Table of Contents

Stop_Look_and_ListenStop, Look, Listen and Live

Railroad crossing safety is surprisingly similar to runway safety.
Seven Steps for Safety - Highway-Rail Grade Crossings
  • 1. Approach crossing with care. Slow down when you see an Advanced Warning Sign.
  • 2. Prepare to STOP. Turn off fans and radio, roll down windows.
LOOK and LISTEN for a train.
  • 3. Stop at least 15 feet from nearest rail, but not more than 50 feet, if you see a train.
  • 4. If it won’t fit, don’t commit. Trains extend beyond the width of the rails at least 3 feet on each side. If your vehicle has a trailer, remember the additional length.
  • 5. Double check, back left and right. Before you move look in both directions.
  • 6. Cross tracks with care. If your vehicle has a manual transmission, use a gear that will not require shifting until you reach the opposite side.
  • 7. Keep going once you start, even if lights start to flash or gates come down.

Runway_Incursion.pngALPA Runway Safety Website

AOPA Air Safety Foundation

FAA Runway Safety Website

Excursion Avoidance: Excursions happen at a much higher frequency than Incursions, but Incursions
carry a higher consequence because 2 aircraft may be involved.

Flight Safety Foundation Runway Safety Initiative

Flight Safety Foundation Approach and Landing Accident Reduction

Fort Worth Aviation Safety Program

19 Jul 12 FAA Runway Safety Webpage Update

The FAA has a new webpage for runway safety. There is a lot of great information there, links to animations and the 2012-2014 Runway Safety Plan. You can also link to airport diagrams and an new "Hot Spots" list.

Hot Spots - A hot spot is defined as a location on an airport movement area with a history of potential risk of collision or runway incursion, and where heightened attention by pilots and drivers is necessary. By identifying hot spots, it is easier for users of an airport to plan the safest possible path of movement in and around that airport. Planning is a crucial safety activity for airport users — both pilots and air traffic controllers alike. By making sure that aircraft surface movements are planned and properly coordinated with air traffic control, pilots add another layer of safety to their flight preparations. Proper planning helps avoid confusion by eliminating last-minute questions and building familiarity with known problem areas.

FMI: FAA Runway Safety

Fly (and taxi) Smart,


PS: The Runway Safety Office recently received the DOT Secretary's Safety Award. Great job!!

21 Jun 12 New Runway Safety Resource

A New Chapter has been added to the Pilot's Handbook of Aeronautical Knowledge (PHAK) entitled,Runway Incursion Avoidance. This chapter, contained in Appendix 1, provides the information pilots will be tested and checked on in the Private Pilot and Commercial Pilot PTS, effective June 1, 2012, and also in the soon to be released CFI and ATP PTS's, which include a required Runway Incursion Avoidance TASK. The new Appendix, which will be available online soon, can be reviewed by clicking on this link (or cutting and pasting the link into your browser):
In light of the fact that General Aviation accounts for 80% of runway incursions, and in respect to pilots accomplishing a 14 CFR section 61.56 Flight Review, it is imperative that the required items listed within the PTS, appropriate to the level of pilot certificate held by the pilot completing a Flight Review, be presented to the pilot. Flight instructors play a key role in this regard!
Further, prior to the use of the appropriate PTS, it is strongly urged that CFIs thoroughly know the content of the new chapter of the PHAK, and also utilize recently revised AC 61.98B, Currency Requirements and Guidance for the Flight Review and Instrument Proficiency Check, (which can be reviewed by clicking on this link or cutting and pasting the link into your browser: to ensure that the pilot completing a Flight Review is knowledgeable and proficient in what is required today to ensure the safety of flight.


Fly Smart,

05 Jan 12 San Francisco International Airport Runway Project is Rolling Along

From The San Francisco Examiner Joshua Sabatini: he planned installation of spongy material at the ends of San Francisco International Airport’s runways — to protect passengers if aircraft overrun the landing strip — is about to enter the design phase.
The airport must install these so-called runway safety areas within three years to comply with Federal Aviation Administration requirements. While the agency requires a 1,000-foot safety area, it has provided an exemption for two of SFO’s four runways, which have no room for them since they are constrained by the Bay and Highway 101.
On Wednesday, the Board of Supervisors Budget and Finance Committee approved the airport’s request not to put the design project out to bid since there is only one company, New Jersey-based Engineer Arresting Systems, authorized by the FAA to do the work. The installation must be completed by December 2015. The design contract is $420,000.
The federal government will pay for 75 percent of the expected total $200 million project, according to a financial plan adopted in May 2010.
The so-called engineered-material arresting system is described as “crushable concrete placed in beds at the end of runways to stop aircraft overruns. The beds cause the tires of an aircraft to sink into the lightweight concrete and the aircraft decelerates as it rolls through the material.”
The technology has been installed on 58 runway ends in 40 airports in the U.S., with the first system of its kind installed at John F. Kennedy International Airport in 1996. As of October 2011, there were seven incidents where the system stopped overrunning aircraft, according to the FAA.
The full Board of Supervisors will vote Tuesday on the bid requirement waiver.
FMI: San Francisco Examiner EMAS

Editor: EMAS is a great system, a low cost mitigation for space constrained airports. Aircraft can engage an EMAS, be removed and the airport runway can be returned to operational status within a short period of time.

Fly Smart,

03 Jan 12 Saved by seconds: How an EgyptAir flight was just 37 feet from JFK's worst runway disaster

image: Flightglobal
From the Daily Mail: "An EgyptAir flight that wandered into the path of a Lufthansa airliner on the runway at JFK International airport was just 37 feet from a catastrophy that could have claimed many hundreds of lives. The incident in June was the most dangerous near-miss of the year at the New York City airport, according to a new report from the Federal Aviation Administration. The German Lufthansa flight carried 286 passengers bound for Munich. The Egyptian jetliner carried 346 passengers headed to Cairo. If they had collided, it could have been the worst commercial air disaster in history. But in the end, the planes missed each other by seconds, FAA officials believe.
The Germans were flying an Airbus A340 and the Egyptian flight was a Boeing 777. With 632 passengers and crew on the line, the death toll from such a disaster could have been even bigger than the Tenerife airport disaster on the Spanish Canary Islands in 1977. That tragedy also involved one aircraft taxiing into the path of another that was taking off. It claimed 586 lives and is the worst commercial air mishap in history."

FMI: Daily Mail

Fly Smart,

13 Dec 11 NTSB Forwards Recommendations On Tailwind Landings To FAA

AA_Kingston.jpgThe NTSB has issued a series of safety recommendations to the FAA in response to an incident in which an American Airlines B737 overran the end of the runway on landing in Kingston, Jamaica in December 2009. The aircraft landed approximately 4,000 feet down the 8,911-foot-long, wet runway with a 14-knot tailwind component and was unable to stop on the remaining runway length. After running off the runway end, it went through a fence, across a road, and came to a stop on the sand dunes and rocks above the waterline of the Caribbean Sea adjacent to the road. While there were no fatalities or postcrash fire, eighty-five of the 154 occupants (148 passengers, 4 flight attendants, and 2 pilots) received injuries ranging from minor to serious. The airplane was substantially damaged. Instrument meteorological conditions and heavy rains prevailed at the time of the accident flight, which originated at Miami, Florida, on an instrument flight rules flight plan.
As a result, the NTSB recommends that the FAA require principal operations inspectors to review flight crew training programs and manuals to ensure training in tailwind landings is (1) provided during initial and recurrent simulator training; (2) to the extent possible, conducted at the maximum tailwind component certified for the aircraft on which pilots are being trained; and (3) conducted with an emphasis on the importance of landing within the touchdown zone, being prepared to execute a go-around, with either pilot calling for it if at any point landing within the touchdown zone becomes unfeasible, and the related benefits of using maximum flap extension in tailwind conditions.
The FAA is also advised it should revise Advisory Circular 91-79, "Runway Overrun Prevention," to include a discussion of the risks associated with tailwind landings, including tailwind landings on wet or contaminated runways as related to runway overrun prevention. Once Advisory Circular 91-79, "Runway Overrun Prevention," has been revised, require principal operations inspectors to review airline training programs and manuals to ensure they incorporate the revised guidelines concerning tailwind landings. The agency should further require principal operations inspectors to ensure that the information contained in Safety Alert for Operators 06012 is disseminated to 14 Code of Federal Regulations Part 121, 135, and 91 subpart K instructors, check airmen, and aircrew program designees and they make pilots aware of this guidance during recurrent training, according to the board.
Air_France_358The National Transportation Safety Board also reiterates the following recommendation to the Federal Aviation Administration and reclassifies it "Open-Unacceptable Response":
Require all 14 Code of Federal Regulations Part 121, 135, and 91 subpart K operators to accomplish arrival landing distance assessments before every landing based on a standardized methodology involving approved performance data, actual arrival conditions, a means of correlating the airplane's braking ability with runway surface conditions using the most conservative interpretation available, and including a minimum safety margin of 15 percent.
Fky Smart,

