47TH ANNUAL CONFERENCE, Arusha, Tanzania, 10-14 March 2008WP No. 92Study the ICAO Manual on the Prevention of Runway IncursionsPresented by TOC |
Summary
In 2001 ICAO Air Navigation Commission took action to address the problem of runway incursions. Several areas of concern were highlighted; an education campaign and a series of safety seminars were held in several regions. One of the proposals that came from these seminars was the concept of a manual. This initiative became “The Manual of the prevention of runway incursion Doc 9870 first edition-2007”. TOC has been asked to review this manual. This paper will provide a high-level overview to assist member associations in understanding the purpose and direction of the manual. TOC has come to the conclusion that the manual is of enormous benefit to ATC in the prevention of runway incursions.
This working paper is recommended as information material only.
Introduction
1.1 In 2001, the ICAO Air Navigation Commission (ANC) took action to address the problem of runway incursions. ICAO considered this to be a global issue and one that affects all States and therefore embarked on an education and awareness campaign. This would assist States in providing an evolutionary approach in safety thinking – from that of an individual to that of an organisation. This important shift of focus was considered timely in the then proposed changes to ICAO Annex 11 Air Traffic Services and ICAO Annex 14 Aerodromes on safety management.
Between 2002 and 2005, runway safety seminars were held in several regions, all with the goal to educate the States on the problem of runway incursion. Recommendations arose from some of the seminars for ICAO to produce a prevention of runway incursion manual.
1.2 The purpose of the manual is to provide expert guidance and reinforce the need for a collaborative effort between air traffic controllers, pilots, vehicle drivers and aerodrome management procedures to safely manage the movements on and around the runway. The manual also provides guidance for regulators, aerodrome designers and planners, aircraft operators, air navigation service providers, aerodrome operators and investigative regimes that need help with runway safety initiatives. This manual will provide States that currently have runway safety initiatives and/or incident reporting systems in place to seek global harmonization with ICAO Safety Management System (SMS) provision.
The manual has been carefully written so to be easily and continually referenced and provides many other links to further documentation supporting the statements and guidance in the manual.
1.3 The Technical and Operations Committee (TOC) has been tasked to review the ICAO Manual on the Prevention of Runway Incursions. This manual addresses the different contributory factors that can lead to a runway incursion; it also explains how to establish a runway incursion prevention programme and gives recommendations on how to prevent a runway incursion. The manual also includes incident reporting and data collection as well classification schemes for the severity of runway incursions.
1.4 This review will deliberately provide a high level overview – to assist Member Associations in understanding the manual.
1.5 The IFATCA representative to ICAO Aerodromes Panel (AD), Antonio Travaglione, provided extensive comments on previous drafts of the manual to ICAO. ICAO accepted a number of these comments and amended the ICAO Manual accordingly; however ICAO did not accept comments including additional causes for runways incursions and comments recommending revised layout of the Manual. Antonio therefore remains concerned that not all aspects are clearly covered in the Manual and would still like the comments addressed in future reviews of the Manual. The Manual as published is still a very important step in preventing runways incursions and so TOC has concentrated on reviewing only the Manual as it will be initially used and without discussing possible future improvements.
1.6 When reference is given to ‘the manual’ or ‘this manual’ it is directly referring to the Manual on the Prevention of Runway Incursions. When reference is given to ‘chapter’ it is referring to chapters contained within the manual.
Discussion
2.1 Structure of the manual
2.1.1 The manual has been structured into six chapters and eleven appendices. The manual is easy to read and gives States many examples of how to reduce the risk of a runway incursion. The States also are given a toolkit to work proactively on a national basis.
2.1.2 Chapter one is the introduction and explains the purpose of the manual.
Chapter two contains information on the “Contributory factors” that can lead to a runway incursion. These factors include the affects that controllers, pilots and drivers can all have in the involvement of a runway incursion. Of significant importance is how communication is often a contributing factor and how the importance of aerodrome design is as well.
Chapter three explains how a runway incursion prevention programme should be established. It describes the necessity of a runway safety team and defines what a ‘hot spot’ is and the importance of these areas being well defined and annotated on aerodrome layout maps. There are also further documented links available for those who want to learn more about runway incursions.
Chapter four is “Recommendation for the prevention of runway incursion”. This chapter details communication recommendations for controllers, pilots, Aircraft Operators (AOs), Air Traffic Service Providers (ATSPs), aerodrome operators and vehicle drivers that are of utmost importance to prevent a runway incursion. It also describes the necessity of both general and regulatory recommendations for the States regarding runway incursion risk reduction.
Chapter five is “Incident reporting and data collection”. This chapter looks at using a standardized approach for reporting and analysing information on runway incursions.
