2. ICAO European Runway Safety and Air Traffic Services Management Seminar Moscow, Russian Federation, 12 - 15 September 2005 Antonio Travaglione IFATCA Aerodrome Safety Representative Runway Incursion A Strategic Approach

3.  Highway Intersection Concept ICAO European Runway Safety and Air Traffic Services Safety Management Seminar Moscow, Russian Federation, 12 - 15 September 2005  Evolution of the ICAO Model  Analysis Models & Results  Intrinsic Safety

4. CROSSROADS VS HIGHWAY INTERSECTIONS ICAO European Runway Safety and Air Traffic Services Safety Management Seminar Moscow, Russian Federation, 12 - 15 September 2005

5. IDEAL LAY-OUT Single runway APRON ICAO European Runway Safety and Air Traffic Services Safety Management Seminar Moscow, Russian Federation, 12 - 15 September 2005

6. IDEAL LAY-OUT Single runway APRON ICAO European Runway Safety and Air Traffic Services Safety Management Seminar Moscow, Russian Federation, 12 - 15 September 2005

7. IDEAL LAY-OUT Two parallels APRON ICAO European Runway Safety and Air Traffic Services Safety Management Seminar Moscow, Russian Federation, 12 - 15 September 2005

8. THE REAL WORLD Charles de Gaulle, Malpensa, Manchester... APRON TWR ICAO European Runway Safety and Air Traffic Services Safety Management Seminar Moscow, Russian Federation, 12 - 15 September 2005

9. !!! CROSSROAD !!! ICAO European Runway Safety and Air Traffic Services Safety Management Seminar Moscow, Russian Federation, 12 - 15 September 2005

10. LIMITATIONS ICAO European Runway Safety and Air Traffic Services Safety Management Seminar Moscow, Russian Federation, 12 - 15 September 2005

11. system descripting Model  Poor system descripting Model, strategic vision  Lack of strategic vision LIMITATIONS Human Errors Human Factors  More focused to Human Errors than Human Factors, ICAO European Runway Safety and Air Traffic Services Safety Management Seminar Moscow, Russian Federation, 12 - 15 September 2005

12. EQUIPMENT PEOPLEPROCEDURE System Descripting Model PPE MODEL ICAO European Runway Safety and Air Traffic Services Safety Management Seminar Moscow, Russian Federation, 12 - 15 September 2005

13. SHELL MODEL S H E L L  Software (S) = Procedures (P) + laws, rules, regulations, EQUIPMENT PEOPLEPROCEDURE  Hardware (H) = Equipment (E) + infrastructures,  Environment (E) = ?  Liveware (L) = People (P), producing HE core of the system, HF to be considered ICAO European Runway Safety and Air Traffic Services Safety Management Seminar Moscow, Russian Federation, 12 - 15 September 2005

14. REASON’S MODEL FAILURES ACTIVE LATENT INCIDENT !!! ACCIDENT !!! DECISION MAKERS LINE MANAGEMENT PRECONDITIONS PRODUCTIVE ACTIVITIES DEFENCES ICAO European Runway Safety and Air Traffic Services Safety Management Seminar Moscow, Russian Federation, 12 - 15 September 2005

15. THREE DIMENSIONS ICAO European Runway Safety and Air Traffic Services Safety Management Seminar Moscow, Russian Federation, 12 - 15 September 2005

16. Software Decision Makers S  “taxi into position and hold, runway…” (FAA) ICAO European Runway Safety and Air Traffic Services Safety Management Seminar Moscow, Russian Federation, 12 - 15 September 2005

17. Lined-up in front of an acft on final that, having acft in sight, went around S   Software Decision Makers “taxi into position and hold, runway…” (FAA) ICAO European Runway Safety and Air Traffic Services Safety Management Seminar Moscow, Russian Federation, 12 - 15 September 2005

