Operational Safety Study: Controller Detection of Potential Runway and Manoeuvring Area Conflicts

Transcription

1 Network Maager omiated by the Europea Commissio EUROCONTROL Operatioal Safety Study: Cotroller Detectio of Potetial Ruway ad Maoeuvrig Area Coflicts Editio 1.0 Editio date: 01/12/2015 Status: Released Issue Iteded for: Geeral Public

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3 DOCUMENT APPROVAL The followig table idetifies all maagemet authorities who have successively approved the preset issue of this documets. Authority Name ad sigature Date Operatioal Safety Coordiator, DNM/NOM/SAF Mr. Tzetomir Blajev 01/12/2015 Head of Safety Uit, DNM, NOM Mr. Atoio Licu 02/12/2015 Head of Network Operatios Maagemet Divisio Mrs. Nicola Cooper 02/12/2015 Director NM Mr. Joe Sultaa 07/12/2015 Operatioal Safety Study Cotroller Detectio of Potetial Ruway ad Maoeuvrig Area Coflicts Editio 1.0 3

4 DOCUMENT CHANGE RECORD The followig table records the complete history of the successive editios of the preset documet. Editio Number Editio Date Reaso for chage Pages affected /09/2013 Creatio of the Workig Draft All /01/2014 First draft versio All /08/2014 Secod draft versio All /10/2015 Third draft versio All /11/2015 Proposed Issue All /12/2015 Released Issue All TIT

5 TABLE OF CONTENTS DOCUMENT APPROVAL 3 DOCUMENT CHANGE RECORD 4 EXECUTIVE SUMMARY 7 CHAPTER 1 - INTRODUCTION What is the purpose of this documet? What are the Network Maager Top 5 ATM Operatioal Safety Priorities for 2014/2015? How was the Top 5 idetified? 10 CHAPTER 2 - STUDY SCOPE AND PRE-SET ASSUMPTIONS Scope Pre-Set Assumptios Defiitio of Barriers for the purposes of this study Prevetative Barriers Mitigatig Barriers 12 CHAPTER 3 - THE GENERIC PROCESS 13 CHAPTER 4 - OPERATIONAL CONTEXT Operatioal cotexts Surveillace iformatio Visibility coditios from the Tower Ruways cofiguratio Lie of sight ATC Safety Net Alerts 16 CHAPTER 5 - GENERIC SCENARIOS How should geeric operatioal scearios be defied? Aalytical decostructio of operatioal scearios The resultig list of geeric operatioal scearios for aalysis 19 CHAPTER 6 - BARRIERS Barriers as a opportuity i some situatios Two types of barriers Barriers prevetig ruway icursio ad groud safety evets ivolvig iadequate detectio by cotrollers (PB) Barriers mitigatig ruway icursio ad groud safety evets ivolvig detectio by cotrollers (MB) 26 OperOperatioal Safety Study Cotroller Detectio of Potetial Ruway ad Maoeuvrig Area Coflicts Editio 1.0 5

6 CHAPTER 7 - ANALYSIS OF BARRIERS IN GENERIC SCENARIOS Prevetio Barrier Assessmet Depedecies Colour code used i the Barrier Aalysis tables Key to Yellow costraits Prevetio Barrier Aalysis Tables Mitigatio Barrier Assessmet Combied Barrier Assessmet 45 CHAPTER 8 - ACTUAL RUNWAY INCURSION AND GROUND SAFETY EVENTS Evet 1. Cleared to cross ruway with aircraft departig Evet 2 Cleared for take-off with aircraft crossig ruway Evet 3. Liig up without clearace Evet 4: Cleared for take-off with ruway still occupied by previous aircraft Evet 5. Cleared for take-off o closed ad obstructed ruway Evet 6: Aircraft uder tow crossig ruway with misuderstood coditioal clearace Evet 7: Cleared for take-off o obstructed ruway Evet 8: Vehicle etered ruway without clearace Evet 9: Cleared for take-off o obstructed ruway Evet 10: Lied up without clearace Evet 11: Etry oto ruway after icorrect ATC coditioal clearace Evet 12: Cleared to lad o obstructed ruway Evet 13: Simultaeous take-off o itersectig ruways after mishear of ATC clearace Evet 14: Cleared for take-off o obstructed ruway Evet 15: Etered ruway without clearace after taxy avigatio error Evet 16: Crossed active ruway after icorrect clearace Evet 17: Cleared to lad o obstructed ruway Evet 18: Crossed ruway without clearace with aircraft takig-off Evet 19: Take-off o taxiway Evet 20: Icorrect taxy route resultig groud collisio 82 CHAPTER 9 - ANALYSIS OF ACTUAL SAFETY EVENTS 84 CHAPTER 10 - CURRENT STUDIES AND FUTURE DEVELOPMENTS 89 CHAPTER 11 - CONCLUSIONS AND RECOMMENDATIONS 101

7 EXECUTIVE SUMMARY The EUROCONTROL Safety Improvemet Sub-Group (SISG), reportig to the EUROCONTROL Safety Team, was tasked to idetify the Top 5 ATM Operatioal Safety Priorities. SISG performed a review durig summer 2012 ad ivolved a series of dedicated workshops with 6 ANSPs, represetig a large part of Europea air traffic. Comprehesive barrier models Safety Fuctios Maps (SAFMAPs) - were developed ad populated with represetative data from the participatig ANSPs. The icidet data is for high severity (classified as A ad B ) evets, which are o oe side thoroughly ivestigated ad o the other side highly iformative because the icidet scearios test the majority of the available safety barriers. As a result of the SAFMAP aalysis the Top 5 priority areas were suggested, agreed by SISG ad edorsed by the Safety Team: Risk of operatio without traspoder or with a dysfuctioal oe Ladig without ATC clearace Detectio of occupied ruway Blid spot iefficiet coflict detectio with the closest aircraft Coflict detectio with adjacet sectors The purpose of this report is twofold: To documet the operatioal safety study o the third of the Top 5 Network Maager operatioal safety priorities for 2014/15 Detectio of occupied ruway. To serve as a referece for the Network actors i case they udertake operatioal safety aalysis ad improvemet activities regardig the risk related to u-detectio of the occupied RWY. Note: It was decided that to exted the origial requiremet to cosider the barriers available to ATC to prevet or mitigate other potetial coflicts o the Maoeuvrig Area. This icludes ladig or departig o a taxiway ad groud collisios. Cosequetly the title was chaged to Cotroller Detectio of Potetial Ruway ad Maoeuvrig Area Coflicts. The priorities were reviewed by SISG with SAFMAP aalysis of the data for year 2013 ad re-cofirmed as Top 5 priorities for The methodology employed was as follows: Geerate a set of geeric scearios from possible sceario sources, mechaisms ad outcomes. Cosider what barriers exist that if implemeted ad deployed correctly could prevet a ruway icursio as result of u-detectio of the ruway occupatio. Cosider what barriers exist that if implemeted ad deployed correctly could mitigate the impact of a ruway icursio as result of u-detectio of the ruway occupatio. Aalysis of each geeric sceario agaist the potetial barriers to establish which of these barriers could be most effective over the whole rage of scearios. Review a set of actual evets to cofirm that the barriers suggested by the geeric aalysis validate that the same barriers should be the most effective i the live eviromet. Cosider curret idustry best practice ad kow future developmets. Draw coclusios from the study ad make recommedatios to stakeholders. This study has idetified eight basic operatioal sceario outcomes ivolvig cotroller detectio of potetial ruway ad maoeuvrig area coflicts. Te barriers were idetified as beig available to ATC to prevet or mitigate the impact of such evets. Operatioal Safety Study Cotroller Detectio of Potetial Ruway ad Maoeuvrig Area Coflicts Editio 1.0 7

8 The sigle most efficiet barrier is the iput ad display of ATC clearaces ad surveillace data to joitly detect o-coformace to clearace ad the potetial impact of icorrect clearaces. This fuctioality is ot yet widely available; however, this study leds strog support to its developmet ad deploymet. This study also foud that ATC resolutio followig a alert from a pilot or driver was the commo ad effective barrier employed i the mitigatio of ruway ad maoeuvrig area coflicts. This validates the importace of cross-idustry traiig i safety awareess. This study idetified that the most frequet ATC cotributig factors preset i the sequece of actios leadig to ruway ad maoeuvrig areas safety occurreces are: Memory most commoly a failure to check/moitor i.e. ot followig ormal practice. Perceptio most commoly a failure to see somethig. Operatioal eviromet commoly distractios, visual impairmets ad oise. Commuicatio errors icomplete, icorrect or ambiguous RTF. The study also oted a sigificat umber of idividual factors that were withi the remit of Airport Authorities. Recommedatios are made that: Europea ANSPs ad Airport Authorities review the idetified prevetive barriers ad cotributory factors i case they udertake operatioal safety aalysis ad improvemet activities for Cotroller Detectio of Potetial Ruway ad Maoeuvrig Area Coflicts Europea ANSPs ad the EUROCONTROL Safety Improvemet Sub-Group (SISG) moitor occurreces ivolvig Cotroller Detectio of Potetial Ruway ad Maoeuvrig Area Coflicts to determie chages i frequecy ad severity. All Europea idustry stakeholders moitor ad support the developmet of tools ad fuctioality that iclude the iput ad display of ATC clearaces ad surveillace data to joitly detect o-coformace to clearace ad the potetial impact of icorrect clearaces. Europea ANSPs ad the EUROCONTROL Safety Improvemet Sub-Group (SISG) udertake a operatioal safety study o the subject of sudde high eergy ruway coflicts. 8

9 CHAPTER 1 - INTRODUCTION 1.1 What is the purpose of this documet? Documetig ad commuicatig The purpose of this report is twofold: To documet the operatioal safety study o oe of the Top 5 Network Maager operatioal safety priorities for 2014 Cotroller Detectio of occupied RWY. To serve as a referece for the Network actors i case they udertake operatioal safety aalysis ad improvemet activities for cotroller detectio of occupied RWY. Note: It was decided to exted the origial requiremet to cosider the barriers available to ATC to prevet or mitigate other potetial coflicts o the Maoeuvrig Area. This icludes ladig or departig o a taxiway ad groud collisios. Cosequetly the title was chaged to Cotroller Detectio of Potetial Ruway ad Maoeuvrig Area Coflicts. 1.2 What are the Network Maager Top 5 ATM Operatioal Safety Priorities for 2014/2015? 1. Risk of operatio without traspoder or with a dysfuctioal oe 2. Ladig without ATC clearace 3. Detectio of occupied ruway 4. Blid spot iefficiet coflict detectio with the closest aircraft 5. Coflict detectio with adjacet sectors Operatios without traspoder or with a dysfuctioal oe costitute a sigle threat with a potetial of passig through all the existig safety barriers up to see ad avoid. For various reasos, aircraft sometimes lad without ATC clearace resultig i Ruway Icursios that are ofte oly resolved by providece. Some Ruway Icursio icidets could have bee preveted if cotrollers had had better meas to detect that the ruway was occupied at the time of issuig clearace to the ext aircraft to use the ruway. Loss of separatio Blid Spot evets are typically characterised by the cotroller ot detectig a coflict with the closest aircraft. They usually occur after a descet clearace ad i the cotext of a rapidly developig situatio ofte whe the coflictig aircraft are 1000ft ad 15 m apart. Losses of Separatio i the E-Route eviromet sometimes ivolve iadequate coordiatio of clearace with a adjacet sector. These typically ivolve either a early (premature) trasfer of cotrol to or from the eighbourig sector. Operatioal Safety Study Cotroller Detectio of Potetial Ruway ad Maoeuvrig Area Coflicts Editio 1.0 9

10 1.3 How was the Top 5 idetified? The Network Maager idetifies Network safety issues to eable aviatio stakeholders to idetify existig hazards ad aticipate ew operatioal risks The first step was to defie broad priority areas for further prioritisatio. Our ultimate goal is to keep the Network safe ad able to icrease its capacity ad efficiecy. The EUROCONTROL Safety Improvemet Sub-Group (SISG), reportig to the EUROCONTROL Safety Team, was tasked to idetify the Top 5 ATM Operatioal Safety Priorities. The SISG followed a structured two-step process of operatioal safety prioritisatio. Firstly SISG idetified a list of priority areas. The agreed list cotais work priority areas addressig operatioal threats, safety precursors or udesired safety outcomes. The list icludes: Airspace Ifrigemet Ruway Icursio Loss of Separatio ATC sector overloads Level Bust Severe Weather Risk Air Groud commuicatios Ruway Excursio The list of agreed priority areas cotais issues that are too broad to be a part of a focussed work program. There was a eed to get more graularity ad select some of the areas for a detailed review. Based o the availability of reliable safety iformatio, two of the risk areas were selected for detailed review: The secod step was a detailed review with SAFMAPS. The priorities were re-cofirmed for 2014 Ruway Icursio ad Loss of Separatio E-Route. The review was performed durig summer 2012 ad ivolved a series of dedicated workshops with 6 ANSPs, represetig a large part of Europea air traffic. Comprehesive barrier models Safety Fuctios Maps (SAFMAPs) - were developed ad populated with represetative data from the participatig ANSPs. The icidet data is for high severity (classified as A ad B ) evets, which are o oe side thoroughly ivestigated ad o the other side highly iformative because the icidet scearios test the majority of the available safety barriers. As a result of the SAFMAP aalysis the Top 5 priority areas were suggested, agreed by SISG ad edorsed by the Safety Team: Risk of operatio without traspoder or with a dysfuctioal oe Ladig without ATC clearace Detectio of occupied ruway Blid spot iefficiet coflict detectio with the closest aircraft Coflict detectio with adjacet sectors The priorities were reviewed by SISG usig the same approach of aalysig the high severity icidet with SAFMAPs. As a result SISG re-cofirmed the Top 5 priorities for

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12 CHAPTER 2 - STUDY SCOPE AND PRE-SET ASSUMPTIONS 2.1 Scope Ruway Icursio coflicts that could have bee preveted if cotrollers had had better meas to detect that the ruway was occupied at the time of issuig clearace to the ext aircraft to use the ruway. This study exteds the origial requiremet to cosider the barriers available to ATC to prevet or mitigate other potetial coflicts o the Maoeuvrig Area. This icludes ladig or departig o a taxiway ad groud collisios. This study is exclusively aimed at tools ad methodology available to ATC. It excludes airport barriers that are primarily to provide barriers to pilots ad drivers e.g. stop bars, ruway guard lights ad sigage. 2.2 Pre-Set Assumptios All barriers are deemed to be operatioally available ad operated correctly. It is assumed that cotrollers will react correctly to all aural ad visual safety ets All barriers are limited by the resposiveess of the players to the sigals. Deliberate o-coformace is excluded from the aalysis. 2.3 Defiitio of Barriers for the purposes of this study Prevetative Barriers I the case of ruway operatios, prevetative barriers are to prevet a ruway icursio. I the case of Maoeuvrig Area operatios it is ormally oly after a actio has commeced that ATC ca react. Prevetio is ATC actio that maitais stadard safety requiremets EUROCONTROL RAT (Risk assessmet Tool) documetatio gives the followig guidace o stadard safety requiremets: a) Evets o the Maoeuvrig Area (excludig active ruways) oly compromise stadard safety requiremets if oe party has to take immediate actio to stop or vacate the area i order to avoid the possibility of a collisio. b) Evets o the Apro ad all evets ivolvig push backs oly compromise stadard safety requiremets if sudde abrupt brakig is required to avoid a potetial collisio Mitigatig Barriers I the case of ruway operatios, mitigatig barriers do ot prevet the icursio but mitigate its impact to prevet a collisio. I the case of Maoeuvrig Area operatios stadard safety requiremets have bee compromised ad the mitigatig barrier is available to prevet a groud collisio. 12

13 CHAPTER 3 - THE GENERIC PROCESS The figure below provides a overview of the geeric steps i the Operatioal Safety Study BARRIERS SCENARIOS ANALYSIS CONCLUSIONS OPERATIONAL CONTEXT A geeric process was desiged to aalyse ATM Operatioal Safety Priorities (the Top 5) i order to provide a commo methodology for assessmet ad evaluatio. The process starts with three preparatory steps: Idetificatio of the operatioal cotext pertaiig to the operatioal area cosidered. Defiitio of the operatioal scearios. Idetificatio of safety barriers (both prevetig ad mitigatig the effect of the evet). Oce all those data are collated a aalysis of effectiveess of barriers agaist the idetified operatioal scearios is performed ad correlated with aalysis of real life occurreces. Oce the aalysis is complete the study provides the coclusios. Operatioal Safety Study Cotroller Detectio of Potetial Ruway ad Maoeuvrig Area Coflicts Editio

14 CHAPTER 4 - OPERATIONAL CONTEXT BARRIERS SCENARIOS ANALYSIS CONCLUSIONS OPERATIONAL CONTEXT. Availability of surveillace iformatio Visibility coditios from the Tower Ruway cofiguratio Lie of sight from the Tower ATC Safety Net Alerts 14