01 Sep 10 Coming To An Airport Near You, 30 Sep: "Line Up And Wait" Will Replace "Position And Hold"

52F_RI.jpgFrom AeroNews Network: "Pilots authorized by air traffic controllers to taxi onto runways and await takeoff clearance will be instructed to “line up and wait” rather than “position and hold” beginning on September 30 under new terminology adopted by the FAA. The new terminology, which was recommended by the National Transportation Safety Board, conforms to terminology used internationally under ICAO guidelines.
A safety analysis conducted by the FAA’s Air Traffic Organization Terminal Services determined that adopting the phrase “line up and wait” will eliminate confusion, particularly among pilots who also fly overseas, and further reduce the risk of runway incursions.
KBOS_APD_AIRPORT_DIAGRAM.pngBeginning September 30, controllers will state the aircraft’s call sign, state the departure runway and then instruct pilots to “line up and wait,” i.e., “United 451, Runway 33L, line up and wait.” The phrase, “traffic holding in position” will continue to be used to advise other aircraft that traffic has been authorized to line up and wait on an active runway." The FAA will continue to emphasize that pilots are not permitted to cross any runway encountered while taxiing without explicit instructions from controllers.
FMI: Aero-News Network, FAA Runway Safety, external image pdf.png [[file/view/Line Up and Wait Operations 7210.754.pdf|Line Up and Wait Operations 7210.754.pdf]]

Editor's Note: One thing to remember about this new phraseology is that several years back, taxi into position and hold (TIPH) clearances were greatly reduced by the FAA in order to reduce the potential for runway collisions. ATC facilities had to get a waiver at each airport that wanted to use the procedure, by demonstrating that they had sufficient risk management strategies in place to eliminate or reduce exposure to the risk. So while there will be lot of focus on the new vocabulary, we need to also refresh ourselves on the residual hazards associated with "line up and wait" (LUAW). Pilots, pedestrians and vehicle operators need to look and listen before entering the protected area of a runway, and controllers ensure the area is clear before issuing clearances to cross, takeoff or land. Night time, reduced visibility, simultaneous intersecting runway operations and intersection departures can add to the level of risk. Being familiar with the airport layout and complexity of operations is a good start for operators, so ask questions, assess the environment and act accordingly.

Fly Smart,

13 Jul 10 The Deadliest Plane Crash

On PBS tonight, an examination of the worst accident in civil aviation history, a March 1977 collision between two 747s on a foggy runway in Tenerife (one of the Canary Islands) that resulted in the deaths of 583 people.

FMI: PBS, Planenews, FAA Runway Safety, AOPA AIrNav,
Editor: Still much to be learned from this mishap, especially regarding team communications. Take time to become familiar with an airport's layout is a good start, avoid checklists while taxiing, keep cockpit chatter on the ground to a minimum and look outside for conflicting traffic. Also, stop when unsure of where to go next, unless you know you are on a runway and need to get clear. Other good resources are Flight Service, where a personal briefer can update us on special considerations for each airport, and AIrNav, where free airport information such as airport diagrams and fuel prices can be found.
Just like railroad crossing safety, remember to "Stop, Look and Listen." There is also a dedicated page on the Signal Charlie website for Runway Safety.

Fly Smart,

14 Jan 10 International Phraseology

The FAA could soon implement a changeover from "position and hold" to "line up and wait," to conform with international phraseology standards, NBAA said this week. If approved later this month, the new terminology could be implemented as soon as this June. It's long overdue, according to NTSB Chairman Deborah Hersman. She said the NTSB issued six recommendations in July 2000, asking the FAA to change various ATC procedures to reduce the risks of runway operations. "In response, we were recently advised that the FAA soon plans to adopt a single change: the use of "line up and wait" instead of "position and hold" to instruct pilots to enter a runway and wait for takeoff clearance," Hersman said at a runway safety summit in Washington last month. "We needed to wait nine years for that?" Bob Lamond, of NBAA, told AVweb on Tuesday he doesn't expect too much distress over the change. "Folks are going to stumble over it at first, but we'll get used to it," he said. "It's been talked about for years, so it's really a non-issue for us."
However, implementation will require an "extensive awareness campaign" to ensure that pilots and controllers are informed, NBAA said. FAA Administrator Randy Babbitt, speaking at the safety summit last month, said the FAA has done a lot to address runway safety concerns. "The numbers prove we've made a dramatic improvement," he said, nothing that in the past year there were just 12 incursions out of more than 50 million operations, and only two of those involved commercial carriers. "We've revamped our on-line courses. We've produced public service spots. And we mailed a half-million runway safety DVDs and brochures to pilots," said Babbitt. "It's been a tremendous joint effort across all parts of the FAA and the aviation industry. It worked." He added, however, that there is still work to be done in the GA community. "We can make every protection possible, but the human in the loop is the challenge of the future," he said. Click here for the full text of Babbitt's talk.

FMI: AvWeb

14 Jan 10 Runway Safety Program by Air France

Runway Safety Programs Presentation summary -

07 Jan 10 Preventing Wrong Runway Departures

The Commercial Air Safety Team and FAA developed an excellent brochure on Wrong Runway Departures. One finding of the team was 8 major factors that can increase the risk of a wrong runway departure:
1) Short taxi distance, 2) Airport complexity, 3) A single taxiway leading to multiple runway thresholds, 4) Close physical proximity of multiple runway thresholds, 5) More than two taxiways intersecting in one area, 6) A short runway (less than 5,000 feet), 7) Joint use of a runway as a taxiway, and 8) Single runway airports.
This brochure is designed to share best practices that you can use to ensure you won’t unintentionally be caught in your own WRONG RUNWAY DEPARTURE! Using these best practices will help guarantee a safe flight, every flight.
external image pdf.png Preventing Wrong Runway Departures.pdf

Another great document there is an update to the implementation plan safety enhancements, put together in late 2009 form global Best Practices. If you have not see this, it is a great review of actions to take at the airport to help prevent both excursions and incursions. This is still a major safety challenge, as last year we had several severe incursions and globally over 30 hull losses from excursions. There is still much system improvement to be done in these areas.

One last thing I've been thinking about. There are some key differences to how we operate when we are on the ground. The priorities of "Aviate, Navigate Communicate" are reversed when we are taxiing. Communication is key when taxiing, listening up to ATC and other aviators to build a mental model of where everyone is and what they are doing. Next it is important to Navigate, to know where we are at all times. While that sounds simplistic, I challenge you to identify a near miss or mishap where a crew KNEW they were lost on the airport but continued on without fixing the problem. Navigation on the surface is different. Lastly, on the ground, we can not "Aviate". We are less maneuverable on the ground, so the ability to avoid a high energy collision is reduced. If we look at all of these factors from a risk assessment perspective, both severity of a mishap AND exposure to hazards are increased, so that increases our overall risk, and higher levels of risk control are required. In some scenarios the safest place to be is in the air, and the risk increases as we move to and from the runways.

So what do we do? Well, as industry works to improve system controls at higher levels, such as ground collision avoidance systems and nav displays with moving airport maps, we can review the latest Best Practice recommendations and brochure on Wrong Runway Departures. They both have good tips to avoid becoming a statistice or headline. The CAST has compiled these items and added them to the Safety Enhancement (SE) Implementation Plan, and I highly recommend taking time to review these five pages and consider how we can increase our level of protection at the airport. You can also visit the CAST and FAA websites, and add an RSS feed to this wikipage.