18. H Acft, after landing, was taxiing to the apron Hardware Infrastructures Decision Makers  ICAO European Runway Safety and Air Traffic Services Safety Management Seminar Moscow, Russian Federation, 12 - 15 September 2005

19. H The other runway is used for departures   Acft, after landing, was taxiing to the apron crossing happened while a take-off was in progress Due to a mistake (pilot? – controller?) crossing happened while a take-off was in progress Hardware Infrastructures Decision Makers ICAO European Runway Safety and Air Traffic Services Safety Management Seminar Moscow, Russian Federation, 12 - 15 September 2005

20. E  Acft was taxiing for departure. Environment Line Managers ICAO European Runway Safety and Air Traffic Services Safety Management Seminar Moscow, Russian Federation, 12 - 15 September 2005

21. E  B737 was taxiing for departure. Environment Line Managers ICAO European Runway Safety and Air Traffic Services Safety Management Seminar Moscow, Russian Federation, 12 - 15 September 2005

22. E  Crew lost its Situation Awareness entered the runway while a take-off was in progress. and entered the runway while a take-off was in progress. B737 was taxiing for departure. Environment Line Managers  ICAO European Runway Safety and Air Traffic Services Safety Management Seminar Moscow, Russian Federation, 12 - 15 September 2005

23. E   Environment Line Managers ICAO European Runway Safety and Air Traffic Services Safety Management Seminar Moscow, Russian Federation, 12 - 15 September 2005

24. E   Environment Line Managers ICAO European Runway Safety and Air Traffic Services Safety Management Seminar Moscow, Russian Federation, 12 - 15 September 2005

25. E   No. 2 misunderstood the clearance, Environment Line Managers ICAO European Runway Safety and Air Traffic Services Safety Management Seminar Moscow, Russian Federation, 12 - 15 September 2005

26. E   No. 2 misunderstood the clearance, entered the runway and gave thrust entered the runway and gave thrust.        Environment Line Managers ICAO European Runway Safety and Air Traffic Services Safety Management Seminar Moscow, Russian Federation, 12 - 15 September 2005

27. Liveware The Human Element of the System L Human ErrorsHuman Factors Human Errors vs Human Factors Prof. Sydney Decker ICAO European Runway Safety and Air Traffic Services Safety Management Seminar Moscow, Russian Federation, 12 - 15 September 2005

28. Liveware The Human Element of the System L  Humans (OP) make mistakes,  Regulators and Service Providers provide OP with awareness campaigns and/or modify proc.  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. ICAO European Runway Safety and Air Traffic Services Safety Management Seminar Moscow, Russian Federation, 12 - 15 September 2005

29. 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 ICAO European Runway Safety and Air Traffic Services Safety Management Seminar Moscow, Russian Federation, 12 - 15 September 2005

30. 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 ICAO European Runway Safety and Air Traffic Services Safety Management Seminar Moscow, Russian Federation, 12 - 15 September 2005

31. 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 ICAO European Runway Safety and Air Traffic Services Safety Management Seminar Moscow, Russian Federation, 12 - 15 September 2005

32. Vulnerable system Average system Resistan t system Prof. James Reason - Intrinsic safety ICAO European Runway Safety and Air Traffic Services Safety Management Seminar Moscow, Russian Federation, 12 - 15 September 2005

33. CONCLUSIONS  Intrinsic Safety Updating Annex 14 SARPs – No RWY crossing Updating Annex 14 SARPs – No RWY crossing Re-assessing Environment Protection Procedures Re-assessing Environment Protection Procedures Endorsing HF Principles in System Design Endorsing HF Principles in System Design ICAO European Runway Safety and Air Traffic Services Safety Management Seminar Moscow, Russian Federation, 12 - 15 September 2005

34. ICAO European Runway Safety and Air Traffic Services Safety Management Seminar Moscow, Russian Federation, 12 - 15 September 2005 Antonio Travaglione IFATCA Aerodrome Safety Representative atravaglione@enav.it