15 4.1 Operatioal cotexts The local operatioal cotext with relevace for the preset study are idetified as follows: The operatioal cotext that may affect the efficiecy of barriers Availability of surveillace iformatio Visibility coditios from the Tower Ruway cofiguratio Lie of sight from the Tower ATC Safety Net Alerts 4.2 Surveillace iformatio The availability of surveillace data affects the likelihood of detectio of RWY icursios ad icorrect movemet o the Maoeuvrig Area. The level of ATC service ad may differ depedig o equipage Basic Surface Movemet Radar (SMR) Advaced Surface Movemet & Guidace Cotrol System (A_ SMGCS) Level 1 Advaced Surface Movemet & Guidace Cotrol System (A_ SMGCS) Level 2 Itegrated Tower Workig Positio (ITWP) usig iput ad display of the ATC clearaces i additio to surveillace to eable the use of early warigs to highlight ay o-coformace to clearace. 4.3 Visibility coditios from the Tower The visibility from Visual Cotrol Room (VCR) ad subsequece ability to recogise potetial coflicts ca be limited by: The possibility of recogisig potetial threats i good time may differ depedig upo visual impairmet Day/Night Fog/Mist Low Cloud affectig high cotrol towers Sulight ad glare durig day Precipitatio o widows Airport floodlightig durig ight, especially temporary work i progress 4.4 Ruway cofiguratio Ruway cofiguratio could impact upo complexity ad performace The ruway cofiguratio ca ifluece how the operatios o each ruway ca be affected by the operatios o the adjacet oes ad therefore how the specific barriers ca be applied: Multiple Parallel/Itersectig ruways, Mixed mode/sigle mode operatios Operatioal Safety Study Cotroller Detectio of Potetial Ruway ad Maoeuvrig Area Coflicts Editio

16 4.5 Lie of sight Geometrical visibility could impact o ATC service The lie of sight from the ATC Tower ca differ based o: The positio, height, desig, equipmet ad distace of the tower ca restrict the direct view of the relevat part of the ruways ad Maoeuvrig Area. 4.6 ATC Safety Net Alerts Availability of ATC Safety Nets could impact upo the timeliess of coflict resolutio The availability ad fuctioality of Safety Net Alerts: A-SMGCS Level 2 Coflictig ATC Clearaces (CATC) Coformace Moitorig for Cotrollers (CMAC) Airport Groud Systems e.g. Ruway Guard Lasers ad Loops 16

17 CHAPTER 5 - GENERIC SCENARIOS BARRIERS. Loss of commuicatio Icorrect ATC clearace No-coformace due spatial/positioal cofusio No-coformace due to misiterpretatio or mishear of the clearace. No-coformace due poor CRM ad forgot plaed actio SCENARIOS ANALYSIS CONCLUSIONS OPERATIONAL CONTEXT Operatioal Safety Study Cotroller Detectio of Potetial Ruway ad Maoeuvrig Area Coflicts Editio

18 5.1 How should geeric operatioal scearios be defied? Combiatio of top-dow ad bottom-up approaches Geeric operatioal scearios are eeded to decostruct the complexity of aalysis. Sceario defiitio is specific to help decide the efficiecy of the safety barriers whilst geeric eough to keep their umber relatively small. The defiitio of geeric operatioal scearios takes the form of a sythesis of two sources of iformatio: A systematic aalytical break-dow of the operatioal sceario ito sub-scearios. This is based o all theoretically possible combiatios of the sceario (1) sources, (2) mechaisms ad (3) outcomes. A review of the publicly available iformatio from ivestigatio reports of accidets ad serious icidets ivestigated followig the provisios of ICAO Aex 13 ad cofidetially provided data i respect of less sigificat icidets. 5.2 Aalytical decostructio of operatioal scearios The followig could lead to a potetial Ruway Icursio pertaiig to the geeric detectio of occupied RWY sceario: Sceario Sources A. Loss of commuicatio B. Icorrect ATC clearace C. No-Coformace with ATC clearace due spatial/positioal cofusio D. No-Coformace with ATC clearace due to misiterpretatio or mishear of the clearace E. No-Coformace with ATC clearace due poor CRM ad forgot plaed actio The mechaisms as a sceario elemet describe the flight after the sceario sources occurred. I this case the actors may be i oe of the followig situatios: Sceario Mechaisms Durig Take-off Durig Ladig Durig Surface Movemet The sceario sources are ot ecessarily applicable to all sceario mechaisms ad the various valid combiatios will be reflected by the geeric operatioal scearios. 18

19 The traffic situatio related to the occupied ruway detectio ca be described by oe of the optios: Sceario Outcomes 1. Ladig o ruway already occupied a. Aircraft/Vehicle already o ruway b. Aeroplae/vehicle with clearace to eter ruway 2. Take-off o ruway already occupied a. Aircraft/Vehicle already o ruway b. Aeroplae/vehicle with clearace to eter ruway 3. Etry of ruway by aircraft taxyig for departure or by vehicle a. Ladig or Departig aeroplae 4. Ruway crossig of ruway by aircraft/vehicle a. Ladig or Departig aircraft 5. Surface Movemet coflict o ruway by two or more a. Aircraft/Vehicles eterig/crossig ruway at reciprocal poits 6. Departig/Ladig o itersectig ruways a. Departig/Departig o itersectig ruways b. Departig/Ladig o itersectig ruways c. Ladig/Ladig o itersectig ruways d. Departig or Ladig agaist surface movemet o itersectig ruways 7. Departig/Ladig o a taxiway ot the active ruway a. Departig or Ladig o a taxiway occupied by aircraft/vehicle 8. Icorrect aircraft movemet o Maoeuvrig Area a. Aircraft takes icorrect taxy route b. Aircraft icorrectly pushes back/eters o to Maoeuvrig Area 5.3 The resultig list of geeric operatioal scearios for aalysis 1. Ladig o ruway already occupied A1a Ladig after loss of commuicatio o ruway already authorised occupied A1b Ladig after loss of commuicatio o ruway together with aircraft/vehicle with clearace to eter ruway B1a Ladig after receivig icorrect ATC clearace o ruway already authorised occupied B1b Ladig after receivig icorrect ATC clearace o ruway together with aircraft/vehicle with clearace to eter ruway C1a Ladig after o-coformace with ATC clearace due spatial/ positioal cofusio o ruway already occupied C1b Ladig after o-coformace with ATC clearace due spatial/ positioal cofusio, together with aircraft/vehicle with clearace to eter ruway D1a Ladig after o-coformace with ATC clearace due misiterpretatio or mishear of the clearace, o ruway already occupied D1b Ladig after o-coformace with ATC clearace due to misiterpretatio or mishear of the clearace, together with aircraft/ vehicle with clearace to eter ruway E1a Ladig without ATC clearace due poor CRM ad forgot plaed actio o ruway already occupied E1b Ladig without ATC clearace due poor CRM ad forgot plaed actio, together with aircraft/vehicle with clearace to eter ruway Operatioal Safety Study Cotroller Detectio of Potetial Ruway ad Maoeuvrig Area Coflicts Editio

20 2. Take-off o ruway already occupied B2a Departig after receivig icorrect ATC clearace o ruway already authorised occupied B2b Departig after receivig icorrect ATC clearace o ruway, together with aircraft/vehicle with clearace to eter ruway C2a Departig after o-coformace with ATC clearace due spatial/ positioal cofusio o ruway already occupied C2b Departig after o-coformace with ATC clearace due spatial/positioal cofusio, together with aircraft/vehicle with clearace to eter ruway D2a Departig after o-coformace with ATC clearace due misiterpretatio or mishear of the clearace, o ruway already occupied D2b Departig after o-coformace with ATC clearace due to misiterpretatio or mishear of the clearace, together with aircraft/vehicle with clearace to eter ruway E2a Departig without ATC clearace due poor CRM ad forgot plaed actio o ruway already occupied E2b Departig without ATC clearace due poor RM ad forgot plaed actio, together with aircraft/vehicle with clearace to eter ruway 3. Etry oto ruway by aircraft taxyig for departure or by vehicle 4. Ruway crossig B3a C3a D3a E3a B4a C4a D4a E4a Etry of ruway by aircraft taxyig for departure or by vehicle due icorrect ATC clearace, together with a ladig or departig aircraft. Etry of ruway by aircraft taxyig for departure or by vehicle after o-coformace with ATC clearace due to spatial/positioal cofusio, together with a ladig or departig aircraft Etry o ruway by aircraft taxyig for departure or by vehicle after o-coformace with ATC clearace due to misiterpretatio or mishear of clearace, together with a ladig or departig aircraft Etry o ruway by aircraft taxyig for departure or by vehicle without ATC clearace due poor CRM ad forgot plaed actio o ruway already occupied, together with a ladig or departig aircraft Aircraft/Vehicle crossig ruway occupied by ladig or departig aircraft due icorrect ATC clearace Uauthorised Aircraft/Vehicle crossig ruway occupied by ladig or departig aircraft after o-coformace with ATC clearace due to spatial/positioal cofusio Uauthorised Aircraft/Vehicle crossig ruway occupied by ladig or departig aircraft after o-coformace with ATC clearace due to misiterpretatio or mishear of clearace Uauthorised Aircraft/Vehicle crossig ruway occupied by ladig or departig aircraft without ATC clearace due to poor CRM or forgot plaed actio 20

21 5. Surface Movemet Coflict o ruway 6. Departig or Ladig o itersectig ruways B5a C5a D5a E5a Surface movemet o ruway by two or more mobiles eterig/ crossig ruway at reciprocal etry poits due to a icorrect ATC clearace Surface movemet o ruway by two or more mobiles eterig/ crossig ruway at reciprocal etry poits after o-coformace with ATC clearace due to spatial/positioal cofusio Surface movemet o ruway by two or more mobiles eterig/ crossig ruway at reciprocal etry poits after o-coformace with ATC clearace due to misiterpretatio or mishear of clearace Surface movemet by Aircraft/Vehicle eterig ruway o reciprocal etry poit to other mobile, without ATC clearace due to poor CRM or forgot plaed actio A6c Ladig/Ladig o itersectig ruways after a loss of commuicatio A6d Ladig agaist surface movemet mobile o itersectig ruways after a loss of commuicatio B6a Departig/Departig o itersectig ruways after a icorrect ATC clearace B6b Departig/Ladig o itersectig ruways after a icorrect ATC clearace B6c Ladig/Ladig o itersectig ruways after a icorrect ATC clearace B6d Departig/Ladig agaist surface movemet mobile o itersectig ruways after a icorrect ATC clearace C6a Departig/Departig o itersectig ruways after a ocoformace with ATC clearace due to spatial/positioal cofusio C6b Departig/Ladig o itersectig ruways after a o-coformace with ATC clearace due to spatial/positioal cofusio C6c Ladig/Ladig o itersectig ruways after a o-coformace with ATC clearace due to spatial/positioal cofusio C6d Departig/Ladig agaist surface movemet mobile o itersectig ruways after a o-coformace with ATC clearace due to spatial/positioal cofusio D6a Departig/Departig o itersectig ruways after o-coformace with ATC clearace due to a misiterpretatio or mishear of clearace D6b Departig/Ladig o itersectig ruways after o-coformace with ATC clearace due to a misiterpretatio or mishear of clearace D6c Ladig/Ladig o itersectig ruways after o-coformace with ATC clearace due to a misiterpretatio or mishear of clearace D6d Departig/Ladig agaist surface movemet mobile o itersectig ruways after o-coformace with ATC clearace due to a misiterpretatio or mishear of clearace E6a Departig/Departig o itersectig ruways without ATC clearace due to poor CRM or forgot plaed actio E6b Departig/Ladig o itersectig ruways without ATC clearace due to poor CRM or forgot plaed actio E6c Ladig/Ladig o itersectig ruways without ATC clearace due to poor CRM or forgot plaed actio E6d Departig/Ladig agaist surface movemet mobile o itersectig ruways without ATC clearace due to poor CRM or forgot plaed actio Operatioal Safety Study Cotroller Detectio of Potetial Ruway ad Maoeuvrig Area Coflicts Editio

22 7. Departig/Ladig o a taxiway ot a ruway C7a D7a Ladig/Departig o a taxiway after a o-coformace with ATC clearace due to spatial/positioal cofusio Ladig/Departig o a taxiway after o-coformace with ATC clearace due to a misiterpretatio or mishear of clearace 8. Icorrect aircraft movemet o Maoeuvrig Area B8a Aircraft takes taxy route with potetial coflict after a icorrect ATC clearace B8b Aircraft pushes back/eters o to Maoeuvrig Area with potetial coflict after a icorrect ATC clearace C8a Aircraft takes icorrect taxy route after a o-coformace with ATC clearace due to spatial/positioal cofusio C8b Aircraft icorrectly pushes back/eters o to Maoeuvrig Area after a o-coformace with ATC clearace due to spatial/positioal cofusio D8a Aircraft takes icorrect taxy route after o-coformace with ATC clearace due to a misiterpretatio or mishear of clearace D8b Aircraft icorrectly pushes back/eters o to Maoeuvrig Area after o-coformace with ATC clearace due to a misiterpretatio or mishear of clearace E8a Aircraft takes icorrect taxy route due to poor CRM or forgot plaed actio E8b Aircraft icorrectly pushes back/eters o to Maoeuvrig Area ruways without ATC clearace due to poor CRM or forgot plaed actio 22

23 CHAPTER 6 - BARRIERS. Prevetio of ruway icursios ad groud coflicts. Mitigatio of the effect of ruway icursios ad groud coflicts BARRIERS SCENARIOS ANALYSIS CONCLUSIONS OPERATIONAL CONTEXT Operatioal Safety Study Cotroller Detectio of Potetial Ruway ad Maoeuvrig Area Coflicts Editio

24 6.1 Barriers as a opportuity i some situatios The barriers are ot recommedatios A barrier model The Barriers icluded i this risk review have bee idetified as possible ways that detectio of a occupied RWY could be employed ad or the cosequeces mitigated. Their iclusio does ot imply that they are relevat to all situatios ad either does it imply that promotio of their adoptio by airport operators or ANSPs would ecessarily be appropriate. It may be possible to idetify more potetially useful barriers tha are icluded here. I order to defie the barrier there is a eed first to defie the geeric barrier groups for reducig the risk of detectio of occupied RWY evets. The figure below represets a geeralised SAFMAP for Detectio of occupied RWY. This geeralised SAFMAP is derived from the Level 0 Ruway Collisio SAFMAP Versio 0.8 ad is the most geeric barrier model for prevetig ruway collisio because of situatios of detectio of occupied RWY. 6.2 Two types of barriers There are two major sets of barriers which ca reduce the risk associated with ruway icursios evets. These barriers are restricted to just oe segmet of Air Traffic Cotrol ad are idetified based o a wide literature search ad cosultatio, ad are: Balacig prevetig ad mitigatig the risk associated with ruway icursios Prevetio of ruway icursios ad groud coflicts. These barriers, whe deployed ad employed correctly, are capable of alertig ATC i time to prevet ruway icursios ad groud coflicts. With regard to evets o the Maoeuvrig Area, these barriers are capable of alertig ATC before stadard levels of safety are compromised. Mitigatio of the effect of ruway icursios ad groud coflicts. These barriers, whe deployed ad employed correctly, are capable of alertig ATC to a ruway icursio or a groud safety evet i sufficiet time for ATC to act i order to prevet a groud collisio. 24

25 Providece Ruway coflict uresolved by ATC ad pilot/driver MITIGATION BARRIERS Pilot/Driver RWY Coflict Resolutio Ruway coflict uresolved by ATC ATC RWY Coflict Resolutio Ruway coflict Prevetig ladig without clearace to tur ito RWY coflict Ruway icursio PREVENTION BARRIERS ATC RWY Coflict Resolutio Operatioal Safety Study Cotroller Detectio of Potetial Ruway ad Maoeuvrig Area Coflicts Editio

26 6.3 Barriers prevetig ruway icursio ad groud safety evets ivolvig iadequate detectio by cotrollers (PB) Barriers to prevet ruway icursios ad maoeuvrig area evets PB1 ATCO memory aids for issued (ot issued) clearaces by stadardised flight data displays icludig dedicated ruway bays, blockig strips etc PB2 ATCO direct visual detectio PB3 ATCO visual detectio usig remote camera displays PB4 ATCO resolutio followig pilot/driver report PB5 ATCO detectio of occupied ruway by use of basic Surface Movemet Radar PB6 A-SMGCS level 1 surveillace with vehicles, i additio to aircraft, equipped with traspoders i order to ehace surveillace PB7 A-SMGCS level 2 coflict alerts PB8a Use of iput ad display of the ATC clearaces that eable the use of early warig surveillace ad data (Itegrated Tower Workig Positio (ITWP)to highlight ay o-coformace to clearace PB8b Use of iput ad display of the ATC clearaces that eable the use of early warig surveillace ad data (ITWP) to highlight the potetial cosequeces of ay icorrect clearace PB9 Use of discrete ames for holdig positios ad pilot reports e.g. reportig poit BARKA istead of W2 PB10 All vehicles eterig o a ruway should display high visibility flashig/strobig lights o i all visibility coditios 6.4 Barriers mitigatig ruway icursio ad groud safety evets ivolvig detectio by cotrollers (MB) Barriers mitigatig the effects of iadequate detectio of ruway icursios ad maoeuvrig area evets MB1 ATCO direct visual detectio MB2 ATCO visual detectio usig remote camera displays MB3 ATCO detectio followig pilot/driver report MB4 ATCO detectio usig basic SMR MB5 ATCO detectio it usig A-SMGCS level 1 MB6 ATCO detectio it after alert from A-SMGCS level 2 MB7 ATCO detectio after alert from airport groud systems that detect etry oto the ruway (e.g. magetic loops or lasers). MB8 ATCO detectio after alert from the use of iput ad display of the ATC clearaces ad surveillace data (ITWP) 26

27 CHAPTER 7 - ANALYSIS OF BARRIERS IN GENERIC SCENARIOS BARRIERS SCENARIOS ANALYSIS CONCLUSIONS OPERATIONAL CONTEXT Operatioal Safety Study Cotroller Detectio of Potetial Ruway ad Maoeuvrig Area Coflicts Editio