FMI: CAST Runway Safety, FAA Office of Runway Safety

Fly Smart,

10 Dec 09 Runway Safety Related Advisory Circulars

From NAFI: Ever read the advisory circulars the FAA puts out relating to runway safety? Have your students? If the answer to either of these is no - or it's just been a while - here's your chance to review the following four runway safety related advisory circulars:
  • AC 120-74: Parts 91, 121, 125, and 135 Flightcrew Procedures during Taxi Operations
  • AC 91-73: Parts 91 and 135 Single-Pilot Procedures during Taxi Operations
  • AC 90-66: Recommended Standard Traffic Patterns and Practices for Aeronautical Operations at Airports without Operating Control Towers
  • AC 90-42: Traffic Advisory Practices at Airports without Operating Control Towers

09 Dec 09 Taxiing Toward Tomorrow: Runway Safety Summit Highlights Need for Collaboration

Debbie_Hersman-144x180.jpgFrom NTSB Chairman Deborah Hersman’s opening remarks, to FAA Director of Runway Safety Wes Timmons’ closing statement and recap of accomplishments, the consensus was clear at last week’s first FAA International Runway Safety Summit: Focus, cooperation, and teamwork are the key components to improving airport surface operations worldwide. To see evidence of this need for global collaboration one only had to look as far as the roster, which included nearly 500 attendees from 17 different nations.

WesTimmons.jpgMany of the topics presented and discussed by safety experts and key industry stakeholders directly involved general aviation, including airport layouts, cockpit and ATC procedures, human factors, and technology. Also discussed were ongoing initiatives, as well as plans for future runway safety improvements in the U.S. and around the world. Presentations from many of the event’s speakers and panelists will be available in two weeks at 091107/.

Fly Smart,

27 Nov 09 Newark Runway Risks Concern FAA: Risk Management 101

cltThere is some wheat to be separated from the chaff here, but there are good risk management lessons to be learned for regulators, managers, controllers and pilots in this story. One is the importance of encouraging an open, reporting and learning culture within an organization. Identification of hazards is THE important first step that must be taken before hazards can be analyzed and risks assessed. People who are most familiar with the task are usually good sources for hazard identification. Once a hazard is identified, operational safety pros can look at the frequency of the event and also consider the severity (or potential severity) posed by the hazard, classify the risk and make risk decisions on proper controls. The decision may be to do nothing or simply to monitor for change, it may be to introduce new procedures, training and technology, or it may be to stop the operation. There should be a balance in this decision making process between production and protection, or else the system can break down or not perform at optimum levels. Within this process, the FAA's mission is to ensure safe skies. Once the decisions are made and implemented, personnel at all levels should monitor the results and make sure that the intended results were achieved, identify residual risk and look for unintended consequences of the change. From there the process should repeat, with people looking for changes in the system and identifying areas where increased production warrants additional changes in training, procedures and equipment.
52F_RI.jpgAn attitude of "we've always done it that way" and a culture of mission accomplishment is a good thing, as long as safety considerations are embedded in that culture and there is a strong management of change process that respects safety boundaries. The lessons learned in Newark need to be captured and applied throughout the system, and not just on intersecting runways. That is the proactive way to improve the system and prevent mishaps.

(CNN) -- "Federal investigators are concerned a potential danger persists because of the simultaneous use of intersecting runways at Newark Liberty International Airport, one of the nation's busiest and a gateway to the New York metro area.
The alert comes after repeated instances in which planes above the Newark airport flew too close to each other in violation of safety standards. There were four such instances last year and at least four this year, according to the U.S. Department of Transportation inspector general.
In one case, on January 16, 2008, two Continental planes -- a Boeing B-737 and an Embraer 145 -- missed each other by 600 feet, according to a DOT inspector general's report."
For the Full Report: CNN

For more on Risk Management

Fly Smart,

07 October 09 Downtown airport boasts a new runway safety system


Concrete blocks waited this week to be installed at the Charles B. Wheeler Downtown Airport. The blocks would stop planes that might overshoot the end of the runway.
  • Melissa Cooper walked this week across the crushable concrete blocks that make up a new runway safety system at the Charles B. Wheeler Downtown Airport. “It feels bouncy,” said Cooper, assistant airport manager. “Kind of like walking on a dock.”
But that will not be the experience of airplanes should they stray onto the $17 million safety feature called EMAS — engineered materials arresting system. Instead, the planes’ weight will crush the cellular cement blocks, stopping the planes with minimal damage if they overshoot the end of the runway.
Crews have been installing the system, which consists of a bed of 2,982 blocks — each 4 feet by 4 feet — on the south end of Runway 1-19, Cooper said. The blocks gradually increase in height, starting at 8 inches and then increasing to 20 inches, she said. Installation is expected to be completed by next week. Some grading, concrete and other finish work will still need to be completed. Construction on a second bed for the north end of the runway is expected to begin next spring.
“The system consists of special blocks that were designed to arrest an airplane traveling up to 70 knots to keep the airplane from departing the runway,” said Mike Barnes, a construction site supervisor with Esco-Za, a Zodiac Aerospace company out of Logan Township, N.J. The blocks collapse to absorb the energy of the airplane while minimizing the damage to the aircraft and allowing the aircraft to be slowed without hurting passengers, he said. “It actually acts like quicksand,” Barnes said. The deeper the plane travels into the bed, the more energy is absorbed.
The airport began studying alternatives 10 years ago, said airport manager Michael Roper. “We had looked at extending the runway into the Missouri River floodplain,” Roper said. “But that was going to require about 90,000 cubic yards of fill. After Hurricane Katrina, the levy districts in Kansas City were a little concerned what that could do during a flood stage.” Federal funds are paying for about 90 percent of project, he said. In his six years at the airport, Roper said, there have been two overruns at the south end of the runway. During his tenure, there have not been any at the north end. Such a system is not needed at Kansas City International Airport because there is plenty of land at the ends of the runways.
FMI: Kansas City . com

19 Sep 09 New Safety System Addresses NTSB's 'Most Wanted' Issue of Runway Safety

To Date, The Only Runway Safety Products To Achieve FAA Milestone
external image honeywelllogo1_tn.gif Honeywell's SmartRunway and SmartLanding technologies, developed to reduce runway accidents at crowded airports, have received FAA Technical Standard Order (TSO) approval, the company announced Wednesday. The approval will allow the company to deliver its runway products to customers for aircraft installation. Honeywell has the only runway safety products to be certified by the FAA for production.
SmartRunway provides visual and aural alerts to pilots about runway and taxi locations and SmartLanding informs pilots of unstable approaches and long landings, when an aircraft lands too far down the runway to safely stop.
"SmartRunway and SmartLanding address the $1 billion cost of runway excursions and incursions to the commercial flight industry," said TK Kallenbach, Honeywell Vice President of Product Management. "This new software provides added situational awareness at increasingly crowded airports while reinforcing standard operating procedures."
SmartRunway helps break the chain of events that can lead to a runway incursion by providing timely advisories -- aural and/or visual -- to the flight crew about aircraft position compared to runway locations in the database. SmartRunway is the next generation of Honeywell's Runway Awareness and Advisory System (RAAS), the first runway advisory system introduced in 2004, and installed on more than 200 air transport and 1,470 business aircraft, with another 800 airline systems on order. SmartRunway offers two additional advisories over RAAS, as well as visual advisories. Boeing recently announced they are offering SmartRunway as an option on the 747-8 and 777 aircraft, and will offer it on the 737 in early 2010.
external image B747-8-Engine-Milestone-0909a_tn.jpg

SmartLanding addresses the chain of events that can lead to a runway excursion event by notifying pilots through aural and/or visual alerts if the aircraft has not met established safety criteria on approach, to help prevent the aircraft from landing too hard or exiting the runway from the end or the sides. The Flight Safety Foundation reports that in the past 14 years, there has been an average of almost 30 runway excursion accidents per year for commercial aircraft.
"The systems support both 'quiet' cockpit and 'heads-up' initiatives while complementing electronic flight bag technology by providing safety information to pilots when runway safety is at risk," said Kallenbach. "SmartRunway and SmartLanding are the latest software enhancements to our EGPWS, which is found on more than 30,000 business and air transport aircraft."
The systems require just one hour of aircraft downtime for installation and minimal pilot training, and are software upgrades to Honeywell's Mark V and Mark VII Enhanced Ground Proximity Warning System (EGPWS), the leading Controlled Flight Into Terrain (CFIT) Warning Systems. Honeywell's EGPWS contains a global terrain, obstacle and runway database and more than 600 million hours of global flight validation.
Aero-News Network

12 Aug 09 What Can be Done to Improve Runway Safety? Human Skill vs Error

The Deadliest Plane Crash
Tuesday, August 11 at 8:00 pm
NOVA looks at what went wrong when two Boeing 747 airliners collided in thick fog on the runway at a tiny airport in the Canary Islands.

