Archive for the ‘Threat and Error Management’ Category
ICAO Manual on the Prevention of Runway Incursions
In 2001, the ICAO Air Navigation Commission took action to address the problem of runway incursions. Several critical areas were identified that needed to be investigated and which had a relation to overall runway safety, including radiotelephony phraseology, language proficiency, equipment, aerodrome lighting and markings, aerodrome charts, operational aspects, situational awareness and Human Factors.
To improve the situation with respect to runway incursions and to encourage the implementation of relevant provisions, ICAO embarked on an education and awareness campaign which began with a comprehensive search for the best available educational material for inclusion in an interactive runway safety toolkit. Information on this toolkit is provided in Appendix J to this manual. To address aerodromes, air traffic management and flight operations, among other subjects, ICAO also conducted a series of runway safety seminars in the ICAO regions, with the aim of disseminating information on the prevention of runway incursions. Between 2002 and 2005, runway safety seminars were held in the following regions as part of the ICAO education and awareness campaign: Africa-Indian Ocean, Asia and Pacific, Caribbean and South American, European, and Middle East. Recommendations were made at the runway safety seminars held in the Asia and Pacific and Middle East Regions for ICAO to produce a manual containing runway incursion prevention guidelines. Therefore, the objective of this manual is to help States, international organizations, aerodrome operators, air traffic service (ATS) providers and aircraft operators to implement runway safety programmes taking into account best practices already implemented by some States, international organizations, aerodrome operators, ATS providers and airlines. All of the above efforts were undertaken to address a specific problem, that of runway incursions. This focus on the so-called “tip of the arrow” was necessary; however, the inherent need to address safety in a proactive and systemic manner cannot be overstressed. An evolution in safety thinking has led to a change in focus: from that of the individual to that of the organization as a whole. It is now acknowledged that senior management decisions are influential in shaping the operational contexts within which operational personnel perform their duties and discharge their responsibilities. It is also accepted that, regardless of the extent to which operational personnel excel in their job performance, they can never ultimately compensate for systemic deficiencies and flaws in the system that binds them. This new way of thinking is reflected in the following recent Standards and Recommended Practices (SARPs) on safety management which, for the first time, explicitly address the contribution and responsibility of senior management regarding safety.
Download the manual.
Fly (and Taxi) Smart
Kent
NTSB Alert: Controlled Flight Into Terrain in Visual Conditions
Recent NTSB investigations have identified several accidents that involved controlled flight into terrain (CFIT) by both instrument flight rules (IFR)-rated and visual flight rules (VFR) pilots operating under visual flight conditions at night in remote areas.
• In many of these cases, the pilots were in contact with air traffic control (ATC) at the time of the accident and receiving radar service.
• The pilots and controllers involved all appear to have been unaware that the aircraft were in danger.
• Increased altitude awareness and better preflight planning would likely have prevented all of these accidents.
Recent examples:
-A Learjet departed Brown Field, south of San Diego, California, and struck terrain while being radar vectored in a mountainous area east of the airport, resulting in three fatalities.
Read the NTSB Safety Alert
Fly Smart
Kent
Teaching ADM
Great article on Aeronautical Decision Making from NAFI:
Teaching Tip
Teaching ADM 101
By David St. George, MCFI
Since more than 80 percent of accidents are pilot error, I argue that the most important airspace is between the pilot’s ears.
Sure, pilots must learn requisite physical skills, and flight instructors must also teach the decision-making skills that keep them out of those situations where extraordinary skill is required. When a pilot rolls a Cessna into a ball while trying to land in a 35-knot crosswind, are his stick skills to blame or his judgment? If we don’t teach aeronautical decision-making (ADM) and risk management, we are not addressing the primary cause of accidents.
A very useful mental model to demonstrate successful safety management is the “Reason Swiss cheese” model, developed by James Reason for the nuclear power industry. Mistakes there are a problem, too.
This model postulates numerous layers of “error defenses” we should always have working for us, insulating us from potential hazards. For most accidents to occur, many levels of safety defenses must be penetrated. An “accident chain” requires denial at each step in order to build into an accident. This chain is always remarkably obvious in retrospect, but quirks of human psychology make it invisible in action.
Your safety barriers start by creating safety awareness at the institutional level: Is my airport, club, or FBO safe? Do they encourage and enforce safety procedures, or are they more interested in maximum utilization at the expense of safety? Are we having too much fun at the expense of discipline? Proceed to the next layer: Is the equipment we fly well-maintained and -suited to the operation I am undertaking?
We often ignore these two levels of defense. Flying in a “safety culture” creates an active awareness of risk management and a constant awareness of our vulnerability. NASA’s analysis of the Columbia and Challenger disasters clearly illustrates the tragic results of “normalizing deviations”—that is, risks or anomalies are accepted as “normal” and escape further scrutiny, moving it closer to a potential accident: “Those O-rings always leak a little,” or “That tank always sheds some foam on liftoff.”
The final safety defense barrier is the aeronautical decision-making psychology of the pilot. A pilot needs an active safety scan of risks and tools to mitigate them. But are we, as CFIs, addressing this issue on every flight and helping the student build up a repertoire of potential safe and unsafe decisions?
If we usurp this responsibility as the “all-knowing CFI,” we deprive the student of one of the most important lessons. By categorically stating that, “It’s fine to fly today,” we remove that important personal decision for the future pilot, and may be “normalizing” a situation that would be hazardous for the student in the future. We all have seen this occur: “This ceiling is low, but we can go today.” Or with equipment: “That nose strut is low, but it’s safe for us.”
