runway safety initiative briefing

Safety R

unw

ayInitiative

Participants• EASA• CANSO• IFALPA• FAA/CAST• LVNL• Boeing• DGAC France• Flight Safety Foundation• IFATCA• NLR• ALTA

• Airbus • Embraer• ACI• IATA• ERA• Eurocontrol• AAPA• US NTSB• AEA• Honeywell• ALPA

1. Initial RSI meeting in Amsterdam 7 and 8 Feb 2007

2. Meeting in Brussels 30 and 31 May 2007

3. Meeting in Toulouse 6 and 7 September 2007

4. Meeting in Miami 9 and 10 January 2008

5. Meeting at NTSB in Washington on 7 and 8 May 2008

6. Meeting at EASA in Cologne on 20 and 21 August 2008

7. Meting in Seattle on 13 and 14 November 2008 8. Meeting in Brussels on 25 and 26 February 2009 9. Steering team meeting at FSF on 16 and 17 April 2009

RSI Meetings

Definition:

A runway safety issue is any safety issue that deals with the runway environment (or any surface being used as a runway) and the areas immediately adjacent to it (e.g., overruns, high-speed taxiways).

• Runway Incursions

Runway Safety Issues

• Runway Confusion

• Runway Excursion

ICAO Definition of Runway Incursion:

“ Any occurrence at an aerodrome involving the incorrect presence of an aircraft, vehicle or person on the protected area of a surface designated for the landing and takeoff of aircraft.”

2007 runway safety events

- TAROM runway incursion accident (0 fatalities)- S7 excursion report from MAK (126 fatalities)- Garuda excursion in Indonesia (21 fatalities)- TAM excursion (187 fatalities)

- Southwest Airlines Midway excursion report- Air France A340 Toronto excursion report

8

2008 Runway Safety Events

- Kalitta B747 excursion (0 fatalities)

- Hewa Bora DC-9 excursion (3 Fatal)

- TACA A-320 excursion (3 Fatal)

- Sudan Airways A-310 excursion (30 fatal)

- Several corporate aircraft fatal excursions

- Continental excursion in Denver (0 fatalities)

2008Runway Safety Data

Total Accidents: 97 (44 Jet/53 TP: all Western and Eastern built commercial jet and turboprop aircraft, Major or substantial damage)

Total Incursion Accidents: 0

Total Confusion Accidents: 0

Total Excursion Accidents: 38 (39%) - 32 Fatalities

• Runway Incursions - Good

Data Availability

• Runway Excursions - Good for Accidents and Incidents with Damage

• Runway Confusion - Limited (normally no damage, no injury, no loss of separation)

1977 - KLM / Pan Am

Los Rodeos Airport, Tenerife, Canary Islands

February 1991

USAir Runway Incursion Accident – Los Angeles: Controller cleared aircraftto land with another aircraft on the runway.

SASOctober 2001

Milan, Italy

Runway Incursions• Part of the new breed of safety challenge - Not a lot of accidents - Numerous incidents• Basic Risk Management: Risk = (Probability) X (Severity)

Runway Excursion:When an aircraft on the runway surface departs the end or the side of the runway surface. Runway excursions can occur on takeoff or on landing. They consist of two types of events:Veer-Off: Excursion in which an aircraft departs the side of a runwayOverrun: A runway excursion in which an aircraft departs the end of a runway

The Players

• Airports• ATC• Regulators

• Operators - Aircrews - Management

• Aircraft Manufacturers

Manufacturers• Safe/reliable aircraft

• Data and procedures for normal operations• Data and procedures for non- normal operations

Operators• Stabilized approach criteria• True no-fault go-around policy

• Decision making

- On approach - On the runway

• Training

Airports• Airport design• Lighting• Approach aids (e.g. ILS, VASI, PAPI)• Runway design (crown, grooved, porous)• Runway markings and signage• Runway clearing/cleaning• Runway condition measurement• Runway end safety areas• Airport ARFF

ATC• Stabilized approach assistance• Pertinent and timely information - Weather - Runway condition

Regulator• Provide appropriate and professional oversight

• Stabilized approach requirements - Approaches with vertical guidance

Runway Safety Products Catalog

Runway Incursion:Product Title Originator Type Product Target Audience1. ICAO Runway Safety Toolkit ICAO CD and web Aircrew, Airports, ATM, Management2. Runway and Surface Safety FAA CD and web Flight Instructors Pilot Examiners3. Taxi 101 FAA CD and web Maintenance personnel

4. Runway Incursion Prevention FAA, ACI, CD and web Aircrew, Airports, ATM Program IATA, PAAST

5. European Action Plan for the Eurocontrol et al CD and web Aircrews, Airports, ATM Prevention of Runway Incursions Vehicle drivers