icon_minu.gif"On March 27, 1977, on the island of Tenerife, two fully loaded 747 jumbo jets collided on a fog-blanketed runway, claiming the lives of 583 people in what is still the deadliest crash in aviation history. Now, almost 30 years later, near misses on the ground are the leading cause of aviation accidents, raising the question of what can be done to improve runway safety. Featuring moving interviews with the few survivors of the disaster and with top accident investigators, this program examines the fateful confluence of events that led to the Tenerife tragedy and its continuing relevance for air travel today.
KLMThree decades ago, the facts of the accident were shocking and inexplicable. In thick fog, a KLM 747 began an unauthorized takeoff, slamming into a Pan Am 747 that was taxiing on the same runway. The best and the brightest pilots, including KLM's senior captain and head of safety, were at the helm. How could such an accident possibly occur?
"The Deadliest Plane Crash" looks back at the crucial four hours before the disaster, when an improbable chain of coincidences, bad luck, and misjudgments snowballed into tragedy. The situation sounds eerily current. It all began with a terrorist bomb threat to the airport on Gran Canaria Island that diverted air traffic to Tenerife. The small Tenerife airport was soon overcrowded while its control tower was understaffed. Thick fog rolled in and destroyed visibility as the KLM plane loaded up a full tank of fuel. A series of unclear communications and time pressure on the Dutch crew ultimately contributed to the KLM captain's fatal error—one that violated the fundamental rules of aviation and baffled expert investigators for decades afterwards. (See The Final Eight Minutes.)
The program reassesses the evidence and conclusions of the official accident investigations by the Spanish and Dutch authorities. It features gripping firsthand testimony and personal stories from Pan Am co-pilot Robert Bragg, flight attendant Joan Jackson, and passengers who somehow fought their way out of the blazing, disintegrating Pan Am 747.
Allentown.jpgNOVA also investigates the improvements in runway safety that have been made in the three decades following the Tenerife crash. Disturbingly, runway incursions in the U.S. are still an everyday event—about 325 of them each year.
National Transportation Safety Board Chairman Mark Rosenker discusses new safety technology and shares NTSB's chilling forensic animation that reconstructs recent runway scares. In 1999 two planes at Chicago O'Hare airport missed each other by 80 feet, and a similar near miss happened in 2005 in Boston. In an age when air travel safety is under constant scrutiny, "The Deadliest Plane Crash" vividly dramatizes the need for renewed vigilance both on the ground as well as in the air."
FMI: NOVA The Deadliest Plane Crash
Fly Smart,

29 Jul 09 Runway Safety Summer Safety Initiative Notice Number: NOTC1789

This past May, the FAA Office of Runway Safety implemented a Summer Initiative targeted at stemming what has become a seasonal pattern of increasing runway incursions during the warm weather months. Compared to the rest of the year, runway incursions average about 30 percent higher per month between May and August.
Two-thirds of all runway incursions are the result of pilot deviations – and three-fourths of those pilot deviations involve a general aviation aircraft.
Part of the problem stems from pilots who, after a period of little or no flying, may be a little rusty on airport procedures. That rust, however, can have tragic consequences in the area of an active runway. In fact, the single most deadly aviation accident in history resulted from a runway incursion. Don’t become a statistic!
Here’s what you can do:
Stop Anytime you’re unclear or unsure about your location or about an ATC instruction or about anything else, don’t hesitate to call the tower and ask for help. If you are on a runway without approval, exit the runway, and contact ATC.
Look Before taxiing: Study the airport diagram before starting your engine. Keep a copy in the cockpit. Download airport diagrams at: Pay careful attention to airfield signs and markings. Complete checklists, programming, and other pre-flight activities. While taxiing: Practice heads-up and eyes-out. Avoid distracting tasks; focus on your route.
Listen Listen carefully to, write down, and read back all air traffic instructions. Get ATC approval before crossing or using any runway. “Taxi to” does not allow you to enter the runway.
Finally, talk to your fellow pilots. Help us raise runway safety awareness. If we, working as a team, can prevent even one runway incursion, this campaign will be a success.
There is a nice reminder card available for you to download at files/notices/2009/Jul/FAA_ Runway_Incursions.pdf
For more information contact Gregory Y. Won, Air Traffic Safety Organization, Runway Safety Office, Risk Reduction Information Group, 202-385-4792

Fly Smart

21 Jul 09 Newark Implements New Runway Safety System

From Aero-News
FAA Says Controllers Will Have A Better Overall View Of The Airport

external image FAA-logo-new-1006a_tn.jpg One of New York's busiest airports is now using an advanced ground radar system to improve safety. Newark Liberty International Airport commissioned the Airport Surface Detection Equipment-Model X (ASDE-X) on July 15.
ASDE-X enhances safety by collecting data from more sources than Newark’s previous ground radar system, and provides controllers with color map displays showing the location of all aircraft and vehicles on the runways and taxiways.
For example, when a plane is approaching the airport to land, ASDE-X puts lines up on a controller’s display to show the edges of the runway. If another plane or vehicle crosses those lines or moves toward them at a certain speed, two alarms go off. An audible alarm sounds telling controllers to instruct the landing plane to go around. A visual alarm shows up on the controller’s screen that circles the two planes or the vehicle and draws a line between them.
The new system also shows data tags for both arriving and departing aircraft. The previous ASDE-3 system only gave information for flights headed to the airport.
In addition to a view of the entire airfield provided by ASDE-X, controllers can pick certain areas to highlight on the display and zoom in to get a better view of what’s happening in each area. For example, if a lot of planes are waiting to depart, a controller can take a closer look at the departure end of the runway. This is especially important in bad weather when visibility from the tower window sometimes is hampered.
external image ASDE-X-graphic-gov-0907a_tn.jpg

ASDE-X differentiates between aircraft sizes, displaying heavy planes as yellow icons and regular planes in white. ASDE-X also gives controllers the ability to mark taxiway closures and safety areas on the screen. The new system is designed to integrate with future components of the Next Generation Air Transportation System, such as the Automated Dependent Surveillance Broadcast, or ADS-B, which can be incorporated into the ASDE-X display.
Boston Logan International Airport also plans to commission ASDE-X on July 23. In all, the FAA has identified 35 airports to receive the system.

Editor's Note: ASDE-X is one step of many that must be taken on the path to increase safety at the airport. The threat for collision is much higher at the airport, where traffic is concentrated and aircraft are less maneuverable. We will not have ASDE-X at every airport for a long time, if ever. We also still do NOT have a Cockpit DIplay of Traffic Information and Collision Avoidance System, except for our eyeball and ears. These types of systems will be required if we are to improve the entire system. ADS-B "In", with Traffic and Flight Information, will be a great advance to operational safety, and we ned to work towards making sure everyone can enjoy those safety systems. KBL

12 Jul 09 Wrong Runway Departures

Comair_5191In light of the crash of Comair, Inc. (doing business as Comair Airlines doing business as Delta Connection), flight 5191 in Lexington, Kentucky, the Federal Aviation Administration’s Aviation Safety Information Analysis and Sharing center conducted a review of event reports that involved airplanes departing from or taxiing into position on a wrong runway. The review involved gathering data from multiple databases (1981 through 2006); identifying event reports of interest; reviewing those reports to find contributing factors; identifying, assigning, and scoring mitigations. The review showed that wrong runway events occurred at many airports and under varying circumstances; however, they occurred most frequently at four airports: Cleveland Hopkins International Airport, Houston Hobby Airport, Salt Lake City International Airport, and Miami International Airport.

KLEX_Comair_Airport_DiagramThese airports share the following common elements or contributing factors:
• Multiple runway thresholds located in close proximity to one another.
• A short distance between the airport terminal and the runway.
• A complex airport design.
• The use of a runway as a taxiway.
• A single runway that uses intersection departures.

The review found that the number of reported wrong runway departure events has decreased from its peak in the 1990s; however, the data show that the common elements are still present. The review identified areas where events have not yet occurred and shows that the following contributing factors can be mitigated and wrong runway events avoided when:
• Airport communities employ a coordinated effort similar to the one taken by Cleveland Hopkins International Airport;
• Technological, procedural, and infrastructure enhancements as proposed by the Commercial Aviation Safety Team are implemented by the Federal Aviation Administration, industry, and airport administrations;
• Aeronautical information enhancements are made;
• Threat analysis based on the contributing factors of past wrong runway departures are conducted at individual airports; and
• Electronic flight bags with own-ship moving map display functionality and/or an aural runway and taxiway advisory system are incorporated into the part 121 fleet.

