NM Top 5 Safety Priorities Tzvetomir BLAJEV
A Serious Incident Analysis A conditional clearance Behind next landing short final, line up 07 behind. Correct readback. No reference that A321 to take-off before. B737 is given clearance to land and ATR42 begins to move onto rwy via a RET. ATC did not see the ATR42 until the pass was taking place. ASMGCS unserviceable. The B737 crew saw late. Crash narrowly missed.
What factors were involved? 1. Convey incomplete information. 2. Plan clearance not relative to the next movement. 3. Risky procedure use of RET with no line of sight. 4. Perception/detection ATC. 5. Airport systems. 6. Perception/detection Crew 7. Providence A conditional clearance Behind next landing short final, line up 07 behind. Correct readback. No reference - the A321 to take-off before. B737 is given clearance to land and ATR42 begins to move onto rwy via a RET. ATC did not see the ATR42 until the pass was taking place. ASMGCS unserviceable. The B737 crew saw late. Crash narrowly missed.
Counting factors is not Grasping reasons! 1. Convey incomplete information. 2. Plan. 3. Risky procedure. 4. Perception/detection ATC. 5. Airport systems. 6. Perception/detection Crew 7. Providence
How to get the safety priorities then? EXPERTISE - Develop an approach based on explicit safety control functions and not on counting factors. DATA - Use a robust data set to see what safety function works and what safety function fails. KNOWLEDGE - Peer group review of the data to make sense of the success and failure and decide on the priorities.
How to get the safety priorities then? EXPERTISE - Develop an approach based on explicit safety control functions and not on counting factors. DATA - Use a robust data set to see what safety function works and what safety function fails. KNOWLEDGE - Peer group review of the data to make sense of the success and failure and decide on the priorities.
Basic Barriers: Runway Collision PROVIDENCE UNRESOLVED BY PILOT / DRIVER RUNWAY CONFLICT PILOT / DRIVER RUNWAY COLLISION AVOIDANCE UNRESOLVED BY ATC RUNWAY CONFLICT ATC RUNWAY COLLISION AVOIDANCE RUNWAY CONFLICT ATC PREVENTING RUNWAY CONFLICT RUNWAY INCURSION PREVENTING RUNWAY INCURSION
ZOOM Preventing Runway Incursion PROVIDENCE UNRESOLVED BY PILOT / DRIVER RUNWAY CONFLICT PILOT / DRIVER RUNWAY COLLISION AVOIDANCE UNRESOLVED BY ATC RUNWAY CONFLICT ATC RUNWAY COLLISION AVOIDANCE RUNWAY CONFLICT ATC PREVENTING RUNWAY CONFLICT RUNWAY INCURSION PREVENTING RUNWAY INCURSION
Level 1 Barriers Zoom PREVENTING RUNWAY INCURSION Preventing ATC to cause incorrect entry of taxiing mobile Preventing taxiing pilot/driver to cause an incorrect entry Preventing incorrect presence of vacating mobile Preventing incorrect presence of landing aircraft Preventing incorrect presence of taking-off aircraft Preventing incorrect presence of person
Level 1 Barriers Zoom PREVENTING RUNWAY INCURSION Preventing ATC to cause incorrect entry of taxiing mobile Preventing taxiing pilot/driver to cause an incorrect entry Preventing incorrect presence of vacating mobile Preventing incorrect presence of landing aircraft Preventing incorrect presence of taking-off aircraft Preventing incorrect presence of person
Level 2 Barriers Zoom PREVENTING RUNWAY INCURSION PREVENTING ATC TO CAUSE INCORRECT ENTRY OF TAXIING MOBILE Error Detection and Resolution ATC Traffic Awareness ATC Traffic Plan ATC Coordination ATC Plan Execution
Level 2 Barriers Zoom PREVENTING RUNWAY INCURSION PREVENTING ATC TO CAUSE INCORRECT ENTRY OF TAXIING MOBILE Error Detection and Resolution ATC Traffic Awareness ATC Traffic Plan ATC Coordination ATC Plan Execution
Level 3 Barriers Zoom PREVENTING RUNWAY INCURSION PREVENTING ATC TO CAUSE INCORRECT ENTRY OF TAXIING MOBILE ATC TRAFFIC PLAN EXECUTION INCOMPLETE INFORMATION IN THE CONDITIONAL CLEARANCE
How to get the safety priorities then? EXPERTISE - Develop an approach based on explicit safety control functions and not on counting factors. DATA - Use a robust data set to see what safety function works and what safety function fails. KNOWLEDGE - Peer group review of the data to make sense of the success and failure and decide on the priorities.
Data Gathering Workshops with European Air Navigation Service Providers. Data for their most serious incidents for one year. Representative sample.