6. Runway Incursion CAST JSIT FAA (CAST) CD Aircrews, Airports, ATM Reports

7. FAA Runway Safety Website FAA Web site Aircrews, ATM, Vehicle Drivers8. Enhanced Taxiway Centerline FAA CD and web Aircrews, ATM, Airports

9. AOPA Runway Safety Course FAA, AOPA Web site General Aviation Pilots

10. ALPA Runway Safety Course FAA, ALPA Web site Aircrews

11. ACI Airside Safety Handbook ACI Handbook Airports

12. Runway Safety: It’s Everybody’s FAA Handbook Pilots, Controllers Business

13. Pilot Guide to Runway Safety Sporty’s CD General Aviation Pilots

Runway ExcursionProduct Title Originator Type Product Target

Audience

1. ALAR Tool Kit Flight Safety Foundation CD Aircrews, ATM, Airports

2. Managing Threats and Errors Flight Safety Foundation Web Aircrews During Approach and Landing: How to avoid a Runway Overrun

3. Takeoff Safety Training Aid FAA CD and web Aircrews



Runway Confusion: (Many runway incursion products may be applicable here)

Runway Confusion

Incursion

Safety DataRunwayConfusion

Excursion

Accident Data1995–2008

Commercial Aircraft(Substantial and Major Damage, Western- and Eastern-built

Turbojets and Turboprops)

Jets Turboprops Major Substantial Major Substantial 286 372 528 243Total 658 771

1,429 Total Accidents (of all types, not just runway safety accidents)

Number Percent of TotalIncursions: 10 (.7/year) .6% Excursions: 417 (29.8/year) 29%

Confusion: 4 (.3/year) .3%

Runway Safety Accident Data

1995–20081,429 Total Accidents

Runway Safety Data1995–2008

Runway Excursion Data

• 36% of jet accidents

• 24% of turboprop accidents

30 years of Taxiway and Runway Incursion / Confusion Accidents1996 to 2007

$2,415M$120M/year

752 Fatal94 Serious

$1800M583 F + 59 SRunway collisionB-747 / B-747Tenerife, Canary Islands

27 Mar 1977

$165M42 F + 5 SRunway collisionB-737 / snow plowCranbrook, BC, Canada

11 Feb 1978

$300M93 F + 30 SRunway collisionB-727 / DC-9Madrid, Spain7 Dec 1983

$150M34 FRunway collisionB-737 / Be-1900Los Angeles, CA, USA

2 Feb 1991

Estimated LossFatalities / Serious

AccidentAircraft Type(s)LocationDate

$366M + $35M = $401M total122 F + 71 SRunway collisionMD-87/ CJ-2Milan, Italy8 Oct 2001

$3M + $7M = $10M total1 FRunway collisionMD-83 / Shorts 330Paris, France25 May 2000

$0M + $3M = $3M total0Taxiway collisionB-747 / grass cutterAmsterdam, Netherlands

1997

$42M + $12M = $54M total14 FRunway collisionBe-1900 / Be-490Quincy, IL, USA19 Nov 1996

$0M + $4M = $4M total0Taxi collisionSA-227 / SA-226Denver, CO, USA3 Dec 2003

$250M + $66M = $316M total83 F + 71 SRunway collisionB-747 / construction equipment

Taipei, Taiwan31 Oct 2001

$808M + $142M = $950M

$95M/year269 Fatal142 Serious

$147M + $15M = $162M total49 FTake off on short runway 26

CRJ-100Lexington, KY, USA27 Aug 2006



$2,415M$120M/year

752 Fatal94 Serious

$1800M583 F + 59 SRunway collisionB-747 / B-747Tenerife, Canary Islands

27 Mar 1977

$165M42 F + 5 SRunway collisionB-737 / snow plowCranbrook, BC, Canada

11 Feb 1978

$300M93 F + 30 SRunway collisionB-727 / DC-9Madrid, Spain7 Dec 1983

$150M34 FRunway collisionB-737 / Be-1900Los Angeles, CA, USA

2 Feb 1991



$366M + $35M = $401M total122 F + 71 SRunway collisionMD-87/ CJ-2Milan, Italy8 Oct 2001

$3M + $7M = $10M total1 FRunway collisionMD-83 / Shorts 330Paris, France25 May 2000

$0M + $3M = $3M total0Taxiway collisionB-747 / grass cutterAmsterdam, Netherlands

1997

$42M + $12M = $54M total14 FRunway collisionBe-1900 / Be-490Quincy, IL, USA19 Nov 1996

$0M + $4M = $4M total0Taxi collisionSA-227 / SA-226Denver, CO, USA3 Dec 2003

$250M + $66M = $316M total83 F + 71 SRunway collisionB-747 / construction equipment

