D3-P1 SMS Faa

Why SMS?
• Heinrich’s Triangle illustrates the number of incidents,

hazardous conditions, and unreported “unsafe acts”
that occur for every one airport accident
Aircraft Accident 1
Incidents (Operational Error/
Runway Incursion, etc.) 30
Hazardous Conditions
300
Unreported “Unsafe Acts”
1000
Federal Aviation
Administration 1
Why SMS?
Other benefits of SMS include:

– Cross-functional Safety Risk Management
among air traffic service providers
– Intra-agency stakeholder participation in
solving safety challenges
– Safety saves money
Federal Aviation 2
Administration
SMS Components
Federal Aviation 3
Administration
SMS Components
Safety Policy
Establishes senior
management’s commitment to
continually improve safety;
defines the methods,
processes, and organizational
structure needed to meet
safety goals.
Federal Aviation 4
Administration
SMS Components
Safety Policy
Establishes senior
management’s commitment to
continually improve safety;
defines the methods,
processes, and organizational
structure needed to meet
safety goals.
Safety Risk Management

Determines the need for, and
adequacy of, new or revised
risk controls based on the
assessment of acceptable risk.
Federal Aviation 5
Administration
SMS Components
Safety Policy
Establishes senior Safety Assurance
management’s commitment to Evaluates the continued
continually improve safety; effectiveness of implemented
defines the methods, risk control strategies, supports
processes, and organizational the identification of new
structure needed to meet hazards
safety goals.

Determines the need for, and
adequacy of, new or revised
risk controls based on the
assessment of acceptable risk.
Federal Aviation 6
Administration
SMS Components
Safety Policy
safety goals.
Safety Risk Management Safety Promotion

Determines the need for, and Includes training,
adequacy of, new or revised communication, and other
risk controls based on the actions to create a positive
assessment of acceptable risk. safety culture within all levels
of the workforce
Federal Aviation 7
Administration
SMS Components
Safety Policy
structure needed to meet Policy hazards
safety goals.
SRM SA
Safety Promotion
of the workforce
Federal Aviation 8
Administration
SMS Components
• The SMS components ensure that a service
provider is able to:
– Systematically look for the things that can and do go
wrong (hazards) in a system or operation
– Find, describe, and track these hazards, their
causes, and inherent risk(s)
– Prioritize the hazards according to risk
– Mitigate the risk(s)
– Verify that the mitigations work
– Document all of the above
Federal Aviation 9
Administration
FAA Example: Safety Assurance
Federal Aviation 10
Administration
Roles and Responsibilities
• The State (regulator) is responsible for the

State Safety Programme (SSP), which includes
establishing requirements for Safety
Management Systems in accordance with
international standards
• Service providers are responsible for
developing and implementing Safety
Management Systems according to applicable
requirements
Federal Aviation 11
Administration
FAA Example: SMS Policy
Annex 11 (ATS)
ICAO SARPS Annex 19

(Safety
Management)
FAA Order FAA Order 8040.4, FAA Order

8000.369, Safety Risk 1100.161,
FAA Directives Safety
Management
Management Air Traffic Safety
Policy Oversight
System
FAA Air Traffic

FAA Order JO
Organization
1000.37,
ATO Safety Air Traffic
Safety
Management
Organization SMS
Management System System Manual
Federal Aviation 12
Administration
Policy
FAA Runway
Safety Program
Presented to:
By:
Federal Aviation Administration
Date:
October 21-25, 2019
Federal Aviation
Administration
Federal Aviation
Administration
Safety Policy
Safety Assurance
Evaluates the continued
Establishes senior management’s effectiveness of implemented
commitment to continually improve risk control strategies, supports
safety; defines the methods, the identification of new
processes, and organizational hazards
structure needed to meet safety goals.

of the workforce
Federal Aviation 14
Administration
The Importance of Runway Safety
• There is great potential for disaster when large,

fast-moving aircraft and vehicles come together
in close proximity
• Complexities of operating on an aerodrome
further identify the need for complete situational
awareness
Federal Aviation 15
Administration
Federal Aviation 16
Administration
Federal Aviation 17
Administration
• Tenerife, Canary Islands, March 27, 1977
• 2 Boeing 747s collided on the runway at Los