28 7.1 Prevetio Barrier Assessmet The first step of the aalysis cosists of assessig the potetial effectiveess of the prevetio barriers i the defied operatioal scearios. The high level assessmet cosiders the various operatioal scearios ad is based o expert judgemet. The barriers are assessed idividually, the aalysis does ot cosider the iteractios or the results of more tha oe barrier actig i combiatio Depedecies All barriers are deemed to be operatioally available ad operated correctly. It is assumed that cotrollers will react correctly to all aural ad visual safety ets. All barriers are limited by the resposiveess of the players to the sigals. Deliberate o-coformace is excluded from the aalysis Colour code used i the Barrier Aalysis tables Red Yellow Gree Barrier that is either iefficiet or is ot iteded for the operatioal sceario Barrier that is partially effective or partially efficiet for the operatioal sceario or efficiet uder certai coditios Barrier that is effective ad efficiet for the operatioal sceario Key to Yellow costraits: 1. Prevetio possible subject to time ad opportuity to act. 2. Prevetio possible subject to cotroller focus of attetio o iformatio that shows discrepacy. 3. Prevetio possible subject to daytime/visibility/lie of sight. 4. Prevetio possible subject to cotroller otig aomaly, challege mid-set ad act. 28

29 7.1.4 Prevetio Barrier Aalysis Tables Table 1: Aalysis of Prevetio Barrier Efficiecy o Scearios Set 1: Ladig with ruway already occupied A1a A1b B1a B1b C1a C1b D1a D1b E1a E1b PB1 - ATC memory aids PB2 - ATC direct visual detectio 1,3 1,3 3,4 1,2,3, PB3 ATC detectio usig remote camera displays PB4 - ATC resolutio followig pilot/driver report PB5 ATC detectio with basic SMR PB6 A-SMGCS level 1 with vehicles, i additio to aircraft, equipped with traspoders PB7 A-SMGCS level 2 coflict alerts PB8a Iput ad display of ATC clearaces ad surveillace data (ITWP) to detect o-coformace to clearace PB8b Iput ad display of ATC clearaces ad surveillace data (ITWP) to detect impact of icorrect ATC clearace 2,3 2,3 2, ,3 2,3 2,3 2,3 2,3 2,3 2,4 2,4 2,4 2, , b i use 8b i use 8a i use 8a i use 8a i use 8a i use 8a i use 8a i use PB9 - Use of discrete ames for holdig positios ad pilot reports e.g. poit BARKA istead of W2 PB10 - Vehicle have high vis flashig or strobe lightig Operatioal Safety Study Cotroller Detectio of Potetial Ruway ad Maoeuvrig Area Coflicts Editio

30 Table 2: Aalysis of Prevetio Barrier Efficiecy o Scearios Set 2: Departig with ruway already occupied B2a B2b C2a C2b D2a D2b E2a E2b PB1 - ATC memory aids PB2 - ATC display visual detectio 1,3 1,3, 1,3, 1,3, 1,3, 1,3, PB3 ATC detectio usig remote camera displays PB4 - ATC resolutio followig pilot/driver report 2,4 2,4 2,4 2,4 2,4 2,4 2, ,3 2,3 PB5 ATC detectio with basic SMR 1,2,4 1,2,4 1,2,4 1,2,4 PB6 A-SMGCS level 1 with vehicles, i additio to aircraft, equipped with traspoders 1,2,4 1,2.4 1,2,4 1,2,4 1,2 PB7 A-SMGCS level 2 coflict alerts 1,2,4 1,2,4 1,2,4 1,2,4 1,2 PB8a Iput ad display of ATC clearaces ad surveillace data (ITWP) to detect ocoformace to clearace PB8b Iput ad display of ATC clearaces ad surveillace data (ITWP) to detect impact of icorrect ATC clearace 8a i use 8a i use 1 1,2 8a i use 8a i use 8a i use 8a i use PB9 - Use of discrete ames for holdig positios ad pilot reports e.g. poit BARKA istead of W2 PB10 - Vehicle have high vis flashig or strobe lightig ,4 3 30

31 Table 3: Aalysis of Prevetio Barrier Efficiecy o Scearios Set 3: Etry of ruway by aircraft taxyig for departure or by a vehicle B3a C3a D3a E3a PB1 - ATC memory aids 1,2,3,4 PB2 - ATC display visual detectio 1,2,3,4 3 3 PB3 ATC detectio usig remote camera displays 1,2 1, 2 1, 2 PB4 - ATC resolutio followig pilot/driver report 2,3 2,3 2,3 2.3 PB5 ATC detectio with basic SMR 2 2 PB6 A-SMGCS level 1 with vehicles, i additio to aircraft, equipped with traspoders 2 2 PB7 A-SMGCS level 2 coflict alerts 2 PB8a Iput ad display of ATC clearaces ad surveillace data (ITWP) to detect o-coformace to clearace 8b i use 2 PB8b Iput ad display of ATC clearaces ad surveillace data (ITWP) to detect impact of icorrect ATC clearace 8a i use 8a i use PB9 - Use of discrete ames for holdig positios ad pilot reports e.g. poit BARKA istead of W2 1,2,4 1,2,4 PB10 - Vehicle have high vis flashig or strobe lightig Operatioal Safety Study Cotroller Detectio of Potetial Ruway ad Maoeuvrig Area Coflicts Editio

32 Table 4: Aalysis of Prevetio Barrier Efficiecy o Scearios Set 4: Ruway crossig B4a C4a D4a E4a PB1 - ATC memory aids PB2 - ATC display visual detectio 2,3 PB3 ATC detectio usig remote camera displays PB4 - ATC resolutio followig pilot/driver report 1,3 1,3 1,3 PB5 ATC detectio with basic SMR PB6 A-SMGCS level 1 with vehicles, i additio to aircraft, equipped with traspoders PB7 A-SMGCS level 2 coflict alerts PB8a Iput ad display of ATC clearaces ad surveillace data (ITWP) to detect o-coformace to clearace 7b i use PB8b Iput ad display of ATC clearaces ad surveillace data (ITWP) to detect impact of icorrect ATC clearace 2 7a i use 7a i use 7a i use PB9 - Use of discrete ames for holdig positios ad pilot reports e.g. poit BARKA istead of W2 PB10 - Vehicle have high vis flashig or strobe lightig 32

33 Table 5: Aalysis of Prevetio Barrier Efficiecy o Scearios Set 5: Surface Movemet coflict o ruway B4a C4a D4a E4a PB1 - ATC memory aids PB2 - ATC display visual detectio 2,3 PB3 ATC detectio usig remote camera displays PB4 - ATC resolutio followig pilot/driver report 1,3 1,3 1,3 PB5 ATC detectio with basic SMR PB6 A-SMGCS level 1 with vehicles, i additio to aircraft, equipped with traspoders PB7 A-SMGCS level 2 coflict alerts PB8a Iput ad display of ATC clearaces ad surveillace data (ITWP) to detect o-coformace to clearace 7b i use PB8b Iput ad display of ATC clearaces ad surveillace data (ITWP) to detect impact of icorrect ATC clearace 2 7a i use 7a i use 7a i use PB9 - Use of discrete ames for holdig positios ad pilot reports e.g. poit BARKA istead of W2 PB10 - Vehicle have high vis flashig or strobe lightig Operatioal Safety Study Cotroller Detectio of Potetial Ruway ad Maoeuvrig Area Coflicts Editio

34 Table 6: Aalysis of Prevetio Barrier Efficiecy o Scearios Set 6: Departig/Ladig o itersectig ruways A6c A6d B6a B6b B6c B6d PB1 - ATC memory aids PB2 - ATC display visual detectio 3 3 PB3 ATC detectio usig remote camera displays PB4 - ATC resolutio followig pilot/driver report PB5 ATC detectio with basic SMR PB6 A-SMGCS level 1 with vehicles, i additio to aircraft, equipped with traspoders PB7 A-SMGCS level 2 coflict alerts 1,2 1,2 PB8a Iput ad display of ATC clearaces ad surveillace data (ITWP) to detect o-coformace to clearace 8b i use 8b i use 8b i use 8b i use PB8b Iput ad display of ATC clearaces ad surveillace data (ITWP) to detect impact of icorrect ATC clearace 8a i use 8a i use 1 1 PB9 - Use of discrete ames for holdig positios ad pilot reports e.g. poit BARKA istead of W2 PB10 - Vehicle have high vis flashig or strobe lightig 34

35 Table 6: Aalysis of Prevetio Barrier Efficiecy o Scearios Set 6: Departig/Ladig o itersectig ruways C6a C6b C6c C6d D6a D6b D6c D6d E6a E6 b E6c E6d PB1 - ATC memory aids PB2 - ATC direct visual detectio PB3 ATC detectio usig remote camera displays 1,3 1,3 1,3 1, ,2 1,2 1,2 1,2 1,2 1,2 1,2 1,2 PB4 - ATC resolutio followig pilot/driver report PB5 ATC detectio with basic SMR PB6 A-SMGCS level 1 with vehicles, i additio to aircraft, equipped with traspoders PB7 A-SMGCS level 2 coflict alerts PB8a Iput ad display of ATC clearaces ad surveillace data (ITWP) to detect o-coformace to clearace PB8b Iput ad display of ATC clearaces ad surveillace data (ITWP) to detect impact of icorrect ATC clearace 1,2 1,2 1,2 1,2 2 1,2 1,2 1,2 1, ,2 1,2 1,2 1,2 1, ,2 8a i use 8a i use 8a i use 8a i use 8a i use 8a i use 8a i use 8a i use 8a i use 8a i use PB9 - Use of discrete ames for holdig positios ad pilot reports e.g. poit BARKA istead of W2 PB10 - Vehicle have high vis flashig or strobe lightig Operatioal Safety Study Cotroller Detectio of Potetial Ruway ad Maoeuvrig Area Coflicts Editio

36 Table 7: Aalysis of Prevetio Barriers for Departig o a taxiway ot a ruway C7a D7a PB1 - ATC memory aids PB2 - ATC display visual detectio 1,2,3 1,2,3 PB3 ATC detectio usig remote camera displays PB4 - ATC resolutio followig pilot/driver report PB5 ATC detectio with basic SMR PB6 A-SMGCS level 1 with vehicles, i additio to aircraft, equipped with traspoders PB7 A-SMGCS level 2 coflict alerts PB8a Iput ad display of ATC clearaces ad surveillace data (ITWP) to detect o-coformace to clearace 1,2 1,2 PB8b Iput ad display of ATC clearaces ad surveillace data (ITWP) to detect impact of icorrect ATC clearace 8a i use 8a i use PB9 - Use of discrete ames for holdig positios ad pilot reports e.g. poit BARKA istead of W2 1,2 1,2 PB10 - Vehicle have high vis flashig or strobe lightig 36

37 Table 8: Aalysis of Prevetio Barriers for Icorrect aircraft movemet o Maoeuvrig Area B8a B8b C8a C8b D8a D8b E8a E8b PB1 - ATC memory aids PB2 - ATC display visual detectio 3,4 3,4 3,4 1,3,4 1,3,4 1,3,4 1,3,4 1,3,4 PB3 ATC detectio usig remote camera displays PB4 - ATC resolutio followig pilot/driver report 3,4 3,4 3,4 1,3,4 1,3,4 1,3,4 1,3,4 1,3,4 PB5 ATC detectio with basic SMR PB6 A-SMGCS level 1 with vehicles, i additio to aircraft, equipped with traspoders PB7 A-SMGCS level 2 coflict alerts PB8a Iput ad display of ATC clearaces ad surveillace data (ITWP) to detect ocoformace to clearace PB8b Iput ad display of ATC clearaces ad surveillace data (ITWP) to detect impact of icorrect ATC clearace PB9 - Use of discrete ames for holdig positios ad pilot reports e.g. poit BARKA istead of W2 8a i use 8a i use a i use 8a i use 8a i use 8a i use 8a i use 8a i use PB10 - Vehicle have high vis flashig or strobe lightig Operatioal Safety Study Cotroller Detectio of Potetial Ruway ad Maoeuvrig Area Coflicts Editio

38 I order to orgaise the results, a scorig system was cosidered. The mai purpose is to give a compariso scale ad a idicatio o how effective a barrier ca be over all the cosidered scearios ad ot to provide a absolute rakig (the higher the score does t ecessarily equate to a more effective barrier). Also, it should be bore i mid that i this specific case the barriers are used for the detectio of occupied ruway meaig that the premises for a potetial ruway icursio are already i place (which may make a differece whe cosiderig the same barrier for the ruway icursio itself). The scorig system utilised to rak the applicatios is as follows: zero poits for a ieffective barrier (red), oe poit for a partially effective barrier (yellow) ad three poits for ad effective barrier. Table 9: The rakig for the Prevetig Barriers; this rakig idicates which are the barriers that are more effective i most operatioal scearios. Barrier Barrier Descriptio Score PB8 Iput ad display of ATC clearaces ad surveillace data (ITWP) to joitly detect o-coformace to clearace ad the potetial impact of icorrect clearaces 100 * PB7 A-SMGCS level 2 45 PB2 ATC visual detectio icludig video ad remote camera displays 42 PB4 ATC resolutio followig pilot/driver alert 34 PB1 ATC memory aids 31 PB3 ATC detectio usig remote camera displays 20 PB6 A-SMGCS level 1 16 PB10 Vehicle have high vis flashig or strobe lightig 12 PB9 Use of amed HPs e.g. BARKA 11 PB5 Basic SMR 8 * No-compliace elemet 67 & cotroller moitorig 33 38

39 7.2 Mitigatio Barrier Assessmet Table 10: Aalysis of Mitigatio Barrier for Scearios Set 1: Icorrect Ladig with ruway already occupied A1a A1b B1a B1b C1a C1b D1a D1b E1a E1b MB1 - ATCO direct visual detectio MB2 - ATCO visual detectio usig remote camera displays MB3 - ATCO detectio followig pilot/driver report MB4 - ATCO detectio usig basic SMR MB5 - ATCO detectio usig A-SMGCS level 1 MB6 - ATCO detectio after alert from A-SMGCS level 2 MB7 - ATCO detectio after alert from airport groud systems that detect etry oto the ruway (e.g. magetic loops or lasers). MB8 - ATCO detectio after alert from the use of iput ad display of the ATC clearaces ad surveillace data (ITWP) Operatioal Safety Study Cotroller Detectio of Potetial Ruway ad Maoeuvrig Area Coflicts Editio

40 Table 11: Aalysis of Mitigatio Barrier for Scearios Set 2: Departig with ruway already occupied B2a B2b C2a C2b D2a D2b E2a E2b MB1 - ATCO direct visual detectio MB2 - ATCO visual detectio usig remote camera displays MB3 - ATCO detectio followig pilot/driver report MB4 - ATCO detectio usig basic SMR MB5 - ATCO detectio usig A-SMGCS level 1 MB6 - ATCO detectio after alert from A-SMGCS level 2 MB7 - ATCO detectio after alert from airport groud systems that detect etry oto the ruway (e.g. magetic loops or lasers). MB8 - ATCO detectio after alert from the use of iput ad display of the ATC clearaces ad surveillace data (ITWP) Table 12: Aalysis of Mitigatio Barrier for Scearios Set 3: Etry of ruway by aircraft taxyig for departure or by vehicle B3a C3a D3a E3a MB1 - ATCO direct visual detectio MB2 - ATCO visual detectio usig remote camera displays MB3 - ATCO detectio followig pilot/driver report MB4 - ATCO detectio usig basic SMR MB5 - ATCO detectio usig A-SMGCS level 1 MB6 - ATCO detectio after alert from A-SMGCS level 2 MB7 - ATCO detectio after alert from airport groud systems that detect etry oto the ruway (e.g. magetic loops or lasers). MB8 - ATCO detectio after alert from the use of iput ad display of the ATC clearaces ad surveillace data (ITWP) 40

41 Table 13: Aalysis of Mitigatio Barrier for Scearios Set 4: Ruway crossig by aircraft/vehicle C4a D4a E4a MB1 - ATCO direct visual detectio MB2 - ATCO visual detectio usig remote camera displays MB3 - ATCO detectio followig pilot/driver report MB4 - ATCO detectio usig basic SMR MB5 - ATCO detectio usig A-SMGCS level 1 MB6 - ATCO detectio after alert from A-SMGCS level 2 MB7 - ATCO detectio after alert from airport groud systems that detect etry oto the ruway (e.g. magetic loops or lasers). MB8 - ATCO detectio after alert from the use of iput ad display of the ATC clearaces ad surveillace data (ITWP) Table 14: Aalysis of Mitigatio Barrier for Scearios Set 5: Surface Movemet coflict o ruway B5a C5a D5a E5a MB1 - ATCO direct visual detectio MB2 - ATCO visual detectio usig remote camera displays MB3 - ATCO detectio followig pilot/driver report MB4 - ATCO detectio usig basic SMR MB5 - ATCO detectio usig A-SMGCS level 1 MB6 - ATCO detectio after alert from A-SMGCS level 2 MB7 - ATCO detectio after alert from airport groud systems that detect etry oto the ruway (e.g. magetic loops or lasers). MB8 - ATCO detectio after alert from the use of iput ad display of the ATC clearaces ad surveillace data (ITWP) Operatioal Safety Study Cotroller Detectio of Potetial Ruway ad Maoeuvrig Area Coflicts Editio

