September 26, 2008
View an animation that recreates this runway incursion.
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Runway incursions continue to be a concern to all segments of aviation. Pilots, whether general aviation, commercial, or military; air traffic controllers; FAA Flight Standards inspectors; and airport operators continue to focus on efforts to eliminate these events.
When examining safety related incidents, we—as an industry—attempt to examine causal factors and then target attention on specific areas to reduce reoccurrences. The most common method of accomplishing this is through an investigation to gather “lessons learned” from the event. The lessons learned are then distributed to the aviation community so others can avoid a similar incident in the future.
We will never really know how successful this approach is but we do know incidents continue to occur. There may be a number of reasons behind this that we will discuss. We will also look at a recent runway incursion and try to gather some lessons learned, although from a somewhat different perspective, and consider additional ways we can improve safety.
It is easy to review an event after it has occurred, but it’s entirely different when you are one of the participants in an incident as it is developing. Adding to the complexity is the fact that most people may not recognize that they are part of the impending event. Just by our very human nature, there is a normal belief that it is always “the other guy” and “it will never happen to me.” To support this, we just have to go back to any accident and listen to the voice recording. What do we normally hear? Surprise.
Unfortunately, this aspect of human nature may weaken one of our major strengths as aviation professionals—our judgment and experience. We can see the different parts of the event happening but we cannot always connect the dots in real time to avoid the event.
So let’s explore another method of examining an incident and see if there may be a different way to carry “lessons learned” into our operations. We’ll examine an actual event but instead of focusing on where mistakes may have occurred, let’s look at how the level of risk increased as the event developed. Keep in mind that we can still experience an increase in the risk of an operation without necessarily making a mistake.
By examining risk, and other early warning signs, we may use those signals during our own flying. Then we can capitalize on our judgment and experience, connect the dots, and make the right decision—before the level of risk turns into an incident.
Let’s look at a specific event that occurred in 2007, at Daytona Beach International Airport, involving a Cessna 182 and a Beechcraft King Air 200. Click here to view a replay of the actual event. The Daytona Beach airport diagram might be a useful reference.
But let’s use a different perspective and imagine ourselves operating each aircraft as they move toward the event. First, we’ll fly the Skylane.
There are two of us in the cockpit and we’re cleared to taxi to Runway 7L for an intersection departure from N5. We’re told to “maintain the right side of November for opposite traffic.” Did that instruction make sense to us? When we’re asked what will be our on course heading after departure, we first say “standby” and in a subsequent transmission, we answer “340 degrees.” Perhaps this is our first flight into DAB and we’re not too familiar with the airport. Are we trying to finds a taxi diagram?
So what are the risk factors at this point? Weather is good and the taxi route appears simple. But we may not be familiar with the airport and we may not know what “maintain the right side on November” means. Could these minor issues be a distraction? Perhaps.
As we taxi, what is happening in the cockpit? One of us taxiing, but the other pilot may be confirming that a 340-degree heading will take us on course. Are we talking about where N5 is and looking for opposite-direction traffic? Did we check the brakes to make sure they worked right after we added power and began to move? Are any of these risk factors?
As we make the right turn onto taxiway November, did we S-turn the aircraft to check the instrumentation response? How did the pedals feel? Then we turn onto taxiway N5 and realize there is a problem with the brakes! But with two of us in the cockpit, who’s “flying the aircraft?” Are we both trying to stop the aircraft or are we both trying to figure out what happened? Do we know how close we are to the runway? Do we see the risks increasing?
We encroach onto Runway 7L and, as we turn the aircraft around and hurry back to the taxiway, the King Air passes us on his takeoff roll, 70 feet away.
Now, let’s hop out of the Skylane and try that again in the King Air. We call for taxi and we’re instructed to taxi to Runway 7L for an intersection departure at P2. The controller said something we missed so, not wanting to risk confusion, we reconfirmed the intersection.
We begin our taxi westbound on taxiway Papa and, even though it was not necessary, we asked ATC to confirm we could taxi across Runway 34. Approaching Runway 7L at intersection P2 we call ready for takeoff and ATC clears us to go as we make the right turn at P2. What are the risks? It’s a quiet time with little traffic, no frequency congestion, and no aircraft on final. Perfect conditions for a rolling takeoff.
But did those perfect conditions create another risk? Did the rolling takeoff negate the opportunity for one last quick scan of the runway before we added the power? Would that have allowed us to see the Skylane as the other aircraft approached the edge of the runway? Was that an increase in risk we didn’t see coming? Perhaps.
Very few incidents can be explained by a single action. Usually there are a series of very small events that build. But perhaps if we look at aircraft operations as managing different risk events, especially on the ground, we can mitigate them and better enjoy the flight.
In 2004, recognizing the increasing level of risk associated with ground operations, Southwest Airlines modified a portion of their procedures. Prior to the change, the crew would push back from a gate and, while the captain taxied the aircraft, the first officer handled many of the pretakeoff tasks. Meanwhile, the captain had to accomplish additional checklist items as part of normal duties. Their new procedure calls for as many tasks as possible to be done before they leave the gate. This way when the aircraft first moves there are two pilots totally focused on the taxi phase of the flight. This change may offer a valuable insight to any operator and is worth examining.
As we continue to operate in an increasingly complex environment, perhaps the perspective of identifying risks, as small as they may seem on an individual basis, and managing them through mitigation can benefit all.
Tom Lintner is an airline transport pilot, CFI, and air traffic controller who works with the FAA’s Office of Runway Safety.
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