Presentazione di PowerPoint

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INTERNATIONAL FEDERATION OF AIR TRAFFIC
CONTROLLERS ASSOCIATIONS Runway Safety Workshop
Brussels 9 10 September 2002
Runway Incursions An ATCOs Perspective
Antonio TRAVAGLIONE
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INTERNATIONAL FEDERATION OF AIR TRAFFIC
CONTROLLERS ASSOCIATIONS Runway Safety Workshop
Brussels 9 10 September 2002
LICC Catania
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INTERNATIONAL FEDERATION OF AIR TRAFFIC
CONTROLLERS ASSOCIATIONS Runway Safety Workshop
Brussels 9 10 September 2002
LICC Catania
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INTERNATIONAL FEDERATION OF AIR TRAFFIC
CONTROLLERS ASSOCIATIONS Runway Safety Workshop
Brussels 9 10 September 2002
LIMC Malpensa
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INTERNATIONAL FEDERATION OF AIR TRAFFIC
CONTROLLERS ASSOCIATIONS Runway Safety Workshop
Brussels 9 10 September 2002
LIMC Malpensa
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INTERNATIONAL FEDERATION OF AIR TRAFFIC
CONTROLLERS ASSOCIATIONS Runway Safety Workshop
Brussels 9 10 September 2002
JAWS
EBBR
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INTERNATIONAL FEDERATION OF AIR TRAFFIC
CONTROLLERS ASSOCIATIONS Runway Safety Workshop
Brussels 9 10 September 2002
- Human errors categorisation
The airport is a
COMPLEX HUMAN CENTRED system
the people being the core element its
strength its weakness
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INTERNATIONAL FEDERATION OF AIR TRAFFIC
CONTROLLERS ASSOCIATIONS Runway Safety Workshop
Brussels 9 10 September 2002
- Human errors categorisation
- The System
TWR Controller Aerodrome
Pilot
Vehicle driver
Vehicle
Aircraft
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INTERNATIONAL FEDERATION OF AIR TRAFFIC
CONTROLLERS ASSOCIATIONS Runway Safety Workshop
Brussels 9 10 September 2002
- A Human errors categorisation
- The System
- The Reasons Model
- The SHELL Model
- Recommendations
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INTERNATIONAL FEDERATION OF AIR TRAFFIC
CONTROLLERS ASSOCIATIONS Runway Safety Workshop
Brussels 9 10 September 2002
HUMAN ERRORS
Design errors
Operational errors