42 Table 15: Aalysis of Mitigatio Barrier for Scearios Set 6: Departig or Ladig o itersectig ruways A6c A6d B6a B6b B6c B6d C6a C6b C6c C6d MB1 - ATCO direct visual detectio MB2 - ATCO visual detectio usig remote camera displays MB3 - ATCO detectio followig pilot/driver report MB4 - ATCO detectio usig basic SMR MB5 - ATCO detectio usig A-SMGCS level 1 MB6 - ATCO detectio after alert from A-SMGCS level 2 MB7 - ATCO detectio after alert from airport groud systems that detect etry oto the ruway (e.g. magetic loops or lasers). MB8 - ATCO detectio after alert from the use of iput ad display of the ATC clearaces ad surveillace data (ITWP) 42

43 Table 15: Aalysis of Mitigatio Barrier for Scearios Set 6: Departig or Ladig o itersectig ruways D6a D6b D6c D6d E6a E6b E6c E6d MB1 - ATCO direct visual detectio MB2 - ATCO visual detectio usig remote camera displays MB3 - ATCO detectio followig pilot/driver report MB4 - ATCO detectio usig basic SMR MB5 - ATCO detectio usig A-SMGCS level 1 MB6 - ATCO detectio after alert from A-SMGCS level 2 MB7 - ATCO detectio after alert from airport groud systems that detect etry oto the ruway (e.g. magetic loops or lasers). MB8 - ATCO detectio after alert from the use of iput ad display of the ATC clearaces ad surveillace data (ITWP) Table 16: Aalysis of Mitigatio Barrier for Scearios Set 7: Departig o a taxiway, ot a ruway C7a D7a MB1 - ATCO direct visual detectio MB2 - ATCO visual detectio usig remote camera displays MB3 - ATCO detectio followig pilot/driver report MB4 - ATCO detectio usig basic SMR MB5 - ATCO detectio usig A-SMGCS level 1 MB6 - ATCO detectio after alert from A-SMGCS level 2 MB7 - ATCO detectio after alert from airport groud systems that detect etry oto the ruway (e.g. magetic loops or lasers). MB8 - ATCO detectio after alert from the use of iput ad display of the ATC clearaces ad surveillace data (ITWP) Operatioal Safety Study Cotroller Detectio of Potetial Ruway ad Maoeuvrig Area Coflicts Editio

44 Table 17: Aalysis of Mitigatio Barrier for Scearios Set 8: Icorrect aircraft movemet o the Maoeuvrig Area B8a B8b C8a C8b D8a D8b E8a E8b MB1 - ATCO direct visual detectio MB2 - ATCO visual detectio usig remote camera displays MB3 - ATCO detectio followig pilot/driver report MB4 - ATCO detectio usig basic SMR MB5 - ATCO detectio usig A-SMGCS level 1 MB6 - ATCO detectio after alert from A-SMGCS level 2 MB7 - ATCO detectio after alert from airport groud systems that detect etry oto the ruway (e.g. magetic loops or lasers). MB8 - ATCO detectio after alert from the use of iput ad display of the ATC clearaces ad surveillace data (ITWP) 44

45 Table 18: The rakig for the Prevetig Barriers; this rakig idicates which are the barriers that are more effective i most operatioal scearios. Barrier Barrier Descriptio Score MB8 ATCO detectio after alert from the use of iput ad display of the ATC clearaces ad surveillace data (ITWP) 115 MB3 ATCO detectio followig pilot/driver report 107 MB2 ATCO detectio usig remote camera displays 60 MB1 ATCO direct visual detectio 57 MB6 ATCO detectio after alert from A-SMGCS level 2 56 MB5 ATCO detectio usig A-SMGCS level 1 32 MB7 ATCO detectio after alert from airport groud systems that detect etry oto the ruway (e.g. magetic loops or lasers). 27 MB4 ATCO detectio usig basic SMR Combied Barrier Assessmet Tables 9 ad 18 show the fuctioality supportig the Barriers PB8 ad MB8 ATCO detectio after alert from the use of iput ad display of the ATC clearaces ad surveillace data (ITWP) is likely to be the most effective ATC tool i the prevetio ad mitigatio of ruway icursios ad groud safety evets. This fuctioality is ot yet widely available; however, this study does led strog support. The study suggests that proactive alerts from pilots ad drivers that lead to ATC detectio ad resolutio (PB4 ad MB3) are likely to be very importat barriers, especially i reducig the risk of collisio i ruway icursios. ATC direct visual detectio (PB2 ad MB1) ad the use of A-SMGCS level 2 (PB7 ad MB6) are both strog barriers i the prevetio ad mitigatio of ruway evets. ATC detectio of icorrect ruway presece, usig remote camera displays (MB2) is a strog mitigatio barrier as it does ot ecessarily deped o good visibility ad lie of sight. ATC memory aids (PB1) are likely to be strog barriers that aid ATC perceptio ad memory. It is these areas of ATC actio however that fail most ofte i actual evets (see chapters 8 ad 9). Operatioal Safety Study Cotroller Detectio of Potetial Ruway ad Maoeuvrig Area Coflicts Editio

46 CHAPTER 8 - ACTUAL RUNWAY INCURSION AND GROUND SAFETY EVENTS The actual safety evets described ad aalysed below are either i the public domai or have bee supplied with the permissio of the relevat authorities. I order to dis-idetify all stakeholders whilst maitaiig the safety lessos, the followig editorial actios have bee take. No airport, aircraft operator or ANSP is specified. The aircraft ivolved i each evet are deoted solely by the aircraft type. Cotroller workig positios have bee geeralised to two terms; TWR meaig the cotroller i cotrol of the ruway, ad GMC meaig the cotroller i charge of the maoeuvrig area excludig the active ruway. Uless ecessary to describe the evet, o ruway desigatio is metioed. I cases where it is ecessary to cosider iteractig ruways, the ruway desigators have bee chaged whilst maitaiig a geeral relatioship. Uless ecessary to describe the evet, o taxiway desigatio is metioed. I cases where it is ecessary to cosider iteractig taxiways, the desigators have bee chaged. A Barrier model is used to show the followig i each evet: Actual Recovery Barrier ATC Barriers Breached Remaiig Barriers available that could have reduced risk of collisio ATC Barriers that, if deployed, could have preveted the ruway icursio ad/or reduced risk of collisio Where x is show, it deotes a available barrier that is ot i the ambit of ATC 8.1 Evet 1. Cleared to cross ruway with aircraft departig Geeric Sceario: Ruway crossig B4a Aircraft/Vehicle crossig ruway occupied by ladig or departig aircraft due icorrect ATC clearace. A B737 is at a holdig poit ready to cross the active ruway (stop bars o). The cotroller has already cleared a E135 for take-off, durig this time the aircraft becomes obscured by a support beam for the glazig i the tower. The cotroller the clears the B737 to cross the active ruway ad deselects the stop bars. The B737 pilot advises tower that there is a departig aircraft o the ruway. The cotroller ackowledges the trasmissio ad istructs the B737 to hold positio ad reselects the stop bars, the B737 did ot move from the holdig poit ad therefore did ot eter the protected area. I mitigatio the cotroller recovery actios were correct. Prior to this evet he had to coted with a emergecy o the opposite parallel ruway...all of this happeig o oe frequecy due to sickess. There is basic SMR but o A-SMGCS. 46

47 Cotributig Factors: Memory - Cotroller forgot previous actio take-off clearace Actio Task priority Clearace give before movig strip Operatio Eviromet Visual Impairmet Operatio Eviromet Distractio from previous emergecy Team Factors Temporary Staffig costraits Actual Recovery Barrier: B4a ATCO resolutio followig pilot/driver report ATC Barriers Breached: PB1 PB2 ATCO memory aids for issued (ot issued) clearaces by stadardised flight data displays icludig dedicated ruway bays, blockig strips etc. ATCO direct visual detectio Remaiig Barriers available that could have reduced risk of collisio: MB1 X X ATCO direct visual detectio Pilot visual detectio (departig aircraft) Providece ATC Barriers that, if deployed, could have preveted the ruway icursio ad/or reduced risk of collisio: PB8b Use of iput ad display of the ATC clearaces that eable the use of early warig surveillace ad data (ITWP) to highlight the potetial cosequeces of ay icorrect clearace MB6 ATCO detectio it after alert from A-SMGCS level 2 MB8 ATCO detectio after alert from the use of iput ad display of the ATC clearaces ad surveillace data (ITWP) Operatioal Safety Study Cotroller Detectio of Potetial Ruway ad Maoeuvrig Area Coflicts Editio

48 8.2 Evet 2. Cleared for take-off with aircraft crossig ruway Geeric Sceario: Ruway crossig B4a Aircraft/Vehicle crossig ruway occupied by ladig or departig aircraft due icorrect ATC clearace. A E190 lads 28R ad taxies towards 28L for crossig of the departure ruway. O the apro side of the departure ruway three aircraft are holdig o the taxiway due to a aircraft that has pushed back ahead of them. The GMC cotroller asked the TWR cotroller to delay crossig the E190. The A320 is cleared to lie up from 28L ad the the E190 is cleared to cross 28L after a log wait. The cotroller is checkig the clock to cofirm correct wake turbulece separatio betwee the A320 ad a previous departed Heavy, which gives him a gap i the departure sequece. The cotroller is also icreasigly moitorig o a tight ladig or go-aroud situatio o 28R. Whe the secod aircraft lads, the previous lader is just clear of the ruway ad beig asked to expedite clear. The A320 is cleared take-off while E190 begis to cross 28L. The cotroller has forgotte that he has cleared the E190 to cross. The pilot of the A320 saw the E190 ad aouced immediately to the cotroller that he does ot roll. The cotroller does ot detect errors i the strip bay. He believes that he was too busy lookig out the widow at the ladig situatio o 28L to look at his display. He was also aware that the E190 had bee waitig a log time to cross ad he was axious to get him to the Apro. Cotributig Factors: Memory - Cotroller forgot previous actio ruway crossig clearace Memory Forgot to check/moitor ruway Operatio Eviromet Distractio from checkig timed separatio Operatio Eviromet Distractio from checkig situatio o other ruway Orgaisatio Factors Balace of safety/service delivery 48

49 Actual Recovery Barrier: MB3 ATCO detectio followig pilot/driver report ATC Barriers Breached: PB1 PB2 ATCO memory aids for issued (ot issued) clearaces by stadardised flight data displays icludig dedicated ruway bays, blockig strips etc. ATCO direct visual detectio Remaiig Barriers available that could have reduced risk of collisio: MB1 X ATCO direct visual detectio Pilot visual detectio (both aircraft) MB6 ATCO detectio it after alert from A-SMGCS level 2 X Providece ATC Barriers that, if deployed, could have preveted the ruway icursio ad/or reduced risk of collisio: MB8 ATCO detectio after alert from the use of iput ad display of the ATC clearaces ad surveillace data (ITWP) 8.3 Evet 3. Liig up without clearace Geeric Sceario: Surface Movemet Coflict o Ruway D5a Surface movemet o ruway by two or more mobiles eterig/crossig ruway at reciprocal etry poits after o-coformace with ATC clearace due to misiterpretatio or mishear of clearace. Ruway 05 was i use for departure. It was daylight ad the ruway holdig poit was visible from the VCR. The followig RTF exchage took place: - ATC to A320: «after (compay) 747 o your left had side, left tur hold Bravo Oe.» - A320: «After 747, lie up ad wait ruway 05» - ATC: «Negative sir, give way to the 747, the hold at Bravo Oe» - A320: «Give way to the 747, Bravo» Operatioal Safety Study Cotroller Detectio of Potetial Ruway ad Maoeuvrig Area Coflicts Editio

50 A B757 holdig o the opposite side of the ruway was issued with a coditioal clearace. «After the (compay) 747 departs, lie up 08». The readback was correct ad the the B747 is cleared for take-off. The A320 begis to eter the ruway, as does the B757 i accordace with his clearace. The B757 questioed the situatio with the cotroller: (B757 call sig), is there a misuderstadig here? We were cleared to lie up behid the (compay), right?» At this time the A320 was see to be holdig positio over the CAT I holdig poit. ATC cofirm the ruway etry clearace ad istruct the A320 to hold positio, which he cofirms. ATC check that the B757 pilot is happy with the wig clearace from the A320 ad it is subsequetly give take-off clearace. The pilot report from the A320 stated: We were at the holdig poit RWY05 by B1, the F/O cofirmed me that he got ackowledgemet from the TWR cofirmig that we were cleared to eter i the RWY05 behid the precedig traffic. I was speakig to the passegers at the time, as soo as that traffic starts his take-off ru, we started to liig up i the RWY05, a aircraft i frot of us, holdig short at o the other side, tured o his ladig lights at that momet so I stopped the plae to request cofirmatio, we had ru 5 meters or so over. TWR said that the correct sequece was to eter i the RWY behid the B757. The cotroller stated that, i hidsight, the secod read back was ot as defiitive as he would have liked. He reported that he believed that after correctig the first icorrect read back usig the word egative the A320 had uderstood that his first read back had bee icorrect. He stated that he could have solved the issue by usig a secod coditioal clearace ad istructed the A320 to lie up after the B757 to ehace situatioal awareess ad esure the A320 did ot misiterpret his clearace. Cotributig Factors: Actio (Pilot) Covey icomplete iformatio Perceptio Misperceive auditory iformatio Pilot Actios CRM issues Actual Recovery Barrier: MB3 ATCO detectio followig pilot/driver report ATC Barriers Breached: Nil 50

51 Remaiig Barriers available that could have reduced risk of collisio: x Pilot visual detectio (both aircraft) MB6 ATCO detectio after alert from A-SMGCS level 2 x Providece ATC Barriers that, if deployed, could have preveted the ruway icursio ad/or reduced risk of collisio: MB7 MB8 ATCO detectio after alert from airport groud systems that detect etry oto the ruway (e.g. magetic loops or lasers) ATCO detectio after alert from the use of iput ad display of the ATC clearaces ad surveillace data (ITWP) 8.4 Evet 4. Cleared for take-off with ruway still occupied by previous aircraft Geeric Sceario: Take-off o ruway already occupied B2a Departig after receivig icorrect ATC clearace o ruway already authorised occupied It is ight ad the ruway lights ad aircraft lights are difficult to establish from the TWR by a large amout of temporary lights for works o the taxiways close to the ruway. Rapid Exit Taxiways Charlie ad Bravo are closed for the work. Ladig aircraft must either vacate earlier at Delta or cotiue to vacate at Alpha, the far ed of the ruway. There is a 5 mile gap i the ladig sequece ad it is iteded to depart oe aircraft i betwee the ladig aircraft. A A319 is istructed to lie-up ad wait after the ladig B737. The B737 lads ad is told to vacate at Delta ad is see to slow approachig Delta. ATC istruct the B737 to cotact Groud Cotrol (GMC). However the B737 misses Delta ad begis to taxi slowly ahead o the ruway. The traiee TWR cotroller, midful of the ext aircraft o the approach at 2 miles, clears the A319 for take-off havig assumed that the B737 was vacatig as istructed. The TWR cotroller does ot visually cofirm the positio of the B737 i the glare of the may temporary lights ad either the cotroller or the traiee see the clear idicatio o the SMR that the B737 is still o the ruway. Operatioal Safety Study Cotroller Detectio of Potetial Ruway ad Maoeuvrig Area Coflicts Editio

52 GMC is uaware of ay problem ad simply istructs the B737 to take the appropriate taxiway towards its stad. It is oly as the A319 accelerates dow the ruway that a alert from A-SMGCS is triggered. The cotroller mometarily cosiders tellig the A319 to stop but cocludes that it is close to rotatio speed ad safer to allow the take-off. Meawhile, GMC realises the situatio ad istructs the B737 to expedite clear of the ruway. The pilot report from the A319 shows that he was uaware of the B737 still beig o the ruway. He said that he saw some uusual lights but there were so may close to the ruway. Cotributig Factors: Perceptio Mis-see aircraft ot vacatig rwy Perceptio Not see aircraft symbol o SMR Decisio Icorrect pla, trasferrig cotrol of B737 to GMC whilst still o rwy Traiig ad Experiece Cotroller traiig i progress Iteractio with Eviromet Airport Work i Progress Iteractio with Eviromet Airport Airport Groud Lightig Actio (Pilot) Covey o iformatio (missed exit) Actual Recovery Barrier: MB6 ATCO detectio it after alert from A-SMGCS level 2 ATC Barriers Breached: PB1 PB2 MB1 ATCO memory aids for issued (ot issued) clearaces by stadardised flight data displays icludig dedicated ruway bays, blockig strips etc. ATCO direct visual detectio ATC direct visual detectio after take-off clearace Remaiig Barriers available that could have reduced risk of collisio: X X Pilot visual detectio (departig aircraft) Providece ATC Barriers that, if deployed, could have preveted the ruway icursio ad/or reduced risk of collisio: MB8 ATCO detectio after alert from the use of iput ad display of the ATC clearaces ad surveillace data (ITWP) 52

