Top 5 ATM Operational Safety Priorities
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Transcript of Top 5 ATM Operational Safety Priorities
Top 5 ATM Operational Safety Priorities
Landing Without Clearance
BLAJEV TzvetomirOperational Safety Coordinator, EUROCONTROL
Captain Ed PooleyThe Air Safety Consultancy
In Brief:
The process to determine the priorities - SAFMAPs
What are the Top 5?
Operational safety study example: Landing without clearance
In Brief:
The process to determine the priorities - SAFMAPs
What are the Top 5 ?
Operational safety study example: Landing without Clearance
How to prioritise
Counting numbers versus understanding mechanisms
Single point of view versus a common picture
Learning from negative versus learning from both negative and
positive
How did we get it?
We studied two risk areas:
(1) Runway incursion (2) Loss of separation en-route
Workshops with 6 ANSPS during Summer 2012
Reviewing severity A and B incidents for 2011
Mapping the incidents on SAFMAPs (Safety Functions Maps) –
3 hierarchical levels were developed
SAFMAP Level 0 – Runway Collision
RUNWAY INCURSION
UNRESOLVED BY ATC RUNWAY CONFLICT
UNRESOLVED BY ATC AND PILOT/DRIVER RUNWAY CONFLICT
RUNWAY CONFLICT
Preventing incorrect presence into RWY protected area
Preventing incorrect RWY presence to turn into RWY conflict
ATC RWY Conflict Resolution
Pilot/Driver RWY Conflict Resolution
Providence
SAFMAP Level 1
No incorrect presence of take-off
aircraft
Taxi pilot/driver adequate
communication
No confusion that there is a
clearance
Correct vacation
Taxi pilot/driver adequate positional
awareness
No incorrect presence of landing
aircraft
No incorrect
presence of person
ATC prevents incorrect presence
ATC prevents incorrect presence
RUNWAY INCURSION
ATCO detects the conflict
Sufficient time and effective ATC decision
Adequate Communication
Crew/driver/person initiates action on time
The avoidance action is correctly implemented and
collision is avoided
UNRESOLVED BY ATC RUNWAY CONFLICT
Opportunity for physical collision avoidance
The conflict is detectable by the pilot / driver
The conflict is detected by the pilot/ driver
Crew/driver/person initiates action on time
The avoidance action is correctly implemented and
collision is avoided
UNRESOLVED BY ATC AND PILOT/DRIVER RUNWAY CONFLICT
PROVIDENCE
Preventing ATC causing
incorrect entry
Pilot/driver detecting that RWY entry will be incorrect
Opportunity to prevent the conflict before or with
intended RWY use clearance ATCO prevents conflict after detecting it before or with intended RWY use clearance
RUNWAY CONFLICT
Crew/driver prevents conflict after detecting it before or with intended RWY use clearance
Opportunity to prevent the conflict before or with
intended RWY use clearance ATCO prevents conflict after detecting it before or with intended RWY use clearance
RUNWAY CONFLICTCrew/driver prevents conflict after detecting it before or with intended RWY use clearance
Incident trajectories on the SAFMAP
No incorrect presence
of take-off aircraft
Taxi pilot/driver adequate
communication
No confusion that there is a
clearance
Correct vacation
Taxi pilot/driver adequate positional
awareness
No incorrect presence
of landing aircraft
No incorrect
presence of person
ATC prevents incorrect presence
ATC prevents incorrect presence
RUNWAY INCURSION
ATCO detects the conflict
Sufficient time and effective ATC decision
Adequate Communication
Crew/driver/person initiates action on time
The avoidance action is correctly implemented and
collision is avoided
UNRESOLVED BY ATC RUNWAY CONFLICT
Opportunity for physical collision avoidance
The conflict is detectable by the pilot / driver
The conflict is detected by the pilot/ driver
Crew/driver/person initiates action on time
The avoidance action is correctly implemented and
collision is avoided
UNRESOLVED BY ATC AND PILOT/DRIVER RUNWAY CONFLICT
PROVIDENCE
Preventing ATC causing
incorrect entry
Pilot/driver detecting that RWY entry will be incorrect
Incident trajectory example 1
No incorrect presence of take-off
aircraft
Taxi pilot/driver adequate
communication
No confusion that there is a
clearance
Correct vacation
Taxi pilot/driver adequate positional
awareness
No incorrect presence of landing
aircraft
No incorrect
presence of person
ATC prevents incorrect presence
ATC prevents incorrect presence
RUNWAY INCURSION
ATCO detects the conflict
Sufficient time and effective ATC decision
Adequate Communication
