1. U.S. National Airspace System: Runway Safety

2. US Safety Management System Overview
Goal of the Safety Management System (SMS) implementation is to enhance the safety of the provision of air traffic services:
Provides common framework for identifying, assessing, mitigating, and tracking safety risk of National Airspace System (NAS) changes
Includes safety assurance (e.g., evaluations and data analyses)
Promotes and strengthens safety culture within FAA through training, dissemination of lessons learned, and sharing of safety data
FAA SMS as documented in FAA SMS Manual will meet ICAO requirements
Stress the following points:
FAA SMS defines safety as the freedom from unacceptable risk. This definition was derived from several accepted definitions of safety.
SMS provides a means of controlling potential hazards from changes that originate within the US airspace system or in which some element of the system is a contributory factor.
Hazards are real or potential conditions that can cause injury, illness, or death to people; damage to, or loss of, a system, equipment, or property; and/or damage to the environment.
Occupational safety hazards are covered under Occupational Safety and Health Administration (OSHA) regulations, not SMS.
Information security hazards are regulated by the Office of the Chief Information Officer in the FAA (AIO). While the SMS addresses random events and occurrences, AIO focuses on malicious intent.
SMS does not address cost. However, cost is understood to be a consideration in everything that an organization does.

3. Safety Risk Management
Safety Risk Management (SRM) is a component of the SMS
Formalized proactive approach to the safe provision of air traffic service
Safety-related changes are documented
Systems
Procedures
Maintenance
Airspace
Risk is assessed and analyzed
Unacceptable risk is mitigated
Hazards are identified and tracked to resolution
Effectiveness of risk mitigation strategies are assessed
Performance of change is monitored throughout lifecycle
Stress the following points:
The SMS ensures a formalized and proactive approach to provisions of air traffic safety through SRM. SRM is the foundation of the SMS. Safety risk assessments are developed for changes with safety impacts to identify the effect on system safety.
The SRM process ensures that:
Safety related changes are documented with regard to systems, procedures, maintenance, and airspace.
Risk is assessed and analyzed.
Unacceptable risk is mitigated.
Hazards are identified and tracked to resolution.
The effectiveness of the risk mitigation strategies is assessed.
The performance of the change is monitored throughout its lifecycle.
Note: SRM focuses on changes to the US airspace system, because the assumption going in is that the US airspace system is safe (given the FAA’s safety record). Because of its size and complexity, baselining US airspace system’s safety is not feasible.

4. The Runway Incursion Challenge
There are millions of aircraft operations
Human error is a certainty
Technology has limitations
Potentially catastrophic events occur infrequently
Causes - Consequences are global in nature
Global proactive risk management is needed
All safety strategies have an “apogee” or asymptotic level they cannot surpass
- Doing more of the same does not yield improvements due to negative collateral effects
- System design must respect naturalistic human decision-making (training cannot always overcome poor design)
- The goal must be to instill a safety culture (bad habits are hard to break)
“Reactive” risk mitigation does not allow for the optimization of resources
- Focuses only on things that have already gone wrong, not things that could go wrong progress and is not necessarily indicative of future performance—“gambler’s fallacy”

5. Types of Runway Incursions
The FAA investigates runway incursions and attributes the occurrence to one or more of the following error types:
An operational error (OE) is an action of an Air Traffic Controller (ATC) that results in:
Less than the required minimum separation between two or more aircraft, or between an aircraft and obstacles (obstacles include vehicles, equipment, and personnel on runways).
An aircraft landing or departing on a runway closed to aircraft.
Operational Errors
A pilot deviation (PD) is an action of a pilot that violates any Federal Aviation Regulation. For example, a pilot fails to obey air traffic control instructions to not cross an active runway when following the authorized route to an airport gate.
Pilot Deviations
A vehicle or pedestrian deviation (V/PD) includes pedestrians, vehicles or other objects interfering with aircraft operations by entering or moving on the runway movement area without authorization from air traffic control.
Vehicle/Pedestrian Deviations