Chapter six “Classification of the severity of runway incursion” introduces a scheme that should be used when classifying the severity of a runway incursion. This scheme should be used to establish a globally harmonised data collection method which would lead to effective data sharing between States.
2.1.3 The manual has eleven appendices:
Appendix A. Communication best practices
Appendix B. Best practices on the flight deck
Appendix C. Air traffic control best practices
Appendix D. Airside vehicle driving best practices
Appendix E. Aerodrome resources management training course
Appendix F. ICAO model runway incursion initial report form
Appendix G. ICAO model runway incursion casual factors identification form
Appendix H. Runway incursion severity classification (RISC) calculator
Appendix I. Aerodrome runway incursion assessment (ARIA)
Appendix J. ICAO runway safety toolkit
Appendix K. Eurocontrol runway safety toolkit
2.2 Review of the foreword
2.2.1 The foreword provides the reader with the history of the manual. This information, as detailed in the introduction, allows the reader to understand how the manual was conceived by ICAO and why the need for such guidance is deemed essential in the current aviation climate.
2.3 Chapter 1- “Introduction of the manual”
2.3.1 ICAO Doc 4444 Air Traffic Management defines a runway incursion as:
“Any occurrence at an aerodrome involving the incorrect presence of an aircraft, vehicle or person on the protected area of a surface designated for the landing and take-off of aircraft.”
2.3.2 Several States and international organizations have embarked on extensive programmes to reduce the risk of runway incursions. The manual details how a Transport Canada report (September 2000) report concluded that:
a) “As traffic volume increases, the likelihood of a runway incursion increases more rapidly when capacity-enhancing procedures are in effect than when they are not;
b) if traffic remains the same, the potential for a runway incursion increases when capacity-enhancing procedures are put into operation;
c) many aerodrome improvement projects have resulted in a more complex aerodrome layout which, together with inadequate aerodrome design standards, signage, markings and lighting, and the lack of standard taxi routes and availability of improved aerodrome diagrams, has worsened the situation; and
d) increasing environmental pressure can compromise safe air traffic control (ATC) practices by requiring too many configuration changes.”
The manual details how these factors combined with inadequate training, poor infrastructure and system design and inadequate facilities, can lead to an increased risk of runway incursions.
When detailing the purpose of the manual it describes it as commencing with a high- level discussion of causal factors then going into detail providing many of the lessons learnt by the analysis of previous incidents and accidents.
2.4 Chapter 2 – “Contributory factors”
2.4.1 The manual begins the chapter by describing how a runway incursion may be the result of many different factors. Analysis of these occurrences can be done using the SHEL model. While the chapter does not spend much time on the use of this model (as it is widely in use and many resources are available on line) it describes how the listed contributory factors do not exclude contributions from other aspects of organizational life (e.g. policies, procedures and environment) which all are significant factors when it comes to safety management systems and must be addressed to improve safety overall.
2.4.2 The chapter then details these factors including inter alia the following:
a) Breakdown of communications – including the use of non-standard phraseology and lack of correct read-backs.
b) Pilot factors – including non-compliance issues and the lack of situational awareness
c) ATC factors – momentarily forgetting about an aircraft, closure of a runway, vehicle on the runway etc.
d) Airside vehicle driver factors – failures to obtain clearances to enter the runway, failure to comply with ATC clearances and inadequate training etc.
e) Aerodrome design factors – complexity of the airport layout, insufficient spacing between parallel runways and departure taxiways that fail to intersect active runways at right angles etc.
2.5 Chapter 3 “Establishing a runway incursion prevention programme”
2.5.1 The manual details how the first thing a runway incursion prevention programme should start with is the establishment of runway safety team at an airport. The primary role of a local runway safety team should be to develop an action plan for runway safety. The team should advise management as appropriate on potential runway incursion issues and recommend strategies for hazard removal and mitigate of residual risk. These strategies may be based on local occurrences or combined with information collected elsewhere.
2.5.2 The objective for a runway safety team must be to come up with ways to improve the safety of runway operations, which must apply both for airports with large number of movements as for smaller airports with fewer movements.
2.5.3 The manual then expands on the ICAO concept of a ‘hotspot’. It provides examples of aerodrome charts detailing the importance of correctly highlighting these known areas of potential risk.
2.5.4 This chapter is concluded with the responsibilities of the runway safety team to establish a plan and to have well defined action items assigned to members and accountability in place to see through the required actions to improve runway incursions. This may also include a review of each item’s effectiveness – comparing the pre and post effects on new initiatives to assess their improvement.