Inevitably, the student learns the lesson of ignoring or normalizing an unsafe situation. Instead, we should treat every flight decision as a “teachable moment.” If we are to create safer pilots, addressing the importance of risk management on every lesson and illuminating the dangers of “normalizing deviations” are essential duties of every CFI.
Got a favorite teaching tip that’s worked for you? Share it with us at nafi@eaa.org.
Fly Smart
Kent
ALPA RUnway Safety Newsletter #2
Here’s newsletter #2 on the ALPA site. There are lots of valuable lessons to be learned here, ones that others have learned for you and are now sharing.
Fly (and Taxi) Smart
Kent
Mastery Flight Training Safety Info
Check out the great info on Tom Turner’s site Mastery Flight Training and sign up for his newsletter.
Fly Smart
Kent
New ALPA Runway Safety Site
Through our new campaign, “Hold Short for Runway Safety” ALPA will focus its efforts on preventing runway incursions, excursions, and confusion. We will provide you with further education and common-sense guidance that will help prevent operational breakdowns. Every pilot knows we have too much to do and not enough time to do it between getting in the cockpit and taking off.
Check out the new Runway Safety site and give us your feedback.
Fly Smart
Kent
Identifying and Mitigating the Hazards Associated with Runway Incursions
AFS Roadshow Presentation Jan 2008: Identifying and Mitigating the Hazards Associated with Runway Incursions
There has been an significant increase of runway incursions lately. In fact
it is so serious that Jim Ballough (AFS-1) and John Allen (AFS-2) traveled
around the country to meet with key management officials from Part 121 carriers to focus on reducing pilot deviations. This issue affects everyone who operates on the protected area of an airport intended for takeoff or landing.
The consequences of a runway collision are severe and it usually results in fatalities to pilots and passengers. As utilization of the National Airspace System (NAS) increases, there will be more exposure to this hazard. That is not a good combination. The key for operators to defend against it today is the use of good judgment and sound operating procedures. There are technological mitigations being developed for tomorrow, but they are not keeping pace with the growth of the NAS. We also need to ensure steps are taken at the Regulatory, Organizational and Supervisory level to ensure that no additional exposure is allowed within the system until the necessary defenses are in place. In other words, let’s not pour any more fuel on this fire. As pilots, it is not our job to fix the problems that production goals create, but many times we are left to deal with it as best we can. It is our job to operate professionally and safely. A valid assessment of the system state coupled with seasoned, conservative judgment leads to efficient decision making. We get one shot at this one, and we have to do it right every time.
This presentation provides educational re-creations of air traffic work.The FAA has provided it to safety professionals for education and awareness. Take a look at it and become part of the solution by sharing your thoughts with your FSDO’s Safety Program Manager. Or post them here and I’ll share them for you.
Fly (and Taxi) Smart
Kent
Airport Surface Movement Event Transgressions (ASMET)
NASA ASRS conducted a study for the FAA Office of Runway Safety in 2003 to analyze Airport Surface Movement Event Transgressions (ASMET).
“The identification of an ASMET event was based on the NASA ASRS definition: “The ASRS defines an ASMET as an incident that involved the erroneous occupation of a runway or its immediate environs by an aircraft, pedestrian or vehicle so as to pose a potential collision hazard to other aircraft that could be using the runway, even if no such other aircraft were actually present. ASMET events also include erroneous takeoffs or landings on the airport surface.””
2772 events were entered into the NASA database over a 4 year period. The FAA categorized approx 1000 events during the same period. These ASRS reports represent the part of the iceberg that is underwater, an equally dangerous part that we don’t see.
Take a few minutes to read through the material, the analysts did a great job of breaking out the most common errors at 75 high threat airports. All of these airports had Air Traffic Control towers. What types of events do you think happened at non-towered fields, and were they reported?
My thanks to the reporters and NASA ASRS analysts.
Fly (and Taxi) Smart
Clark
Runway Safety Recurrent Training
From the FSDO Safety Program Manager and myself; Our goal is to increase awareness and education about Runway Safety. Take 20 minutes and look it over.
“Hello everyone,
There has been an significant increase of runway incursions lately. In fact
it is so serious that Jim Ballough (AFS-1) and John Allen (AFS-2) traveled
to the Eastern Region and Southern Region to meet with key management
officials from Part 121 carriers to focus on reducing pilot deviations.
This week, Ballough has been holding similar meetings in the Central, Great
Lakes, and Southwestern Regions, while Allen has West Coast duty in the
Alaska, Northwest Mountain, and Western Pacific Regions. You can view the
presentation on
http://www.faa.gov/safety/programs%5Finitiatives/pilot%5Fsafety/deviations/ReducingPDs/
Within it is a reference to the ALPA/AOPA/FAA Runway Safety Program, an on-line, interactive course. You can complete it in 30-45 minutes and get a completion certificate. Armed with this certificate, you can request credit for a portion of the new Wings pilot proficiency program, which may help lower your insurance rate if you fly GA on the side. To check out the course, go to http://flash.aopa.org/asf/runway_safety_alpa/
Don’t be fool that the above message addresses the 121 arena only . We are
experiencing the same problem in the GA world as well!”
Things you can do:
1. Identify airport surface operational hazards to NASA ASRS, the FAA Safety Hotline and airport management.
2. Review cockpit procedures to identify elements that may contribute to pilot distraction during taxi and develop a TEAM approach to Transfer, Eliminate, Accept or Mitigate those hazards.
3. Use an airport diagram, free from airnav.
If you have questions about the new Wings program, give me a holler, I am a Lead Rep for the FAASTeam at the Ft Worth FSDO.
Fly (and Taxi) Smart
Clark
Signal Charlie 