Best Practices Guide. For the Prevention of Runway Excursion for Air Traffic Controllers and Pilots

Transcription

1 Best Practices Guide For the Prevention of Runway Excursion for Air Traffic Controllers and

2 Introduction Runway excursions are the most common type of accident. From , there were 594 total commercial accidents during this period: 164 of these accidents were runway excursions (28%) 20 runway excursion accidents involved fatalities This resulted in 483 passenger and crew fatalities Excursions as ratio to # of accidents Runway Excursions % 24% 24% 35 27% 27% 32% The % is relative to the total number of accidents during that year Actual Runway Excursions Runway excursions occur during takeoff and landing, and are may result in the aircraft ending up off of the side of the runway (e.g., a veer off ) or off the end of the runway (e.g., an overrun). Of these 164 runway excursions: 89 were veer off accidents (54%) 75 were overrun accidents (46%) 17% occurred during takeoff 83% occurred during landing Many different casual factors are normally present in each accident or incident. For takeoff, accurate planning, runway information, and cockpit preparations are essential. Runway excursions during landing often are a result of a poorly executed approach. A stable approach is the desired outcome, and results when the air traffic controller and the pilots partnership allows the aircraft to achieve an approach to a suitable runway that is on glide slope and stabilized at the planned approach speed at a reasonable altitude. The purpose of this document is to provide both controllers and pilots with best practices in communications and procedures that ensure that safe takeoffs and stabilized approaches are routinely achieved. It does not happen by accident but is the result of extensive planning, monitoring, communication, proficiency, and professionalism. Communications between the flight crew and controller is vital: both sides must communicate their needs and capabilities in a clearly understood and timely manner. If either party is uncomfortable, rushed, or otherwise feels compromised- discontinue the operation and set up for another try. It can happen in any phase of flight but is most critical in the approach and landing. Best practices Guide Runway Excursion Prevention 2 RERR 2 nd Edition

3 RISK ASSESSMENTS by phase of flight 1. Risk Assessment Prior to Commencing Flight Operations Flight Operations Dept/ Dispatcher/ Pilot-in-command Airspace Design/ Air Navigation Service Provider (ANSP) Conduct thorough risk assessment of the operational and environmental characteristics of the airfield layout and limitations and the available published departure and approach procedures by using a systematic study of charts and AIP, pilot reports, NOTAMS and intelligence from local ATC and operators Having identified significant potential threats, analyze them and determine whether they are unacceptable, acceptable or manageable. If manageable, then develop risk management strategies to ensure that the residual risk is acceptable. If the risks are unacceptable then alternatives must be found or not operate the flight. All residual threats and the associated quantified risk should be catalogued in the appropriate operational airfield guide for pilots. Review the characteristics of the airspace, the approaches and the airfield, ideally in coordination with the airport authority and local operators to determine conditions and characteristics with the potential to unduly hazard operations Having identified the hazards, devise solutions which are operationally efficient, or where that is not possible lobby for inclusion in the local AIP to ensure that operators and pilots are made aware via their aeronautical charting. Establish a process to gain routine operator input to identify emerging hazards 2. Risk Mitigation Studies Flight Operations Dept. (if available) Utilize Flight Data Analysis (FDA, or Flight Operations Quality Assurance Data (FOQA)) to identify runways with high rates of unstable approach. Provide this information to the appropriate ATSU along with recommendations on procedural changes to improve performance ANSP/Air Traffic Services Unit (ATSU) Work with operators in identifying procedural changes to systematically reduce the rate of unstable approaches. Request deidentified, aggregated FDA information from operators to proactively assist in reducing unstable approaches Best practices Guide Runway Excursion Prevention 3 RERR 2 nd Edition

4 3. Preparation Prior to a Flight/Controller Shift Change Gather necessary information on the destination meteorological, field conditions, and when appropriate/ required the alternate airfield(s) Consider seasonal weather effects, terrain, available approaches, runway length and orientation, and any other factors affecting the safe conclusion of the flight Controllers Develop a background understanding of the environmental conditions, which historically have caused problems for pilots, by discussing with colleagues and supervisors Consider what influence the forecast weather and expected traffic density might have on these conditions 4. Taxi and Takeoff Ensure takeoff data is calculated and accurate Ensure all Flight Management System/ Electronic Flight Bag/thrust settings/airspeeds, etc, are set properly and crosschecked Know your aircraft performance capabilities and ensure that adequate margins are utilized Do not rush takeoff preparations; request takeoff delays when necessary ATC Ensure that pilot is kept informed of: Planned takeoff runway / intersection. Provide advance notification of runway changes when possible Runway Friction Reports/Runway Surface Condition Reductions in runway length and other significant changes (e.g., NOTAMS) Wind, including local wind effects Ensure appropriate radio transmissions Best practices Guide Runway Excursion Prevention 4 RERR 2 nd Edition

