Runway Incursion Causal Analysis

1. Section 3 Runway Incursion Causal Analysis

2. Genesis of a Incursion A safety hazard/ runway incursion is likely to occur when the exact location of an aircraft or vehicle on the airport surface in relation to a specific ATC clearance is unknown. PILOTS and VEHICLE OPERATORS must taxi and maneuver their aircraft/vehicles on taxiways and runways in accordance with ATC instructions. CONTROLLERS must monitor the location and progression of the aircraft and vehicles operating on the airport surface, in accordance with instructions issued, to provide separation assurance.

3. Runway Incursion Causal Categories OPERATIONAL ERROR (OE)- A human error caused by a tower controller. There are over 8000 tower controllers in the U.S. PILOT DEVIATION (PD) - A human error caused by a pilot. There are over 675,000 licensed pilots in the U.S. VEHICLE/PEDESTRIAN DEVIATION (V/PD) - A human error caused by a vehicle operator or pedestrian which results in an entry onto the movement area that has not been authorized by ATC.

4. V/PD OE/D 21% 23% PD 56% Runway Incursion History Comparison by Error Distribution (data as of July 2002) Vehicle/Pedestrian Deviation Operational Error Pilot Deviation - Office of Runway Safety

5. Operational Error (OE) CONTROLLERS are at risk of being a party to an incursion when they are unable to correlate their visual observations of the aircraft/vehicle location with previously issued ATC instructions. Some contributing factors include: -FAILURE TO FOLLOW ESTABLISHED STANDARDIZED PROCEDURES -FAILURE TO UNDERSTAND THE IMPLICATIONS OF THEIR ACTIONS OR INACTIONS -LACK OF TRAINING & PRACTICE TO INTERNALIZE PROCEDURES -LOSS OF SITUATIONAL AWARENESS

6. Primary Performance Factors of Operational Error Runway Incursions (1997-2001) There were 430 Operational Error Runway Incursions 398 of these Operational Errors were analyzed • 186 loss of arrival/departure separation on same/intersecting runways 55 involved a simultaneous runway crossing with an aircraft landing or departing with coordination

7. Primary Performance Factors of Operational Error Runway Incursions (Continued) 54 other operational errors included: mistaking the location of aircraft or vehicle on/near runway, clearing aircraft to land/depart from closed runway, and errors involving taxi into position and hold (TIPH). • 52 simultaneous runway crossings with an aircraft landing or departing with lack of coordination 51 “hear back/read back” involving entries or crossings

8. 200 186 180 158 160 140 51 120 100 52 80 60 40 55 20 0 Primary Performance Factors of Operational Error Runway Incursions (1997-2001) Loss of Separation on the Runway Crossing “Read Back/ Hear Back” Lack of Coordination between Ground and Local with Crossing Simultaneous Runway Crossing with Arrival and Departure Other OEs included mistaken traffic location, usage of closed runway, and misuse of TIPH clearance.

9. 50 45 40 35 30 Percentage 25 20 15 10 5 0 Lost Situational Improper Procedures Poor Judgement Faulty Crew Poor Communications Awareness Coordination Causal Factors Operational Errors (OE) (data from category A & B incursions between 1997-2000) - FAA Report on Runway Incursion Information Evaluation Program, 10/12/01 for the period of March 17, 2000 through March 16, 2001.

10. Pilot Deviation (PD) PILOTS are at risk of being a party to an incursion when they are unable to correlate their visual observations of airport signs, markings and lighting and other physical features on the airport with the specific ATC taxi instructions. Contributing Factors: -FAILURE TO ASK FOR HELP WHEN CONFUSED -FAILURE TO USE THE AIRPORT DIAGRAM -LACK OF TRAINING -NOT FAMILIAR WITH THE AIRPORT

11. Primary Performance Factors of Pilot Deviation Runway Incursions (1997-2001) There were 972 Pilot Deviation Runway Incursions 719 of these Pilot Deviations were analyzed 87 other pilot deviations included: landing over aircraft in position and landing/departing on closed/wrong runways, taxiways, etc. • 537 pilots entered the runway or crossed the hold short line after acknowledging hold short instructions 95 pilots took off without clearance after acknowledging “taxi into position and hold” (TIPH) instructions

12. 600 537 500 400 300 200 90 95 100 0 Primary Performance Factors of Pilot Deviation Runway Incursions (1997-2001) Landed over Traffic in Position or Used Incorrect Surface for Departure / Landing Violated Hold Line after Acknowledging Hold Short Departed without Clearance after Acknowledging TIPH Instructions

13. Conditions at Time of Runway Incursions 60 50 40 Percentage 30 20 10 0 Not Familiar with Not Familiar with Unfavorable Clearance was Inexperienced at Airport Diagram Failed to Follow Airport Signage Airport Environmental Not Readback Towered Airports Not Used Instructions Conditions Causal Factors Pilot Deviations (PD) Pilot Interviews (data from category A & B incursions between 1997-2000) - FAA Report on Runway Incursion Information Evaluation Program March 17, 2000 through March 16, 2001

14. Other 2% Commercial 21% VPD OE PD General Aviation 77% Distribution of Pilot Deviations(approximate percentages) - Office of Runway Safety

15. Pedestrian Deviation (V/PD) VEHICLE OPERATORS and PEDESTRIANS are at risk of being a party to an incursion when they are unable to correlate their visual observations of airport signs, markings and lighting and other physical features on the airport with the specific ATC taxi instructions. Some contributing factors include: -FAILURE TO ASK FOR HELP WHEN CONFUSED -FAILURE TO USE THE AIRPORT DIAGRAM -LACK OF TRAINING -NOT FAMILIAR WITH AIRPORT

16. Primary Performance Factors of Vehicle/Pedestrian Runway Incursions. All 350 Vehicle/Pedestrian Runway Incursions were analyzed • 217 entered the runway without communications or authorization 157 POVs and pedestrians60 airport vehicles 133 instructed to hold short and read back but still entered the runway 109 airport vehicles24 by a non-pilot maintenance taxiing an aircraft End of Section 3