seminar Moscow, Russian Federation, 12 - 15 September 2005 Liveware The Human Element of the System L SUGGESTED WAYS remove hazards: eliminate runway crossing – obstacles to visibility; re-assess environment protection procedures mitigate results of good faith acts (slips, lapses, mistakes) through redundancy: back-up voice com with data-link; associate warning signs with voice recorded messages; enhance situation awareness through Aerodrome Resource Management In all preceding examples you can find a human operator to blame. This is common management behaviour, since they have to state that “the system is perfect, we only have to take the bad-apple away from the basket”. This also is what the public want to hear. But is not the truth and is not what can prevent next occurrence.

Prof. James Reason - Intrinsic safety ICAO European Runway Safety and Air Traffic Services Safety Management Seminar Moscow, Russian Federation, 12 - 15 September 2005 Prof. James Reason - Intrinsic safety Vulnerable system Average system This slide presents a metaphor to help you understand the notion of resilience. Imagine a ball-bearing (representing a system) resting on three different kinds of milled steel block. In each case, the ball is perturbed by outside forces—comparable to the operating hazards. It is evident that the top ball-bearing is much more vulnerable to falling over the edge (that is, having an accident) than the one at the bottom. In this case, it is still possible for the ball-bearing to be pushed over the edge, but it would take more external agitation to achieve it. In other words, the set-up at the bottom is much more resistant than the one at the top. Resistant system

CONCLUSIONS Intrinsic Safety Updating Annex 14 SARPs – No RWY crossing ICAO European Runway Safety and Air Traffic Services Safety Management Seminar Moscow, Russian Federation, 12 - 15 September 2005 CONCLUSIONS Intrinsic Safety Updating Annex 14 SARPs – No RWY crossing Re-assessing Environment Protection Procedures Endorsing HF Principles in System Design

Antonio Travaglione atravaglione@enav.it ICAO European Runway Safety and Air Traffic Services Safety Management Seminar Moscow, Russian Federation, 12 - 15 September 2005 Antonio Travaglione IFATCA Aerodrome Safety Representative atravaglione@enav.it