2.6 Chapter 4 “Recommendations for the prevention of runway incursion”
2.6.1 In this chapter recommendations are made, following a systematic analysis of a number of runway incursions. The purpose of this is to identify the causes and contributory factors, both active and latent failures, which have led to the accident. The intention is that these recommendations will enhance the safety of runway operations through the consistent and uniform application of existing ICAO provisions. Some of the recommendations include:
a) Communication – full callsign use, standard ICAO phraseology, correct read- backs, operations across a runway should be on the same frequency as utilised for the take-off and landing of aircraft
b) Aircraft operators – thorough training for all pilots in aerodrome signage, markings and lighting, explicit clearance to cross any runway and promoting ‘best practices’ in the planning of ground operations.
c) Pilots – never cross illuminated red stop bars, if holding on the runway for more than 90 sec – contact ATC and advise that they are holding on the runway etc.
d) ATC – Safety Management Systems (SMS) in place in accordance with ICAO provisions. Standard taxi routes should be developed, stop bars switched on, ATC should be head-up for a continuous watch.
e) Aerodrome Operators – limit the physical possibility for pilots and vehicle drivers to mistakenly enter the runway, SMS should be implemented, formal driver training and assessment program and vehicle drivers should be head-up for continuous watch.
f) Regulatory – covered in the oversight activities, accountability for the airport team, local runway incursion prevention awareness campaign.
g) Incident reporting and investigation – full reporting and investigations need to identify specific causal and contributory factors.
h) Aeronautical information – Time critical information dissemination and in accordance with ICAO provisions.
2.7 Chapter 5 “Incident reporting and data collection”
2.7.1 The objective of this chapter is to promote the use of a standardised approach for reporting and analysing information on runway incursions. A global approach for analysis and collection will allow the dissemination of reliable and accurate information between States. Consistent data collection and analysis will define the base-line for States to determine if improvement is being achieved. ICAO stresses the importance of sharing information between States and this data, while locally generated needs to be formatted and presented in a way that comparisons can accurately be made.
2.7.2 The chapter then details the importance of a ‘just culture’. This cultural change to the safety atmosphere is essential in the accurate collection of data needed for analysis. It also provides the detail in what behaviour is acceptable and what is not. Part of establishing this culture provides important considerations to the systemic issues that belly nearly all incidents. While in isolation, human error may seem the major contributor for many incidents, errors are never in isolation and the correct scoping of all the external factors will provide a detailed picture in understanding the issues. Many references are then listed to help States develop this standardised approach.
2.8 Chapter 6 “Classification of the severity of runway incursion”
2.8.1 The objective of runway incursion severity classification is to produce and record an assessment of each runway incursion. All runway incursions should be adequately investigated to determine the causal and contributory factors and to ensure risk mitigation measures are implemented to prevent any recurrence. This classification will also aid in effective data sharing and global harmonisation.
2.8.2 The manual then outlines the classification scheme and factors that influence severity. A CD is also available to assist States; this CD will provide a runway incursion risk calculator.
2.9 Appendices A-I
2.9.1 The appendix is to provide help to the pilots, controllers, drivers and aerodrome resource management in how best to avoid runway incursions. It provides very specific information, detailed directly at the particular causal factors researched in the preparation of this manual.
Two models are also included and they are the ‘ICAO model runway incursion initial report form’ and ‘ICAO model runway incursion casual factors identification form’. Both these models intend to facilitate learning by analysing previous incidents and accidents this also will facilitate a global approach to data collection. The ‘Runway incursion severity classification (RISC) calculator’ is to help States to define the severity of the runway incursion. ‘Aerodrome runway incursion assessment (ARIA)’ will help the local runway team to identify factors that can lead to a runway incursion. These appendices are to be used by States as a complement to prevent runway incursions.
2.9.2 Appendix A “Communication best practices”
Communication is proven to be a regular casual or contributory factor in many runway incursions. Therefore, this appendix provides specific guidance to the reader on how to improve the communication on the airport; irrespective of the audience, many of the points detailed here are for all participants of aerodrome communication. This emphasis on communication is a timely reminder of the importance of consistent ICAO phraseology and the manual details the location in the relevant ICAO documentation to assist States in re-affirming this practice. It also provides many examples. It then details the equally important read-back requirements and the ‘hand in glove’ approach to firstly correctly applied ICAO phraseology and then obtaining the required read-back.
2.9.3 Appendix B “Best practice on the flight deck”
The purpose of this appendix is to highlight some of the causal or contributory factors that have resulted in a runway incursion. It looks at the critical phases of flight and the importance of planning for taxi operations. It also encourages diligent preparation of the required detailed charting and aerodrome layout charts required and minimising possible distractions.The chapter then details taxi procedures including a preparation for taxi check-list. It details language issues, read-backs and other communication ‘best-practices’. It concludes with situational awareness skills including another checklist and concludes with emphasis on crew resource management and defensive actions in the cockpit.