Rodeos Airport, killing 583
• One of the primary causes was

misunderstanding of radio communications
• https://youtu.be/kjLrZ2SDDaU
Federal Aviation 18
Administration
FAA at a Glance
• Over 15 million flights handled in 2016, with more

than 40,000 daily average
• More than 2.5 million passengers flying in and out of

the U.S. every day
• FAA Air Traffic Services are part of the aviation

authority
Federal Aviation 19
Administration
Federal Aviation
Administration
Runway Safety Program Key
Principles
• Based on the pillars of Safety Management

system (SMS)
• Creates awareness and cooperation among
all stakeholders
• Educates aerodrome users on runway
safety risks
• Espouses Safety Culture
Federal Aviation
Administration
FAA SMS Order
• FAA SMS Order 8000.369B
– Requires adopting a common approach to

implementing and maturing an integrated SMS
including fostering a positive safety culture and other
attributes as applicable
– Defines the roles and responsibilities of the FAA
organizations, FAA SMS Executive Council and FAA
SMS Committee regarding safety management
Federal Aviation 22
Administration
Federal Aviation 23
Administration
FAA Runway Safety Order
• FAA Order 7050.1B – Runway Safety
Program
– Establishes policy, assigns responsibility, and
delegates authority for the FAA Runway Safety
Program
– Intended to improve runway safety by decreasing
the number and severity of runway incursions,
runway excursions, and other surface incidents
Federal Aviation 24
Administration
Runway Safety SMS Process
Surface Safety
Group
25 Federal Aviation
Administration
Surface Safety
Group
26 Federal Aviation
Administration
Surface Safety
Group
27 Federal Aviation
Administration
Surface Safety
Group
28 Federal Aviation
Administration
Surface Safety
Group
29 Federal Aviation
Administration
Surface Safety
Group
30 Federal Aviation
Administration
Runway Safety Policy
Runway Safety Council
 Executive Steering
 Provides government and industry

leadership to develop and focus
implementation of an integrated, data-
driven strategy to reduce the number and
severity of runway incursions
 Data-driven, risk-based, integrated

systems approach
Surface Safety  Governs the work of the Surface Safety

Group
Group
 National Runway Safety Plan
31 Federal Aviation
Administration
Safety Assurance
Runway Incursion Assessment Team and

Surface Risk Analysis Process
 Determines runway incursion severity

classification
 Comprised of one or more members from

ATC, Flight Standards (Regulator), and
Office of Airports
Surface Safety
Group
32 Federal Aviation
Administration
Surface Safety Group
 Identify and understand the contributing

factors
 Analyze risk factors
 Develop safety strategies and mitigations

to maintain the safest levels of surface
operations
Surface Safety  Collect, find, fix, monitor work that is

Group
steered by the executive members of the
Runway Safety Council (RSC)
33 Federal Aviation
Administration
Surface Safety Initiative Team
 Serve as a forum for the identification,

discussion, research, analysis, and
recommendation of possible solutions to
potential surface safety gaps
 Develop a standardized, data-driven

methodology for the identification,
selection and prioritization of surface
safety gaps
Surface Safety
Group
 Assess alternatives that may include,
but are not limited to, policy, procedures,
training, technology, and/or personnel
changes to address gaps by priority
34 Federal Aviation
Administration
Safety Promotion
Communication and Outreach Team
 Training
 Promotional materials (signage,

videos, email blasts, posters, etc.)
 Conferences
 Stakeholder meetings
Surface Safety
Group
 Airport Construction Advisory Council
35 Federal Aviation
Administration
Three Levels of Governance
• National
– Policy direction and implementation
– Data analysis
– Stakeholder engagement
– Safety Promotion
• Regional
– Data analysis
– Stakeholder engagement
– Safety Promotion
• Local
– Data collection and analysis
– Runway Safety Teams
– Mitigation implementation
Federal Aviation 36
Administration
FAA Stakeholder Engagement
• Every aspect of Runway Safety program