53 8.5 Evet 5. Cleared for take-off o closed ad obstructed ruway Geeric Sceario: Take-off o ruway already occupied B2a Departig after receivig icorrect ATC clearace o ruway already authorised occupied This evet occurred at ight. The souther ed of the ruway 17R/35L was uder costructio. Available ruways are 35L oly (reduced TORA) ad 17L/35R. No departures 17R (towards the work). Ruway 17L is the otified duty ruway i use. The aircraft ivolved i this icidet is a C510, a MEDEVAC flight. The C510 requests taxi ad is cleared to taxi ad cross ruway 17R for ruway 17L departure. There is a airport vehicle o ruway 17R just south of the ruway crossig poit leadig to ruway 17L. A illumiated white cross lies o the threshold of ruway 17R to show it is closed. I order to avoid aircraft liig up ruway 17R from the crossig poit the procedure specified red lightig to be istalled across the ruway. However, to facilitate a quicker chage of ruway betwee 17 ad 35 the red lightig had bee replaced by a mii cross attached to a vehicle. The cotroller ivolved i the icidet kew the existece of this vehicle. ATC wated to help the MEDEVAC flight by optimizig its departure route. The cotroller offers the C510 a ruway 35L departure, givig the shortest taxi ad direct flight routig. ATC gave the surface wid ad the distaces available. The C510 respoded that the distace was sufficiet. ATC cleared the C510 for take-off ruway 35L. The C510 takes off ad the iforms TWR that he just avoided collisio with a truck o the ruway. ATC the remembers it had ot bee removed. Because all cotrollers kow the temporary procedure, there was o specific strip used for showig the vehicle blockig 17R/35L. Aother factor is that may spurious cotacts exist o the groud radar display, especially with costructio work, so vehicles have to be equipped with a specific beaco to allow ATC to cofirm real cotacts. The truck carryig the cross was ot however equipped with this specific beaco. Operatioal Safety Study Cotroller Detectio of Potetial Ruway ad Maoeuvrig Area Coflicts Editio

54 Cotributig Factors: Orgaizatioal balace of service/safety (desire to help CAT A) Memory o recall from workig memory (vehicle o rwy) Memory o recall from log term memory (ATC procedure) Perceptio Not see Procedures Aerodrome (ot followig agreed procedure) Procedures Aerodrome (allowig vehicle without ecessary equipmet) Procedures ATC (display of log term rwy closure) Actual Recovery Barrier: X Providece ad possible last miute visual detectio by pilot ATC Barriers Breached: PB1 PB2 PB5 PB10 x MB1 MB4 ATCO memory aids for issued (ot issued) clearaces by stadardised flight data displays icludig dedicated ruway bays, blockig strips etc. ATCO direct visual detectio ATC detectio with basic SMR All vehicles display high itesity flashig or strobe lightig ATC Procedures for cotrol ad display of closed ruways Belated ATC visual detectio Belated ATC detectio with SMR Remaiig Barriers available that could have reduced risk of collisio: Nil 54

55 ATC Barriers that, if deployed, could have preveted the ruway icursio ad/or reduced risk of collisio: PB3 MB6 MB8 ATC detectio usig remote camera displays ATC detectio after A-SMGCS alert ATCO detectio after alert from the use of iput ad display of the ATC clearaces ad surveillace data (ITWP) 8.6 Evet 6. Aircraft uder tow crossig ruway with misuderstood coditioal clearace Geeric Sceario: Ruway crossig D4a Uauthorised Aircraft/Vehicle crossig ruway occupied by ladig or departig aircraft after ocoformace with ATC clearace due to misiterpretatio or mishear of clearace Ruway 05L is used for ladig ad ruway 05R for take-off. A towed Beluga cotacts TWR o holdig poit short of 05L for crossig of both ruways for the mai. ATC asks him to report i sight of the aircraft o fial. A A319 is taxyig for departure rwy 05R. He is cleared to lie up ad take-off 05R. ATC ask the Beluga tug driver if he is i sight of the traffic o fial, the driver aswers he is seeig a aircraft about to lad. ATC clears the Beluga tug to cross ruway 05L behid the traffic o fial ad the maitai holdig poit Lima (betwee 05L ad 05R). The tug driver replies Roger for crossig rwy 05L ad maitaiig holdig poit 05R The departig A319, o hearig this coversatio asks for cofirmatio of its lie-up ad take-off clearace ad to check the ruway of the ladig aircraft. The aircraft o fial rwy 05L is cleared to lad. Some 20 secods later, ATC istruct the Beluga tug to hold positio ad the asks him if he is o the ruway, to which the tug driver replies that he is. ATC cacel the A319 take-off clearace ad istruct the aircraft o short fial for 05L to go-aroud. The driver did ot uderstad the situatio ad made his ow iterpretatio of the clearace he was give, which was that the ladig aircraft some 4m out was ladig o 05R ot 05L. ATC did however detected the coflict ad properly recovered the icidet givig the right orders to both aircrafts ad the towed Beluga. Operatioal Safety Study Cotroller Detectio of Potetial Ruway ad Maoeuvrig Area Coflicts Editio

56 Cotributig Factors: Actio Covey icomplete iformatio Comms No-stadard phraseology Comms Complexity of ATC trasmissio Comms Coditioal Clearace Comms Tug driver comms experiece Comms Laguage. Comms to driver i ative laguage, comms to aircraft i Eglish reduced situatioal awareess Perceptio (Driver) Misperceive auditory iformatio Actio (Driver) Covey icorrect iformatio Decisio Icorrect pla Not challege iaccurate readback Actual Recovery Barrier: MB1 Belated ATC visual detectio ATC Barriers Breached: X Correct use of ATC phraseology ad read back requiremets Remaiig Barriers available that could have reduced risk of collisio: MB3 X ATC resolutio followig pilot/driver report Pilot visual resolutio ATC Barriers that, if deployed, could have preveted the ruway icursio ad/or reduced risk of collisio: MB2 MB6 MB8 ATC detectio usig remote camera displays ATC detectio after A-SMGCS alert ATCO detectio after alert from the use of iput ad display of the ATC clearaces ad surveillace data (ITWP) 56

57 8.7 Evet 7. Cleared for take-off o obstructed ruway Geeric Sceario: Departig o occupied ruway B2a Departig after receivig icorrect ATC clearace o ruway already authorised occupied Durig this icidet, there has bee three cotrollers succeedig o the TWR positio (ATC1, ATC2 ad ATC3). A check of the side lights of the ruway is to be carried out by a maiteace team escorted by a airport Ops vehicle. ATC1 clears the airport Ops vehicle ad the maiteace vehicle to eter the ruway. Six miutes later ATC2 (TWR Supervisor) relieves ATC1. 10 miutes after that ATC3 relieves ATC2. ATC2 iforms ATC3 that a PC12 is about to taxy for departure but does ot iclude the ruway works i the hadover. ATC3 tells the PC12 to taxi for the holdig poit of the ruway ad 5 miutes later ATC3 clears the PC12 to lie up ad take-off. The Airport Ops vehicle driver hears the icrease of the egies ad calls back ATC to sigal his presece o the ruway. ATC3 immediately stops the take-off of the PC12. The aircraft is already movig but stops quickly. The pilot of the PC12 did ot see vehicles. The driver of the airport Ops vehicle did ot immediately react to the take-off clearace give o the frequecy. It was give i Eglish so there is a possibility that the driver of the airport Ops vehicle, a ative speaker, did ot uderstad it. He heard the icrease egie oise. Cotributig Factors: Memory (ATC2) Iaccurate recall from workig memory Actio (ATC2) Covey icorrect iformatio Operatioal Eviromet Distractio from job-related issues (ATC2 Supervisory role) Team Factors Hadover Issues Operatioal Eviromet Visual Impairmet (lie of sight from TWR) Procedures Airport. Lack of stadard method for display of occupied ruway Comms Laguage. AGA to vehicle i ative laguage. AGA to aircraft i Eglish Operatioal Safety Study Cotroller Detectio of Potetial Ruway ad Maoeuvrig Area Coflicts Editio

58 Actual Recovery Barrier: MB3 ATC resolutio after alert from pilot/driver ATC Barriers Breached: X X ATC strip display procedures ATC hadover procedures Remaiig Barriers available that could have reduced risk of collisio: X X Driver resolutio Pilot visual resolutio ATC Barriers that, if deployed, could have preveted the ruway icursio ad/or reduced risk of collisio: PB3 MB4 MB5 MB6 MB8 ATC detectio usig remote camera displays ATC detectio with basic SMR ATC detectio with Stage 1 A-SMGCS ATC detectio after A-SMGCS alert ATCO detectio after alert from the use of iput ad display of the ATC clearaces ad surveillace data (ITWP) 58

59 8.8 Evet 8. Vehicle etered ruway without clearace Geeric Sceario: Etry oto ruway by aircraft taxyig for departure or by vehicle D3a Etry o ruway by aircraft taxyig for departure or by vehicle after o-coformace with ATC clearace due to misiterpretatio or mishear of clearace, together with a ladig or departig aircraft A bird scarig vehicle operated by the airport had bee cleared to holdig poit Alpha just south of the ruway threshold by GMC ad istructed to cotact TWR for permissio to eter the ruway. A carrier wave was heard o the TWR frequecy, which is likely to have come from the vehicle. ATC istruct a ERJ190 which had just laded to Report Vacated. This is immediately followed by a further carrier wave with a uclear word or two. The bird scarig vehicle the etered the ruway ad had begu to drive alog it, stoppig for a time where the driver had observed some birds. The birds dispersed ad the vehicle cotiued alog the ruway. A hadover of the TWR cotroller positio took place ad icluded the iformatio that the bird scarig vehicle was holdig at Alpha but had ot yet checked i o the TWR frequecy. The ocomig cotroller attempted to call the vehicle to cofirm his positio but whe there was o reply, he asked GMC to attempt cotact who, after receivig a reply, remided the driver that he eeded to cotact TWR before eterig the ruway. The respose was hesitat which led the GMC cotroller to ask for cofirmatio that the vehicle was still at Alpha. The driver replied Negative, I m leavig the ruway at Bravo which is at the far ed of the ruway. It became apparet that the vehicle had etered ad drive the full legth of the ruway without permissio. TWR, aware of this exchage, was about to istruct a E121 aircraft o short fial to go-aroud but the aircraft declared a go aroud due to lack of visual referece. The RVR beig aroud 550 metres at the time. The driver reported that he uderstood that it was ecessary to moitor both frequecies, he had tued the vehicle radio to GMC ad the portable radio to TWR. He stated that he had established cotact with GMC ad bee cleared to proceed to Holdig Poit Alpha ad to cotact Tower. Upo arrival there, he reported havig cotacted TWR usig the portable radio ad received a clearace to eter the ruway ad to report vacated. The vehicle ivolved was fitted with a radio ad the driver also carried a separate portable radio. The portable radio was iteded to be used as a back -up i the evet of radio failure or if the driver eeds to temporarily leave the vehicle. However, it became apparet that some drivers habitually used the portable radios for ormal commuicatios ad that a sigificat umber of persoel did ot properly uderstad the correct radio commuicatio procedures. Operatioal Safety Study Cotroller Detectio of Potetial Ruway ad Maoeuvrig Area Coflicts Editio

60 Cotributig Factors: Pilot/Driver Actio Readback by wrog aircraft/vehicle AGA RTF Desig. Suitability for portable radios, sigal stregth. Exteral Airport Authority Airside Ops ad Stadards Weather Low Vis Procedures Actual Recovery Barrier: X Providece ATC Barriers Breached: PB2 ATC direct visual detectio Remaiig barriers available that could have reduced risk of collisio: Nil ATC Barriers that, if deployed, could have preveted the ruway icursio ad/or reduced risk of collisio: MB2 MB6 MB8 MB2 MB6 MB8 ATC detectio usig remote camera displays ATC detectio with basic SMR ATC detectio with Stage 1 A-SMGCS ATC detectio after A-SMGCS alert ATCO detectio after alert from airport groud systems that detect etry oto the ruway (e.g. magetic loops or lasers). ATCO detectio after alert from the use of iput ad display of the ATC clearaces ad surveillace data (ITWP) 60

61 8.9 Evet 9. Cleared for take-off o obstructed ruway Geeric Sceario: Departig o occupied ruway B2a Departig after receivig icorrect ATC clearace o ruway already authorised occupied Durig this icidet, the traffic is light so TWR ad APP positio are grouped with oly oe cotroller dealig both frequecies. Work is i progress i the buildig of the Tower with the presece of fireme testig the fire alarm which adds a lot of oise aroud the cotroller. Moreover, a military exercise is plaed durig the day ad ATC is busy searchig for iformatio. Start-up is approved for a E145. A Airport Ops vehicle is set to the ruway for ispectio before the departure of the E145. The E145 is cleared to taxi to the ruway holdig poit. ATC gives a iitial clearace for departure to E145 ad tells him to report ready for departure at the holdig poit. A couple of other aircraft call for start or taxi. ATC starts coordiatio by telephoe with a military ATC uit cocerig a aircraft i trasit ad also the departure of the E145. Durig the telephoe coversatio, the E145 calls ATC ready for departure at the holdig poit. ATC does ot respod. At the ed of the telephoe coversatio, The E145 calls ATC a secod time to repeat he is ready for departure. ATC is still busy with coordiatio ad mechaically respods to the pilot. ATC gives the surface wid ad clears the E145 to lie up ad for take-off. The vehicle driver immediately calls to cofirm his presece o the ruway. ATC cacels the take-off clearace give to the E145. ATC did ot look outside ad did ot look at his strips while givig the take-off clearace. Cotributig Factors: Memory Forgot previous actio (clearace for vehicle) Memory Forgot to moitor/check (strips) Memory Forgot to moitor/check (ruway) Perceptio Did ot see (vehicle) Operatioal Eviromet Noise from equipmet Distractio Job related (coordiatio) Operatioal Safety Study Cotroller Detectio of Potetial Ruway ad Maoeuvrig Area Coflicts Editio

62 Actual Recovery Barrier: MB3 ATC resolutio followig driver report ATC Barriers Breached: PB1 PB2 PB10 ATCO memory aids for issued (ot issued) clearaces by stadardised flight data displays icludig dedicated ruway bays, blockig strips etc ATC direct visual detectio All vehicles eterig o a ruway should display high visibility flashig/strobig lights o i all visibility coditios Remaiig Barriers available that could have reduced risk of collisio: X X X Vehicle driver resolutio Pilot visual detectio Providece ATC Barriers that, if deployed, could have preveted the ruway icursio ad/or reduced risk of collisio: MB6 MB8 ATC detectio after A-SMGCS alert ATCO detectio after alert from the use of iput ad display of the ATC clearaces ad surveillace data (ITWP) 8.10 Evet 10. Lied up without clearace Geeric Sceario: Etry o rwy by aircraft taxyig for departure E3a Etry o ruway by aircraft taxyig for departure or by vehicle without ATC clearace due poor CRM ad forgot plaed actio o ruway already occupied, together with a ladig or departig aircraft. A DH8D failed to follow its correctly ackowledged ATC taxi clearace to the ruway holdig poit for 05 ad etered ad lied up o the active ruway at ight i ormal visibility at the same time as a B737 was ladig o the opposite (23) directio of the same ruway. The ladig B737 was able to slow ad vacate the ruway before reachig the other aircraft. The B737 was cleared to lad o 23 at 8m fial whilst DHC8 was pushig back. ATCO attetio was focused o the B737 ladig ad did ot observe the ruway icursio 62

63 The DH8D Captai requested taxi checks from the FO. Last item clearaces was respoded to as to come. FO was predomiately heads i. The Captai the istructed FO to carry out Lie Up checks. The Captai commeted about a previous departure where they were held o the ruway for a log time after lie up before a take-off clearace was give. The Captai believes he reverted this sceario. As the DH8D bega to eter the ruway, the FO commeted o some movig lights o the rwy. The Captai believed it to be a vehicle. FO said it looked like a aircraft. At that poit the Captai realized that o ruway etry clearace had bee give. ATCO moitored B737 ladig roll ad oly the saw the lights of DHC8 o the ruway. The B737 oly saw DHC8 as approachig taxi speed shortly before vacatig the ruway about 400m ahead. It was cocluded that the co-pilot was ot adequately moitorig the commader ad that a cocurret discussio betwee the pilots about a earlier departure that day from the same airport was likely to have coditioed the crew to expect the same clearace from ATC o this sector. The aircraft commader had asked for the Lie Up Check List despite the Taxi checklist ot havig bee completed. All of these factors led the crew to become distracted eough to exceed their taxi clearace limit. The Airport does ot have red stop bars ad that Licesig requiremets oly specify their provisio at Holdig Positios iteded for use i RVR coditios less tha 800 m, which did ot apply. There are flashig wig wags at holdig poit B2, which are crossed before reachig the CAT1/visual holdig poit B1. Cotributig Factors: Memory(pilot) Forgot plaed actio (to stop at holdig poit) Pilot Actios CRM issues Memory ATC Forgot to moitor/check (ruway) Perceptio ATC Did ot see aircraft o rwy Actio Icomplete iformatio (checklists) Distractio (pilot) Job related Actual Recovery Barrier: X Belated pilot detectio Operatioal Safety Study Cotroller Detectio of Potetial Ruway ad Maoeuvrig Area Coflicts Editio

64 ATC Barriers Breached: MB1 ATC direct visual detectio Remaiig Barriers available that could have reduced risk of collisio: X Providece ATC Barriers that, if deployed, could have preveted the ruway icursio ad/or reduced risk of collisio: MB4 ATCO detectio usig basic SMR MB5 ATCO detectio it usig A-SMGCS level 1 MB6 MB7 MB8 ATC detectio after A-SMGCS alert ATCO detectio after alert from airport groud systems that detect etry oto the ruway (e.g. magetic loops or lasers). ATCO detectio after alert from airport groud systems that detect etry oto the ruway (e.g. magetic loops or lasers). ATCO detectio after alert from the use of iput ad display of the ATC clearaces ad surveillace data (ITWP) 8.11 Evet 11. Lied up without clearace Geeric Sceario: Etry o rwy by aircraft taxyig for departure B3a Etry of ruway by aircraft taxyig for departure or by vehicle due icorrect ATC clearace, together with a ladig or departig aircraft Durig the hours of darkess a ATR42 was give a coditioal lie up clearace for Ruway 07 but, cotrary to this clearace, the taxied oto that ruway as a B737 was ladig o it. The ladig aircraft missed the right wigtip of the ATR42 by a few metres at high speed. A coditioal clearace is give to the ATR42 Behid ext ladig short fial, lie up 07 behid The readback is correct. No referece, however, to the fact that a A321 will take-off before the ext ladig. 64