2.9.4 Appendix C “Air traffic control best practices”
The purpose of this appendix is to highlight some of the casual or contributory factors that have resulted in runway incursion. This includes:
a) Clearances – whenever possible enroute clearances should be passed to an aircraft before the start of taxi. Eliminating any confusion that the ‘airways clearance’ is not a clearance to enter a runway or to take-off.
b) Read-back requirements – strict adherence to read-back requirements is directly related to the possible seriousness of misunderstandings in the transmission and receipt of ATC clearances and instructions.
c) Taxi instructions – must always include a clearance limit. When a clearance contains a taxi beyond a runway an explicit clearance must be issued to cross the runway even if the runway is not in use. Aircraft must be on the aerodrome controller’s frequency if needing to cross a runway.
d) Stop bars – an aircraft taxiing on the manoeuvring area shall stop and hold at all highlighted stop bars and may proceed further when the lights are switched off.
e) Take off procedures – correct transfer at the necessary location to eliminate any possible confusion. Correct unambiguous phraseology by ATC to make sure that no confusion could exist.
f) Careful and deliberate ‘hand-overs’ to eliminate operational errors.
2.9.5 Appendix D “Airside vehicle driving best practices”
The purpose of this appendix is to highlight some of the casual or contributory factors that have resulted in a runway incursion.
The appendix also details the required training program and what it should take into consideration. It then offers ‘good practice’ techniques to develop a framework for vehicle driving training. General airside driving will involve mandatory training. To then operate on the manoeuvring area a period of experience in general airside driving followed by specific further training should be developed. This would also include relevant radio-transmission training to correctly understand ATC instruction and clearances.
2.9.6 Appendix E “Aerodrome resource management training course”
Eurocontrol has produced an aerodrome resource management training course which is intended to enhance the team role of all those involved in runway operations. The course emphasizes on developing the team role at each airport and also on educating staff about the exact tasks and difficulties of others who operate on the manoeuvring area. A web site link is provided for this course within the manual.
2.9.7 Appendix F “ICAO model runway incursion initial report form”
Appendix G “ICAO model runway incursion casual factors identification form”
Both these models intend to learn by analysing previous incidents and accidents this also will facilitate a global approach to data collection. Comprehensive analyses of data are essential to distinguish trends and casual factors and develop cost-effective risk reduction strategies.
2.9.8 Appendix H “Runway incursion severity classification (RISC) calculator”
Use of this RISC calculator will enable a consistent assessment to be made of the severity of runway incursion. The appendix details the intent of this model detailing how it starts with a set of situations or ‘scenarios’ that broadly subsume all types of runway incursions that involve an aircraft and either another aircraft, vehicle or pedestrian.
The user of the calculator enters information into the appropriate fields and clicks on the ‘calculate rating’ virtual button. The severity rating and a rating table is displayed. The appendix then details a link for obtaining the risk model from the ICAO website.
2.9.9 Appendix I “Aerodrome runway incursion assessment (ARIA)”
Information about a computer programme (ARIA) that can help local runway safety teams to identify factors that contribute to runway incursions at a specific aerodrome is provided in this Appendix. The appendix then details how to obtain this from Eurocontrol.
2.9.10 Appendix J “ICAO runway tool kit”
The appendix details a CD ROM that has been developed by ICAO and the Embry Riddle Aeronautical University, as part of a continuing effort to assist States in the implementation of runway incursion prevention programs.
The CD contains:
a) An opening statement by the President of the ICAO Council;
b) Introduction;
c) Modules for ATC, flight operations, aerodrome and management responsibilities; and
d) Supplementary material.
The appendix then provides a link to obtain this from the ICAO website.
Conclusions
3.1 The ICAO Manual on the Prevention of Runway Incursions is written as a high-level document that could be referenced over and over. It provides enough specific detail to structure a program that would assist in the reduction of runway incursions.
3.2 The manual stresses the need to be compliant with the ICAO Annexes. It provides substantial emphasis on how improvement to communication is fundamental in decreasing the rate of runway incursions.
3.3 The checklists are substantive and the example reporting forms would allow easy implementation and accountability.
3.4 The manual complies with ICAO policy on SMS and encourages States to continue with the important ‘just culture’ improvements needed to complete the link of successful analysis.
3.5 Many of the links and references in the manual allow the reader to follow up further on many of the concepts in this document. It also provides access to calculators and tools needed to introduce the more complex parts of the manual.
Recommendations
It is recommended that;
4.1 This working paper be accepted as information material.
Last Update: September 29, 2020