FMI: ASIAS Wrong Runway Report

11 Jul 09 Summer 2009 Runway Safety Newsletter

Volume 1, Issue 2

52F_RI.jpgSafety Tips
1) Always review NOTAMS. Although many airports have lengthy lists of notams, this is the best source of data regarding taxiway conditions and surface warnings. Company notams and flight plan remarks are also important to review prior to your arrival. They can contain type-specific warnings to flight crews as a result of past incidents via ASAP or NASA ASRS reporting systems.
2) Always have the Airport Diagram out and Available. This is to guarantee your situational awareness on the field. Even in the best of conditions, it is easy to lose your whereabouts on the taxiway complex. Should a non-standard taxi clearance be issued, you have the chart out and can react with the minimum of confusion.
3) Review all notes and boxed items on the airport diagram. Many airport diagrams have notes and warnings about taxiways and intersections which may be prohibited or not allowed for larger aircraft use. These are not there to test your eyesight, they usually contain extremely important data to avoid excursions.
4) Safe Taxi speed. Keeping the aircraft controlled and slow prior to entering turns will guarantee safe passage through some of the tighter angles of our taxiways. Your Airplane Manual will offer guidance on maximum speeds for entering turns.
5) Ask Questions. Outside of our base, many pilots may only fly into some airports very infrequently. We are not experts yet we must handle our taxi-in or out EXPERTLY!! There can be a team approach to this. Use the Ground or Local controller as guidance. They know the airport, this is their office and you need to find a chair or use the door. They can be the best eyes on how to maneuver your aircraft and where to position it. If the turn looks unsafe, ASK!! They are not paid to hide secrets, and will always assist when prompted. It is up to you to get that help.
6) Speak Up. All Flight crewmembers are responsible when taxiing. If something doesn’t seem right to you, ask the other crewmember. Maybe if he or she heard something different or sees something which looks unsafe, perhaps a quick timeout to discuss the situation may be in order. This guarantees 4 eyes are on the task at hand and usually keeps the situational awareness up and the errors down.

We know thousands of flights are completed safely every single day by our membership and that is attributed to your constant attention and safe practices. This is an elementary approach to avoid excursions, but nonetheless, some have overlooked these simple tasks and have been involved in what has proven to be costly and unnecessary damage to aircraft and airman records.

Steve Jangelis is a dedicated air safety advocate, with extensive experience in both the GA and Commercial aviation communities.

Safety Pilot: Overrun!

By Bruce Landsberg

The following article is reprinted with permission from the AOPA Air Safety Foundation and AOPA Pilot.
December 2008 Volume 51 / Number 12: Safety Pilot: Overrun! Landmark Accidents: Southwest slides off the runway

southwest-airlines-boeing-737-700_midway.jpgIt was three years ago Dec 2005 that a Southwest Airlines (SWA) Boeing 737-700 slid off the end of Runway 31C after landing at Chicago Midway International Airport (MDW) on a snowy evening. Tragically, a child's life was lost as his parents' car was in the wrong place at the wrong time. The Boeing rolled through blast and airport perimeter fences before stopping on the roadway with the car underneath. There was one serious injury and several minor injuries in the car.

How could a diligent professional crew flying for one of the world's most successful airlines in one of the most reliable aircraft find themselves sliding off the end of a runway that they had landed on many times before, at an airport that has seen hundreds of thousands of landings without mishap? Sometimes, situations that seem simple aren't. Arcane information involving braking action reports, confusing flight operation policies, inconsistent computer programming, and airport environment all played a part in this mishap. There's plenty to ponder, regardless of what size aircraft you fly.

Southwest Flight 1248 departed Baltimore/Washington International Thurgood Marshall Airport (BWI) on December 8, 2005, about two hours late because of deteriorating weather in Chicago. The six to nine inches of snow that was predicted for Chicago started at Midway just before 2 p.m. An amendment to the forecast surface winds revising "calm to 090 at 11 knots" and runway braking action from "wet-good" to "wet-fair" was sent to the flight en route. The winds were accurate, but the braking action report turned out to be wrong.

At 6:53 p.m., about 20 minutes before the accident, the weather was reported as wind 100 degrees at 11 knots, visibility one-half statute mile in moderate snow, and freezing fog. The ceiling was broken at 400 feet and overcast at 1,400 feet.

The runway was plowed one-half hour before the accident with an average runway friction reading of 0.67 (out of a possible 1.00, which indicates perfect conditions). After the accident a second test revealed the friction at 0.40. Aeronautical Information Manual guidance states that, with values below 0.40, "aircraft braking action begins to deteriorate and directional control begins to be less responsive." (For more information see the AOPA Air Safety Foundation Safety Brief on braking action reports.)

Braking action advisories were in effect, which require pilots and controllers to provide each other with the latest updates on aircraft stopping performance.

Why did Midway continue to operate on Runway 31 with a significant tailwind? Changing runways might have had a negative impact on operations at Chicago O'Hare International, 13 nm to the northwest, so the air traffic considerations must be weighed against the safety implications.

The crew
The captain, age 59, a retired Air Force pilot, had 15,000 total flight hours with 4,500 hours in the Boeing 737. He had flown for SWA since August 1995 and had an exemplary flight record. He told investigators he had slept well and was not fatigued. He also noted in post-accident interviews that the weather was "the worst" he had experienced, but he had "encountered similar conditions about a dozen times" in his tenure at SWA and "expected to be able to land safely."

The 34-year-old first officer had flown as a regional airline pilot before joining SWA in 2003. He had about 8,500 hours total time with 2,000 in the 737. He claimed extensive winter weather flying as a regional airline captain.

The flight
It was the captain's leg to fly, and during the flight the crew discussed braking action reports, required landing distances, use of autobrakes, and possible diversion to an alternate airport. A confounding factor was the mixed braking-action reports. Braking was generally reported "good to fair" on the first half of the runway and "poor" on the second half. The tailwind component was eight knots, and the crew had some discussion on diversions to alternate airports in the Midwest.

Everything was routine, despite some holding that delayed all flights going into MDW as the runway was plowed. The most recent report, about 30 minutes before the accident, showed "Runway 31C-trace to 1/16th of an inch of wet snow over 90 percent of the surface, 10 percent clear and wet."

The landing was unremarkable as the flight data recorder (FDR) verified main gear touchdown at 1,250 feet from the runway threshold (well within the recommended touchdown zone) at 124 knots airspeed, at target airspeed with a ground speed of 131 knots. Ground spoilers and autobrakes deployed immediately, as designed.

The captain had difficulty applying reverse thrust, which was essential for this difficult landing. As soon as the first officer noticed that the reversers were not engaged, he deployed them. According to the NTSB report, "The first indication of thrust reverser deployment was recorded at 15 seconds after touchdown with full deployment at 18 seconds." The four airliners that landed in the 20 minutes preceding the accident deployed reverse thrust within four to six seconds of touchdown according to their FDRs. Considering that none of them probably should have landed under these conditions, there is something of a herd
mentality that is admittedly very difficult to go against. We've all done it. How do you explain to the passengers that you diverted when all the other flights were getting in? It doesn't mean it was right, it just means that they were lucky.

The autobrakes on SWA Flight 1248 deactivated 12 seconds after touchdown as the pilot manually applied the brakes. Even with maximum braking and maximum reverse thrust, the nosewheel departed the runway overrun at 53 knots. The aircraft stopped 500 feet beyond the runway end on the public road, after sliding through two fences. The passengers and crew evacuated the aircraft with a few minor injuries.

The computer
SWA equips all of its aircraft with an on-board performance laptop computer (OPC) to assist the crew in a variety of calculations, including landing performance and stopping margins. Pilots enter pertinent data such as landing runway, prevailing wind conditions, aircraft weight, ambient temperature, and reported braking conditions. Up to 10 knots of tailwind is allowed with good or fair braking action, but only five knots is permissible under poor conditions.

The OPC computed margins of 560 feet and 40 feet based on fair and poor braking action, respectively. A 40-foot margin in this business is no margin at all, but company guidance was that any positive number was acceptable. Additionally, the computer did not clearly indicate that five knots was the maximum tailwind used in its calculation. It accepted an eight-knot entry but did not compute the distances based on the actual eight-knot tailwind. Had the OPC computed using the actual tailwind entry, the calculation would have shown a 260-foot overrun.

