By Robert Baron (email@example.com)
When I was at Milan Italy's Linate Airport in the winter of last year I had a real bad feeling about what I saw (or didn't see). I was flying a Learjet 31A, giving a Swiss businessman some training in his new aircraft. Our flight had departed Geneva, Switzerland around mid-morning. We did some airwork, and then shot the ILS 36R approach into Milan's single runway airport. If you have ever flown in European airspace in the winter, you have found a whole new appreciation for IFR procedures, ATC clearances, and holding (yes, holding!). With the reported weather at Linate Airport right at minimums, it was just another typical morning in the area. Low dense fog was obscuring visibilities to ½ mile. At times it was less and at times it was more. We lucked out…. we were treated to ½ mile visibility on our approach!
We had spent a few hours on the ground in Milan. When we got back to the airport to prepare for our short trip to Cannes, France, I started to get a bad feeling about surface movements in low visibility at Linate Airport. The general aviation-parking ramp has two routes in and out (please see exhibit A). There is a north route and a south route. When exiting the ramp, the normal and safest way to taxi is via the north route (this precludes having to cross the active runway). The south route, which can also be used to taxi to the active runway, involves crossing the runway at midpoint to get to the taxiway on the opposite side. Due to construction at the time, the only route available to get to runway 36R was the south route. We were instructed to taxi via R6, and hold short of runway 36R. At the time, the visibility was about 200 feet. We could barely see two taxi lights ahead. When we arrived at the runway 36R hold short line, I had made a mental comment to myself that this airport was ripe for a major runway incursion. Even on our taxi-out, there were factors in place that could have led to a serious ground incident.
Some of those factors included:
Whether it was luck, skill, or a combination of both, we managed to "break a link or two in the chain” and departed uneventfully to our destination. Unfortunately, my biggest fear at Linate would be realized seven months later as Italy's worst aviation disaster.
- Closed north ramp due to construction.
- Low visibility.
- Language problems.
- A “jog” in the taxi to cross 36R. Normally there are perpendicular taxiways in addition to the high-speed turn-offs. In this case they are angled. This creates more time crossing the active runway as well as confusion. During low visibility, this became quite a handful!
- No surface ground radar.
- Limited visibility of surface movements from the tower.
- Unfamiliarity of the airport.
October 08 2001
118 Killed as Jetliner, Business jet Collide on Italy Runway
MILAN, Italy (AP)- “An SAS airliner taking off for Denmark hit a private jet that wandered across the runway, then careened into an airport building in a fiery crash that killed all 114 people on both planes and four people on the ground Monday. It was Italy's worst aviation disaster.”
In an analysis of this accident, we can see how the "links in the chain” remained connected. The business jet was in the wrong place at the wrong time. Causal factors, including chilling similarities to my visit at Linate, included:
Needless to say, after hearing about this accident, I was very disheartened. As a pilot who experienced firsthand precisely what was going on at that airport, it came as no surprise that a tragedy such as this was one day bound to happen.
- The Business jet pilot using the R6 taxi route (south) for undetermined reasons.
- Low visibility (approx 700 feet).
- No surface ground radar (which, combined with low visibility, includes a general rule that all aircraft are prohibited from crossing the runway).
- Limited visibility of surface movements from the tower.
WHERE ARE WE?
I used a major runway incursion as an example from another country because of its significance and relevancy. But what is going on here in our own country? Are we safe? Could this or has this happened in the United States? Where have we been and where are we going on runway incursion mitigation? What measures are being taken to make sure that a tragedy of this magnitude can never happen? Let's take a closer look at some of these questions.
To quickly put this into perspective, let's keep in mind that the accident that caused the greatest loss of life in aviation history was a runway collision at Tenerife Airport in the Canary Islands on March 27, 1977, involving two 747's. There were 583 people killed. The FAA defines a runway incursion as “Any occurrence at an airport involving an aircraft, vehicle, person, or object on the ground that creates a collision hazard or results in loss of separation with an aircraft taking off, intending to take off, landing, or intending to land.”
During a recent four-year period, total reported runway incursions increased 54% from 186 to 287. Detailed investigations of these incidents have identified three major areas contributing to runway incursions¹:
- AIRPORT KNOWLEDGE
- COCKPIT PROCEDURES FOR MAINTAINING ORIENTATION
Pilot/controller communication is paramount to airport surface operations. All instructions must be fully understood, particularly during high workload or when the frequency is busy. It is mandatory to read back runway “hold short” instructions verbatim. For effective communications, clear and concise is the name of the game.
Airport knowledge is very important. If you frequent a particular airport, you probably know your way around pretty well. However, flying into an unfamiliar airport can pose many challenges. Having an airport diagram and asking ATC for “progressive taxi” can be a big help at an unfamiliar airport! I can say for a fact that taxiing around a large, unfamiliar airport at night (e.g.; Kennedy) can be the most complex part of our entire flight!
Cockpit procedures and/or Standard Operating Procedures during taxi are also very important. The “sterile cockpit” rule is in effect during all taxi operations. There is no place for non-essential chatter while maintaining vigilance and running checklists during the taxi. Familiarity with light gun signals is essential should you lose radio contact with ground control. As a general rule, one pilot must always have his head outside to scan for other traffic and to prevent incursions. The other pilot may be performing checklists, talking on the radio, and doing last minute paperwork.
