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Transcript of ICAO European Runway Safety and Air Traffic Services Management Seminar Moscow, Russian Federation,...
ICAO European Runway Safetyand Air Traffic Services Management Seminar
Moscow, Russian Federation, 12 - 15 September 2005
Antonio Antonio TravaglioneTravaglioneIFATCA Aerodrome Safety IFATCA Aerodrome Safety
RepresentativeRepresentative
Runway IncursionRunway IncursionA Strategic A Strategic ApproachApproach
Highway Intersection ConceptHighway Intersection Concept
ICAO European Runway Safetyand Air Traffic Services Safety Management Seminar
Moscow, Russian Federation, 12 - 15 September 2005
Evolution of the ICAO ModelEvolution of the ICAO Model
Analysis Models & ResultsAnalysis Models & Results
Intrinsic SafetyIntrinsic Safety
CROSSROADS VS HIGHWAY INTERSECTIONS
ICAO European Runway Safetyand Air Traffic Services Safety Management Seminar
Moscow, Russian Federation, 12 - 15 September 2005
IDEAL LAY-OUT
Single runway
APRON
ICAO European Runway Safetyand Air Traffic Services Safety Management Seminar
Moscow, Russian Federation, 12 - 15 September 2005
IDEAL LAY-OUT
Single runway
APRON
ICAO European Runway Safetyand Air Traffic Services Safety Management Seminar
Moscow, Russian Federation, 12 - 15 September 2005
IDEAL LAY-OUT
Two parallels
APRON
ICAO European Runway Safetyand Air Traffic Services Safety Management Seminar
Moscow, Russian Federation, 12 - 15 September 2005
THE REAL WORLD
Charles de Gaulle, Malpensa, Manchester...
APRONTWR
ICAO European Runway Safetyand Air Traffic Services Safety Management Seminar
Moscow, Russian Federation, 12 - 15 September 2005
!!! CROSSROAD !!!
ICAO European Runway Safetyand Air Traffic Services Safety Management Seminar
Moscow, Russian Federation, 12 - 15 September 2005
LIMITATIONSLIMITATIONS
ICAO European Runway Safetyand Air Traffic Services Safety Management Seminar
Moscow, Russian Federation, 12 - 15 September 2005
Poor system descripting system descripting ModelModel,
Lack of strategic visionstrategic vision
LIMITATIONSLIMITATIONS More focused to Human Human
ErrorsErrors than Human FactorsHuman Factors,
ICAO European Runway Safetyand Air Traffic Services Safety Management Seminar
Moscow, Russian Federation, 12 - 15 September 2005
EQUIPMENT
PEOPLE PROCEDURE
System Descripting ModelSystem Descripting ModelPPE MODEL
ICAO European Runway Safetyand Air Traffic Services Safety Management Seminar
Moscow, Russian Federation, 12 - 15 September 2005
SHELL MODEL
S
H
E
L
L
Software (S) = Procedures (P) + laws, rules, regulations,
EQUIPMENT
PEOPLE PROCEDURE
Hardware (H) = Equipment (E) + infrastructures, Environment (E) = ? Liveware (L) = People (P), producing HE
core of the system, HF to be considered
ICAO European Runway Safetyand Air Traffic Services Safety Management Seminar
Moscow, Russian Federation, 12 - 15 September 2005
REASON’S MODELFAILURES
ACTIVE
ACTIVE
LATENT
LATENT
LATENT
LATENT
INCIDENTINCIDENT
!!! ACCIDENT !!!!!! ACCIDENT !!!
DECISION MAKERS
LINE MANAGEMENT
PRECONDITIONS
PRODUCTIVE ACTIVITIES
DEFENCES
ICAO European Runway Safetyand Air Traffic Services Safety Management Seminar
Moscow, Russian Federation, 12 - 15 September 2005
THREE DIMENSIONS
ICAO European Runway Safetyand Air Traffic Services Safety Management Seminar
Moscow, Russian Federation, 12 - 15 September 2005
SoftwareDecision Makers
FAA educated Captain““taxi to holding position, runway…” taxi to holding position, runway…”
(ICAO)(ICAO)
S
“taxi into position and hold, runway…” (FAA)
ICAO European Runway Safetyand Air Traffic Services Safety Management Seminar
Moscow, Russian Federation, 12 - 15 September 2005
Lined-up in front of an acft on final Lined-up in front of an acft on final that, having acft in sight, went aroundthat, having acft in sight, went around
S
SoftwareDecision Makers
FAA educated Captain““taxi to holding position, runway…” taxi to holding position, runway…”
(ICAO)(ICAO)“taxi into position and hold, runway…” (FAA)
ICAO European Runway Safetyand Air Traffic Services Safety Management Seminar
Moscow, Russian Federation, 12 - 15 September 2005
H
Acft, after landing, was taxiing to the apron
Hardware Infrastructures
Decision Makers
that is beyond another runway.that is beyond another runway.
ICAO European Runway Safetyand Air Traffic Services Safety Management Seminar
Moscow, Russian Federation, 12 - 15 September 2005
H
The other runway is used for departures
Acft, after landing, was taxiing to the apronthat is beyond another runway.that is beyond another runway.
Due to a mistake (pilot? – controller?) crossing happened while a take-off was in crossing happened while a take-off was in
progressprogress
Hardware Infrastructures
Decision Makers
ICAO European Runway Safetyand Air Traffic Services Safety Management Seminar
Moscow, Russian Federation, 12 - 15 September 2005
E
Acft was taxiing for departure.