There was another "gotcha" in the computer programming. For the 737-700, stopping distances were based on the use of reverse thrust-but not on the 737-300 and -500, so a crew might extrapolate that with reverse thrust the aircraft would stop several hundred feet shorter than shown on the OPC. This important dissimilarity was not clearly explained in differences training. The accident crew assumed, as did many other SWA crews interviewed after the accident, that the OPC computed the same way for all models. Pilots were required to remember which formula applied to which aircraft, and they might fly all three models in the course of a day. Allowing reverse thrust to be credited with decreased landing distance, while economically and operationally expedient, does lessen the margins.

Procedural confusion
SWA requirements were for crews to use the most adverse braking-action report for planning purposes and not depend on a "blended" report. Thus, any part of the runway that was reported as poor would override a good/fair report on other parts. Post-accident interviews showed that a number of SWA crews did not understand that. With an eight-knot tailwind and a poor braking-action report for any part of the runway, SWA Flight 1248, and the ones preceding it, should have diverted. A five-knot tailwind is the maximum allowed with poor braking.

The Midway tower controller did not provide all the braking action reports to SWA Flight 1248, as required by FAA procedure. A Gulfstream III that landed shortly before the Southwest flight reported "poor" conditions, but the tower did not pass that along. While there might be some validity in SWA guidance to only accept braking action reports from other "commercial" aircraft, this might have alerted the crew that conditions were deteriorating.

SWA did not allow crews to use autobrakes, but was implementing a change to standardize use across the fleet as the system became available on all SWA aircraft. Crews interviewed and tested on the procedure afterward showed some confusion and uncertainty. The change was not to take effect until four days after the accident, but the crew had read about procedural changes before the flight and was unsure on the use of autobrakes. Distraction was clearly a factor.

Midway Airport
KMDW_Aerial.jpgAt the time of the accident, Midway was not optimally configured for large airline jet operations. Runway 31C was the only approach available because of visibility requirements, according to the NTSB. The runway had a displaced threshold and usable landing distance of 5,826 feet. As early as September 2000 the FAA had determined that the runway safety areas (RSA) were not in compliance with an airport design advisory circular, which considers a 1,000-foot overrun as standard. Runway 31C's RSA was a mere 81 feet.

In 2003, the FAA again asked for a reassessment, but the city of Chicago stated that there were "no alternatives." Their contentions: The runway could not be shortened and still allow air carrier operations; there was no space to extend the RSA beyond the existing airport perimeter without a major impact to the surrounding community. The use of an engineered materials arresting system (EMAS-a soft surface where an overrunning aircraft sinks in and stops with minimal damage) was not feasible since it would encroach on either the runway or extend beyond the airport perimeter. After-accident simulations showed that a modified EMAS would have stopped SWA Flight 1248 on the airport property. It was installed on several runways shortly afterward.

Braking-action reports
Snow_PlowThe NTSB had "long been concerned about runway surface condition assessments." There is considerable variability between pilot braking-action reports, airport contaminant type and depth observations, and ground surface vehicle friction measurements. There may be little or no correlation between the three, and there is no standard for how a particular aircraft will perform under given conditions. It almost amounts to "Y'all be careful out there."

Air carriers are required to perform landing distance calculations before departure to determine if the aircraft can land safely. However, the NTSB noted, "The assessments do not attempt to comprehensively account for actual conditions." There are many variables to consider and much subjectivity. While the FAA requires operators to take the aircraft manufacturers' maximum performance data and add margins of 62 percent for dry runways and 92 percent for contaminated runways, which may not be sufficient for all conditions.

Probable cause
NTSB_logoThe NTSB determined the probable cause "was the pilots' failure to use available reverse thrust in a timely manner to safely slow or stop the airplane after landing. This failure occurred because the pilots' first experience and lack of familiarity with the airplane's autobrake system distracted them from thrust reverser usage during the challenging landing." Numerous contributing factors included SWA's failure to provide clear guidance on landing distance calculations, programming of the OPC, implementation of the new autobrake procedure without appropriate familiarization, failure to include appropriate
margins of safety to account for operational uncertainties, the pilots' failure to divert to an alternate, and the lack of an EMAS system given the restricted runway environment.

In summary
In all air carrier operations, margins are built into the system to allow for the inevitable human or mechanical malfunction. However, there will be a one-in-a-million series of occurrences that leads to a mishap. The odds of the captain having difficulty deploying thrust reversers are small, but it was a critical-if understandable-lapse. Multiple crews misunderstood company procedure regarding mandatory diversion to alternates. The nonstandard programming of the OPC shows the importance of standardization.

This seemly simple accident demonstrates multiple facets and serves to remind us that the physics of flying never takes a day off. Do you anticipate contingencies? If you're betting that everything will work exactly as planned on a snowy runway, I have a bridge for sale.

AOPA_asf.gifBruce Landsberg is the executive director of the AOPA Air Safety Foundation.

Note: KMDW now has an Engineered Material Arresting System (EMAS) in the overrun area of 31C.


KCLTapt.jpgThe National Transportation Safety Board is investigating a runway incursion that occurred on Friday morning at the Charlotte Douglas International Airport (CLT) involving a general aviation aircraft and a regional jet airliner bound for New Bern, NC (EWN).

PSA_CRJ_200At about 10:17 a.m. on May 29, a PSA Airlines CRJ-200 regional jet operated as US Airways Express flight 2390, was cleared for takeoff on runway 18L. After the regional jet was into its takeoff roll, a Pilatus PC-12, a single engine turboprop aircraft, was cleared to taxi into position and hold farther down the same runway in preparation for a departure roll that was to begin at the taxiway A intersection. After the ground-based collision warning system (ASDE-X) alerted controllers to the runway incursion, the takeoff clearance for the regional jet was cancelled. The pilot of the PC-12, seeing the regional jet coming down the runway on a collision course, taxied the PC-12 to the side of the runway. The FAA reported that the regional jet stopped approximately 10 feet from the PC-12.

Visual meteorological conditions prevailed with 9 miles visibility. There were no reported injuries to any of the 42 passengers or crew of three aboard the jet, or to any of those on the PC-12.

PC-12NTSB Media Contact: Peter Knudson

Root Cause Analysis

The FAA's RCAT is also developing causal maps for recent runway incursions at Boston Logan, Milwaukee General Mitchell and Cleveland Hopkins International.

KBOS_APD_AIRPORT_DIAGRAM.png- Incident: US Airways A320 at Boston on Jun 18th 2009, near collision on runway after runway incursion
NTSB Identification: OPS09IA008
Scheduled 14 CFR Part 121: Air Carrier operation of USAirways
Incident occurred Thursday, June 18, 2009 in Boston, MA
Aircraft: AIRBUS A320, registration: N662AW
Injuries: 89 Uninjured.

A320On Thursday, June 18, 2009 at about 0636 eastern daylight time, a runway incursion occurred at the General Edward Lawrence Logan International Airport (BOS), Boston, Massachusetts involving a US Airways Airbus and a construction vehicle. The construction crew crossed runway 15R at taxiway M without approval as the Airbus was on departure roll.

According to the Federal Aviation Administration (FAA), the operator of a Ford Explorer, was not in radio communication with BOS tower air traffic controllers and had not been cleared to cross runway 15R. The Airbus rotated approximately 500 feet from the intersection of runway 15R and taxiway M as the vehicle cleared the runway edge southbound on taxiway M. The FAA stated that it appeared the tower controller was aware of the vehicle operating on taxiway M but not its intension to cross. The ground radar alerted the controllers of the event.

Ford_ExplorerTaxiway M is currently under construction and runway 15R is occasionally closed due to the construction. The Airport Authority designates the runway closure with signage which was not in place during this event indicating that the runway was an active runway. The Airport Authority also indicated that all personnel were briefed that the runway was active. The driver of the vehicle indicated that he had not been briefed to that fact. The driver has been suspended from driving on the airport pending an investigation.

The Airport Authority has ceased all construction upon completion of an investigation into the incident. US Airways flight 27, an Airbus A320, was departing Boston for Phoenix, Arizona with 84 passengers and five. There were no injuries to the crew and passengers nor damage to the airplane. The incident occurred during daylight visual meteorological conditions.

Note: Everyone survived a recent ditching in a 320. The results from hitting a vehicle at high speed are likely to be much different.