• Runway Safety Council, Surface Safety
Group, and Surface Safety Initiative Team
• Data collection and analysis
• Safety Risk Management Panels
• Runway Safety Teams
• Promotional activities
Federal Aviation 37
Administration
Safety Assurance
Safety Policy
Establishes senior
Safety Assurance
safety goals.

of the workforce
Federal Aviation 38
Administration
Safety Assurance
Federal Aviation 39
Administration
Federal Aviation
Administration
Safety Culture
Just Culture Safety Self
Assessment
Federal Aviation 41
Administration
Encouraging Safety Culture
• Safety culture is the way safety is perceived,

valued, and prioritized
– Reflects the real commitment to safety at all levels in
the organization
• Safety culture is important to regulators and
ANSPs
• Safety culture can be positive, negative, or
neutral
SKYbrary: Category: Safety Culture (http://www.skybrary.aero/index.php/Category:Safety_Culture)
Federal Aviation 42
Administration
• An organization with a negative safety culture:

– Does not address staff concerns about safety
– Does not learn from safety events
– Does not include safety management in decision-
making
SKYbrary: Toolkit: Safety Culture, A1.3 What is a “good” safety culture? (http://www.skybrary.aero/index.php/Solutions:Safety_Culture)
Federal Aviation 43
Administration
• An organization with a positive safety culture:

– Recognizes that safety is a business imperative
– Prioritizes safety over other pressures (economic,
societal, etc.)
– Believes that safety is everyone’s responsibility
SKYbrary: Toolkit: Safety Culture, A1.3 What is a “good” safety culture? (http://www.skybrary.aero/index.php/Solutions:Safety_Culture)
Federal Aviation 44
Administration
Positive Safety Culture
• Encourages employees to divulge information about all safety hazards
Reporting
they encounter
• Holds employees accountable for deliberate violations of the rules but

encourages and rewards them for providing essential safety-related
Just information
• Adapts effectively to changing demands and allows quicker, smoother

Flexible
reactions to off-nominal events
• Willing to change based on safety indicators and hazards uncovered

Learning
through assessments, data, and incidents
James Reason, Managing the Risks of Organizational Accidents, Hants: Ashgate, 1997, p. 196)
Federal Aviation 45
Administration
• To develop a positive safety culture:

– Understand the concept of safety culture
– Measure safety culture
– Improve safety culture
SKYbrary: Toolkit: Safety Culture (http://www.skybrary.aero/index.php/Solutions:Safety_Culture)
Federal Aviation 46
Administration
Measuring Safety Culture
• Conduct a safety culture assessment to:
– Establish a shared understanding of the
organization’s (CAA or ANSP) safety culture and
identify its strengths and weaknesses
• The safety culture assessment process
includes:
– Pre-launch phase
– Data collection
• Safety culture questionnaire, interviews, workshops
– Safety culture analysis
– Diagnosis, feedback, and way forward
SKYbrary: Toolkit: Safety Culture, B1.1 How do you measure safety culture? (http://www.skybrary.aero/index.php/Solutions:Safety_Culture)
Federal Aviation 47
Administration
• Strategies for conducting a safety culture

assessment:
– Collaborate with an external, independent
assessment team of experts
– Appoint an internal “champion”
– Seek staff contribution and involvement
SKYbrary: Toolkit: Safety Culture, B1.2 and B1.3 (http://www.skybrary.aero/index.php/Solutions:Safety_Culture)
Federal Aviation 48
Administration
• The safety culture questionnaire is tool to collect data about the
current safety culture
– Set of statements that respondents are asked to agree or disagree with
– Designed to elicit responses on a variety of topics that indicate how the
ANSP(or regulator!) approaches and manages safety in practice
Example safety culture