Crew/driver/person initiates action on time
The avoidance action is correctly implemented and
collision is avoided
UNRESOLVED BY ATC RUNWAY CONFLICT
Opportunity for physical collision avoidance
The conflict is detectable by the pilot / driver
The conflict is detected by the pilot/ driver
Crew/driver/person initiates action on time
The avoidance action is correctly implemented and
collision is avoided
UNRESOLVED BY ATC AND PILOT/DRIVER RUNWAY CONFLICT
PROVIDENCE
Preventing ATC causing
incorrect entry
Pilot/driver detecting that RWY entry will be incorrect
Opportunity to prevent the conflict before or with
intended RWY use clearance ATCO prevents conflict after detecting it before or with intended RWY use clearance
RUNWAY CONFLICTCrew/driver prevents conflict after detecting it before or with intended RWY use clearance
• A vehicle entered RWY for maintenance work without clearance after confusion of the position
• ATCO detected the incorrect entry with the red stop bar crossing alarm at the time of issuing clearance for a take-off aircraft
• ATCO immediately cancel the take-off clearance
Incident trajectory example 2
No incorrect presence of take-off
aircraft
Taxi pilot/driver adequate
communication
No confusion that there is a
clearance
Correct vacation
Taxi pilot/driver adequate positional
awareness
No incorrect presence of landing
aircraft
No incorrect
presence of person
ATC prevents incorrect presence
ATC prevents incorrect presence
RUNWAY INCURSION
ATCO detects the conflict
Sufficient time and effective ATC decision
Adequate Communication
Crew/driver/person initiates action on time
The avoidance action is correctly implemented and
collision is avoided
UNRESOLVED BY ATC RUNWAY CONFLICT
Opportunity for physical collision avoidance
The conflict is detectable by the pilot / driver
The conflict is detected by the pilot/ driver
Crew/driver/person initiates action on time
The avoidance action is correctly implemented and
collision is avoided
UNRESOLVED BY ATC AND PILOT/DRIVER RUNWAY CONFLICT
PROVIDENCE
Preventing ATC causing
incorrect entry
Pilot/driver detecting that RWY entry will be incorrect
Opportunity to prevent the conflict before or with
intended RWY use clearance ATCO prevents conflict after detecting it before or with intended RWY use clearance
RUNWAY CONFLICTCrew/driver prevents conflict after detecting it before or with intended RWY use clearance
• During high workload, wet RWY, many Arrivals, more time than usual to vacate the RWY
• ATCO focussing on the one vacating the outer RWY, tired at the and of the day
• Clear an a/c to cross (after landing) after already given TOF clearance to another a/c
• No stop bars used - only for low visibility procedures
• After identifying the conflict ATCO instructed the crossing to expedite
Incident trajectory example 3
No incorrect presence of take-off
aircraft
Taxi pilot/driver adequate
communication
No confusion that there is a
clearance
Correct vacation
Taxi pilot/driver adequate positional
awareness
No incorrect presence of landing
aircraft
No incorrect
presence of person
ATC prevents incorrect presence
ATC prevents incorrect presence
RUNWAY INCURSION
ATCO detects the conflict
Sufficient time and effective ATC decision
Adequate Communication
Crew/driver/person initiates action on time
The avoidance action is correctly implemented and
collision is avoided
UNRESOLVED BY ATC RUNWAY CONFLICT
Opportunity for physical collision avoidance
The conflict is detectable by the pilot / driver
The conflict is detected by the pilot/ driver
Crew/driver/person initiates action on time
The avoidance action is correctly implemented and
collision is avoided
UNRESOLVED BY ATC AND PILOT/DRIVER RUNWAY CONFLICT
PROVIDENCE
Preventing ATC causing
incorrect entry
Pilot/driver detecting that RWY entry will be incorrect
Opportunity to prevent the conflict before or with
intended RWY use clearance ATCO prevents conflict after detecting it before or with intended RWY use clearance
RUNWAY CONFLICTCrew/driver prevents conflict after detecting it before or with intended RWY use clearance
• Landing aircraft mistuned frequency of the TWR and decided to follow the loss of communication landing procedure in VMC
• Take-off aircraft on the RWY already but no opportunity for take-off or for vacating the RWY
• The landing aircraft failed to see that RWY is occupied and landed on top of the a/c at the threshold
In Brief:
The process to determine the priorities - SAFMAPs
What are the Top 5?