Cleveland June 3, 2009: NTSB Identification: OPS09IA007A

CoEx_E-145southwest_737s.jpgScheduled 14 CFR Part 121: Air Carrier
Incident occurred Wednesday, June 03, 2009 in Cleveland, OH: On Wednesday, June 3, 2009, at 3:15 p.m. eastern daylight time, a runway incursion occurred at the Cleveland Hopkins International Airport, Cleveland, Ohio involving an E-145 and B737 during daylight visual meteorological conditions. At the time of the incident, a developmental controller being monitored by a certified controller was working the local control positions 1 and 2 combined. The developmental controller cleared Continental Express/ExpressJet Airlines flight 2942 (BTA2942), an E145, for takeoff from the full length of runway 6L. A few seconds later, the developmental controller instructed Southwest Airlines flight 1080 (SWA1080), a Boeing 737, to taxi into position and hold on the same runway. SWA1080 entered the runway on taxiway T approximately 500 feet downfield from BTA2942 that was entering the runway for takeoff.


Milwaukee Complex Geometry Plus Runway Crossings

In Milwaukee, a Skywest CRJ taxiing on taxiway M to runway 25L taxied past a displaced Hold Short line on M, which resulted in a controller issued go around for an aircraft on final approach.

Displaced Hold Short and Precision Obstacle Free Zone (POFZ) Primer

KPIT_APD_AIRPORT_DIAGRAM.pngSeveral yeas back many airports began moving the Hold Short lines further away from the runway in order to increase the Precision Obstacle Free Zone (POFZ). In the process, many Hold Short lines are now no longer near the end of the runway, where they may have been for years. Add to that the fact that the new non-standard locations are frequently NOT depicted on the NACO or Jeppesen airport diagram, and a recipe for an incursion starts brewing. Taxiway E at KPIT is an example, as you taxi for takeoff on 28C the Hold Short is crossed well before you reach the end of the runway.

The displaced Hold Short lines have proven to be problematic throughout the industry for all pilots, and air safety advocates are working with the FAA’s National Runway Safety office, NACO and Jeppesen to educate users on the changes to Hold Short locations. If you come across a hazard like this, please identify it to NASA ASRS or your regional runway safety office.

Can you find the displaced hold short lines on this diagram? Don't bother, not there.

How about if you zoom in on google maps? Check out Taxiway Echo, as if you are taxiing to 28C for takeoff? Are there any surface painted Runway Holding Position signs, like the other runways? If you answered "No" you are correct. So why not mark this Hold Short like all the others?

Keep a look out for roving bands of Hold Short lines :)

KPIT Hold Short line for runway 28C, located on taxiway E.


KPIT Runway Holding position sign, located next to Taxiway E.

KPIT Taxiway E enhanced Hold Short and wig wags


For More Information: FAA Runway Safety

20 Dec 08 Continental 737 Denver Veers off Runway

KDEN_737NTSB Identification: DCA09MA021 Scheduled 14 CFR Part 121: Air Carrier operation of CONTINENTAL AIRLINES INCAccident occurred Saturday, December 20, 2008 in Denver, CO
Aircraft: BOEING 737, registration: N18611 Injuries: 5 Serious, 27 Minor, 83 Uninjured. This is preliminary information, subject to change, and may contain errors.
On December 20, 2008, at 1818 mountain standard time, Continental flight 1404, a Boeing 737-500 (registration N18611), equipped with CFM56-3B1 engines, departed the left side of runway 34R during takeoff from Denver International Airport (DEN). The scheduled, domestic passenger flight, operated under the provisions of Title 14 CFR Part 121, was enroute to George Bush Intercontinental Airport (IAH), Houston, Texas. There were 37 injuries among the passengers and crew, and no fatalities. The airplane was substantially damaged and experienced post-crash fire. The weather observation in effect nearest the time of the accident was reported to be winds at 290 and 24 knots with gusts to 32 knots, visibility of 10 miles, a few clouds at 4000 feet and scattered clouds at 10,000 feet. The temperature was reported as -4 degrees Celsius.

31 May 08 Grupo TACA A-320 Runway Excursion Honduras

TEGUCIGALPA, Honduras -- A plane skidded off a runway killing five people and injuring 38 in Honduras on Friday.
The Salvadoran passenger plane veered onto a road and smashed into cars and a building at Tegucigalpa airport.
The TACA airlines Airbus A320, on a flight from San Salvador with 135 passengers and crew, lay broken in three parts and was spewing fuel after the accident, which happened in heavy rain and fog.
Full Article

Photograph by : Orlando Sierra, Getty Images

Our next ALPA Runway Safety newsletter will focus on runway excursions. Sadly, the hazards associated with landing on contaminated runways have not been effectively mitigated by the aviation industry. If we are to take the next step towards reduction of the global mishap rate, we must study these events and gain as much knowledge from them as we can. Within the past few years we have had loss of life and property at Burbank, Midway, Toronto, Cleveland, Traverse City, Yogyakarta, to name only a few.
From the NTSB Most Wanted:
"Analysis performed by the Flight Safety Foundation has shown that runway excursions accounted for approximately 29 percent of all accidents involving turboprop and turbojet aircraft worldwide between 1995 and 2006. A runway excursion occurs when an aircraft either overruns or undershoots a runway while landing or taking off. Existing FAA regulations do not specify either the type of arrival landing distance assessment that should be performed or a safety margin that should be applied. The FAA advocates a minimum safety margin of 15 percent for arrival landing distance assessments and a 15-percent factor is included in the European Aviation Safety Agency and Joint Airworthiness Authorities operational requirements for contaminated runway landing performance. The FAA has sought voluntary operator compliance with performing landing distance assessments, and applying a 15-percent safety margin. However, runway overruns continue to occur in the United States when the flightcrews have not performed a landing distance assessment before landing on a contaminated runway."

Editor: A new culture needs to emerge that provides flightcrews with the training, technologies and accurate information needed to make valid situational assessments. Current system behavior does not support that, and we must improve system performance in this area.

Fly Smart

25 May 08 Kalitta 747 Overrun Brussels

Saturday, July 11, 2009 Final report issued for Kalitta Air Boeing 747 freighter accident at Brussels

Kalitta B747 Brussels, AAIU photo
Kalitta B747 Brussels, AAIU photo
The Air Accident Investigation Unit (AAIU) of Belgium's Federal Public Service Mobility and Transport agency has released its final report on the 2008 Kalitta Air freighter accident at Brussels, Belgium. On May 25, 2008, the Boeing 747-200 aircraft (registration N704CK) overran runway 20 of Brussels Zaventem Airport (EBBR) after a rejected takeoff. The aircraft came to a stop 300 meters beyond the end of the runway, where it broke into three parts. The four crew members and one passenger suffered minor injuries.

The accident aircraft was departing Brussels for Bahrain at the time of the accident. A bird, later identified as a European kestrel, was ingested by the number three engine during the takeoff roll. According to the AAIU report, the bird strike caused "a momentary loss of power, accompanied by a loud bang, heard by the crew and external witnesses, and by flames, seen from the control tower."

The bang and the loss of power occurred four seconds after the V1 speed call-out.

Two seconds after the bang, all four engines were brought back to idle, and braking action was initiated. The aircraft reached a first embankment, dropping from a height of 4 m, and broke in three parts. The aircraft came to a stop just above the top of the railroad embankment.
There was no post crash fire.

Although the captain stated he applied maximum braking power during the stop run, the thrust reversers were not deployed. The captain stated he applied speed brakes, however "the speed brake lever was found in the retract position in the cockpit, while the speed brakes themselves seemed in a stowed / retract position."

The AAIU has determined that this accident "was caused by the decision to Reject the Take-Off 12 knots after passing V1 speed."

The report lists the following contributing factors:
  • Engine Nr 3 experienced a bird strike, causing it to stall. This phenomenon was accompanied by a loud bang, noticed by the crew.
  • The aircraft line up at the B1 intersection although the take-off parameters were computed with the full length of the runway.
  • The situational awareness of the crew,
  • Less than maximum use of deceleration devices.
  • Although the RESA [runway end safety area] conforms to the minimum ICAO requirement, it does not conform to the ICAO recommendation for length.
Several safety recommendations are included in the report, including this one regarding Kalitta’s training program:

We recommend to modify the training program of the flight crew (initial and recurrent), and related documentation, to highlight the risks involved in rejecting TO around V1, as well as the importance of respecting procedures.