How come we don't hear too much about runway incursions? Quite frankly, if it doesn't end as an accident with loss of life the media is generally not interested. Therefore, there are more incursions taking place than the general public knows about. For example, less than a year ago an American Airlines jet nearly collided with a cargo plane on a runway at Dallas/Fort Worth Airport. American Flight 2393, carrying 60 people en route to Chicago Midway Airport, had to lift off before reaching the proper takeoff speed because a cargo plane was in its path. The American flight crew estimated that they missed the other craft by 10-20 feet. The American jet was traveling more than 100 miles per hour when it passed over the other plane. According to the investigation, controllers had cleared the cargo plane to cross the runway, but after doing so, the pilots made a wrong turn back onto the runway². Was this in the news? Most likely not. Had the aircraft collided you bet it would have been front-page headlines!
Runway incursions are such a high priority that the National Transportation Safety Board (NTSB), every year since 1990, has named runway incursions as one of the nation's top transportation safety issues, including it on its “Most Wanted” list of safety improvements. The NTSB believes that runway incursions are one of the most significant hazards in aviation today! Keep in mind that the NTSB can only make recommendations to the FAA and the FAA can accept or reject those recommendations. The NTSB has no regulatory or enforcement power.
In the early 1990's, the number of runway incursions was declining. Beginning in 1994, however, that trend reversed, and runway incursions have since increased each year. Let's take a look at some numbers:
Runway Incursions at FAA-Towered Airports
The FAA records three types of runway incursions: Operational Errors; Pilot Deviations; and Vehicle/Pedestrian Deviations. All three of these categories are based on human error and a loss of appropriate separation between aircraft and/or a vehicle. An Operational Error is when an air traffic controller inappropriately clears an aircraft or vehicle into a situation that results in a collision hazard. A Pilot Deviation is when a pilot moves an aircraft into a position, without air traffic control approval, that leads to a loss of separation. Vehicle/Pedestrian Deviation is one where a vehicle or individual enters a runway without air traffic control approval that leads to a collision hazard.
FACT: Between the years 1994 to 2001, Pilot Deviation was the main cause of runway incursions in every year except 1994. The FAA has further broken down the data to show that general aviation pilots were most likely to be involved in a runway incursion. In 2000, general aviation pilots committed 76 percent of the pilot deviations³.
Runway Incursions By Type
THE TOP 10 AIRPORTS WHERE RUNWAY INCURSIONS OCCUR MOST FREQUENTLY (1997 TO 2000 DATA)
1. Los Angeles (33)
2. St. Louis (30)
3. Orange County (27)
4. North Las Vegas (26)
5. Long Beach (25)
6. Dallas/Fort Worth (23)
7. San Francisco (21)
8. San Diego/Montgomery Field (20)
9. Fort Lauderdale Executive (20)
10. Phoenix (18)
WE HAVE THE NUMBERS-SO WHAT CAN BE DONE?
There are a number of initiatives that the FAA and the NTSB are undertaking to make airport surface operations safer. Some are technical and some are simply education/awareness.
Some of the non-technical initiatives include the following:
Some of the technical initiatives include the following:
Some additional recommendations by the NTSB include the following:
In conclusion, we can be
optimistic in that the most recently released data on runway incursions (last
part of 2001) has indicated a decline for the first time in many years. This is
encouraging! But we have a lot of work ahead of us. As is typically the case,
FAA is moving at a painfully slow rate to implement all the new technology that
has been previously discussed. The equipment is long overdue and is way over
budget (typical bureaucracy). We can only hope that a catastrophe such as
Milan or Tenerife can be averted until the technology and education is in place.
In the meantime, we always need to be extra vigilant in airport surface operations. Know your airport marking and signs. Read back all “hold short” instructions. If in doubt, ask for progressive taxi instructions. We know we can never eliminate runway incursions. But with a concerted effort, we can continue the trend downward and make airport surface operations as safe as possible.
1. Federal Aviation Administration Website (2002). Runway Incursions-A Growing Problem at Controlled Airports. Washington, DC.
2. U.S. House of Representatives Website (2001). Subcommittee on Aviation: Hearing on Runway Incursions, Focusing on the Technology to Prevent Collisions. Washington, DC.
3. Federal Aviation Administration Website (2002). Runway Safety. Washington,
Robert Baron is the president and chief consultant of The Aviation Consulting Group, an aviation consulting firm with a core specialization in CRM/Human Factors training and research, and expert witness support for aviation law firms. He holds an Airline Transport Pilot Rating and has over 16 years of aviation experience, including a Line Captain, Instructor and Check Airman in Learjet aircraft. He's also type-rated in the Cessna Citation and holds a Flight Engineer Rating for Turbojet aircraft. His academic achievements include a Bachelor's Degree in Professional Aeronautics/Aviation Safety, a Master's Degree in Aeronautical Science with dual specializations in Aviation Safety/Human Factors, and is currently working towards a PhD in General Psychology with an emphasis on Aviation/Aerospace Psychology. Mr. Baron is also an adjunct professor at Everglades University, where he teaches Graduate and Undergraduate courses in Aviation Safety and Human Factors. Mr. Baron can be reached at 1-954-803-5807. Company website is http://www.tacgworldwide.com.
Robert J. Boser
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