Operational safety study example: Landing without clearance
Top 5: (1) Risk of operations without transponder or with dysfunctional one
A single threat often removing all the barriers up to ‘see and avoid’;
No ATC awareness;
No STCA;
No TCAS/ACAS.
Top 5: (2) Landing without clearance
For numerous reasons, aircraft sometimes land without ATC clearance;
This results in runway incursions that are often only resolved through ‘providence’.
Top 5: (3) Detection of Occupied Runway
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.
Top 5: (4) “Blind Spot”
Conflict was not detected with the closest aircraft;
After descending clearance;
Rapidly developing situation – often 1000ft and 15 Nm between the conflicting a/c.
Top 5: (5) Conflict detection with adjacent sectors
Involve “inadequate coordination” of clearance with an adjacent sector;
These typically involve either an early (premature) transfer of control to or from the neighbouring sector.
In Brief:
The process to determine the priorities - SAFMAPs
What are the Top 5 ?
Operational safety study example: Landing without clearance
Top 5 Safety Priorities 19
Operational Safety Study
Provide additional insights on causal/contributory factors
Suggest actions to reduce or eliminate risk factors
Identify industry ‘best’ practice and lessons learned
Inform development of SKYbrary material
Top 5 Safety Priorities 20
The Generic Study Process
CONCLUSIONSCONCLUSIONSANALYSISANALYSISSCENARIOSSCENARIOS
BARRIERSBARRIERS
OPERATIONALCONTEXT
OPERATIONALCONTEXT
Top 5 Safety Priorities 21
The Generic Study Process
CONCLUSIONSCONCLUSIONSANALYSISANALYSISSCENARIOSSCENARIOS
BARRIERSBARRIERS
OPERATIONALCONTEXT
OPERATIONALCONTEXT
Top 5 Safety Priorities 22
Example Conflict Scenarios (1)Active RWY
2a
2b3e3d3c3b3a
1. Unoccupied RWY and no clearance given
2. Unoccupied but a clearance has been given
3. Occupied RWY
A. Loss of communication
B. RWY confusion
C. Communication misunderstanding
D. Absence of clearance overlooked
E. Deliberate
LANDING WITHOUT CLEARANCE
1
Top 5 Safety Priorities 23
The Generic Study Process
CONCLUSIONSCONCLUSIONSANALYSISANALYSIS
BARRIERSBARRIERS
OPERATIONALCONTEXT
OPERATIONALCONTEXT
SCENARIOSSCENARIOS
Top 5 Safety Priorities 24
Barriers
RUNWAY INCURSION
RUNWAY CONFLICT UNRESOLVED BY ATC
RUNWAY CONFLICTUNRESOLVED BY ATC AND PILOT/DRIVER
Preventing landing without clearance situations
Preventing landing without clearance to turn into RWY conflict
ATC RWY Conflict Resolution
Pilot/Driver RWY Conflict Resolution
Providence
RUNWAY CONFLICT
PREVENTION BARRIERS
MITIGATION BARRIERS
Top 5 Safety Priorities 25
RUNWAY INCURSION
ATCO detects the conflict
Sufficient time and effective ATC decision
Adequate Communication
Crew/driver/person initiates action on time
The avoidance action is correctly implemented and
collision is avoided
UNRESOLVED BY ATC RUNWAY CONFLICT
Opportunity for physical collision avoidance
The conflict is detectable by the pilot / driver
The conflict is detected by the pilot/ driver
Crew/driver/person initiates action on time
The avoidance action is correctly implemented and
collision is avoided
UNRESOLVED BY ATC AND PILOT/DRIVER RUNWAY CONFLICT
PROVIDENCE
Opportunity to prevent the conflict before or with