The training program of Kalitta was amended and an in-house DVD training video was developed, that demonstrates proper and improper reject procedures that is modeled after rwy 20 in BRU. The content of the DVD was reviewed by both Boeing and FAA.

This revised training program is currently in place.
The AAIU Final report, in English, is available for download here: Ref. AAIU-2008-13, July 10, 2009 (66-page 'PDF'file)

FMI: Aircrew Buzz

02 Aug 2005 Air France A340 Toronto Landing in Stormy Conditions

Overrun: making life or death decisions By David Learmount

Air_France_358Pilots - and the industry - need to look again at the issue of decision-making when faced with landing in stormy conditions. That is the conclusion drawn by the Transportation Safety Board of Canada (TSB) in its report on the Air France Airbus A340-300 runway overrun at Toronto airport in 2005.
The Board is right. It has not ventured an opinion based merely on this accident itself the report studies seven accidents or incidents involving other Air France aircraft landing in stormy weather, cites four more involving other airlines, quotes a NASA examination of pilot decision-making in these circumstances, and finally provides an analysis of incidents involving go-arounds reported to the International Air Transport Association's safety data exchange system STEADES.
The report observes: "Thorough investigations into accidents similar to this one, along with very well thought-out conclusions, findings and recommendations, have not made much of a dent in the number of such accidents, which continue to happen around the world." The TSB concludes: "We seem unable to develop adequate tools to mitigate this specific risk."
Tools include windshear prediction and warning systems at airports and in aircraft, massively improved real-time storm-cell tracking systems for air traffic controllers - in other words, systems that can provide the aircrew and controllers with high-quality information, on the basis of which pilots can make clear judgements about whether to proceed with an approach or not. But improved tools alone are not the whole story, and while their development and adoption is awaited, pilot training in decision-making when landing in bad weather needs to be developed and implemented by airlines, says the TSB.
This is easier said than done. The report quotes NASA's study, Pilot decision-making - assessment of risk and weather, which comes to the conclusion that four factors contribute to decision errors: "Ambiguity of information dynamically changing risks goal conflicts (organisational or social pressures) and unanticipated consequences."
At Toronto airport there is no ground-based windshear alert system and the controllers have rudimentary information about the location of convective weather cells on their displays but the A340 had a windshear prediction and alert system and a good weather radar.
NASA's point about "ambiguity of information" is highly applicable in this case: the crew knew from weather reports that storm activity existed close to the airport, they could see it on their radar, they could see the runway was very wet, yet the veering of the wind on short final approach from a crosswind with a headwind component to one with a tailwind component did not trigger a windshear alert from their onboard systems at any time. Meanwhile the crew would have noted that aircraft were landing successfully just ahead of them and were sequenced behind them to carry out approaches.
There is also an embedded conflict in the minds of all pilots: unless they are very new, they have landed successfully many times in bad weather, so the problem on each new approach is to determine whether the bad weather today is any worse than that in which they have successfully landed before.
NASA's point about "dynamically changing risks" is highly significant here. The report categorises this approach as one in which the crew faced continual dynamic changes, which implies high mental workload and, for the pilot flying (PF), demands that reach saturation level. When this aircraft ran into torrential rain which deprived the pilots of visibility just as it was touching down, the PF had his hands full just keeping the aircraft on the runway, let alone worrying about stopping. Hence the delay in selecting reverse thrust.
On the other hand, if severe convective weather is in the vicinity, the existence of "dynamically changing risks" is more or less a given state of affairs, and pilots know that. So why do they persist with an approach in such conditions? Part of the reason is that, if the situation is known to be changing, the crew's mentality is to proceed on a discovery basis: 'If the weather is okay we land if it isn't we throw it away'. But carrying out a go-around that passes through a storm cell carries risks too.
The only way to deal with all this is to replace the ambiguity with high-quality real-time data on the basis of which high-quality decisions can be made.
Despite the damage and fire, no lives were lost NASA's point about "ambiguity of information" is highly applicable in this case.

03 May 08 The Limits of Expertise: Rethinking Pilot Error and the Causes of Airline Accidents

I’m reading a new book, The Limits of Expertise: Rethinking Pilot Error and the Causes of Airline Accidents (2007) This book will help build the bridge that will move us beyond the probable cause determination required for today’s mishaps. It would also be an excellent text for a mishap investigation course. One of the case studies I found particularly interesting was on an American AIrbuss 300 that departed controlled flight. After the aircraft departed, the PFDs blanked and the pilots were left with only the standby attitude indicator for pitch and roll information. This was actually a design feature of the aircraft, as designers determined that the PFD would not provide reliable information beyond certain parameters. So the aircraft was in state that the designer had not imagined, and that the operator had not trained the pilots to recover from. I’d chalk this one up as a system failure, which led to threats that the pilots had to “manage” (pretty sterile term for wrestling an Airbus out of a fully developed stall). I also recently spoke to one of the authors, Key Dismukes. His group at NASA is doing some great work in the areas of concurrent task management and prospective memory (when Key is not out flying a sailplane). These are come new areas that we need to take a look at as we tackle the system’s runway safety problems, an area where we do not have fully independent and redundant systems safeties. Amazon Review: By Alan N. Hobbs “The authors have applied insights from cognitive psychology to nineteen flight-crew-related accidents. In place of the dry narratives of accident reports, we are presented with compelling three- dimensional accounts in which pilots are routinely faced with time pressure, the need to make judgments under uncertainty, and rare but potentially lethal system failures. In examining each accident, the authors attempt to reconstruct the mindset of the pilots, and place the actions of the crew in the context of the flow of events. In contrast to other reviews of accidents, the authors avoid the phrase “the pilots should have…”. Instead we are gently encouraged to understand how skilled and professional operators can come to make mistakes in circumstances that are unforgiving of error. Through the lens of cognitive psychology, the aviation industry becomes a massive human performance laboratory, in which hapless operators are faced with situations and problems produced not by experimenters, but by the complexities of the system of which they are a part. The authors take pains to counter the common presumption that catastrophic accidents must somehow result from extreme acts of villainy or incompetence. In this book, we repeatedly see how accidents often arise from combinations of everyday problems and situations. By the end of the book, some fascinating patterns begin to emerge. A surprising number of the accidents involved apparently simple slips and lapses. Additionally, the majority of accidents occurred on approach and landing, and most of the accident flights were running late. The failure to go-around from an un-stabilized approach is a common theme in the accident scenarios.” The Limits of Expertise Fly Smart Kent ----=


Airport Diagrams and other aeronautical charting information and resources:

Office of Runway Safety:

Aeronautical Information Manual - Chapter 2 Section 3, Airport Marking Aids and Signs

AC 91-73A, Part 91 and Part 135 Single-Pilot Procedures during Taxi Operations

AC 120-74, Flight Crew Procedures During Taxi Operations

AC 90-42F, Traffic Adviosry Practices at Airports without Operating Control Towers

AC 90-66A, Recommended Standards Traffic Patterns for Aeronautical Operations at Airports without Operating Control Towers

14 CFR part 61
14 CFR part 91
AC 00-6
AC 00-45
AC 60-22
AC 60-28
AC 61-134
AC 61-84
AC 90-48
AC 90-94
AC 120-51
Certification: Pilots and Flight Instructors
General Operating and Flight Rules
Airplane Flying Handbook
Instrument Flying Handbook
Rotorcraft Flying Handbook
Pilot's Handbook of Aeronautical Knowledge
Instrument Procedures Handbook
Aviation Weather
Aviation Weather Services
Aeronautical Decision Making
English Language Skill Standards Required by
14 CFR parts 61, 63, and 65
General Aviation Controlled Flight into
Role of Preflight Preparation
Pilots’ Role in Collision Avoidance
Guidelines for Using Global Positioning
System Equipment for IFR En Route and
Terminal Operations and for Nonprecision
Instrument Approaches in the U.S. National
Airspace System
Crew Resource Management Training
Aeronautical Information Manual
Instrument Departure Procedures
Standard Terminal Arrivals
Airport Facility Directory
National Flight Data Center Notices to Airmen
Instrument Approach Procedures
Pertinent Pilot’s Operating Handbooks
FAA-Approved Flight Manuals
En Route Low Altitude Chart

Fly Smart,

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Pilot Handbook of Aeronautical Knowledge
Aviation Instructors Handbook
Instrument Flying Handbook