Taipei, Taiwan31 Oct 2001

$808M + $142M = $950M

$95M/year269 Fatal142 Serious

$147M + $15M = $162M total49 FTake off on short runway 26

CRJ-100Lexington, KY, USA27 Aug 2006



$100M/year Due to Runway Incursions

Prior to 1996

Three years of Runway Excursion Accidents2005 to 2007

$15MLanded longB737-400Makassar, Indonesia25 Dec 2006

$52M23 F + 15 SLanded long & fastB737-400Yogyakarta, Indonesia

7 Mar 2007

$37MLanded longEMB-190Santa Maria, Columbia

17 Jul 2007

$602M199 F + 11 SLanded longA320Sao Paulo, Brazil17 Jul 2007

$20MLanded long & fastMD-82Phuket, Thailand16 Sep 2007

$60MLanded longA320Butuan, Philippines26 Oct 2007

$10MLanded long & fastB727Lagos, Nigeria7 Sep 2006

$15MLanded longB737-200Tarakan, Indonesia3 Oct 2006

$7MLanded longBAe-146Stord, Norway10 Oct 2006

$20MFloated on wet runwayDC-10Barranquilla, Columbia

17 Nov 2006

$35M1 F + 1 SLate thrust reverserB737-700Chicago, IL, USA8 Dec 2005

$15MThrust reverserMD-82Surabaya, Indonesia4 Mar 2006$15MLanded longDC-10Managua, Nicaragua4 Jun 2006

$70M131 FThrust reverserA310Irkutsk, Russia9 Jul 2006

$60MLanded long & fastB747-200Dusseldorf, Germany24 Jan 2005

$25MLanded long & fastMD-83Cali, Columbia8 Jan 2005

$235M11 SLanded long & tailwindA340Toronto, Canada2 Aug 2005

$25MUnstable approachDC-10Chittagong, Bangladesh

1 July 2005

$1,518M $506M/year

354 Fatal38 Serious

$200MLanded long & tailwindA340Quito, Ecuador9 Nov 2007



$15MLanded longB737-400Makassar, Indonesia25 Dec 2006

$52M23 F + 15 SLanded long & fastB737-400Yogyakarta, Indonesia

7 Mar 2007

$37MLanded longEMB-190Santa Maria, Columbia

17 Jul 2007

$602M199 F + 11 SLanded longA320Sao Paulo, Brazil17 Jul 2007

$20MLanded long & fastMD-82Phuket, Thailand16 Sep 2007

$60MLanded longA320Butuan, Philippines26 Oct 2007

$10MLanded long & fastB727Lagos, Nigeria7 Sep 2006

$15MLanded longB737-200Tarakan, Indonesia3 Oct 2006

$7MLanded longBAe-146Stord, Norway10 Oct 2006

$20MFloated on wet runwayDC-10Barranquilla, Columbia

17 Nov 2006

$35M1 F + 1 SLate thrust reverserB737-700Chicago, IL, USA8 Dec 2005

$15MThrust reverserMD-82Surabaya, Indonesia4 Mar 2006$15MLanded longDC-10Managua, Nicaragua4 Jun 2006

$70M131 FThrust reverserA310Irkutsk, Russia9 Jul 2006

$60MLanded long & fastB747-200Dusseldorf, Germany24 Jan 2005

$25MLanded long & fastMD-83Cali, Columbia8 Jan 2005

$235M11 SLanded long & tailwindA340Toronto, Canada2 Aug 2005

$25MUnstable approachDC-10Chittagong, Bangladesh

1 July 2005

$1,518M $506M/year

354 Fatal38 Serious

$200MLanded long & tailwindA340Quito, Ecuador9 Nov 2007



$500M/year Due to Runway Excursions

Runway Safety Fatality Data

1995–2008

Number of Fatal Accidents (Onboard Fatalities)

Incursions: 5 (129)

1,429 Total Accidents492 fatal accidents (33%)

Excursions: 34 (712)

Confusion: 2 (132)

Fatal and Non-Fatal Runway Accidents by Type, 1995 Through 2008

0 50 100 150 200 250 300 350 400 450

Runway Excursion

Runway Confusion

Runway Incursion

Fatal

Non-Fatal

Number of Accidents

05/03/23

FSF RSI - E Weener

47

Runway Excursions - Type

0

50

100

150

200

250

300

350

400

450

500

Takeoff Landing

Coun

ts (n

=548

)

21%

79%

05/03/23

FSF RSI - E Weener

480

10

20

30

40

50

60

70

80

Veer Off Overrun

Coun

ts (n

=113

)Takeoff Excursions

37%

63%

05/03/23

FSF RSI - E Weener

490

50

100

150

200

250

Overrun Veer Off

Coun

t (n=

435)

