Signal Charlie

Dedicated to the continuous improvement of aerospace safety

Stop, Look and Listen

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From our local FAA Safety Program Manager…

“DOT Says Serious Runway Incursions Still a Danger
The Department of Transportation Office of the Inspector General (IG) said
in a report  released last Thursday that runway incursions remain a
persistent, serious problem, despite the FAA?s efforts to reduce their
frequency. Though the focus of the IG?s study was at Boston Logan, Los
Angeles International, Philadelphia International and Chicago O?Hare
airports, where incursions have recently increased, the results of the
study gave recommendations for system-wide improvements. The study said the
FAA should engage in better information sharing to communicate root causes
of deviations and communicate best practices that have worked to reduce
incursions; focus more on controller human-factor issues and training; and
improve accountability at the national level to ensure runway incursions
remain a top priority. According to the study, runway incursions have
decreased from a high of 407 in fiscal year 2001 to a low of 323 in fiscal
year 2003. Since then, the numbers have remained relatively flat. According
to the IG?s study, the FAA did not comment on how it would address the
concerns noted in the report.”

And my thoughts on the matter….

An open, learning, just reporting culture will be a good start so that rich data can be gathered. then throw in valid risk assessment and a vigorous safety awareness campaign. “Stop. Look. Listen”. Another risk management system that works is “Ask, Assess, Act.”

We need to go beyond who did what, and look at “Why” it happened, and at what level the hazard was generated. Runway Incursions are an area where “Production” goals are outstripping “Protection” mitigations. Time pressure is huge at large airports to increase capacity, and it shouldn’t be. There’s only one thing that can happen when you try to put too much stuff in too small of a bag. There are latent hazards that reside at the Decision/Policy Maker and Line Management level, and they become active failures during the productive activities of controllers, ground vehicle operators and pilots. High ops tempo is always a factor, cognitive task loading leads to increased slips, lapses and mistakes. Invalid assumptions about system performance lead to skewed behaviors, high risk consequences and sub-optimal decisions.

Is the hazard more frequent (percentage wise) at these high capacity airports vs small towered fields? If so, capacity (production) is a risk element that needs to be transferred, eliminated, or mitigated.

Do air traffic controllers have reporting protections similar to those offered by ASAP? When we extend those privileges to everyone, all users of the NAS, then the number of reports will actually go up, which is a sign of a healthy reporting system. Then we will have a better contextual view of the system and be able to focus on “Why”, not “Who”. From there we can develop and implement valid action items and monitor their effectiveness.

Fly Smart

Clark

Written by Clark

May 31, 2007 at 11:26 am

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