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


Evolution of the ICAO ModelEvolution of the ICAO Model

Analysis Models & ResultsAnalysis Models & Results

Intrinsic SafetyIntrinsic Safety

CROSSROADS VS HIGHWAY INTERSECTIONS



IDEAL LAY-OUT

Single runway

APRON



IDEAL LAY-OUT

Two parallels

APRON



THE REAL WORLD

Charles de Gaulle, Malpensa, Manchester...

APRONTWR



!!! CROSSROAD !!!



LIMITATIONSLIMITATIONS



Poor system descripting system descripting ModelModel,

Lack of strategic visionstrategic vision

LIMITATIONSLIMITATIONS More focused to Human Human

ErrorsErrors than Human FactorsHuman Factors,



EQUIPMENT

PEOPLE PROCEDURE

System Descripting ModelSystem Descripting ModelPPE MODEL



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



REASON’S MODELFAILURES

ACTIVE

ACTIVE

LATENT

LATENT

LATENT

LATENT

INCIDENTINCIDENT

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

DECISION MAKERS

LINE MANAGEMENT

PRECONDITIONS

PRODUCTIVE ACTIVITIES

DEFENCES



THREE DIMENSIONS



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)



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)



H

Acft, after landing, was taxiing to the apron

Hardware Infrastructures

Decision Makers

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



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



E

Acft was taxiing for departure.

EnvironmentLine Managers



E

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

B737 was taxiing for departure.




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.




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

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




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.




E


No. 1 was instructed to line-up.Few seconds later take-off clearance was

issued.

No. 2 misunderstood the clearance,




E


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.




LivewareThe Human Element of the SystemL

Human ErrorsHuman Errors vs Human FactorsHuman FactorsProf. Sydney Decker




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.




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




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




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



Vulnerable

system

Average

system

Resistant system

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



CONCLUSIONSCONCLUSIONS




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





Antonio Antonio TravaglioneTravaglioneIFATCA Aerodrome Safety IFATCA Aerodrome Safety

RepresentativeRepresentative

atravaglione@[email protected]

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

Documents

intrinsic safety slide

russian federation

strategic approach slide

icao model analysis

model poor system

shell model s h e

ideal lay

software s