1. 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

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

3. 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

4. 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

5. 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

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

7. Runway Excursions A Worldwide Challenge
Between :
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.

8. 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

9. 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

10. 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

11. 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

12. 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

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

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

15. 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

16. Stopping Aircraft Safely

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

18. 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

19. 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

20. 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

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

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

23. 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

24. 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).

25. QUESTIONS?

27. 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).

28. 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.