Landing Excursions - Type

47%53%

Takeoff Excursions - Fleet Composition

0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

30.0%

35.0%

40.0%

45.0%

50.0%

Other Business Jets Jet Transports Turboprop

6%

17%

36%

41%

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

50%

Other Business Jet Turboprop Jet Transports

Landing Excursions - Fleet Composition

3%

19%

35%

43%

Takeoff Excursions – Top 10 Factors

Landing Excursions – Top 10 Factors

Corp/Biz Aircraft vs. Full Fleet - Landing Excursions

Runway Safety Observations

• Severity of runway excursions dependent on: - Energy of aircraft when departing the runway - Airport layout, geography, and rescue capability

• Data shows we are being effective in preventing runway incursion accidents, but the number of incidents and severity still indicates a very high risk• Data shows runway excursions are the most common type of runway safety accident (96%) and the most common type of fatal runway safety accident (80%)

Runway Safety Observations• New procedures (e.g., Auckland, NZ)

may be helpful in reducing the risk in some runway incursion and runway confusion situations – but not all• In the case of runway confusion, many runway incursion interventions may be useful (e.g., moving map) • In the case of runway excursions, a major risk reduction factor is flying a stabilized

approach with landing in the touchdown zone

Basics

- Energy = Mass X V2

- Effect of reverse thrust is significantly greater on a contaminated runway- Calculations and rules are important, but so is adhering to the conditions used to calculate them: * e.g., abort past V1 * Land long, land fast

- Stabilized approach with landing in touchdown zone

Top Mitigating Factors• A mishandled Rejected Takeoff (RTO)

increases risk of takeoff runway excursion

– Operators should emphasize and train for proper execution of RTO decision

– Training should emphasize recognition of takeoff rejection issues• Sudden loss or degradation of thrust• Tire and other mechanical failures• Flap and spoiler configuration issues

– Training should emphasize directional control during deceleration

– CRM and adherence to SOPs are critical in time critical situations such as RTOs

58

Top Mitigating Factors (cont.)

• Takeoff performance calculation errors increase the risk of a takeoff runway excursion

– Operators should have a process to ensure proper weight and balance, including error detection

– Operators should have a process to ensure accurate takeoff performance data

59


• Unstable approaches increase the risk of landing runway excursions– Operators should define, publish, and train

the elements of a stabilized approach– Crews should recognize that fast and high

on approach, high at threshold, and fast, long and hard touchdowns are major factors leading to landing excursions

– ATC/ATM should assist crews to meet stabilized approach criteria

60


• Failure to recognize the need for and to execute a go-around is a major cause of landing runway excursions

– Operator policy should dictate a go-around if an approach does not meet the stabilized approach criteria

– Operators should implement, and support no-fault go-around policies

– Training should reinforce these policies61


• Contaminated runways increase the risk of runway excursions

– Aircrews should be given accurate, useful, and timely runway condition information

– A universal, easy to use method of runway condition reporting should be developed to reduce the risk of runway excursions

– Manufacturers should provide operational and performance information to operators for the spectrum of runway conditions they might experience

62


• Thrust reverser issues increase the risk of runway excursions

– Flight crew application of reverse thrust is most effective at high speeds

– Flight crews should be prepared for mechanical malfunctions and asymmetric deployment

63


• Combinations of risk factors (such as abnormal winds and contaminated runways or unstable approaches and thrust reverser issues) have an undesirable synergistic effect on the risk of runway excursions

– Airports and controllers should insure that accurate winds for landing are provided to the aircrew in a timely manner

– Aircrews should use a runway excursion risk awareness tool to increase their awareness of the runway excursion risks involved with each landing

64


• Establishing and adhering to standard operating procedures (SOPs) will enhance flight crew decision making and reduce the risk of runway excursions

• – Management and aircrews should mutually

develop SOPs– SOPs should be regularly reviewed and

updated by a management and aircrew team

65


• The survivability of a runway excursion depends on the energy of the aircraft as it leaves the runway surface and the terrain it must traverse prior to coming to a stop

– All areas surrounding the runway should conform to ICAO Annex 14 specifications

– All runway ends should have a certified runway end safety area (RESA) or appropriate substitute (e.g., EMAS)

– Aircraft rescue and fire fighting (ARFF) personnel should be trained and available at all times during flight operations

66


• Universal standards related to the runway and the conditions, and comprehensive performance data related to aircraft stopping characteristics, assist in reducing the risk of runway excursions

– Regulators should develop global, uniform standards for runway condition measuring and reporting, and aircraft performance data

67

• 3 Critical Items for Success:

Basic Plan

1. Identify high risk areas (with data) 2. Develop interventions to reduce the risk in the highest risk areas 3. Get information out

internationally * On a regionally tailored basis * In a user friendly format

Report of the Runway Safety Initiative

Reducing the Risk of Runway Excursions

FSF Goal:Make aviation safer by reducing the risk of an accident

runway safety initiative briefing

Documents