intended RWY use clearance ATCO prevents conflict after detecting it before or with intended RWY use clearance
RUNWAY CONFLICT
Crew/driver prevents conflict after detecting it before or with intended RWY use clearance
Mitigation Barriers
Top 5 Safety Priorities 26
The Generic Study Process
CONCLUSIONSCONCLUSIONSANALYSISANALYSIS
BARRIERSBARRIERS
OPERATIONALCONTEXT
OPERATIONALCONTEXT
SCENARIOSSCENARIOS
Top 5 Safety Priorities 27
Operational Context (1)
Availability of radar guidance for the approach Meteorological conditions and time of the day Runway status Clearance conditions Visual surveillance capability from the Tower
Top 5 Safety Priorities 28
The Generic Study Process
CONCLUSIONSCONCLUSIONSANALYSISANALYSISSCENARIOSSCENARIOS
BARRIERSBARRIERS
OPERATIONALCONTEXT
OPERATIONALCONTEXT
Top 5 Safety Priorities 29
OPERATIONAL SCENARIOS v BARRIER EFFECTIVENESS
All Scenarios formulated are not equally prevalent! And:
All Prevention Barriers (PB) are not equal in their relevance to the various scenarios
All Mitigation Barriers (MB) are not equal in their relevance to the various scenarios
But In both cases there are some clear indications of best “value-added” in responding to the risk of LwC
Assign each ‘PB’ and each ‘MB’ to the defined scenarios as fully effective, partially effective or ineffective/not intended to address – traffic light system:
Top 5 Safety Priorities 30
PREVENTION BARRIER MATRIX
PB1 PB2 PB3 PB4 PB5 PB6 PB7 PB8 PB9 PB10 PB11 PB12 PB13 PB14
A1
A2
A3
B1
B2
B3
C1
C2
C3
D1
D2
D3
E1
E2
E3
Top 5 Safety Priorities 31
MITIGATION BARRIER MATRIX
MB1 MB2 MB3 MB4 MB5 MB6 MB7 MB8 MB9 MB10
A1
A2
A3
B1
B2
B3
C1
C2
C3
D1
D2
D3
E1
E2
E3
Top 5 Safety Priorities 32
RANKING OF PREVENTION BARRIER EFFECTIVENESS
Arbitrary weighting of Green: Yellow at 3:1 (use of 2:1 would make little relative difference)
Best Ranked Prevention Barriers (score range 3-31):
PB 5 an automated (probably visual), alerting of pilots to an occupied runway and thus the (probable) absence of a landing clearance
PB9 a controller-activated (probably visual) alerting of pilots to the absence of a landing clearance.
Best/Worst Coverage of Prevention Barriers by Scenario:
Best - ‘D’ (pilot unaware)
Intermediate - ‘B’ (runway confusion); ‘C’ (comms confusion); ‘A’ (loss of comms)
Worst - ‘E’ (deliberate act)
Top 5 Safety Priorities 33
RANKING OF MITIGATION BARRIER EFFECTIVENESS
Same Arbitrary weighting of Green: Yellow at 3:1 (again use of 2:1 would make little relative difference)
Best Ranked Mitigation Barriers (score range 20-33 plus one outlier at 3):
MB 2 - controller intervention prompted by an automatic alert with or without prior issue of a conflicting clearance.
MB 4 - pilot/driver action prompted by an automatic (probably visual) alert.
MB3 – pilot/driver action promoted by proactive monitoring of traffic visually or on the radio
Best/Worst Coverage of Mitigation Barriers by Scenario:
Best - ‘B’ (runway confusion)
Intermediate - ‘A’ (loss of comms); ‘C’ (comms confusion); ‘D’ (unaware)
Worst - ‘E’ (deliberate act)
VALIDATION OF BARRIER EFFECTIVENESS
Identifies the barriers that could have prevented or mitigated an actual event had they been
Available and Used
×Is not an analysis of what actually happened since the test events were not prevented.