65 The A321 takes off. B737 is give clearace to lad ad ATR42 begis to move oto rwy. Whe the B737 laded, the ATR42 is 40m from rwy c/l. The B737 crew saw the ATR42 ad deviated to right as soo as possible. ATC did ot see the ATR42 util the pass was takig place. ATR42 crew said they saw the A321 pass them ad assumed that was the ladig aircraft i the coditioal clearace. The holdig poit for 07 that the ATR42 was usig was a RET for rwy 25 ad therefore the view from the flight deck of the ATR42 towards the 07 approach was restricted. Cotributig Factors: Actio Covey icomplete iformatio (coditioal clearace) Decisio Icorrect Pla (to give coditioal clearace ot relatig to ext rwy movemet) Perceptio ATC Did ot see aircraft liig up Perceptio (Pilot) Did ot see ladig acft Perceptio (pilot) Misiterpreted visual iformatio (aircraft takig off) Airport Lie of sight from RET Procedures Airport Use of RET for departures i mixed mode Airport Systems A-SMGCS failure Actual Recovery Barrier: X Pilot visual detectio ATC Barriers Breached: MB1 ATC direct visual detectio MB5 ATCO detectio it usig A-SMGCS level 1 Remaiig barriers available that could have reduced risk of collisio: X Providece ATC Barriers that, if deployed, could have preveted the ruway icursio ad/or reduced risk of collisio: Nil Operatioal Safety Study Cotroller Detectio of Potetial Ruway ad Maoeuvrig Area Coflicts Editio

66 8.12 Evet 12. Cleared for take-off o obstructed ruway Geeric Sceario: Ladig o ruway already occupied B1a Ladig after receivig icorrect ATC clearace o ruway already authorised occupied Itersectig ruways 05 ad 14 were i use. A B717 was o a ILS approach to ruway 14. A hadover of the TWR positio took place ad soo afterwards, the B717 checked i o TWR frequecy. The ew cotroller the cleared a A330 to lad o ruway 05. At about the same time, a airport vehicle called i positio at the holdig poit for ruway 14 ear the ladig threshold awaitig etry to carry out a routie ruway ispectio. The TWR cotroller cleared the vehicle to eter ruway 14 but hold short of ruway 05 ad wrote the callsig of the vehicle o the ruway strip to idicate that the ruway was occupied. At that time, the B717 had 7m to ru for ruway 14; either of its pilots recalled hearig the vehicle clearace. The vehicle bega to proceed alog ruway 14 i the directio of use, evetually arrivig at the holdig poit prior to the itersectio with ruway 05. The A330 laded o ruway 05 ad, oce it had vacated, the TWR cotroller cleared a FK100 to take off o ruway 05. Whilst simultaeously observig the FK100 get airbore, the TWR cotroller the scaed ruway 14 without seeig the vehicle o it, picked up the strip for the B717 ad put it i the ruway bay without oticig the vehicle strip also there. With the B717 ow at a rage of about 1.5m (although still i cloud at that time), he gave it a ladig clearace. The Vehicle Driver subsequetly advised that they had heard this clearace but ot the assiged ruway ad had assumed the aircraft would lad o ruway 05. As the B717 touched dow o ruway 14 approximately 370 metres from the threshold, the FO saw the flashig lights of a vehicle ahead o the ruway ad immediately called «go roud, car o the ruway» ad the Captai commeced a go-aroud. The aircraft became airbore agai after a groud roll of about 370 metres. At this time, the vehicle was stopped o the cetrelie of ruway 23 ad 440 meters ahead. The vehicle driver did ot see the aircraft util it had passed about 150 feet over his vehicle ad promptly queried what had happeed. Util two moths earlier, ruway ispectios such as the oe beig carried out were always coducted by a vehicle drivig alog ay active ruway i the opposite directio to that i use. However, followig a request at that time from the ANSP, ispectios had bee coducted i the directio of active ruway use. Cosequetly, the vehicle driver could ot see the ladig aircraft behid. The B717 Captai commeted that had they selected reverse thrust, which is usually doe as soo as the aircraft has touched dow, they would have bee committed to completig a ladig. 66

67 Cotributig Factors: Memory Forgot previous actio (clearig vehicle oto rwy) Perceptio Did ot see rwy blocked idicator o display Perceptio Did ot see vehicle o rwy Perceptio (driver) Did ot see approachig aircraft Perceptio (driver) Misheard the rwy elemet of ladig clearace Procedures Airport ruway ispectio procedure Actual Recovery Barrier: X Pilot visual detectio ATC Barriers Breached: PB1 PB2 MB1 ATCO memory aids for issued (ot issued) clearaces by stadardised flight data displays icludig dedicated ruway bays, blockig strips etc. ATC direct visual detectio ATC direct visual detectio Remaiig barriers available that could have reduced risk of collisio: Nil ATC Barriers that, if deployed, could have preveted the ruway icursio ad/or reduced risk of collisio: PB8b MB4 Use of iput ad display of the ATC clearaces that eable the use of early warig surveillace ad data (ITWP) to highlight the potetial cosequeces of ay icorrect clearace ATCO detectio usig basic SMR MB5 ATCO detectio it usig A-SMGCS level 1 MB6 ATCO detectio it after alert from A-SMGCS level 2 MB8 ATCO detectio after alert from the use of iput ad display of the ATC clearaces ad surveillace data (ITWP) Operatioal Safety Study Cotroller Detectio of Potetial Ruway ad Maoeuvrig Area Coflicts Editio

68 8.13 Evet 13. Simultaeous take-off o itersectig ruways after mishear of ATC clearace Geeric Sceario: Departig or Ladig o itersectig ruways D6a Departig/Departig o itersectig ruways after o-coformace with ATC clearace due to a misiterpretatio or mishear of clearace A ATR42 bega take off i good daylight visibility o ruway 27 without ATC clearace, at the same time as a A340 bega take off from itersectig ruway 33 i accordace with its ATC clearace. ATC were uaware of this util alerted to the situatio by the crew of aother aircraft (C) which was waitig to take off from ruway 27, after which the ATR 42 was immediately istructed to stop. It did this i time to clear the ruway before the itersectio with ruway 33 whilst the A340 cotiued its departure o ruway 33. The ATR 42 had bee previously advised that take off clearace should ot be aticipated for a further 7 miutes after the lie-up ad wait istructio. Aircraft C was statioary at the ruway 27 holdig of the threshold at this time. Oe miute after the ATR 42 had received lie up clearace, the A340 o ruway 33 had bee give take off clearace as follows: ATC: (compay) 971 wid 280/07 kts ruway 33 cleared for take-off. This was correctly read back. Ukow to ATC, the ATR 42 flight crew trasmitted we re cleared take-off (compay) 937. This almost simultaeous trasmissio was ot received by ATC. The ATR42 begu to roll o ruway 27. The crew of aircraft C had heard the A340 readback but had also heard the words cleared for take-off from a distictively differet voice ad whe the ATR 42 bega take off, had called TWR you may have two aircraft takig off at the momet. The reactio of the (TWR) cotroller to this report was immediate ad resolved the situatio. The ATR 42 had reached a speed of 74 kots before begiig to decelerate. It had bee able to clear the ruway at a poit approximately 750 metres prior to the itersectio of ruway 27 with ruway 33. It was cocluded that the situatioal awareess of the ATR42 crew was iadequate. The take-off clearace from ATC to the A340 correctly icluded both the radio call sig ad amed ruway 33. Give this ad that they had previously bee iformed that could expect a take-off clearace i 7 miutes; had they bee moitorig other trasmissios o the TWR frequecy, they would have recogised that aother aircraft had received a coditioal clearace to taxi oto ruway 33 ad was also awaitig a take-off clearace. Callsig similarity may have bee a factor. Although the compay radio call sigs of the two operators were completely differet, two or the three digits i the flight umber were the same. The coflict situatio was mitigated by the crew of Aircraft C who showed a very good overview of the situatio ad a active egagemet with the perceived potetial coflict. 68

69 The automatic selectio of groud receiver locatio for the feed of each aircraft trasmissio to TWR had sigificatly favoured the relatively stroger sigal from the A340 over the simultaeous oe from the ATR 42; thus ATC could ot hear the ATR42 trasmissio. A Stage 2 RIMCAS Alert activated oly after ATR 42 had already started to reject their take off ad was movig at 61 kots ad the A340 was acceleratig through 71 kots. This was because this activatio required that both aircraft must be, o the basis of the calculated projectio, i the «critical circle». At the time of the icidet, a buildig programme was uder way i ad aroud the TWR VCR which caused a obstructio to the view towards the threshold of ruway 27 ad caused abormal chages i the backgroud oise level. Cotributig Factors: Perceptio(pilot) Mis hear auditory iformatio Pilot Actios Readback by icorrect aircraft AGA Comms Call Swampig Operatioal Eviromet Visual Impairmet Operatioal Eviromet Noise Pilot Comms Similar Call sigs Actual Recovery Barrier: MB3 ATC resolutio followig pilot report ATC Barriers Breached: PB2 ATCO direct visual detectio Remaiig Barriers available that could have reduced risk of collisio: MB1 ATC direct visual detectio MB6 ATCO detectio it after alert from A-SMGCS level 2 x Providece ATC Barriers that, if deployed, could have preveted the ruway icursio ad/or reduced risk of collisio: MB2 MB8 ATC detectio usig remote camera displays ATCO detectio after alert from the use of iput ad display of the ATC clearaces ad surveillace data (ITWP) Operatioal Safety Study Cotroller Detectio of Potetial Ruway ad Maoeuvrig Area Coflicts Editio

70 8.14 Evet 14. Cleared for take-off o obstructed ruway Geeric Sceario: Departig o occupied ruway B2a Departig after receivig icorrect ATC clearace o ruway already authorised occupied A B727 bega take-off i ormal ight visibility util two sow clearig vehicles were observed o the ruway ahead at which poit a high speed rejected take off was accomplished with the aircraft comig to a stop clear of the positio of the vehicles. The TWR/GMC Cotroller, workig aloe whilst the other cotroller o duty was takig a break with all trasmissios o GMC ad TWR frequecies audible o both frequecies had, despite the idicatios o his strip display that the ruway was occupied, issued a take-off clearace to the B727 whilst it was backtrackig the ruway. However, immediately after doig so, he had realized his error ad without releasig his PTT switch, after a short pause added actually stadby». The B727 First Officer actig as PM had begu to ackowledge the clearace as soo as the cotroller had fiished givig it ad as a result, oly the very ed of the readback - the aircraft callsig - was heard by the cotroller who assumed that the iteded «cacellatio» of the take of clearace had bee uderstood. He issued a istructio for the sow clearace vehicles to clear the ruway ad the looked away from it whilst givig taxi istructios to aother departig aircraft still o the apro ad, by the time he retured his attetio to the ruway, was surprised to see the B727 o the take-off roll. The take-off roll had goe uoticed by the cotroller for more tha 20 secods». Upo seeig the aircraft approximately 350 metres dow the ruway ad acceleratig, he istructed the B727 to abort take off». There was o respose or ackowledgemet from the crew. The aircraft was just passig 80 kts ad the required SOP check was beig called ad ackowledged. The first third of the ruway has a iclie from the threshold before flatteig out. At that time of the istructio to abort the take-off, the crew were uable to see ay obstructio ahead due to still beig o the upslope. Shortly afterwards, as the aircraft approached the mid-sectio of the ruway at 122 Kts, they saw the lights of the sow clearace vehicles ahead ad immediately iitiated a rejected take off. The B727 was brought to a stop approximately 365m from the sow sweepers. The vehicles had moved to the side of the ruway i case the aircraft was uable to stop i time. I respect of the overlooked Blocked Ruway idicatio o the cotrollers display, a review of 4 hours of recordig aroud the time of the occurrece showed that aircraft had departed o ruways that had a blocked ruway depictio at least three other times, although i all three cases, the ruway was ot i fact physically occupied». The cotroller was his o first scheduled day off but he had bee called 6 hours before commecemet ad offered the shift as overtime. He had iitially declied. A secod phoe call iformed him that o oe else had voluteered. He felt he had to accept. The cotroller reported feelig fatigued at the time of the occurrece. 70

71 Cotributig Factors: Perceptio Not see ruway blocked idicator Actio Covey uclear iformatio (use of two istructios without release of PTT) Actios Covey icorrect iformatio (o-stadard phraseology) No-Coformace Did ot cofirm partial readback No-Coformace Routie givig clearace with ruway blocked idicatio Airport Airfield Layout (upslope o rwy reducig time to visually detect coflict) Orgaisatioal Factors Adequacy of maagemet support (Pressure to work o rostered day off) Persoal Factors Fatigue Actual Recovery Barrier: MB3 Pilot visual detectio ATC Barriers Breached: PB1 PB2 MB1 ATCO memory aids for issued (ot issued) clearaces by stadardised flight data displays icludig dedicated ruway bays, blockig strips etc. ATCO direct visual detectio Belated ATC visual detectio (did work but ot correctly employed) Remaiig Barriers available that could have reduced risk of collisio: X X Vehicle driver detectio Providece Operatioal Safety Study Cotroller Detectio of Potetial Ruway ad Maoeuvrig Area Coflicts Editio

72 ATC Barriers that, if deployed, could have preveted the ruway icursio ad/or reduced risk of collisio: PB8b MB2 MB4 Use of iput ad display of the ATC clearaces that eable the use of early warig surveillace ad data (ITWP) to highlight the potetial cosequeces of ay icorrect clearace ATCO detectio usig remote camera displays ATCO detectio usig basic SMR MB5 ATCO detectio it usig A-SMGCS level 1 MB6 ATCO detectio it after alert from A-SMGCS level 2 MB8 ATCO detectio after alert from the use of iput ad display of the ATC clearaces ad surveillace data (ITWP) 8.15 Evet 15. Etered ruway without clearace after taxy avigatio error Geeric Sceario: Etry oto ruway be aircraft taxyig for departure C3a Etry of ruway by aircraft taxyig for departure or by vehicle after o-coformace with ATC clearace due to spatial/positioal cofusio, together with a ladig or departig aircraft A Raytheo 390 Premier did ot taxi for a ight departure i good visibility i accordace with its clearace. It etered the departure ruway 03 ahead of a Bombardier CRJ200 which had just begu its take- off roll. The CRJ200 crew saw the other aircraft ad rejected their take off from a low speed, comig to a stop before reachig it. The Raytheo crew had correctly read back their taxi clearace to the holdig poit for a full legth departure. They had the become cofused at the poit where the taxiway cetrelie o taxiway B idicates two right tur optios close together, first oto taxiway J, which was ot i use ad the further o, taxiway K (as cleared ad with the cetrelie lit). The cetrelie lightig leadig ahead oto taxiway B3 ad the itermediate holdig poit for the ruway was also lit ad the aircraft followed that lie istead of the right tur oto K. The aircraft cotiued past the co-located flashig Ruway Guard Lights, marked ruway etry Cat 1 holdig poit ad its four embedded ad flashig lights ad the paited words Ruway Ahead ad oto the ruway where they tured right. 72

73 The crew reported that they had briefed taxiway K was the secod tur ad thus followed the secod lit tur. They did ot realise that they had passed the holdig poit B3 ad oly became aware that they were o the ruway whe they saw the white edge lightig. At the time of the icidet, both the AIP taxi chart ad the proprietary charts did ot correctly depict the detail of the movemet area layout at the juctio of taxiways. This, ad the use of lit taxiway cetrelies o all taxiways available for use if so cleared were probable factors. Crew expectatio ad vigilace also led to the icursio. The airport was ot equipped with ay SMR or system for detectig potetial ruway occupacy coflicts. Cotributig Factors: Perceptio (pilot) Misiterpreted visual iformatio Perceptio (pilot) Not see ruway guard lightig Perceptio (pilot) Not see Ruway Ahead sigage Perceptio Not see aircraft takig icorrect route Documetatio Airport Charts Airport Airfield Lightig procedures Actual Recovery Barrier: X Pilot visual detectio ATC Barriers Breached: MB1 Belated ATC visual detectio Remaiig barriers available that could have reduced risk of collisio: Nil ATC Barriers that, if deployed, could have preveted the ruway icursio ad/or reduced risk of collisio: MB4 ATCO detectio usig basic SMR MB5 ATCO detectio it usig A-SMGCS level 1 MB6 ATCO detectio it after alert from A-SMGCS level 2 MB8 ATCO detectio after alert from the use of iput ad display of the ATC clearaces ad surveillace data (ITWP) Operatioal Safety Study Cotroller Detectio of Potetial Ruway ad Maoeuvrig Area Coflicts Editio

