icao european runway safety and air traffic services management seminar moscow, russian federation,...

ICAO European Runway Safetyand Air Traffic Services Management Seminar

Moscow, Russian Federation, 12 - 15 September 2005

Antonio Antonio TravaglioneTravaglioneIFATCA Aerodrome Safety IFATCA Aerodrome Safety

RepresentativeRepresentative

Runway IncursionRunway IncursionA Strategic A Strategic ApproachApproach

Highway Intersection ConceptHighway Intersection Concept

ICAO European Runway Safetyand Air Traffic Services Safety Management Seminar

Moscow, Russian Federation, 12 - 15 September 2005

Evolution of the ICAO ModelEvolution of the ICAO Model

Analysis Models & ResultsAnalysis Models & Results

Intrinsic SafetyIntrinsic Safety

CROSSROADS VS HIGHWAY INTERSECTIONS

ICAO European Runway Safetyand Air Traffic Services Safety Management Seminar

Moscow, Russian Federation, 12 - 15 September 2005

IDEAL LAY-OUT

Single runway

APRON

ICAO European Runway Safetyand Air Traffic Services Safety Management Seminar

Moscow, Russian Federation, 12 - 15 September 2005

IDEAL LAY-OUT

Single runway

APRON

ICAO European Runway Safetyand Air Traffic Services Safety Management Seminar

Moscow, Russian Federation, 12 - 15 September 2005

IDEAL LAY-OUT

Two parallels

APRON

ICAO European Runway Safetyand Air Traffic Services Safety Management Seminar

Moscow, Russian Federation, 12 - 15 September 2005

THE REAL WORLD

Charles de Gaulle, Malpensa, Manchester...

APRONTWR

ICAO European Runway Safetyand Air Traffic Services Safety Management Seminar

Moscow, Russian Federation, 12 - 15 September 2005

!!! CROSSROAD !!!

ICAO European Runway Safetyand Air Traffic Services Safety Management Seminar

Moscow, Russian Federation, 12 - 15 September 2005

LIMITATIONSLIMITATIONS

ICAO European Runway Safetyand Air Traffic Services Safety Management Seminar

Moscow, Russian Federation, 12 - 15 September 2005

Poor system descripting system descripting ModelModel,

Lack of strategic visionstrategic vision

LIMITATIONSLIMITATIONS More focused to Human Human

ErrorsErrors than Human FactorsHuman Factors,

ICAO European Runway Safetyand Air Traffic Services Safety Management Seminar

Moscow, Russian Federation, 12 - 15 September 2005

EQUIPMENT

PEOPLE PROCEDURE

System Descripting ModelSystem Descripting ModelPPE MODEL

ICAO European Runway Safetyand Air Traffic Services Safety Management Seminar

Moscow, Russian Federation, 12 - 15 September 2005

SHELL MODEL

S

H

E

L

L

Software (S) = Procedures (P) + laws, rules, regulations,

EQUIPMENT

PEOPLE PROCEDURE

Hardware (H) = Equipment (E) + infrastructures, Environment (E) = ? Liveware (L) = People (P), producing HE

core of the system, HF to be considered

ICAO European Runway Safetyand Air Traffic Services Safety Management Seminar

Moscow, Russian Federation, 12 - 15 September 2005

REASON’S MODELFAILURES

ACTIVE

ACTIVE

LATENT

LATENT

LATENT

LATENT

INCIDENTINCIDENT

!!! ACCIDENT !!!!!! ACCIDENT !!!

DECISION MAKERS

LINE MANAGEMENT

PRECONDITIONS

PRODUCTIVE ACTIVITIES

DEFENCES

ICAO European Runway Safetyand Air Traffic Services Safety Management Seminar

Moscow, Russian Federation, 12 - 15 September 2005

THREE DIMENSIONS

ICAO European Runway Safetyand Air Traffic Services Safety Management Seminar

Moscow, Russian Federation, 12 - 15 September 2005

SoftwareDecision Makers

FAA educated Captain““taxi to holding position, runway…” taxi to holding position, runway…”

(ICAO)(ICAO)

S

“taxi into position and hold, runway…” (FAA)

ICAO European Runway Safetyand Air Traffic Services Safety Management Seminar

Moscow, Russian Federation, 12 - 15 September 2005

Lined-up in front of an acft on final Lined-up in front of an acft on final that, having acft in sight, went aroundthat, having acft in sight, went around

S

SoftwareDecision Makers

FAA educated Captain““taxi to holding position, runway…” taxi to holding position, runway…”

(ICAO)(ICAO)“taxi into position and hold, runway…” (FAA)

ICAO European Runway Safetyand Air Traffic Services Safety Management Seminar

Moscow, Russian Federation, 12 - 15 September 2005

H

Acft, after landing, was taxiing to the apron

Hardware Infrastructures

Decision Makers

that is beyond another runway.that is beyond another runway.

ICAO European Runway Safetyand Air Traffic Services Safety Management Seminar

Moscow, Russian Federation, 12 - 15 September 2005

H

The other runway is used for departures

Acft, after landing, was taxiing to the apronthat is beyond another runway.that is beyond another runway.