Top 5 Safety Priorities 34
SCENARIO ‘A’ (LOSS OF COMMS)
Non-precision approach by private business flight by aircraft owner. Mistuned TWR in IMC and when no contact possible assumed radio failure and did not revert to APP. Broke cloud at 1.5nm and continued land over a Q400 lined up for departure at the threshold without seeing it.Three effective Prevention Barriers:
PB4, PB5, PB9 These include the top two ranked barriers
Two effective Mitigation Barriers: MB2, MB4 These include two of the three top ranked barriers
Top 5 Safety Priorities 35
SCENARIO ‘B’ (RUNWAY CONFUSION)
Two parallel runways, one closed long term for nearly- completed reconstruction. In VMC, ATC approved an inbound CRJ crew request to land in the reciprocal direction to that in use. The aircraft was then landed on the closed runway without encountering obstacles - ATC only noticed as the aircraft was about to touch down. The crew said they were used to programming the FMS for the runway they actually used and failed to appreciate or correct their error even when flying a
visual approach. Seven effective Prevention Barriers:
PB5, PB6, PB7, PB8, PB9, PB11, PB13 These include the top two ranked barriers
Two effective Mitigation Barriers: MB3, MB8 These include the one of the top three ranked barriers
Top 5 Safety Priorities 36
SCENARIO ‘C’ (COMMS CONFUSION)
ATC instructed pilot to “continue approach” to which the pilot readback was “continue”. ATC made no further attempt to communicate to the aircraft and it was landed in the belief that
clearance had been given. Five effective Prevention Barriers:
PB5, PB9, PB10, PB11, PB12 These include the top two ranked barriers
Six effective Mitigation Barriers: MB2, MB3, MB4, MB5, MB6, MB8 These include the top three ranked barriers
Top 5 Safety Priorities 37
SCENARIO ‘D’ (PILOT UNAWARE)
On initial contact with TWR, the aircraft was instructed to continue advised to expect to be called back. After landing without clearance in the belief that it had been received, the pilot, who was familiar with the airport involved, observed that landing clearance there was usually given a long way out and the absence of the promised call back with clearance was easily missed. Nine effective Prevention Barriers:
PB1, PB2, PB3, PB5, PB9, PB10, PB11, PB12, PB14 These include the top two ranked barriers
Nine effective Mitigation Barriers: MB1, MB2, MB3, MB4, MB5, MB6, MB7, MB8, MB10 These include the top three ranked barriers
Top 5 Safety Priorities 38
SCENARIO ‘E’ (DELIBERATE ACT)
An en-route light aircraft lost positional awareness in VMC and, unequipped with GPS, saw what was considered to be a convenient airport, and made a downwind join in the opposite circuit direction to that in use and continued onto finals and landed without radio contact. TWR saw the aeroplane when it was downwind and instructed another aircraft approaching from the opposite in-use direction to make a go around.Two effective Prevention Barriers:
PB5, PB9 These are the top two ranked barriers
Effective Mitigation Barriers: MB1, MB2, MB3, MB4, MB5, MB6, MB7, MB8, MB10 These include the top three ranked barriers
Top 5 Safety Priorities 39
Top 5 Safety Priorities 40
The Generic Study Process
CONCLUSIONSCONCLUSIONSANALYSISANALYSISSCENARIOSSCENARIOS
BARRIERSBARRIERS
OPERATIONALCONTEXT
OPERATIONALCONTEXT
SOME CONCLUSIONS (1)
The study has identified the best performing potential prevention and mitigation barriers. Some barriers are likely to be more cost effective than others.
Other studies referenced in the Paper are supportive of these findings but also advocate looking at barriers which would directly reduce the prevalence of pilots not being on the TWR frequency as the landing runway is approached.
Combinations of the most effective barriers are likely to make an impressive impact on LwC prevalence and mitigation.
Top 5 Safety Priorities 41
SOME CONCLUSIONS (2)
The top two ranked Prevention Barriers, PB5 and PB9, were applicable in all five scenario examples.
The top three ranked Mitigation Barriers, MB2, MB3, & MB4 were all applicable in Scenarios C (Comms confusion), ‘D’ (Pilot unaware) and ‘E’ (Deliberate Act) and at least one was applicable in the other two scenarios - ‘A’ (Loss of Comms) and ‘B’ (runway confusion.
An outstanding PB5 solution, ‘FAROS’ as currently being deployed in the USA, was estimated prior to this implementation as likely to prevent 65% of runway conflicts – some of which are LwC!
Top 5 Safety Priorities 42
Top 5 Safety Priorities 43
Questions?