74 8.16 Evet 16. Crossed active ruway after icorrect clearace Geeric Sceario: Ruway Crossig B4a Aircraft/Vehicle crossig ruway occupied by ladig or departig aircraft due icorrect ATC clearace Ruway 06 was i use for arrivals ad departures, ad Ruway 13 was beig used for departures of aircraft leavig the de-icig pad. As a cosequece, the GMC ad TWR cotrollers frequetly exchaged resposibility for the cotrol of Ruway 13. Uder these circumstaces, best practices for issuig taxi istructios to ay aircraft taxiig to Ruway 06 would iclude a restrictio to hold short of Ruway 13. Noetheless, the groud cotroller issued a Piaggio P180 a taxi clearace to cross ruway 13 without restrictio for departure o Ruway 06. The GMC cotroller issued istructios to a DH8C to taxi from the de icig pad to Ruway 13. It was istructed to cotact TWR oce holdig short of Ruway 13. Coordiatio betwee the GMC ad TWR was completed for the exchage of resposibility for Ruway 13 to allow its use by the DHC8, at which poit the airport cotroller took over resposibility for Ruway 13. The TWR cotroller completed a sca of the airport Maoeuvrig Area ad the Electroic Flight Display System. The TWR cotroller saw a aircraft (the P180) o the taxiway; however, as there was o idicatio o the airport cotroller s display scree that the aircraft was taxiig for a ruway, it was assumed that the aircraft would tur right towards the de-icig pad. The DHC8 was cleared for takeoff o Ruway 13. Some 30 secods later the P180 etered Ruway 13. Whe the P180 was i the middle of Ruway 13, the horizotal distace betwee the two aircraft was approximately 1000m. The GMC cotroller oticed the ruway icursio ad estimated that P180 would be clear of the ruway by the time DHC8 reached the same poit, if ot airbore. Thus, o call was made for DHC8 to abort the takeoff. Neither P180 or DHC8 was aware of the ruway icursio. The electroic data display system provides red ruway obstructio headers that are used whe a ruway is uavailable for takeoff ad ladig ad is uder the jurisdictio of the GMC cotroller. Sice the ruway obstructio markers represet exchage of resposibility for the ruway, whe the airport ad groud positios are ot combied, oly the AIR cotroller ca isert the ruway obstructio markers ad oly the GMC cotroller ca remove them. Immediately before the evet the GMC cotroller ackowledged a ruway vacatio call from a sow removal vehicle, ad the removed the ruway obstructio marker to trasfer resposibility for Ruway 13 to the AIR cotroller, temporarily forgettig the ruway crossig clearace give to the P180. Whe the groud cotroller trasfers the Flight data etry (FDE) for a departig aircraft to the Taxied pael, it will appear o the TWR cotroller s display i the Departures pael for the iteded departure ruway. The ANSP maual requires that the GMC cotroller forward the FDE of a aircraft taxiig for departure to the Taxied pael so that a FDE will be geerated i the applicable Departure pael of the AIR cotroller s display scree. However, it do ot idicate whe to iitiate this 74

75 trasfer, leavig the decisio to the discretio of idividual cotrollers. Followig the issuace of taxi istructios to P180, the GMC cotroller did ot iitially forward the FDE from the Cleared pael to the Taxied pael, ad therefore the AIR cotroller s display did ot idicate that P180 was taxiig for Ruway 06. Cotributig Factors: Decisio Icorrect Pla GMC rwy crossig clearace Memory Forgot previous actio GMC trasfer rwy after crossig give Actio Covey o iformatio GMC did ot forward FDE Memory Forgot to check o positio of P180 before trasfer of rwy Perceptio Neither ATC saw P180 eter rwy i time to stop DH8 takeoff Persoal Factors High workload o GMC. Actual Recovery Barrier: MB1 Belated ATC visual detectio ATC Barriers Breached: PB1 PB2 ATCO memory aids for issued (ot issued) clearaces by stadardised flight data displays icludig dedicated ruway bays, blockig strips etc. ATCO display visual detectio Remaiig barriers available that could have reduced risk of collisio: X X Pilot visual detectio Providece ATC Barriers that, if deployed, could have preveted the ruway icursio ad/or reduced risk of collisio: MB6 ATCO detectio it after alert from A-SMGCS level 2 MB8 ATCO detectio after alert from the use of iput ad display of the ATC clearaces ad surveillace data (ITWP) Operatioal Safety Study Cotroller Detectio of Potetial Ruway ad Maoeuvrig Area Coflicts Editio

76 8.17 Evet 17. Cleared to lad o obstructed ruway Geeric Sceario: Ladig o occupied ruway B1a Ladig after receivig icorrect ATC clearace o ruway already authorised occupied A B737 was lied up for departure whe ATC were heard to issue a ladig clearace for the same ruway to a A320, which was still IMC o fial approach. After two usuccessful attempts to iform ATC of the error, the commader of the 737 istructed the A320 to go aroud. This was ackowledged ad actioed from approximately 1m ad 400 feet by the A320 crew. The TWR cotroller s pla was to depart 3 aircraft before the arrival of the A320. The first, a A319 had take-off ad the subject B737 was istructed to lie up after the ext departig A320 (B), which was subsequetly also cleared for take-off. At this poit the iboud A320 (A) checked i o frequecy ad would ot have heard the lie clearace already issued to the B737. As A320 (B) became airbore, the previously departed A319 requested a tur for weather avoidace. A tur ad altitude restrictio was coordiated with radar ad relayed to the A319. By this time the iboud A320 (A) was 2.5m from touchdow with the B737 still lied up o the ruway. The electroic flight strip for the B737 was still i the ruway bay but the ATCO cocluded that he must have forgotte to move it, ad cleared A320 (A) to lad. The read back was blocked by a call from the 737 First Officer to the effect that they were still o the ruway. The ladig clearace was the re-iterated by ATC ad read back. A secod attempt by the 737 First Officer to advise ATC of their positio was agai blocked ad a few secods later, the 737 commader trasmitted to the A320 go aroud I say agai go aroud. The cotroller stated that he had the heard the A320 crew read back the istructio to go-aroud. Havig become aware that the 737 was still o the ruway, he the gave go aroud istructios to the A320. B734 pilot subsequet reported seeig the iboud A320 at 4.5m o TCAS as they lied up ad were costatly aware of it. The cotroller error was attributed to the icorrect use of flight progress strips by the cotroller ivolved ad his failure to make either a visual or Aerodrome Traffic Moitor check of the ruway before issuig the A320 with a ladig clearace. The cotroller s pla was iadequate i that it required everythig to happe at optimum speed. The cotroller became distracted from the pla. 76

77 Cotributig Factors: Decisio Misjudgmet Distractio Job-related dealig with weather avoidace co-ordiatio Memory Icorrect recall from memory aircraft lied up Memory Forgot to check ruway sca before ladig clearace Memory Forgot to check situatio display moitor Decisio Icorrect decisio removed strip from rwy bay AGA Comms Call swampig trasmissios blocked Actual Recovery Barrier: X Pilot actio ATC Barriers Breached: PB1 PB2 PB6 MB1 MB3 ATCO memory aids for issued (ot issued) clearaces by stadardised flight data displays icludig dedicated ruway bays, blockig strips etc. ATCO direct visual detectio A-SMGCS level 1 Surveillace with vehicles, i additio to aircraft, equipped with traspoders i order to ehace surveillace iformatio ATCO direct visual detectio ATCO detectio followig pilot/driver report MB5 ATCO detectio it usig A-SMGCS level 1 Remaiig barriers available that could have reduced risk of collisio: x Pilot visual detectio MB6 ATCO detectio it after alert from A-SMGCS level 2 x Providece Operatioal Safety Study Cotroller Detectio of Potetial Ruway ad Maoeuvrig Area Coflicts Editio

78 ATC Barriers that, if deployed, could have preveted the ruway icursio ad/or reduced risk of collisio: PB3 MB2 PB8b MB8 ATCO detectio usig remote camera displays Belated ATCO detectio usig remote camera displays ATCO detectio after alert from the use of iput ad display of the ATC clearaces ad surveillace data (ITWP) after icorrect clearace ATCO detectio after alert from the use of iput ad display of the ATC clearaces ad surveillace data (ITWP) 8.18 Evet 18. Crossed ruway without clearace with aircraft takig-off Geeric Sceario: Ruway Crossig E4a Uauthorised Aircraft/Vehicle crossig ruway occupied by ladig or departig aircraft without ATC clearace due to poor CRM or forgot plaed actio A Bombardier DHC-8 laded o Ruway 23. The GMC cotroller istructed the DHC8 to taxi o Taxiway E ad hold short of Ruway 27, which eeded to be crossed to get to the gate. The hold short istructio was correctly read back. The TWR cotroller cleared a Beech A100 Kig Air to take off from Ruway 27. Approximately 2 miutes later, the DHC8 etered Ruway 27 without stoppig. The BE100, which was approachig rotatio speed, aborted take-off as soo as it saw the DHC8 o the ruway. The BE100 veered to the right of the ruway cetrelie ad passed about 10m behid the DHC8. O receipt of take-off clearace, the Kig Air crew switched o the ladig lights, ad without comig to a stadstill, the aircraft cotiued its mometum to begi take-off. At this time, the flight crew of the DHC8, which was some 200m from the hold lie of Ruway 27, visually scaed the ruway. The first officer idicated that the ruway was clear to the right of the aircraft, ad the captai did the same for the part of the ruway to the left. The GMC ad TWR cotrollers simultaeously observed that the DHC8 was about to cross the ruway. The GMC cotroller ordered the crew to stop, while the TWR cotroller oly trasmitted the DHC8 call sig. At about the same time, the DHC8 cotacted the apro maagemet service ad cotiued travellig straight ahead, crossig the ruway. The BE100 aborted its take-off at 102 kots ad braked heavily. The deceleratig Kig Air veered to the right of the ruway cetrelie ad passed at 37 kots, about 10m behid the DHC8. A few secods later, the DHC-8 cotacted groud cotrol after beig requested to do so by Apro Cotrol. 78

79 The DHC8 pilots did ot cofirm betwee themselves the groud cotroller s istructio to hold short of Ruway 27 otwithstadig the first officer s accurate readback of the istructio. The visual sca coducted by the DHC8 captai was ieffective ad did ot idetify that the BE100 was o Ruway 27. Durig the actio of ruway crossig, the captai of the DHC8 was talkig to Apro Cotrol, cotrary to the operator s SOPs. Cotributig Factors: Pilot Actios CRM issues Perceptio (pilot) Did ot see acft departig No-Coformace Isolated Team o-coformace deliberate departure from operator SOPs Actual Recovery Barrier: X Pilot actio ATC Barriers Breached: Nil Remaiig barriers available that could have reduced risk of collisio: Nil ATC Barriers that, if deployed, could have preveted the ruway icursio ad/or reduced risk of collisio: Nil Operatioal Safety Study Cotroller Detectio of Potetial Ruway ad Maoeuvrig Area Coflicts Editio

80 8.19 Evet 19. Take-off o taxiway Geeric Sceario: Departig/Ladig o taxiway C7a Ladig/Departig o a taxiway after a o-coformace with ATC clearace due to spatial/positioal cofusio A B737 took off i ormal ight visibility from a taxiway parallel to the ruway for which take off clearace had bee give. Because of the available distace ad the absece of obstructios, the take-off was completed uevetfully. ATC had give a istructio to taxi to the departure ruway via taxiway A. There were two parallel taxiways adjacet to the ruway, A ad B. Taxiway B is otified as ati-clockwise ad geerally used for departure traffic. Taxiway A is otified as clockwise ad is ormally used for laded traffic ad towig traffic towards the gate. However the de-icig area was i use, which meat that some de-iced aircraft were usig taxiway A iitially agaist the flow of ormal traffic. The crew expected a switch oto Taxiway B. Istead ATC kept the B737 o A ad offered the B737 a departure from C3, which was accepted. This etailed a 90 degree right across taxiway B ad oto C3 which was primarily a RET for ladig aircraft usig the reciprocal ed of the ruway. Soo afterwards ad whilst betwee taxiway A ad taxiway B received lie up ad wait ad the take off clearaces i quick successio. It tured right agai oto taxiway B ad after a short pause bega a stadig start take off. At first, the TWR cotroller did ot realize what had happeed but, o becomig aware, decided ot to order the aircraft to stop the take-off because it had already gaied too much speed ad there was o risk of collisio ahead of it. Oce the aircraft was safely airbore ad i the climb, ATC advised the crew of the taxiway take-off, who were uaware of this. Subsequetly, it was foud that aother aircraft had bee taxiig o Taxiway B i the ormal had bee approachig the left tur oto the sectio which the B737 was usig for take-off to taxi alog it i the opposite directio. As the B737 aircraft passed at a high groud speed i frot of the other taxiig aircraft, the latter aircraft had bee 280 metres away from the itersectio. There is o gree cetrelie lights for etry to the ruway from C3 (it primarily beig a RET for the other ed). A thi layer of sow impeded crew awareess of their positio. The ruway lights were icospicuous at the locatio where the error occurred but the taxiway lights were clearly visible. The gree taxiway cetrelie lights are all illumiated at all times the lightig system is i use rather tha selected to correspod to a cleared taxiway route as applies at some other airports with complex taxiway etworks. The taxiway routig used by ATC was permissible, however if ATC had complied with the ormal routig via taxiway B the crew error could ot have occurred. The flight deck crew s workload had icreased after they had accepted the shorter route. As a result the crew had to eter chages i the flight maagemet computer ad had less time to visually check the aircraft s positio at the airport from 80

81 the cockpit. The crew was ot usig a groud movemet chart as they felt they were sufficietly familiar with their home base. The pilot i commad was distracted by commuicatios betwee the air traffic cotroller ad a Boeig 747 taxiig i frot of the aircraft that had take a wrog route. Cotributig Factors: Pilot Actios Rushed Taxi Perceptio (pilot) Misiterpreted visual iformatio airport lightig Weather Sow Airport Groud lightig procedure of geeral illumiatio Decisio (pilot) Isufficiet Pla Complacecy, ot usig aerodrome chart Distractio(pilot) Ops related Perceptio (ATC) Did ot see acft take icorrect route or commece take-off. Actual Recovery Barrier: MB1 Belated ATC visual detectio ATC Barriers Breached: PB2 ATCO direct visual detectio Remaiig barriers available that could have reduced risk of collisio: X X Pilot visual detectio Providece ATC Barriers that, if deployed, could have preveted the ruway icursio ad/or reduced risk of collisio: PB8a MB8 Use of iput ad display of the ATC clearaces that eable the use of early warig surveillace ad data (ITWP) to highlight ay ocoformace to clearace ATCO detectio after alert from the use of iput ad display of the ATC clearaces ad surveillace data (ITWP) Operatioal Safety Study Cotroller Detectio of Potetial Ruway ad Maoeuvrig Area Coflicts Editio

82 8.20 Evet 20. Icorrect taxy route resultig groud collisio Geeric Sceario: Icorrect aircraft movemet o Maoeuvrig Area C8a Aircraft takes icorrect taxy route after a o-coformace with ATC clearace due to spatial/ positioal cofusio A B747 was taxiig for departure at ight i ormal groud visibility whe the aircraft was ivolved i a collisio with a buildig adjacet to the taxiway. A failure to re-brief for a uexpected taxi routig ad a loss of situatioal awareess caused the crew to taxi oto a arrow taxiway usuitable for B747s. ATC were uaware of the deviatio i routig util after the collisio. All flight crew members were familiar with the airport through multiple previous visits ad all had sigificat experiece o the B747. A preflight brief was coducted prior to push back which icluded the expectatio that the taxi routig they would get for departure ruway would be via taxiway B. Whe the clearace came it was ot the oe briefed but the alterative of proceedig via taxiway A. No revisio to the earlier crew brief took place. Iitially, the clearace as correctly read back was followed but, whe taxiway A tured to the left as it approached the ruway Cat 2 holdig poit which was the clearace limit, the aircraft wrogly cotiued straight ahead o a arrower taxiway L which ulike A had o cetrelie lightig, just blue edge lights.. As soo as the aircraft etered L, the FO, who was PF, expressed his doubts about the apparet arrowess of the taxiway but there was o respose from either of his colleagues ad he cotiued ahead. A further remark by the FO whe the aircraft was about 10 metres from the buildig to the right of the taxiway that the wig was ot very far from the buildig, was followed almost immediately by impact of the right wig with the buildig. Just prior to the collisio, whe he was uable to see the aircraft o taxiway A the TWR cotroller checked the A-SMGCS display ad discovered that the aircraft was o L. He immediately trasmitted to the aircraft to hold positio but by this time, the collisio had already occurred. The Captai reported that as the juctio betwee the A ad L taxiways approached, the crew has just completed the before take-off checks so that his mid was focused o the objective of gettig to the ruway. He did ot react adequately to cocers raised by the FO before the groud collisio. The pre-flight briefig had used oly the aerodrome overview chart ad ot the text page which cotaied iformatio which icluded a cautio ote specifically o the potetial for cofusio at the juctio of taxiways A ad L. Some of the cetrelie lights o A were userviceable. It was also oted that over a distace of approximately 300 metres up to the holdig poit, o cetrelie lights were istalled. The directio iformatio sig o the left side of taxiway A ahead of the itersectio of A ad L which cosisted of a black iscriptio o a yellow backgroud was ot lit. 82

83 Cotributig Factors: Decisio (pilot) Isufficiet pla o use of taxi charts Decisio (pilot) Icorrect pla o chage of pla whe cleared route was ot as briefed Perceptio (pilot) Misiterpreted visual iformatio airport lightig Decisio(pilot) No pla o respose by Capt. to cocers raised Airport Groud lightig Airport Sigage Perceptio (ATC) did ot see aircraft take icorrect route Actual Recovery Barrier: Nil ATC Barriers Breached: MB1 MB4 ATCO direct visual detectio ATC detected from A-SMGCS data Remaiig barriers available that could have reduced risk of collisio: Nil ATC Barriers that, if deployed, could have preveted the ruway icursio ad/or reduced risk of collisio: PB8a PB9 MB8 Use of iput ad display of the ATC clearaces that eable the use of early warig surveillace ad data (ITWP) to highlight ay ocoformace to clearace Use of discrete ames for holdig positios ad pilot reports e.g. reportig poit BARKA istead of W2 ATCO detectio after alert from the use of iput ad display of the ATC clearaces ad surveillace data (ITWP) Operatioal Safety Study Cotroller Detectio of Potetial Ruway ad Maoeuvrig Area Coflicts Editio