• Wrong
• Procedure
• HMI
• Env. cond.
• Training

Regardless of the involved professional category
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INTERNATIONAL FEDERATION OF AIR TRAFFIC
CONTROLLERS ASSOCIATIONS Runway Safety Workshop
Brussels 9 10 September 2002
Reasons Model
FAILURES
LATENT
DECISION MAKERS
LATENT
LINE MANAGEMENT
LATENT
PRECONDITIONS
INCIDENT
ACTIVE
PRODUCTIVE ACTIVITIES
ACTIVE
LATENT
DEFENCES
ACCIDENT
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INTERNATIONAL FEDERATION OF AIR TRAFFIC
CONTROLLERS ASSOCIATIONS Runway Safety Workshop
Brussels 9 10 September 2002
SHELL Model
H
S
E
L
L
is this the right instrument the operational
personnel needs to provide a safe and efficient
service?
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INTERNATIONAL FEDERATION OF AIR TRAFFIC
CONTROLLERS ASSOCIATIONS Runway Safety Workshop
Brussels 9 10 September 2002
S
Software
Does the legal system in our countries
promote anonymous and non-punitive reporting
systems?
Is the regulation current with the operational
needs?
Is the phraseology clear and unambiguous?
Rules and procedures clearly specify when to work
head up and when head down?
Published procedures are easy and safe
instruments for the operational personnel?
In IFATCAs opinion, compulsory runway crossing
procedures are not intrinsically safe and
represent a trap for both pilots and controllers.
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INTERNATIONAL FEDERATION OF AIR TRAFFIC
CONTROLLERS ASSOCIATIONS Runway Safety Workshop
Brussels 9 10 September 2002
H
Hardware
General movement area lay-out
Is the general configuration of the airport
intrinsically safe?
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INTERNATIONAL FEDERATION OF AIR TRAFFIC
CONTROLLERS ASSOCIATIONS Runway Safety Workshop
Brussels 9 10 September 2002
H
Hardware
Towers structure
The ATS Planning Manual DOC 9426 states The
tower must permit the controller to survey those
portions of the aerodrome and its vicinity over
which he exercises control
If the tower controller is the core element to
tactically guarantee the safety in the airport
system, has his controlling position (the tower
cab) being located in the best possible place of
the airport, at best height?
Has the tower structure been designed with the
purpose of minimising the interference of tower
frames with the sight-line of controllers from
their working positions?
Is the sight-line from the tower to the whole
manoeuvring area free of obstacles?
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INTERNATIONAL FEDERATION OF AIR TRAFFIC
CONTROLLERS ASSOCIATIONS Runway Safety Workshop
Brussels 9 10 September 2002
E
Environment
Physical Environment Is the area under control
visible to operational personnel?
Anthropic environment Are there anthropic
constraints affecting airport operations?
Institutional environment Are the political
authorities aware of the severity of the RI
problem?
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INTERNATIONAL FEDERATION OF AIR TRAFFIC
CONTROLLERS ASSOCIATIONS Runway Safety Workshop
Brussels 9 10 September 2002
L
Liveware
Is staffing adequate to assigned tasks?
Is the operational personnel properly trained?
Joint training, joint refresher courses, exchange
visits could change the operational personnel
overall perception, providing a better
situational awareness. IFATCA considers that
every time a pilot visits an ATC facility, every
time a controller flies on the jump-seat in the
cockpit, total safety of the system is enhanced.
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INTERNATIONAL FEDERATION OF AIR TRAFFIC
CONTROLLERS ASSOCIATIONS Runway Safety Workshop
Brussels 9 10 September 2002
RECOMMENDATIONS
General
It is recommended that
G1 every new, modification of and, either,
existing airport system be safety assessed
taking into account Reasons Model vision, to
realise at decision makers and middle
management level all those actions that can ease
the tactical management of the runway safety by
operational personnel, minimising the latent
failures.
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INTERNATIONAL FEDERATION OF AIR TRAFFIC
CONTROLLERS ASSOCIATIONS Runway Safety Workshop
Brussels 9 10 September 2002
RECOMMENDATIONS
Software
It is recommended that
S1 the aviation authorities promote the
institution of anonymous and non-punitive
reporting systems in those countries where these
systems are not yet in force.
S2 new, modification of and, either, existing
regulation be safety assessed to verify their
currency with operational practices and that
operational practices be surveyed to verify their
compliancy to regulations, cross checking both.
S3 published procedures be safety assessed to
verify their consistency to human factors
criteria.
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INTERNATIONAL FEDERATION OF AIR TRAFFIC
CONTROLLERS ASSOCIATIONS Runway Safety Workshop
Brussels 9 10 September 2002
RECOMMENDATIONS
Software
It is recommended that
S4 the phraseology related to taxi to holding
position be suspended and that a safety
assessment of it be conducted before introduction
or deletion.
S5 clear instruction be inserted in regulations
and procedures to specify the conditions in which
a controller is required to work head-up or
head-down, avoiding ambiguity and mixed
situations, provided that a surveillance
controller should always be kept free from tasks
other than surveilling.
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INTERNATIONAL FEDERATION OF AIR TRAFFIC
CONTROLLERS ASSOCIATIONS Runway Safety Workshop
Brussels 9 10 September 2002
RECOMMENDATIONS
Hardware
It is recommended that
H1 Criteria expressed in ICAO Airport Planning
Manual DOC 9184 be evaluated for upgrading to
ICAO standards and/or to Eurocontrol Safety
Regulatory Requirements, Master plans of
existing airport be adapted for compliancy in a
reasonable amount of time, Temporary (although
being years) non compliancy be notified in the
AIPs as hazard for air navigation.
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INTERNATIONAL FEDERATION OF AIR TRAFFIC
CONTROLLERS ASSOCIATIONS Runway Safety Workshop
Brussels 9 10 September 2002
RECOMMENDATIONS
Hardware
It is recommended that
H2 Criteria expressed in ICAO ATS Planning
Manual DOC 9426 be evaluated for upgrading to
ICAO standards and/or to Eurocontrol Safety
Regulatory Requirements, Existing towers and
master plans of existing airports be adapted for
compliancy in a reasonable amount of
time, Temporary (although being years) non
compliancy be notified in the AIPs as warning
related to limitation to visibility of Air
Traffic Controllers in sectors or areas.
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INTERNATIONAL FEDERATION OF AIR TRAFFIC
CONTROLLERS ASSOCIATIONS Runway Safety Workshop
Brussels 9 10 September 2002
RECOMMENDATIONS
Hardware
It is recommended that
H3 A criterion expressing that the sight-line
from tower to the whole manoeuvring area shall be
free of obstacles be inserted in ICAO standards
and/or in Eurocontrol Safety Regulatory
Requirements, Master plans of existing airport
be adapted for compliancy in a reasonable amount
of time, Temporary (although being years) non
compliancy be notified in the AIPs as warning
related to limitation to visibility of Air
Traffic Controllers in sectors or areas.
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INTERNATIONAL FEDERATION OF AIR TRAFFIC
CONTROLLERS ASSOCIATIONS Runway Safety Workshop
Brussels 9 10 September 2002
RECOMMENDATIONS
Environment
It is recommended that
E1 A an information campaign be conducted to
airport and aircraft operators to clarify that
physical (low visibility) constraints to
capacity can only be handled within the
regulation in force and that exercising pressure
on operational personnel degrades their
situational awareness.
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INTERNATIONAL FEDERATION OF AIR TRAFFIC
CONTROLLERS ASSOCIATIONS Runway Safety Workshop
Brussels 9 10 September 2002
RECOMMENDATIONS
Environment
It is recommended that
E2 procedures in force due to anthropic
constraint (noise and air pollution abatement)
be safety assessed and possible risks published
in AIPs as warnings.
E3 periodic runway safety surveys be
conducted results be published and provided to
institutional authorities.
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INTERNATIONAL FEDERATION OF AIR TRAFFIC
CONTROLLERS ASSOCIATIONS Runway Safety Workshop
Brussels 9 10 September 2002
RECOMMENDATIONS
Liveware
It is recommended that
L1 independent safety studies be conducted with
the cooperation of ANSPs and IFATCA to define
capacity, workload and minimum staffing.
L2 Basic and recurrent training courses for
operational personnel be updated to introduce
joint and cross training, Cross visits or
flights in the cockpit for operational personnel
be eased.
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INTERNATIONAL FEDERATION OF AIR TRAFFIC
CONTROLLERS ASSOCIATIONS Runway Safety Workshop
Brussels 9 10 September 2002
CONCLUSIONS
- A Human errors categorisation
- The System
- The Reasons Model
- The SHELL Model
- Recommendations
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INTERNATIONAL FEDERATION OF AIR TRAFFIC
CONTROLLERS ASSOCIATIONS Runway Safety Workshop
Brussels 9 10 September 2002
CONCLUSIONS
IFATCA seeks a wider approach to the runway and
to the entire aviation system safety
antravaglione_at_hotmail.com