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Transportation Safety Board of Canada

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  1. Transportation Safety Board of Canada Bureau de la sécurité des transports du Canada Presentation to the National Transportation Safety Board Runway Incursion Forum 27 March 2007

  2. Transportation Safety Board of CanadaLothar HoppSenior Investigator/Air Traffic Services Specialist

  3. Object of the TSB of Canada The object* of the Board is to advance transportation safety by • conducting independent investigations, including, when necessary, public inquiries, into selected transportation occurrences in order to make findings as to their causes and contributing factors; • identifying safety deficiencies as evidenced by transportation occurrences; • making recommendations designed to eliminate or reduce any such safety deficiencies; and • reporting publicly on its investigations and on the findings in relation thereto. *Canadian Transportation Accident Investigation and Safety Board (CTAISB) Act

  4. However … In making its findings as to the causes and contributing factors of a transportation occurrence, it is not the function of the Board to assign fault or determine civil or criminal liability, but the Board shall not refrain from fully reporting on the causes and contributing factors merely because fault or liability might be inferred from the Board's findings.

  5. TSB Investigations Since 1997, the TSB has conducted 13 investigation involving runway incursion at Canadian airports. Some of the more significant findings that resulted from those investigations were… http://www.tsb.gc.ca/en/air/

  6. TSB Report Findings Situational Awareness • The airport controller assumed that runway 25 had been transferred to the control of the airport controller when the ground controller advised that the Cessna was released. (A99H0004) • No active warning system to serve as a reminder for the FSS specialist that a vehicle is operating on a runway is in place at the Terrace FSS. (A98H0004) • The Cessna 172 took off without clearance from Runway 30, causing a risk of collision with the Airbus A320. (A04Q0089)

  7. TSB Report Findings (con’t) Phraseology • A review of taped ATC communications revealed a number of instances of non-standard and casual R/T communications … (A97O0037) • The expression "runway available", from a local order, caused confusion… (A97Q0005) • The air controller did not use the phraseology recommended in ATC manuals for situations in which an aircraft is cleared to position on an intersecting runway, but is not number one for take-off. (A99W0036)

  8. TSB Report Findings (con’t) Equipment/Procedures • There is no automated runway incursion warning system, such as inductive loop or similar technology, that warns pilots directly of incursions; the runway incursion monitor/collision avoidance system may not provide sufficient warning to prevent an accident.(A01O0299) • The aircraft and the vehicle were operating on different radio frequencies, which was in accordance with established procedures (uncontrolled airport). (A98H0004) • …There is no requirement for a pilot to immediately advise the tower when unable to comply with the (acknowledged runway) exit instructions.(A04P0047)

  9. TSB Report – Safety Action Taken • The new radios will allow vehicle operators to hear communication from and to aircraft flying into or out of Terrace Airport, thereby increasing their situational awareness.(A98H0004) • The … Airport Authority is in the process of instituting a refresher training program, in addition to the regular annual program held in the fall of each year, that will include a re-emphasis of proper radio procedures by its drivers. (A97O0037) • (Reaction to) Non-compliance situations by a pilot are taught (to controllers) in the classroom, and are practised in a number of exercises in the dynamic 360-degree airport simulator throughout the course. (A04Q0089)

  10. Runway Incursion Incidents • From 1997 to 1999, there was a significant increase in the number of reported runway incursion incidents in Canada • The regulator, Transport Canada, and the ATS service provider, NAV CANADA, both launched studies as a result of this trend • Both agencies produced their own reports with recommendations

  11. Reported Runway Incursion Occurrences 440 400 360 320 280 240 Number 200 160 120 80 40 2002 2003 2004 2005 0 Year Runway Incursion Reports

  12. Incursion Prevention Action Team(IPAT) • In 2001, decision to establish a joint implementation team to address the recommendations of the aforementioned two reports in a coordinated manner • Under the leadership of Transport Canada and NAV CANADA, along with other stakeholder and observers, the IPAT was formed • The recommendations from the two reports were combined, and over the next four years, the IPAT met regularly to address them

  13. IPAT Results • Common definition for what is a runway incursion • Better statistical data • Airport diagrams available on the internet (free of charge) • Changes in ATC procedures such as - • Clearances include intersection name when take-off being conducted from an intersection • Specific clearance across all runways when taxiing to the departure runway • Taxi to position procedures and phraseology • Establishing standard taxi routes at some airports • Focus on education and procedures

  14. IPAT Results (con’t) • Awareness posters for aircrew, vehicle operators and ATS personnel http://www.tc.gc.ca/civilaviation/systemsafety/posters/menu.htm

  15. Reported Runway Incursion Occurrences 440 400 360 320 280 240 Number 200 160 120 80 40 2002 2003 2004 2005 0 Year Runway Incursion Reports

  16. Runway Safety and Incursion Prevention Panel The Next Initiative (2005) • Identify interested stakeholders • Form discussion panel • Follow-up on panel discussions and recommendations • Result – formation of the Runway Safety and Incursion Prevention Panel (RSIPP)

  17. RSIPP Scope • … the panel is to provide a forum for the exchange of safety related information pertaining to the movement of aircraft and vehicles in the vicinity of the runway with the aim of promoting runway safety and with a primary focus on the reduction in the risk of runway incursions. The panel should identify findings and make recommendations to improve safety and prevent runway incursions.

  18. RSIPP Organization • This multi-disciplinary group is composed of: • NAV CANADA, • Canadian Airports Council (CAC); • Canadian Owners and Pilot's Association (COPA); • Airline Pilot's Association (ALPA); • Canadian Air Traffic Controller Association (CATCA); • Air Traffic Specialists Association of Canada (ATSAC); • Air Transportation Association of Canada (ATAC); • other aviation stakeholders as identified by the panel; and • observers with a direct interest in runway safety (such as Transport Canada, the Transportation Safety Board of Canada or technical specialists from stakeholder organizations).

  19. RSIPP The duties of the panel were agreed to as follows: • Review the current runway incursion prevention activities applicable to operations at Canadian aerodromes; • Review international runway incursion prevention activities with the objective of identifying and promoting proven best practices where feasible; • Recommend methods for sharing safety information within the aviation community and suggest runway incursion strategies/initiatives; • Share available runway incursion data to identify and analyze potential runway incursion safety issues or trends; • Make recommendations for runway safety and incursion prevention to supporting agencies.

  20. RSIPP However – • It will not be the mission of this panel to assign fault or determine liability. • This panel in no way replaces local runway safety committees (that is at airports, ATS units, operators etc) And – • Recommendations of the panel will be based on consensus, and although not binding on any of the parties shall be given full consideration by the affected supporting agencies.

  21. CASS explores emerging safety issues with a view to creating awareness thereof and offering strategies to eliminate hazards or manage their effects. http://www.tc.gc.ca/CivilAviation/SystemSafety/CASS/2007/menu.htm

  22. Where to from here?

  23. Transportation Safety Board of Canada Bureau de la sécurité des transports du Canada