84 CHAPTER 9 - ANALYSIS OF ACTUAL SAFETY EVENTS This aalysis aligs with the Safety Fuctio Map (SAFMAP) methodology i cosiderig the levels of barriers i ay safety evet chai. 1. What available ATC barriers were breached i the evet? 2. What barrier stopped the evet? 3. What available barriers remaied utested? 4. What barriers may have reduced the risk of collisio had they bee deployed? 5. What are the most commo cotributig factors? 9.1 What available ATC barriers were breached i the evet? Table 19: The 4 most commo breached ATC barriers PB2 ATCO Direct Visual Detectio 12 PB1 ATC Memory Aids 9 MB1 Belated ATCO Direct Visual Detectio 7 MB5 ATCO detectio with A-SMGCS level 1 3 This shows that ATCO perceptio of visual iformatio ad lapses i memory are the most commo failure modes. 9.2 What barrier stopped the evet? Table 20: The barrier that effectively stopped the evet MB3 ATCO resolutio after pilot/driver alert 7 MB1 Belated ATCO Visual Detectio 4 X Belated pilot detectio 4 X Providece 2 MB6 ATCO detectio after A-SMGCS alert 1 X Proactive pilot actio 1 Nil Collisio 1 This table shows the importace of the oe team awareess ethos ivolvig ATC, pilots ad drivers i stoppig coflicts becomig collisios. It provides empirical evidece of the effectiveess of cross-idustry safety awareess traiig. I 3 of 84

85 the 20 evets all applied barriers failed, two were saved by providece but oe evet eded i a groud collisio betwee a aircraft ad a structure. 9.3 What available barriers remaied utested? Table 21: The 4 most commo barriers that remaied i place ad utested whe the evet was stopped. X Pilot/driver visual detectio 13 X Providece 12 MB6 ATCO detectio after A-SMGCS alert 5 MB1 Belated ATCO Visual Detectio 3 This shows that the pilot resolutio domai was still available i most circumstaces as was Providece. However, as far as ATC barriers are cocered, i oly 5/20 evets did ATC have ay remaiig barrier available. MB6 x2, MB1+MB6 x 2 ad MB1 x What barriers may have reduced the risk of collisio had they bee deployed? Table 22: The 6 most commo barriers that may have reduced the risk of collisio if deployed. MB7 ATCO detectio after alert from the use of iput ad display of the ATC clearaces ad surveillace data (ITWP) 18 MB5 ATCO detectio after A-SMGCS alert 11 MB3 ATCO detectio with basic SMR 6 MB4 ATCO detectio with A-SMGCS level 1 6 PB7 ATCO detectio after alert from the use of iput ad display of the ATC clearaces ad surveillace data (ITWP) 6 MB2 ATCO detectio usig remote camera displays 5 This shows that fuctioality usig the iput ad display of ATC clearaces ad surveillace could have reduced the risk of collisio i all but two high-eergy evet, icludig the groud collisio. This also shows that ay level of Surface Movemet Radar would decrease risk, effectiveess icreasig i lie with icreased fuctioality. The study of actual evets validates the aalysis of geeric barriers. Operatioal Safety Study Cotroller Detectio of Potetial Ruway ad Maoeuvrig Area Coflicts Editio

86 9.5 What are the most commo cotributig factors? ATC This study pricipally cocers ATC barriers. The first table shows the ATC cotributig factors across the 20 evets. Table 23: ATC cotributig factors Memory Forgot to check/moitor 7 Forgot previous actio 5 Recall from workig memory 3 Recall from log-term memory 1 Perceptio Not see 12 Misiterpret visual ifo. 2 Misiterpret audio ifo. 1 Mis-see Operatioal Eviromet Distractio 6 Visual Impairmet from VCR 3 Noise i VCR 2 11 Actio Covey icomplete iformatio 2 Covey icorrect iformatio 2 Covey uclear iformatio 1 Covey o iformatio 1 Task priorities 1 Decisio Icorrect Pla 4 Misjudgemet Orgaisatioal Factors No-Coformace Team Factors Desire to provide service over-ridig safety 2 Maagerial pressure o staff rostered day-off 1 Routie idividual o-coformace Isolated idividual o-coformace Temporary staffig costraits Hadover issues Traiig Cotroller traiig i progress 1 Persoal Factors Fatigue 1 86

87 This data is aliged with the barriers see to be breached i the evets. ATC cotributig factors are maily Memory or Perceptio; pricipally forgettig about somethig or ot seeig somethig. Various tools ad stadard operatig procedures are available to aid ATC idetificatio of potetial coflicts ad they work very well, i geeral. This study shows however that there are still safety gais to be achieved by developig ew tools ad i maitaiig a vigorous traiig ad day to day competecy. It is of iterest that the third highest commo area of cotributig factors is that of the ATC Operatioal Eviromet. Approximately half of these issues are orgaisatioal; visual impairmets ad oise i the VCR. The other half cocers job-related distractios. This is chiefly about usig the available attetio effectively. Tasks ot ivolvig the subject aircraft are prevalet e.g. checkig a situatio o aother ruway, cocetratig o correct departure wake separatio or co-ordiatios Pilot/Driver Pilot/Driver cotributig factors are pricipally those of Perceptio, followed by poor Commuicatio techiques, as show i the table below: Table 24: Pilot/Driver cotributig factors Perceptio 9 Actio (Comms) 5 Decisios 4 CRM Issues Airport Procedures ad Equipmet The study of 20 evets foud 12 examples of Airport procedures or airport equipmet beig cotributig factors, these were: Ruway Ispectio procedure Use of Rapid Exit Taxiways (RET) for departures durig mixed mode operatios. Routie icorrect use of portable radios carried by airside drivers i additio to the mai radio Routie iappropriate use of compay radio frequecy whilst airside Use of ative laguage to commuicate with airside drivers ad Eglish for pilots Airports Ops departmet ot followig agreed procedure Permittig vehicles o airside without required lightig or radio Taxiway cetrelies beig permaetly lit Work i Progress (WIP) agreemets with ATC that severely restrict operatioal optios, especially at ight Excessive lightig aroud WIP severely restrictig the ability of ATC to iterpret visual iformatio at ight. Iadequate directioal sigage ad sigage lightig at ight. Airfield lightig userviceability Operatioal Safety Study Cotroller Detectio of Potetial Ruway ad Maoeuvrig Area Coflicts Editio

88 9.5.4 Combied cotributig factors from all players Table 25: Mai areas of cotributig factors from all players Perceptio 25 Memory 17 Operatioal Eviromet 14 Actio/Commuicatio 12 Airport Procedures 12 The above table shows that the Huma Performace areas of Perceptio, Memory ad Commuicatio actios are, as expected, promiet i ruway icursio ad groud safety evets. Perhaps less aticipated are the cotributios from the Operatioal Eviromet ad from Airport Procedures. 88

89 CHAPTER 10 - CURRENT STUDIES AND FUTURE DEVELOPMENTS 10.1 EUROCONTROL Air Traffic Cotrol Situatioal Awareess Occupied Ruways (2008) This documet idetifies some of the operatioal tools widely used to provide a memory aid to air traffic cotrollers that a ruway is already occupied. The report focussed o the followig areas: Air Traffic Cotrol work statio; Methods to show a occupied ruway; Reiforcemet of air traffic cotrol awareess; Dedicated tools. The report provided possible or potetial methods to show a occupied ruway Methods to show a occupied ruway RUNWAY OCCUPIED strip This may be placed i a dedicated Strip holder of a differet colour, usually red, to make it more oticeable. Fig 1 Dedicated flight strip for ruway ispectio (oe per ruway) Operatioal Safety Study Cotroller Detectio of Potetial Ruway ad Maoeuvrig Area Coflicts Editio

90 Fig 2 Electroic Flight Strip display with a clear idicatio i the left bay that a ruway is occupied Ruway Occupied Boxes Ruway occupied boxes are a tool to remid a cotroller that the ruway is occupied by a vehicle. It requires maual iput by the cotroller. The cotroller places the box o the flight strip board durig occasios whe a vehicle is authorised to eter the ruway. These types of devices ormally have a flashig red light to remid the cotroller that the ruway is occupied. Figure 3. Ruway occupacy idicator Figure 4. «A ruway occupied box» display pael - Flashig red light 90

91 Ruway Occupacy Plate The Ruway Occupacy Plate (ROP) is maually activated ad de-activated by the cotroller ad provides a remider for the cotroller that a ruway is obstructed or closed. The ruway occupacy plate is built to physically represet the ruway cofiguratio. Whe the cotroller switches o the ROP, i additio to a flashig red light, which acts as a memory aid that the ruway is obstructed, the wid iformatio is suppressed from the meteorological displays. It is a requiremet whe givig a take-off or ladig clearace to trasmit the actual surface wid. If the wid iformatio is ot available this will act as a further remider that the ruway is occupied. The wid iformatio remais uavailable util the ruway occupacy plate is switched off by the cotroller. The occupied ruway is idicated by a red light o the ruway occupacy plate that bliks util a ew iput is made by the Air Traffic Cotroller after the driver reports ruway vacated. Whe a request is made for oe hour or more, the status of the ruway will be CLOSED ad represeted by a steady red light displayed o the ruway occupacy plate. The ROP is operatioal at Paris, Charles de Gaulle. Figure 5. Ruway ope ad free (all ROP lights are gree) Figure 6. Picture to the left (above) depicts the Ruway closed ad to the right the associated ATC MET Report Display is depicted with wid iformatio suppressed. NOTE, whe the ruway is occupied the light is blikig red Dedicated Tools Advaced Surface Movemet Guidace ad Cotrol Systems (A-SMGCS) A-SMGCS covers applicatios ad systems for the air traffic cotroller, vehicle drivers ad the aircraft pilots. Operatioally available systems offer: Cotroller surveillace display, Ruway icursio alerts for the cotroller, Selective switchig of taxiway lights, stop ad hold bars ad Routig guidace fuctios, Ruway protected areas peetratio alerts ad ruway occupied alerts for the vehicle driver. Operatioal Safety Study Cotroller Detectio of Potetial Ruway ad Maoeuvrig Area Coflicts Editio

92 Figure 7. A-SMGCS display whe a aircrafts i the ruway strip ad a car is o the ruway The most commo level of implemetatio of A-SMGCS across Europe is a Surface Movemet Radar together with a Mode S multi-lateratio system ad a ruway icursio alertig system i the air traffic cotrol tower. A-SMGCS techologies ca help to prevet ruway icursios ad coflicts betwee aircraft ad vehicles o the maoeuvrig area. Figure 8. Example of A-SMGCS level II warig ad alert i a approach sceario 92

93 10.2 SESAR - Airport Safety Nets P SESAR1 has studied ad validated ew Airport Safety Nets which are ow icludig as oe of the cocepts that is part of the PCP (Pilot Commo Project) 716/2014. The ew Safety Nets build o the A-SMGCS Surveillace ad Ruway Icursio Moitorig System already i use at may Europea Airports today ad have bee categorised as follows. The cocepts have bee evolved as part of the developmet of the Itegrated Tower Workig Positio (ITWP) at the EUROCONTROL Experimetal Cetre (EEC), Bretigy WA3 - Coflictig ATC Clearaces (CATC) This cocept compares the clearaces iput by the Tower Ruway Cotroller ad provides a early predictio of situatios that if ot corrected would ed up i hazardous situatios that would be detected i tur by the RIMS if i operatio. The detectio of CATC is performed by the ATC system ad the HMI ca show the ATCO which clearace would be usafe to give ad i the case that a wrog clearace is made i error the ATCO will receive a CATC alert. Several validatios have bee performed usig idustry prototypes ad the cocept should be able to be implemeted relatively quickly if EFS ad A-SMGCS Surveillace are already available WA4 - Coformace Moitorig Alerts for Cotrollers (CMAC) The itroductio of Electroic Flight Strips (EFS) at may airports meas that the istructios give by the ATCO are ow available electroically ad ca be itegrated with other data such as flight pla, surveillace, routig, published rules ad procedures. The itegratio of this data allows the system to moitor the iformatio ad whe icosistecies are detected, the ATCO ca be alerted via the HMI or audibly. The mai beefit of this is the early detectio of flight crew / vehicle driver errors that, if ot detected ad resolved, might result i a hazardous situatio. The curret A-SMGCS RIMS will still exist as the last miute warig system based o the positio of the mobiles. The V3 phase of validatios will be completed by 2016 (may idustry parters are developig CMAC ad CATC prototypes) ad already the cocept is well defied (some of the alerts have already bee implemeted at airports i Europe). Like CATC, the CMAC alerts are icluded i PCP implemetatio pla Categories of Alerts A-SMGCS Level 2 RIMS Stage 1 Triggers: No-LVP: INFORMATION aroud T1 = 30 LVP: INFORMATION aroud T1 = 45 CONFLICT A-SMGCS Level 2 Surveillace Iformatio Alert Operatioal Safety Study Cotroller Detectio of Potetial Ruway ad Maoeuvrig Area Coflicts Editio

94 A-SMGCS Level 2 RIMS Stage 1 ROUTE DEV RWY/TWY TYPE STATIONARY A aircraft deviates from cleared route o a taxiway For a flight, whe a selected ruway is iappropriate / usuitable w.r.t the aircraft type, i.e. ruway is too short. (A380 a/c to take off RWY26, egative) Aircraft has received a clearace ad fails to move withi a defied period RWY CLOSED For a flight, whe a selected ruway is closed. (e.g. 19L CLOSED) (RED Alarm if Aircraft give LUP/TOF) TWY CLOSED The taxi route is plaed to go through a closed taxiway (RED Alarm if Aircraft eters closed area) NO PUSH/TAXI CLR Aircraft Pushes back or taxi without clearace from ATC NO CONTACT /NO TRANSFER Aircraft has reached a defied poit without beig assumed/trasferred by the ATCO HIGH SPEED Aircraft taxies with speed exceedig x kots A-SMGCS Level 2 RIMS Triggers: No-LVP: ALARM aroud T2 = 15 secods LVP: ALARM aroud T2 = 30 secods CONFLICT A-SMGCS Level 2 (Surveillace Alarm) CMAC Alarms (Stage 2) RWY INCURSION Mobile i ruway protectio area ROUTE DEV A aircraft deviates from cleared route o a taxiway ear a active RPA NO TOF CLR Aircraft cleared to lie-up ad it takes-off without TOF clearace NO LND CLR Aircraft close to ruway without a Ladig Clearace STATIONARY IN RPA Aircraft that has laded ad is withi RPA for 30secods, or lied up for more tha 200secs or more without movig RED STOP BAR CROSSED Mobile Crosses a RED Stop bar 94

95 Safety Support Tools for Cotrollers The system detects whe 2 clearaces are cosidered as ot safe or ot allowed. Ay combiatio of: Ladig clearace Take-Off clearace RWY Crossig clearace RWY Eter clearace Cosidered as ot safe or ot allowed will trigger a Coflictig ATC Clearace alert. There follows some examples of the iformatio ad alert messages geerated i the ITWP cocept. The list is illustrative ad ot exhaustive Icorrect ATC Clearace I this example the ATCO has iput cleared to lad o LGL8011 ad a pop up widow appears askig the ATCO if they really wat to accept the coditio. Figure 9. Pop up widow i cetre asks for cofirmatio of apparet coflictig clearaces Operatioal Safety Study Cotroller Detectio of Potetial Ruway ad Maoeuvrig Area Coflicts Editio

96 NO CONTACT This alert is geerated for a aircraft o short fial (less tha 4NM) that is ot o the RWY frequecy. Figure 10. Yellow Highlight appears i Alert Widow at top of display ad yellow highlight o ATM elemet for o TWR frequecy cotact with a aircraft withi 4 miles. 96

97 NO LND CLR This alert is geerated for a aircraft o short fial (less tha 30 sec from threshold) that has ot received a ladig clearace Figure 11. Red highlight appears i Alert Widow at top of display ad red highlight o ATM elemet ad Arrivals elemets for aircraft with o ladig clearace withi 1 mile. Operatioal Safety Study Cotroller Detectio of Potetial Ruway ad Maoeuvrig Area Coflicts Editio

98 NO LUP CLR This alert is geerated whe a aircraft is liig up the ruway without a ruway etry clearace. Figure 12. Red Highlight appears i Alert widow at top of display ad red highlight i Holdig poit bay ad ruway etry poit for a aircraft that is eterig the ruway without a clearace. 98

99 Route Geeratio Automatically geerated for every aircraft movemet Takes ito accout default routes ad taxiway usage rules Display of Route iformatio triggered by placig the mouse cursor over the callsig (i EFS or i Radar Label) Routes ca oly be modified by cotroller who has ASSUMED the aircraft Route iformatio is pre-requisite for Coformace Moitorig Route Deviatio Detectio ad DTAXI (uplik of Routes to the cockpit) Figure 13. White lie shows the default route from stad to holdig poit Operatioal Safety Study Cotroller Detectio of Potetial Ruway ad Maoeuvrig Area Coflicts Editio

100 ROUTE DEV This alert is geerated whe a aircraft that is ot taxiig i accordace with the clearace. Cleared Trajectory is be displayed oce the deviatio is detected. Figure 14. Yellow Highlight appears i Alert Widow at top of display ad yellow highlight o aircraft symbol ad i Taxi bay for a aircraft that has deviated from the cleared routig. 100