Transportation Safety Board of Canada Runway Safety Presentation to the Canadian Airports Council’s Operations, Safety and Technical Affairs Committee Kathy Fox, Board Member Transportation Safety Board of Canada May 18, 2010

Outline About the TSB, our mandate TSB Watchlist Action Required Landing accidents and runway overruns Runway incursions Safety Management Systems Action Required Summary/ Discussion

About the TSB Independent organization investigating marine, pipeline, rail and air occurrences. The CTAISB Regulations define which types of occurrences (incidents or accidents) are required to be reported to the TSB for each of the modes. Approximately 230 employees. Board consists of up to 5 Board Members, including the Chair. 3 3

TSB Mandate To advance transportation safety in the air, marine, rail and pipeline modes of transportation that are under federal jurisdiction by: conducting independent investigations identifying safety deficiencies making recommendations to address safety deficiencies reporting publicly on investigations It is not the function of the TSB to assign fault or determine civil or criminal liability. 4 4

WATCHLIST Landing accidents and runway overruns Risk of collisions on runways Safety Management Systems Emergency preparedness on ferries Passenger trains colliding with vehicles Operation of longer, heavier trains Controlled flight into terrain Fishing vessel safety Data recorders

WATCHLIST Issue: Landing accidents and runway overruns Runway overrun, Air France Airbus A340, Toronto, ON

Runway Excursions A Worldwide Challenge Between 1995-2008: 435 landing runway excursions (205 overrun, 230 veer-off) (1) Runway excursions (takeoff and landing): 34 fatal accidents, 712 fatalities (2) Sources: SMS Specialties, Report on the Design and Analysis of a Runway Excursions Database, produced on behalf of the Flight Safety Foundation, May 2009. Flight Safety Foundation, Reducing the Risk of Runway Excursions, May 2009.

Approximate Runway Overrun Accident Rates, 1990-2006 All Runway Conditions Wet Runway Conditions Country Annual Landings Number of Accidents Rate/Million Landings Canada 929,000 4 0.25 3 1.7 US 11,332,000 18 0.09 5 0.2 Rest of World 13,683,000 37 0.16 20 0.6 Total - World 25,944,000 59 0.13 28 0.4 Source: Jacobs Consultancy, Risk and Benefit-Cost Analyses of Procedures for Accounting for Wet Runway on Landing, prepared for Transport Canada, July 2008. 8 8

Landing Runway Overrun Accidents Involving Airplanes Over 5,700 kg in Canada, 1989-2006 Year Location Aircraft Type Distance off Runway End 1993 Tofino, BC Convair CV440 150’ 1995 Jasper/Hinton, AB Mitsubishi MU-300 255’ 1998 Gander, NL Antonov AN-124 200’ Kasabonika, ON BAe 748 450’ Peterborough, ON Dassault Mystère E20 236’ 1999 St. John’s, NL Fokker F-28 420’ 2001 Boeing 737 75’ 2003 Mildred Lake, AB Beech 300 King Air Unknown 2004 Oshawa, ON Shorts SD3-60 1500’ 2005 Toronto, ON Airbus A340 1,090’ Hamilton, ON IAI Astra SPX Total landing overrun occurrences involving airplanes over 5,700 kg: 46 Source: TSB database 9 9

Runway Overruns – A Complex Problem Board Recommendations following Air France Approach/landing standards: Establish clear standards limiting approaches and landings in convective weather for all air transport operators at Canadian airports. (A07-01) Pilot training: Mandate training for all pilots involved in Canadian air transport operations to better enable them to make landing decisions in deteriorating weather. (A07-03) Procedures: Require crews to establish the margin of error between landing distance available and landing distance required before conducting an approach into deteriorating weather. (A07-05) 10 10

What Else Can We Do? “The severity of runway excursion accidents depends primarily on the energy of the airplane as it departs the runway, and the airport’s layout, geography and rescue capability.” James M. Burin Flight Safety Foundation

Board Recommendation on RESA The Department of Transport require all Code 4 runways to have a 300 m runway end safety area (RESA) or a means of stopping aircraft that provides an equivalent level of safety. 12 12

Why a 300m RESA? Stopping Distance Following a Runway Overrun (FAA 1975-1987 study) Graph Source: ATSB, Runway excursions, Part 2: Minimising the likelihood and consequences of runway excursions. An Australian perspective, 2009.