Sample to population representativeness ALL PHASES A AND B SEPARATION MINUMA INFRINGEMENTS 264 ALL A AND B RUNWAY INCURSIONS ANALYSED RUNWAY INCURSIONS 101 ANALYSED EN-ROUTE INCIDENTS
Geographical representativeness Participation of 14 ANSPs
Runway Incursion: The scenario trigger 4 incorrect presence of vacating aircraft 3 conflicting take-off clearance 1 incorrect take off after air-ground communication 4 insufficient spacing 22 Taxiing mobile incorrectly entering 7 landing without clearance 8* ATC causing an incorrect entry of taxing mobile * 1 event was a prevented runway incursion 8 ATC not providing correct and timely landing clearance
How many times a barrier failed and worked? PROVIDENCE PILOT / DRIVER RUNWAY COLLISION AVOIDANCE 3 28 3 ATC RUNWAY COLLISION AVOIDANCE 14 31 ATC PREVENTING RUNWAY CONFLICT 11 45 PREVENTING RUNWAY INCURSION 1 56 WORKED OR NOT NEEDED FAILED
How many incidents are stopped by a barrier? 3 PROVIDENCE 28 PILOT / DRIVER RUNWAY COLLISION AVOIDANCE 14 ATC RUNWAY COLLISION AVOIDANCE 11 ATC PREVENTING RUNWAY CONFLICT 1 PREVENTING RUNWAY INCURSION
Sudden High Energy Runway Conflict 2 PROVIDENCE 9 PILOT / DRIVER RUNWAY COLLISION AVOIDANCE 1 ATC RUNWAY COLLISION AVOIDANCE 0 ATC PREVENTING RUNWAY CONFLICT 0 PREVENTING RUNWAY INCURSION
Basic Barriers: Separation minima infringement en-route PROVIDENCE POTENIAL COLISION UNRESOLVED BY PILOT PILOT COLLISION AVOIDANCE - VISUAL POTENIAL COLISION UNRESOLVED BY ACAS PILOT COLLISION AVOIDANCE - ACAS POTENTIAL COLISION UNRESOLVED BY ATC ATC COLLISON AVOIDANCE LOSS OF SEPARATION ATC TACTICAL SEPARATION ASSURANCE POTENTIAL AIRBORNE (TACTICAL) CONFLICT PREVENTING TACTICAL CONFLICT
Separation infringement The scenario trigger 4 executive plan of work 4 vertical speed deviation 1 Overlooked 2 ATCO aircraft execution 1 Airspace infringement 1 Lateral deviation 30 Blind Spot 6 Air-ground communication 7 military activity 13 Sector coordination 8 pre-tactical conflicts 8 altitude deviation 10 ATCO controlling technique
How many times a barrier failed and worked? PROVIDENCE PILOT COLLISION AVOIDANCE - VISUAL PILOT COLLISION AVOIDANCE - ACAS ATC COLLISION AVOIDANCE 2 1 2 41 3 55 44 ATC SEPARATION ASSURANCE 95 PREVENTING TACTICAL CONFLICT 95 WORKED OR NOT NEEDED FAILED
How many incidents are stopped by a barrier? 2 PROVIDENCE 1 PILOT COLLISION AVOIDANCE - VISUAL 41 PILOT COLLISION AVOIDANCE - ACAS 51 ATC COLLISON AVOIDANCE ATC TACTICAL SEPARATION ASSURANCE PREVENTING TACTICAL CONFLICT
Does the incident scenario make a difference? PROVIDENCE PILOT COLLISION AVOIDANCE - VISUAL Reported additionally to the study sample 11 19 PILOT COLLISION AVOIDANCE - ACAS ATC COLLISON AVOIDANCE ATC TACTICAL SEPARATION ASSURANCE PREVENTING TACTICAL CONFLICT BLIND SPOT SECTOR COORDINATION ACAS RA NOT FOLLOWED TRANSPONDER FAILURE
From a representative sample of EVAIR automatic Mode S monitoring (2010-2014) Pilot responses to initial RAs Pilot responses to secondary RAs Below required rate 12% Opposite 8% Excessive 5% Followed 75% Below required rate 15% Opposite 18% Excessive 3% Followed 64%
How protected we are? Separation infringements vs. Runway Incursions 2 1 2 Big proportion saved by the last available barriers 3 28 3 55 44 95 41 3 14 31 11 45 95 1 56 Separation Infringement En-Route Runway Incursion WORKED OR NOT NEEDED FAILED
How to get the safety priorities then? EXPERTISE - Develop an approach based on explicit safety control functions and not on counting factors. DATA - Use a robust data set to see what safety function works and what safety function fails. KNOWLEDGE - Peer group review of the data to make sense of the success and failure and decide on the priorities.
The suggested Top 5 safety priorities
Risk of operation without transponder or with a dysfunctional one A single threat often removing all the barriers up to see and avoid ; No ATC awareness; No STCA; No TCAS/ACAS.
ACAS RA not followed The associated risk is extremely high; No ATC control; Often the providence is the only available barrier;
Blind Spot Conflict was not detected with the closest aircraft; Often after descending clearance; Majority are triggered by sector exit constraints or rushed clearance after a pilot request Rapidly developing situation often 1000ft and 15 Nm between the conflicting a/c.
Controller detection of potential runway conflict Good share of the severe Runway Incursion incidents could have been prevented; Need for the controllers to detect that the runway was occupied at the time of giving a clearance for the next aircraft to use it.
Sudden High Energy Runway Conflict Typically involves rapidly developing situation Runway entry in front of a high energy landing or taking-of aircraft At position where the available reaction time is close to or less than the needed reaction time for detection, communication and collision avoidance manoeuvre
In Summary EXPERTISE - Develop an approach based on explicit safety control functions and not on counting factors. DATA - Use a robust data set to see what safety function works and what safety function fails. KNOWLEDGE - Peer group review of the data to make sense of the success and failure and decide on the priorities.