6. Distribution by Type of Runway Incursions
FY 2005 YTD (08/31/05)
Data are preliminary and subject to change

7. Current FAA Runway Incursion Severity Categories
Operational dimensions affecting runway incursion severity:
Available
Reaction
Time
Evasive or
Corrective
Action
Environmental
Conditions
Speed of
Aircraft and/or
Vehicle
Proximity of
Aircraft and/or
Vehicle
Increasing Severity
Category D
Little or no chance of collision, but meets the definition of a runway incursion.
Category C
Separation decreases, but there is ample time and distance to avoid a potential collision.
Category B
Separation decreases and there is a significant potential for collision.
Category A
Separation decreases and participants take extreme action to narrowly avoid a collision, or the event results in a collision.

8. Severity Distribution of Runway Incursions
FY 2005 YTD (08/31/05)
Data are preliminary and subject to change

9. Category A Incursion - Boston

10. Category D Incursion
A technical deviation occurred when the crossing aircraft failed to comply with the hold short instruction by crossing the line.
However, the pilot of the crossing aircraft was aware of the error and came to a full stop. The actual runway surface was not violated and no action was required by the landing pilot or by the air traffic controller.
The risk level was very low and the assessment was a category D.
The potential for a collision is low, but by definition, a Runway Incursion has taken place.

11. Runway Incursions 2002-2004 (Preliminary Data)
Entering runway safety area in front of an aircraft landing – 45% of all runway incursions
69% of landing aircraft went around
Entering runway safety area in front of an aircraft taking off – 32% of all runway incursions
38% of aircraft aborted
45% rotated before reaching the intersection
17% rotated after reaching the intersection

12. Common ATC Errors in Runway Incursions
Forget (about a closed runway, a clearance that they issued, an aircraft waiting to take off or cleared to land)
“Prospective memory” – Remembering to do something later is the weakest function of human memory
Distractions, interruptions – Number one enemy of memory
Unusual or temporary occurrences (such as vehicle on the runway, wrong altitude for direction) are easy to forget about
“forgetting” most common error category – developing training materials to address this
Can’t “improve controllers’ memory”, but can inform controllers of natural limitations of human memory, memory killers (distractions) and importance of memory aids and good teamwork as back up
Electricity out
Assume the aircraft did what it was told (and read back)

13. Operational Errors Involving TIPH

14. Common ATC Errors in Runway Incursions (continued)
Lack of (or inadequate) coordination between controllers
Most often ground and local on a crossing
Misidentify aircraft
Readback/Hearback errors

15. Results of Common ATC Errors
Most (54%) controller errors that result in runway incursions involve pilots completely crossing the runway in front of a takeoff or landing
27% involve pilots entering the runway (includes crossing the runway edge and lining up and waiting for takeoff)
19% resulted in pilots crossing the hold short lines, but not crossing the runway edge.

16. What Controllers Can Do
Recognize limitations of human memory and attention (protect against)
Don’t clear an aircraft to “Line Up and Wait” if you plan on it being there for more than a minute
Optimize teamwork
Never “assume” – keep up your scan and check
Recall number one pilot error follows a correct readback
Good communication techniques
Always inform pilots of similar call signs
Notable EXCEPTION is departure only runways.
Always inform pilots of similar call signs on same frequency
Don’t try to talk to pilots during landing and rollout
issue taxi instructions at taxi speed

17. Common Pilot Errors
Most common pilot error in runway incursions is reading back the air traffic instruction (for example, to “hold short”) correctly and then doing something else
Most common reason for the error is that pilots lose track of where they are (misidentifying their location)
Most common factor cited for losing track of location is that one pilot is “heads down” programming FMC or conducting checklists

18. What other reasons cause air carrier pilots to cross the hold short lines without authorization?
Frequency congestion & blocked transmissions
Complex airport geometry
Signs and markings confusion
Hold short lines in an unexpected location
These findings are based on a study of 231 ASRS reports of airport surface movement events (runway incursions and surface incidents) at the 34 busiest towered airports submitted between May 2001 and August The reports were filed by pilots operating under FAA Part 121, 135, or 95 rules and directly involved in the incident.

