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

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

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

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

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

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

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

8. !!! CROSSROAD !!! ICAO European Runway Safety
and Air Traffic Services Safety Management Seminar
Moscow, Russian Federation, September 2005
!!! CROSSROAD !!!

9. LIMITATIONS ICAO European Runway Safety
and Air Traffic Services Safety Management Seminar
Moscow, Russian Federation, September 2005
LIMITATIONS

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

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

12. ICAO European Runway Safety
and Air Traffic Services Safety Management Seminar
Moscow, Russian Federation, 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

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

14. THREE DIMENSIONS ICAO European Runway Safety
and Air Traffic Services Safety Management Seminar
Moscow, Russian Federation, September 2005
THREE DIMENSIONS

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

16. S Software Decision Makers Q Q FAA educated Captain
ICAO European Runway Safety
and Air Traffic Services Safety Management Seminar
Moscow, Russian Federation, 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

17. H Hardware Infrastructures Decision Makers Q
ICAO European Runway Safety
and Air Traffic Services Safety Management Seminar
Moscow, Russian Federation, 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

18. H Hardware Infrastructures Decision Makers Q Q
ICAO European Runway Safety
and Air Traffic Services Safety Management Seminar
Moscow, Russian Federation, 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

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

20. E Environment Line Managers Q B737 was taxiing for departure.
ICAO European Runway Safety
and Air Traffic Services Safety Management Seminar
Moscow, Russian Federation, 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

21. 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, 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

22. E Environment Line Managers Q Q
ICAO European Runway Safety
and Air Traffic Services Safety Management Seminar
Moscow, Russian Federation, 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

23. E Environment Line Managers Q Q
ICAO European Runway Safety
and Air Traffic Services Safety Management Seminar
Moscow, Russian Federation, 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

24. E Environment Line Managers Q Q
ICAO European Runway Safety
and Air Traffic Services Safety Management Seminar
Moscow, Russian Federation, 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

25. 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, 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

26. L Liveware Human Errors vs Human Factors Prof. Sydney Decker
ICAO European Runway Safety
and Air Traffic Services Safety Management Seminar
Moscow, Russian Federation, 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.

27. ICAO European Runway Safety
and Air Traffic Services Safety Management Seminar
Moscow, Russian Federation, 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.

28. ICAO European Runway Safety
and Air Traffic Services Safety Management Seminar
Moscow, Russian Federation, 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.

29. L Liveware Different approach to Human Factors:
ICAO European Runway Safety
and Air Traffic Services Safety Management Seminar
Moscow, Russian Federation, 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.

30. L Liveware SUGGESTED WAYS remove hazards:
ICAO European Runway Safety
and Air Traffic Services Safety Management Seminar
Moscow, Russian Federation, 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.

31. Prof. James Reason - Intrinsic safety
ICAO European Runway Safety
and Air Traffic Services Safety Management Seminar
Moscow, Russian Federation, 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

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

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