5 LANDING 5. Prior to Descent Having established a good understanding of the fixed characteristics of the airfield and its environment, review those that are subject to change. Attention should focus upon the most likely runway/ approach combination in the prevailing and forecast conditions but due consideration must be given to the implications of change. Critical factors in the avoidance of unstable approaches and runway excursions include: Latest airfield information- NOTAMS changes to published characteristics Available runway length* desired turn off and retardation schedule Runway condition* dry, wet, contaminated, braking action Landing performance calculated based on factors marked* Displaced threshold effect on visual cues Approach/runway lighting effect on visual cues Monitor ATIS and select auto- updates if field conditions rapidly change. Repeat as necessary for possible runway/approach changes ATC Traffic Pattern Planning Pattern density potential for holding/ track shortening Radar/ procedural control degree of flexibility from ATC Possible track shortening appropriate margin in descent plan Arrival Procedure and Planning- Correct FMS programming for primary and secondary plan Descent point appropriate altitude/ distance relationship Descent wind effect on descent point Speed & altitude constraints implications for descent planning Controllers As the shift proceeds, it will be possible to develop a picture of the short-term weather and traffic situation and begin to predict the general implications for arriving aircraft. In order to manage the energy of their aircraft a function of speed and altitude - throughout descent and approach pilots will need to know how these determining factors may change. Good, accurate communication is essential and early notification of impending change will significantly reduce cockpit workload during critical phases of flight. Consideration should be given to: Weather conditions possible weather deviation requests In-flight icing conditions require higher power settings during descent (for engine anti-icing), resulting in longer descent segments Turbulence will require aircraft to slow down, increasing the necessary distance to descend Descent wind effect on descent point Tailwinds have a very significant effect on descent capabilities: noting the location where pilots are requesting a lower altitude can provide an indication where onboard computers have calculated the optimum descent point for each cruise altitude Traffic density effect on arrival and approach Aircraft types relative performance characteristics Continuous Descent Operations, from the aircraft perspective, are the most efficient and easily managed descent/approach profile Holding early notification to allow Best practices Guide Runway Excursion Prevention 5 RERR 2 nd Edition

6 Some operations specifications forbid or limit FMS re-programming below a set altitude, transition level or MSL Approach Planning Approach type speed/ configuration/ workload Approach path angle speed/ rate of descent/ configuration implications Approach offset late maneuvering and visual acquisition Approach wind effect on rate of descent and groundspeed Meteorological Conditions- Surface wind* effect on flare, landing distance and crosswind technique Density altitude* effect on speed, flare and landing distance Aircraft Performance Aircraft weight* effect on speed, flare and landing distance Aircraft serviceability* effect on speed, technique and landing distance Approach briefing to include: Required approach stabilization criteria Intended speed/configuration profile for approach Requirement to go-around if stabilization criteria not met Special considerations due to weather or other factors Implications of increasing cockpit workload for decision making and monitoring Highest threat on that approach and mitigation. speed/descent planning Anticipated changes all operational changes have implications for cockpit workload and consideration should be given to the implications: Track shortening significant effect on descent management and may not be desirable or even acceptable Descent speed requests: any decrease in requested airspeed will increase the aircraft energy state, and a longer deceleration segment should be anticipated Approach type any change of approach requires reprogramming of the aircraft systems and nonprecision approaches have higher workload, tighter speed/configuration constraints, and provide less accurate flight path guidance. Most operations specifications forbid or limit FMS reprogramming below a set altitude, transition level or MSL Deceleration path: aircraft are much more capable of effective deceleration when level than on a descending glide path; speed increases for capacity/traffic issues should take this into consideration Runway change can have significant effect on distance to touchdown and may require recalculation of landing performance; the fewer changes in characteristics between the old and the new runways the better Runway changes below MSL should be minimized and inside of 15nm should be avoided. Last minute arrival or runway changes should include a vector or clearance direct to the final approach fix, or allow for a visual landing without FMS programming If a runway change is offered to pilot for expedition, etc., use phraseology that makes it clear that the change of runway is optional Best practices Guide Runway Excursion Prevention 6 RERR 2 nd Edition

