How Did That Happen?

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How Did That Happen?

• Analyzing
• Prevention
• Resources Available

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• Line-Oriented Safety Audit
• 23 of errors
• 38 of threats
• Occur before leaving the ground

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March 2003 - Taiwan. A TransAsia Airbus landed
on Runway 36 at Taiwan Airport and hit a
maintenance vehicle on the runway. There
were no injuries to the passengers and crew. The
flight was late and AT cleared the
aircraft to land on the runway shortly after it
was closed for maintenance activity.
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The two people in the maintenance vehicle were
only slightly injured.
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Heads up!
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Best Practice TIMELY AND ACCURATE NOTAMS
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SO WHAT WENT WRONG?QUE PASO?
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Conditions at Time of Runway Incursions
Airport Diagram Not Used
Failed to Follow Instructions
Not Familiar with Airport
Unfamiliar With Airport Signage
Inexperienced at Towered Airports
(Phraseology)
Unfavorable Environmental Conditions
Clearance Not Read back
HUMAN ERROR
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Israir 102 B767 Entered RWY.
ABX 50 DC85 Over flew Israir 102 by less than 100
feet.
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EJA 377 C550 At taxi speed.
N525VV C525 Entered RWY
2,000 feet horizontal
MIA
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NATIONAL SURVEY Types of errors caused by
Pilots

• Pilot enters/crosses a runway after acknowledging
  hold short
• Pilot crosses the hold line after acknowledging
  hold short
• Pilot enters/crosses a runway without
  authorization, hold short not required
• Pilot crosses the hold line with authorization,
  hold short not required
• Pilot departs without communication or
  authorization

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NATIONAL SURVEY Types of errors caused by
Controllers

• Failure to provide required Arrival/Departure
  separation for the same or intersecting runway(s)
• Authorizing a crossing or a holding within the
  safety area then clearing an aircraft to
  land/takeoff
• Cleared an aircraft for takeoff on a
  closed/occupied runway
• Did not correct an incorrect readback

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USA 1170 is 171 feet from intersection as EIN 132
is just through intersection climbing.
USA 1170 B737
EIN 132 A333 Airborne
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NATIONAL SURVEY Types of errors caused by
Vehicles/Pedestrians

• An unauthorized POV or pedestrian on the airfield
  that entered or crossed an active runway
• Airport personnel entered a runway without
  communications or authorization
• Airport personnel instructed to hold short/remain
  clear of a runway. Readback correct but crossed
  the hold line or entered the runway.

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Cause of errorsnumerous human factors

• Inaccurate Position Awareness
• Expectation Bias
• Preoccupation
• Forgetfulness
• Task Saturation
• Confusion
• Incomplete Training
• Poor Judgment

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FACTORS
HUMAN
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• Human Factors
• Fatigue (double shifts)
• Employee turnover
• Inadequate initial and recurrent training
• Stress (job related - home related)
• Distractions in Cockpit- down head time,
  attention to squawked items
• NO CELL PHONES
• Complacency

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• Language
• Responsibility
• Trust no one to come behind to check if you do
  it wrong
• Poor Judgement

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A Few Common Mistakes

• No clearance obtained to push-back
• No contact made with ATC when repositioning
• Wrongfully accept an ATC clearance as your own
• Misinterpret an ATC clearance
• Dont want to look stupid by contacting ATC
  again
• Wrong ATC instruction given
• Unfamiliar with airfield layout
• In a big rush to stay on schedule (everyone)

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Changing Our Behaviors
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Resources
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Safety Culture
The agents for improving airport safety

• Airport Management and Staff
• Air Traffic Control
• Airline Station Managers
• Fixed Base Operators
• Tenants
• Pilots
• Everyone at this meeting

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Runway Safety is Everyones Responsibility
Be a part of the SOLUTION!