RESAs: ICAO Standards Source: IFALPA Statement, Runway End Safety Areas (RESA) 14 14

Engineered Materials Arresting System Successful Aircraft Stoppages Date Aircraft Type Location May 1999 Saab 340 KJFK May 2003 McDonnell-Douglas MD-11 January 2005 Boeing 747 July 2006 Dassault Falcon 900 KGMU July 2008 Airbus A320 KORD January 2010 Bombardier CRJ-200 KCRW 15 15

Stopping Aircraft Safely

WATCHLIST Issue: Risk of collisions on runways © Australian Transport Safety Bureau Reproduced with permission

Runway Incursions ICAO definition: “Any occurrence at an aerodrome involving the incorrect presence of an aircraft, vehicle, or person on the protected area of a surface designated for the landing and take-off of aircraft.” 18 18

Runway Incursions Canada: 3,831 runway incursions between 1999-2008. Source: Transport Canada Civil Aviation Daily Occurrence Reporting System (CADORS) Still images of runway incursion animations © National Transportation Safety Board 19 19

Runway Incursions – Causes Lack of situational awareness – air crews, ATS, ground personnel Ambiguous or non-standard communications/ phraseology Runway/taxiway geometry and signage Lack of warning systems Beech 1900, following runway collision with Beech A90 King Air, Quincy Municipal Airport, IL, USA. © Scroggins Aviation, reproduced with permission 20 20

Runway Incursions Potential Defences Runway status light systems Using “stop bars” in daylight/ good weather Avoid vehicles crossing in middle of runways 21 21

WATCHLIST Multi-modal issues Safety Management Systems Derailed locomotive, Lillooet, BC Touchdown short of runway, Bombardier Global 5000, Fox Harbour, NS

Summary These are complex and challenging safety issues requiring many solutions from multiple stakeholders. If persistent safety problems are not addressed, there will be more accidents. An effective SMS can help operators identify and mitigate the risks associated with landing accidents and runway incursions 23 23

More Action Required Assess all Canadian Code 4 runways to identify highest risks and take appropriate action to mitigate these risks (e.g. lengthen RESA; EMAS). Participate actively in runway incursion mitigation (e.g. vehicle use of perimeter roads, not crossing in middle of runway).

QUESTIONS?

References Flight Safety Foundation, Reducing the Risk of Runway Excursions: A Report of the Runway Safety Initiative, May 2009. SMS Specialties, Report on the Design and Analysis of a Runway Excursions Database, produced on behalf of the Flight Safety Foundation, May 2009. Jacobs Consultancy, Risk and Benefit-Cost Analysis of Procedures for Accounting for Wet Runway on Landing, produced on behalf of Transport Canada, July 2008. Australian Transport Safety Bureau, Runway Excursions, Part 1: A worldwide review of commercial jet aircraft runway excursions, April 2009. Australian Transport Safety Bureau, Runway Excursions, Part 2: Minimising the likelihood and consequences of runway excursions. An Australian perspective, May 2009. Mark Lacagnina, Margin for Error, Aero Safety World, August 2008. IFALPA Statement: Runway End Safety Areas (RESA).

References I.D.L. Kirkland et al., An Improved Methodology for Assessing Risk in Aircraft Operations at Airports, Applied to Runway Overruns, Safety Science 42 (2004) 891–905. D.K.Y. Wong et al., The Development of a More Risk-Sensitive and Flexible Airport Safety Area Strategy: Part I. The Development of an Improved Accident Frequency Model, Safety Science 47 (2009) 903–912. D.K.Y. Wong et al., The Development of a More Risk-Sensitive and Flexible Airport Safety Area Strategy: Part II. Accident Location Analysis and Airport Risk Assessment Case Studies, Safety Science 47 (2009) 913–924. Kirkland et al., The Normalisation of Aircraft Overrun Accident Data , Journal of Air Transport Management 9 (2003) 333–341.