7 6. Descent and Arrival Every arrival is subject to change so it is vital to maintain situational awareness throughout and amend the energy management plan as required to ensure that it meets the safe operation criteria for the prevailing conditions. Controllers expect the descent to be flown at consistent speeds. Advise ATC if planning to use significant changes of airspeed to manage the energy (accelerating and slowing in step descents for example). Consider the auto flight system modes appropriate to the required descent profile and understand the different mode performance characteristics. Monitor: wind and adjust descent as required compliance with speed and altitude constraints Notify ATC if they won t be met If vectored off STAR verify any constraints Make weather deviation requests early Confirm runway and approach in use Maintain situational awareness by listening for changes given to aircraft ahead. Communicate early to ATC when a specific runway or approach is: requested for ground flow, proficiency, etc. o required for landing if aircraft non-normal situations require special handling. Examples: Heavy weight aircraft may need the longest runway aligned with the wind Allow for apparent controller fatigue/high-workload /inexperience. Symptoms include: repeated missed calls, misunderstandings, incorrect read backs/language difficulties. Ensure that you use standard terminology and speak slowly and clearly when apparent misunderstandings occur. Aircraft with system malfunctions affecting final approach airspeed Controllers The magnitude of any change to the pilots original arrival and approach plan is directly proportional to the increase in cockpit workload entailed, and the more time they have to adapt the less impact this will have on other critical tasks. From top-of-descent to touchdown pilots must manage the total energy of the aircraft (potential energy or altitude, plus kinetic energy or speed), against the distance of the assigned flight track, while minimizing the use of thrust and drag to reduce fuel burn. For separation, note that pilots may slow down at intermediate level-off altitudes and accelerate in step descents to reduce need for thrust while achieving optimal rates of descent. Notify any unpublished or optional speed/altitude constraints, delays or holding early If necessary to delay descent, consider the potential need for additional track miles Pass on pilot reports of weather in the vicinity Allow for pilots needing to reduce speed in turbulence Prior to top of descent, or as soon as possible thereafter, advise track miles to touchdown If a runway change becomes likely, notify all potentially affected aircraft If cancelling STAR advise if speed/altitude constraints still apply Allow for apparent pilot fatigue/highworkload /inexperience/language difficulties. Symptoms include: repeated missed calls, misunderstandings, incorrect read backs. Ensure that you use standard terminology and speak slowly and clearly when apparent misunderstandings occur. Be aware that aircraft technical faults and bad weather inherently Best practices Guide Runway Excursion Prevention 7 RERR 2 nd Edition

8 (e.g., slat or flap failures), or deceleration capability (e.g., antiskid or braking systems, ground spoilers, engine reversers, etc) may require longer or more suitable runways increase cockpit workload When vectoring on the downwind leg, advise flight crews of the anticipated length of final or anticipated landing sequence; expect aircraft with a short final or low sequence number to need to slow and descend sooner If the pilot hasn t asked for a visual approach don t be tempted to offer it to them believing that you are doing them a favor by getting them on the ground quicker. If they haven t briefed for it they won t be expecting it. This could lead to a rushed approach increasing the risk of an unstable approach. Additionally, the crew may not be as familiar with flying a visual approach when compared to a precision approach, which again will increase the workload in the cockpit. If ATC doesn t offer the option then the pilots won t be tempted into accepting a situation that can lead to an increased risk of a rushed unstable approach Never assume that the flight crew are familiar with the approach/airport even though the aircraft operator may be unit based Ensure ATIS is current with landing runway information including significant NOTAMs Best practices Guide Runway Excursion Prevention 8 RERR 2 nd Edition

9 7. Approach Initial Approach Fix (IAF): Advise ATC if Final Approach Speed (FAS) will be different from average FAS for aircraft type In busy environments be aware that although ATC seeks to minimize speed changes, some speed changes may be necessary Review fuel state in relation to possible extended ATC vectors and/or missed approach Request track miles to touchdown (or length of final, landing sequence) if on vectors or use FMS/ approach chart to calculate if not Determine what, if any, track shortening could be acceptable Plan deceleration and configuration schedule to arrive at FAF at desired speed/configuration; do not accept unacceptably high FAF airspeeds from FAF Monitor wind and adjust energy management as necessary If offered track shortening review aircraft energy vs. remaining distance to determine if acceptable politely decline if not If required profile becomes unmanageable for any reason request extra miles early Listen out for pilot/atc reports of conditions on final approach and adjust speed and configuration as appropriate; notify ATC of unusual weather conditions via PIREP Plan to intercept final approach descent path from below Use autopilot as appropriate to reduce workload Final Approach Fix: Confirm final approach descent path (glidepath) has been intercepted /captured Confirm configuration completed in accordance with SOP Complete landing checklist in Controllers Initial Approach Fix (IAF): Unless advised otherwise pilots will be expecting to be in the groove from the IAF and should have a plan for deceleration and configuration to meet any constraints and to arrive at the FAF ready for the final approach. Any ATC changes to speed, altitude and distance may disrupt the plan and increase the cockpit workload, and ideally should be minimized. Monitor altitude/distance relationship if unusually high consider offering additional miles Provide regular and accurate track mileage information Do not shorten the track of an aircraft that already appears high do not request additional miles unless they really need them Advise of any pilot weather reports on approach Advise of any significant changes in surface conditions, the pilots will no longer be listening to the ATIS Minimize changes to missed approach and if necessary keep as simple as possible and advise as early as possible. Final Approach Fix: From the FAF onwards pilots options for changing the energy management plan are very limited, as they are committed to a specific flight path trajectory to landing. Any new instructions to change speed will almost certainly disrupt the plan. The emphasis also changes from communicating as much information as possible in a timely manner, to restricting communications to only information vital to the safe completion of the approach. Best practices Guide Runway Excursion Prevention 9 RERR 2 nd Edition