Due to a mistake (pilot? – controller?) crossing happened while a take-off was in crossing happened while a take-off was in

progressprogress

Hardware Infrastructures

Decision Makers

ICAO European Runway Safetyand Air Traffic Services Safety Management Seminar

Moscow, Russian Federation, 12 - 15 September 2005

E

Acft was taxiing for departure.

EnvironmentLine Managers

ICAO European Runway Safetyand Air Traffic Services Safety Management Seminar

Moscow, Russian Federation, 12 - 15 September 2005

E

While taxiing, departure runway and taxi route was While taxiing, departure runway and taxi route was changedchanged

B737 was taxiing for departure.

EnvironmentLine Managers

ICAO European Runway Safetyand Air Traffic Services Safety Management Seminar

Moscow, Russian Federation, 12 - 15 September 2005

E

Crew lost its Situation Awareness and entered the runway while a take-off was in entered the runway while a take-off was in

progress.progress.

While taxiing, departure runway and taxi route was While taxiing, departure runway and taxi route was changedchanged

B737 was taxiing for departure.

EnvironmentLine Managers

ICAO European Runway Safetyand Air Traffic Services Safety Management Seminar

Moscow, Russian Federation, 12 - 15 September 2005

ETwo acft were holding positions at Two acft were holding positions at

opposite heads of the same runway.opposite heads of the same runway.

EnvironmentLine Managers

ICAO European Runway Safetyand Air Traffic Services Safety Management Seminar

Moscow, Russian Federation, 12 - 15 September 2005

E

Two acft were holding positions at Two acft were holding positions at opposite heads of the same runway.opposite heads of the same runway.

No. 1 was instructed to line-up.

EnvironmentLine Managers

ICAO European Runway Safetyand Air Traffic Services Safety Management Seminar

Moscow, Russian Federation, 12 - 15 September 2005

E

Two acft were holding positions at Two acft were holding positions at opposite heads of the same runway.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,

EnvironmentLine Managers

ICAO European Runway Safetyand Air Traffic Services Safety Management Seminar

Moscow, Russian Federation, 12 - 15 September 2005

E

Two acft were holding positions at Two acft were holding positions at opposite heads of the same runway.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 thrustentered the runway and gave thrust.

EnvironmentLine Managers

ICAO European Runway Safetyand Air Traffic Services Safety Management Seminar

Moscow, Russian Federation, 12 - 15 September 2005

LivewareThe Human Element of the SystemL

Human ErrorsHuman Errors vs Human FactorsHuman FactorsProf. Sydney Decker

ICAO European Runway Safetyand Air Traffic Services Safety Management Seminar

Moscow, Russian Federation, 12 - 15 September 2005

LivewareThe Human Element of the SystemL

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 Safetyand Air Traffic Services Safety Management Seminar

Moscow, Russian Federation, 12 - 15 September 2005

LivewareThe Human Element of the SystemL

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 Safetyand Air Traffic Services Safety Management Seminar

Moscow, Russian Federation, 12 - 15 September 2005

LivewareThe Human Element of the SystemL

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 Safetyand Air Traffic Services Safety Management Seminar

Moscow, Russian Federation, 12 - 15 September 2005

LivewareThe Human Element of the SystemL

SUGGESTED WAYSSUGGESTED WAYS remove hazards:remove hazards:

eliminate runway crossing – obstacles to visibility;eliminate runway crossing – obstacles to visibility; re-assess environment protection proceduresre-assess environment protection procedures

mitigate results of good faith acts mitigate results of good faith acts (slips, lapses, (slips, lapses, mistakes) mistakes) through redundancy:through redundancy: back-up voice com with data-link; back-up voice com with data-link; associate warning signs with voice recorded associate warning signs with voice recorded

messages; messages; enhance situation awareness through Aerodrome enhance situation awareness through Aerodrome

Resource ManagementResource Management

ICAO European Runway Safetyand Air Traffic Services Safety Management Seminar

Moscow, Russian Federation, 12 - 15 September 2005

Vulnerable

system

Average

system

Resistant system

Prof. James Reason - Intrinsic safetyProf. James Reason - Intrinsic safety

ICAO European Runway Safetyand Air Traffic Services Safety Management Seminar

Moscow, Russian Federation, 12 - 15 September 2005

CONCLUSIONSCONCLUSIONS

Intrinsic SafetyIntrinsic Safety

Intrinsic SafetyIntrinsic Safety

Intrinsic SafetyIntrinsic Safety

Updating Annex 14 SARPs – No RWY Updating Annex 14 SARPs – No RWY crossingcrossing

Re-assessing Environment Protection Re-assessing Environment Protection

ProceduresProcedures

Endorsing HF Principles in System DesignEndorsing HF Principles in System Design

ICAO European Runway Safetyand Air Traffic Services Safety Management Seminar

Moscow, Russian Federation, 12 - 15 September 2005

ICAO European Runway Safetyand Air Traffic Services Safety Management Seminar

Moscow, Russian Federation, 12 - 15 September 2005

Antonio Antonio TravaglioneTravaglioneIFATCA Aerodrome Safety IFATCA Aerodrome Safety

RepresentativeRepresentative

atravaglione@enavatravaglione@enav.it.it