1. Presented to: By: Date: Federal Aviation Administration How Did This Happen? Southern Region Runway Safety Team ORL CFI Workshop BJ Ault-Meyers, ctr Senior FS Systems Analyst May 06, 2006

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

3. Incursion Comparison to Date April 28, 2006/2005 OVER LAST YEARUNDER LAST YEAR OVER LAST YEAR – UNDER LAST YEAR

4. Federal Aviation Administration 4 <How Did That Happen? May 6, 2006 March 2003 - 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.

5. Federal Aviation Administration 5 <How Did That Happen? May 6, 2006 The two people in the maintenance vehicle were only slightly injured.

6. Federal Aviation Administration 6 <How Did That Happen? May 6, 2006 Best Practice: TIMELY AND ACCURATE NOTAMS

7. Federal Aviation Administration 7 <How Did That Happen? May 6, 2006

8. Federal Aviation Administration 8 <How Did That Happen? May 6, 2006

9. Federal Aviation Administration 9 <How Did That Happen? May 6, 2006

10. Federal Aviation Administration 10 <How Did That Happen? May 6, 2006

11. Federal Aviation Administration 11 <How Did That Happen? May 6, 2006 ABX 50 DC85 Over flew Israir 102 by less than 100 feet. Israir 102 B767 Entered RWY.

12. Federal Aviation Administration 12 <How Did That Happen? May 6, 2006 USA 1170 B737 EIN 132 A333 Airborne USA 1170 is 171 feet from intersection as EIN 132 is just through intersection climbing.

13. Federal Aviation Administration 13 <How Did That Happen? May 6, 2006

14. Federal Aviation Administration 14 <How Did That Happen? May 6, 2006 National Survey – Most Frequent RI Errors caused by: Pilots Pilot enters/crosses a runway after making a correct readback of a hold short instruction Pilot used a wrong taxi route and entered the runway Pilot used wrong runway/closed runway/taxiway for departing/landing Pilot departs without communication or authorization

15. Federal Aviation Administration 15 <How Did That Happen? May 6, 2006 Best Practice: ALWAYS EYES OUT WHEN TAXIING

16. Federal Aviation Administration 16 <How Did That Happen? May 6, 2006 Best Practice: ALWAYS HEADS UP WHEN TAXIING

17. Federal Aviation Administration 17 <How Did That Happen? May 6, 2006 Best Practice: INFORMING AFSS ANY TIME THERE IS CHANGE IN YOUR RUNWAY STATUS TEACHING, ADVOCATING, STRESSING, AND UNDERSTANDING SITUATIONAL AWARENESS

18. Federal Aviation Administration 18 <How Did That Happen? May 6, 2006 National Survey – Most Frequent RI Errors caused by: Controllers Authorized aircraft to enter/cross on runway, then cleared an arrival/departure on same runway Cleared an aircraft for takeoff on a closed/occupied runway Did not correct an incorrect read back

19. Federal Aviation Administration 19 <How Did That Happen? May 6, 2006 National Survey- Most Frequent RI Errors caused by: Vehicles/Pedestrians An unauthorized vehicle or pedestrian on the airfield that entered or crossed an active runway Airport personnel entered a runway without communication or authorization Airport personnel instructed to hold short/remain clear of a runway. Readback correct but crossed the hold line or entered the runway

20. Federal Aviation Administration 20 <How Did That Happen? May 6, 2006 Causes of Errors – human factors Inaccurate Position Awareness Expectation Bias Preoccupation Forgetfulness Task Saturation Confusion Incomplete Training Poor Judgment

21. Federal Aviation Administration 21 <How Did That Happen? May 6, 2006 Enhanced Taxiway Centerline 9-27 8’ (2.44 m) 150’ (45.72 m) 2’-4’ (0.67-1.34 m) 3’ (0.91 m) Drawing not to scale Optional Adopted

22. Federal Aviation Administration 22 <How Did That Happen? May 6, 2006 Southern Region Enhanced Taxiway Centerline Markings Florida FLLFort Lauderdale/Hollywood International JAXJacksonville International MCOOrlando International MIAMiami International PBIPalm Beach International RSWSouthwest Florida International TPATampa International Georgia Hartsfield-Jackson Atlanta International Kentucky CVGCincinnati/Northern Kentucky International SDFLouisville International-Standiford Field

23. Federal Aviation Administration 23 <How Did That Happen? May 6, 2006 Southern Region Enhanced Taxiway Centerline Markings North Carolina CLTCharlotte/Douglas International RDURaleigh-Durham International Puerto Rico SJULuis Munoz Marin International Tennesee BNANashville International MEMMemphis International

24. Federal Aviation Administration 24 <How Did That Happen? May 6, 2006 Resources

25. Presented to: By: Date: Federal Aviation Administration