EnvironmentLine Managers
ICAO European Runway Safetyand Air Traffic Services Safety Management Seminar
Moscow, Russian Federation, 12 - 15 September 2005
E
While taxiing, departure runway and taxi route was While taxiing, departure runway and taxi route was changedchanged
B737 was taxiing for departure.
EnvironmentLine Managers
ICAO European Runway Safetyand Air Traffic Services Safety Management Seminar
Moscow, Russian Federation, 12 - 15 September 2005
E
Crew lost its Situation Awareness and entered the runway while a take-off was in entered the runway while a take-off was in
progress.progress.
While taxiing, departure runway and taxi route was While taxiing, departure runway and taxi route was changedchanged
B737 was taxiing for departure.
EnvironmentLine Managers
ICAO European Runway Safetyand Air Traffic Services Safety Management Seminar
Moscow, Russian Federation, 12 - 15 September 2005
ETwo acft were holding positions at Two acft were holding positions at
opposite heads of the same runway.opposite heads of the same runway.
EnvironmentLine Managers
ICAO European Runway Safetyand Air Traffic Services Safety Management Seminar
Moscow, Russian Federation, 12 - 15 September 2005
E
Two acft were holding positions at Two acft were holding positions at opposite heads of the same runway.opposite heads of the same runway.
No. 1 was instructed to line-up.
EnvironmentLine Managers
ICAO European Runway Safetyand Air Traffic Services Safety Management Seminar
Moscow, Russian Federation, 12 - 15 September 2005
E
Two acft were holding positions at Two acft were holding positions at opposite heads of the same runway.opposite heads of the same runway.
No. 1 was instructed to line-up.Few seconds later take-off clearance was
issued.
No. 2 misunderstood the clearance,
EnvironmentLine Managers
ICAO European Runway Safetyand Air Traffic Services Safety Management Seminar
Moscow, Russian Federation, 12 - 15 September 2005
E
Two acft were holding positions at Two acft were holding positions at opposite heads of the same runway.opposite heads of the same runway.
No. 1 was instructed to line-up.Few seconds later take-off clearance was
issued.
No. 2 misunderstood the clearance, entered the runway and gave thrustentered the runway and gave thrust.
EnvironmentLine Managers
ICAO European Runway Safetyand Air Traffic Services Safety Management Seminar
Moscow, Russian Federation, 12 - 15 September 2005
LivewareThe Human Element of the SystemL
Human ErrorsHuman Errors vs Human FactorsHuman FactorsProf. Sydney Decker
ICAO European Runway Safetyand Air Traffic Services Safety Management Seminar
Moscow, Russian Federation, 12 - 15 September 2005
LivewareThe Human Element of the SystemL
Humans (OP) make mistakes,Regulators and Service Providers
provide OP with awareness campaigns and/or modify proc.
After an awareness campaign has been held, Regulators and Service Providers are relieved from their responsibility; OP retains his responsibility, since he has been informed about the risks.
ICAO European Runway Safetyand Air Traffic Services Safety Management Seminar
Moscow, Russian Federation, 12 - 15 September 2005
LivewareThe Human Element of the SystemL
A physiological amount of actions producing results different from intended cannot be avoided,
Awareness campaigns and/or new procedures are:
short term and relatively cheap actions,
NOT A PANACEA
ICAO European Runway Safetyand Air Traffic Services Safety Management Seminar
Moscow, Russian Federation, 12 - 15 September 2005
LivewareThe Human Element of the SystemL
Different approach to Human Factors: NOT ONLY when academically studying
them, BUT endorsing and implementing HF
principles into SARPs, Guidelines, Action Plans, Procedures, Infrastructure Design, AS WELL
ICAO European Runway Safetyand Air Traffic Services Safety Management Seminar
Moscow, Russian Federation, 12 - 15 September 2005
LivewareThe Human Element of the SystemL
SUGGESTED WAYSSUGGESTED WAYS remove hazards:remove hazards:
eliminate runway crossing – obstacles to visibility;eliminate runway crossing – obstacles to visibility; re-assess environment protection proceduresre-assess environment protection procedures
mitigate results of good faith acts mitigate results of good faith acts (slips, lapses, (slips, lapses, mistakes) mistakes) through redundancy:through redundancy: back-up voice com with data-link; back-up voice com with data-link; associate warning signs with voice recorded associate warning signs with voice recorded
messages; messages; enhance situation awareness through Aerodrome enhance situation awareness through Aerodrome
Resource ManagementResource Management
ICAO European Runway Safetyand Air Traffic Services Safety Management Seminar
Moscow, Russian Federation, 12 - 15 September 2005
Vulnerable
system
Average
system
Resistant system
Prof. James Reason - Intrinsic safetyProf. James Reason - Intrinsic safety
ICAO European Runway Safetyand Air Traffic Services Safety Management Seminar
Moscow, Russian Federation, 12 - 15 September 2005
CONCLUSIONSCONCLUSIONS
Intrinsic SafetyIntrinsic Safety
Intrinsic SafetyIntrinsic Safety
Intrinsic SafetyIntrinsic Safety
Updating Annex 14 SARPs – No RWY Updating Annex 14 SARPs – No RWY crossingcrossing
Re-assessing Environment Protection Re-assessing Environment Protection
ProceduresProcedures
Endorsing HF Principles in System DesignEndorsing HF Principles in System Design
ICAO European Runway Safetyand Air Traffic Services Safety Management Seminar
Moscow, Russian Federation, 12 - 15 September 2005
ICAO European Runway Safetyand Air Traffic Services Safety Management Seminar
Moscow, Russian Federation, 12 - 15 September 2005
Antonio Antonio TravaglioneTravaglioneIFATCA Aerodrome Safety IFATCA Aerodrome Safety
RepresentativeRepresentative
atravaglione@[email protected]