19. Results of Common Pilot Errors
Only 23% of pilot deviations that result in runway incursions involve pilots completely crossing the runway (in front of a takeoff or landing)
40% involve pilots crossing the hold short lines, but not crossing the runway edge
37% result in pilots entering the runway (includes partially crossing the runway edge and lining up and waiting for takeoff

20. What Pilots Can Do Minimize “heads down” activity while taxiing
Is there a runway between you and your departure runway or between you and the gate?
“Out and In Use” of airport diagram
Both pilots should LISTEN UP for clearances to land, taxi, takeoff, and for all clearances involving your runway
Is there an aircraft on final?
This method worked for USAir altitude busts

21. What Pilots Can Do (continued)
LOOK OUT for conflicting traffic
When is doubt about your position or your clearance, ASK.
(For Air Carriers) Turn landing lights on when takeoff clearance is received (this is a signal that aircraft is moving)

22. What Is Being Done?
Enhanced markings to alert pilots and vehicle drivers that they are approaching hold-short lines are being implemented
Advisory Circulars have been published to encourage pilots to:
Reserve use of landing lights for takeoff
Know the the airport layout
Listen for all clearances involving “their” runway
Avoid performing heads-down tasks until clear of all runways

23. Description of the Enhanced Taxiway Centerline:
Dashed yellow lines are placed on both sides of the taxiway centerline
The modified centerline will be implemented approximately 150 feet prior to the runway holding position marking (if sufficient space is available)
The enhanced centerline may or may not be supplemented by surface painted holding position signs

24. Enhanced Taxiway Centerline
2’-4’ ( m)
8’ (2.44 m)
150’ (45.72 m)
9-27
Optional
3’ (0.91 m)
Adopted
Drawing not to scale

25. Key Revisions to Advisory Circular 120-74A
Turn on landing lights when cleared for takeoff as a signal that the aircraft is moving
Suggestion to contact ATC if a takeoff clearance is not received within expected time when on the runway
More comprehensive use of clearance “Read Back” technique by pilots regarding use of runways

26. Landing Lights Two competing priorities
Rear-aspect visibility & Landover risk
Can you see an aircraft on the runway from final approach?
Visibility to aircraft crossing the runway downfield
Can the crossing aircraft sense when TIPH aircraft is accelerating for takeoff?

27. Runway Incursions at 35 U.S. Towered Airports
From , 47% of serious runway incursions involved aircraft crossing in front of a takeoff
AFTER publication of Advisory Circular A in 2004, 26% of serious runway incursions involved aircraft crossing in front of a takeoff

28. Safe Surface Operations for Commercial Pilots
Reduce the Risk
Might add: Wide awake, well-rested, health food junkie.
(and I’m not just saying that because I had one).
Malevolent - 911
I don’t mean to minimize the importance of experience and training for pilots and vehicle drivers. But the point is that we can not assume that every runway incursion is the result of complacency or poor training.
Used to say that none of the runway incursions were intentional – one was –stole a plane and took off without a clearance
Interpretive rule –
We have to appreciate the complexity of the task that we ask people to perform. AND we have to structure the situation (the equipment that we give people and the job we ask them to do) to help ensure that we don’t set people up to make mistakes.

29. Looking Ahead Improve safety data reporting
Improve replay and simulation capabilities
Automate incident reporting process

30.
You can check out our progress and view some of our performance measures at
With the establishment of the ATO, we’re creating room for the professionals in the FAA to exercise their judgment and apply their knowledge to achieve goals that are explicitly stated and clearly measured.
We’re creating a government organization that honors performance above process, cost-awareness above fiscal indifference, innovation above rigidity, and transparency above the self-protective cover of sometimes arcane rules and regulations.
I’m delighted to be part of such an exciting and rewarding adventure.