Anatomy of a Runway Incursion

1. Anatomy of a Runway Incursion Or What Went Wrong?

6. SO WHAT WENT WRONG?

7. Los Rodeos Airport Tenerife, Canary Islands, March 27, 1977 Day/IFR Weather - Light Rain Visibility - Restricted; Fog & Low Clouds 583Passengers & Crew

8. Taipei’s Chang Kai Shek International Airport, October 31, 2000 Night/IFR Weather - Heavy Rain Visibility - 600 meters Typhoon in area 179 Passengers & Crew 83 Fatalities Aircraft impacted equipment on closed runway during takeoff

9. Linate Airport, Milan, Italy October 8, 2001 Citation strayed onto runway during MD-80’s takeoff roll Day/IFR Visibility - Restricted; Fog 114 Passengers & Crew 114 Fatalities

10. WHAT WENT WRONG?

12. RUNWAY INCURSION FAA Order 7210.58 Any occurrence at an airport involving an aircraft, vehicle, person, or object on the ground that creates a collision hazard or results in a loss of separation with an aircraft taking off, intending to takeoff, landing, or intending to land.

13. Severity Categories A B Runway Incursion Severity Categories C D

14. Severity Categories Animated Illustration 9 A B C D Significant potential for collision Barely avoid collision Ample time and distance to avoid collision Little or no risk of collision • Above scenarios are all classified as runway incursions, but with different severity codes. • In each case the taxiing aircraft penetrated the runway safety area (hold position) AND • A collision hazard or loss of separation occurred with the landing aircraft.

15. Surface Incident • An unauthorized movement within the area • An occurrence in a movement area affecting safety of flight Examples: VPD’s, taxiway incursion, animal on runway, operational deviation, etc.

16. Pilot Deviations Actions that violate a Federal Air Regulation

17. Operational Errors Occurrences that result in: 1) less than applicable separation, or 2) authorization for aircraft to land or depart closed runway

18. Vehicle or Pedestrian Deviations Occur when a vehicle operator, pedestrian, non-pilot operator or aircraft enters a movement area without ATC authorization.

19. SO WHAT WENT WRONG?Let’s Review

20. Conditions at Time of Runway Incursions Airport Diagram Not Used Unfamiliar with Airport Signage Not Familiar with Airport Failed to Follow Instructions Inexperienced at Towered Airports (Phraseology) Unfavorable Environmental Conditions Clearance Not Read back HUMAN ERROR

21. Major Runway Incursion Causes • Spatial Disorientation • Loss of Situational Awareness • Unclear/Ineffective CRM • Misunderstanding ATC • Disorientation • Lapse in short term memory HUMAN ERROR

22. FACTORS HUMAN

23. Human Factors Fatigue (double shifts) Employee turnover Stress (job related) Distractions in Cockpit- down head time, attention to squawked items NO CELL PHONES Complacency Language

24. 5 Hazardous Attitudes Anti-Authority Impulsitivity Invulnerability Macho Resignation Responsibility Trust… no one to come behind to check if you do it wrong Poor Judgement

25. Case Study:December 6, 1999 Approximately 8:35 PM Theodore Francis Green State Airport Providence, Rhode Island Click to Continue

26. On 12/6/99, at about 8:35 p.m., United Airlines Flight 1448, a Boeing 757, was involved in a runway incursion on Runway 5R at Theodore Francis Green State Airport, near Providence, Rhode Island.

27. At the time of the incident, it was dark and the reported visibility was 1/4 mile in dense fog. Tower and Ground Control positions were combined. Click to Continue

28. V 16 23R A 23L M B N N N T B C K T K 5L D Tower K 34 S 5R The following slides contain the actual ATC recording of the runway incursion incident. Transcription of the audio will appear in this area. Aircraft movement and position will appear in the diagram to the right. Click Here to Begin

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