10 accordance with SOP Monitor wind on final approach report significant variations to ATC (after landing) Be aware that, although ATC give landing clearances as soon as possible, if following ICAO procedures and using minimum separation, a landing clearance may not become available until approximately 500 feet above runway If stabilization criteria not met as required, go-around Make all flight path deviation callouts as required by SOP If stabilization criteria subsequently breached, go-around MDA/DH: Confirm required visual references are met, if not go-around Confirm visual picture meets expectation displaced threshold for example Establish/maintain rate of descent to achieve correct touchdown point Be alert to low level wind changes and adjust accordingly If stabilization criteria breached below MDA/DH, go-around Minimize radio calls and ensure timely/accurate response and read back Avoid instructions with regard to speed if possible Give landing clearance as early as practical If necessary to amend the published missed approach keep it simple Report significant changes in surface conditions When the aircraft is on short finals, don t change the configuration or brilliance of the approach lighting unless requested to by the landing aircraft. Be aware that the ILS is designed to intercept the localiser first and then the glide path (GP). If the GP is captured first then the aircraft may not be able to continue the approach without becoming unstable and the associated risk of CFIT increases MDA/DH: Confine radio calls to matters of urgency or emergency only 8. Landing Land the aircraft per the operating manual. Avoid a tailstrike or nosewheel first touchdown Deploy retardation devices (spoilers, reversers, brakes) in a timely manner Monitor deceleration and manage retardation as required to guarantee stopping on the runway Maintain the centerline using approved crosswind technique Land in runway s touchdown zone If past the touchdown zone- go-around Following a significant bounce, goaround Controllers Confine radio calls to matters of urgency or emergency only until the aircraft has slowed nearing taxi speeds Provide minimal taxi clearance information during landing rollout: (e.g. next left turn on Alpha, contact ground ) Notify flight crew when crossing runways are available for runway exit Best practices Guide Runway Excursion Prevention 10 RERR 2 nd Edition

11 9. Go-Around/ Balked Landing Unless there is risk of ground contact or collision do not rush initiation Use autopilot to reduce workload Announce clearly and use SOP Confirm correct auto flight modes engage Check correct missed approach altitude set Visually clear for traffic (when applicable) Expect instructions for a visual goaround Advise ATC when able Controllers Be aware of increased cockpit workload If necessary/desirable to change missed approach altitude/track ensure correct understanding For visual approaches, provide missed approach instructions with the go-around request Best practices Guide Runway Excursion Prevention 11 RERR 2 nd Edition

12 Reference Documents ICAO Doc 9426-AN/924 Air Traffic Services Planning Manual ICAO Accident Prevention Programme 2005 ICAO Annex 11 to the Convention on International Civil Aviation- Air Traffic Control Service; Flight Information Service; Alerting Service CHAPTER 2. General 2.16 Coordination between the operator and air traffic services 2.20 Coordination between meteorological and air traffic services authorities 2.21 Coordination between aeronautical information services and air traffic services authorities 2.27 Safety management CHAPTER 7. Air traffic services requirements for information 7.1 Meteorological information 7.2 Information on aerodrome conditions and the operational status of associated facilities 7.3 Information on the operational status of navigation aids ICAO Annex 13 to the Convention on International Civil Aviation- Aircraft Accident and Incident Investigation CHAPTER 8. Accident Prevention Measures Incident reporting systems Database systems Analysis of data Preventive actions Exchange of safety information Civil Air Navigation Services Organization (CANSO) Unstable Approaches-ATC Considerations, Aug 2009 Direction generale de l Aviation Civile (DGAC), Air France Stabilized Approaches Good Practice Guide Flight Safety Foundation (FSF) Approach and Landing Reduction (ALAR) toolkit IATA and Flight Safety Foundation (FSF) Runway Excursion Risk Reduction (RERR) toolkit Aug 2009 Best practices Guide Runway Excursion Prevention 12 RERR 2 nd Edition