questions
Safety Culture in Air Traffic Management: A White Paper; FAA/EUROCONTROL AP 15
Federal Aviation 49
Administration
• Additional sources of information about safety
culture include:
– Website
– Safety programs and safety initiatives in place
– Documented policies and procedures
– Internal publications (organization structure, mission statement,
etc.)
– Incident reports
• How often voluntary reporting processes are used
• Quality and scope of incident reports, and whether important issues
are covered appropriately
• Whether reports are acted on, how feedback is communicated, and
what the process for responding to reports entails
• How trends in incident data are collected and acted upon
SKYbrary: Assessing Safety Culture in ATM (http://www.skybrary.aero/index.php/Assessing_Safety_Culture_in_ATM#Data_Collection:_The_Safety_Culture_Questionnaire)
Federal Aviation 50
Administration
Improving Safety Culture
• A safety culture assessment may suggest

specific opportunities for improvement
• The following practices also support a
positive safety culture:
– Encourage open discussion of safety concerns
among staff and management
– Establish and foster voluntary safety reporting
programs
Federal Aviation 51
Administration
Improving Safety Culture
• Strategies for managing culture change:

– Establish commitment to improving safety culture at
all levels of the organization
– Set up monitoring processes (for resources,
objectives, implementation, timelines)
– Report progress and communicate achievements
– Celebrate success
SKYbrary: Toolkit: Safety Culture, C1.3 Planning for safety culture change (http://www.skybrary.aero/index.php/Solutions:Safety_Culture)
Federal Aviation 52
Administration
Encourage Voluntary Reporting
• Voluntary safety reporting programs are a

component of a positive safety culture
– Non-punitive
• Voluntary reporting philosophy:
Value
– Value mistakes mistakes
– Learn from mistakes

– Make safety improvements
Make safety Learn from

improvements mistakes
Federal Aviation 53
Administration
Encourage Voluntary Reporting
• Successful voluntary safety reporting
programs require:
– Incentives to report
• Limited immunity from enforcement and/or disciplinary actions
– Legal protection of identities and reported information
(de-identification)
– Collaboration between regulator and service provider(s)
• Agreement on terms and conditions to be upheld by each
party
– Dedicated program manager
– Documented process for report handling and analysis
– Resolution of identified safety issues
– Data-sharing processes to provide access to safety
information gathered by the program(s)
Federal Aviation 54
Administration
Why Voluntary Reporting?
• FAA (regulatory) perspective:

– Many accident precursors do not entail
noncompliance with regulations/requirements
– Access to safety information not otherwise known
– Incentive to exceed minimum standards
– Additional means of achieving corrective action
– Improve the ability to ensure future compliance
Federal Aviation 55
Administration
Root Cause Analysis
• Root cause analysis is a Accidents/incidents/occurrences
deductive method used to
analyze a problem, identify
its causes and the measures
that could be taken to
prevent it from occurring
again
– Symptoms of the problem
may be visible but you are
unable to see and identify the
causes
• Voluntary safety reports
support root cause analysis
Using Root Cause Analysis to Drive Process Improvement (http://intland.com/blog/safety-engineering/using-root-cause-analysis-to-drive-process-improvement/)
Federal Aviation 56
Administration
FAA Voluntary Reporting Tools
Aviation Safety Action Program
(ASAP)
Air Traffic Safety Action Program
(ATSAP)
Technical Operations Safety
Action Program (T-SAP)
Aviation Safety Reporting System
(ASRS)
Federal Aviation 57
Administration
Acceptable Reports
• Voluntary reporting programs do not
tolerate intentionally reckless or criminal
behavior
• Acceptable reports:
– Must be inadvertent
– Must not involve gross negligence (that is, the
individual did not intentionally introduce risk)
– Must not appear to involve criminal activity
– Must not appear to involve substance abuse,
controlled substances, or alcohol
– Must not appear to involve intentional falsification
Federal Aviation 58
Administration
FAA Example: Protecting Safety
Information
• Limitations on disclosure of safety information
are contained in U.S. statutes and regulations
– 49 U.S. Code § 44735: Limitation on Disclosure of Safety
Information
– Title 14 of the Code of Federal Regulations
• Part 91.25 – Aviation Safety Reporting Program: Prohibition
Against use of Reports for Enforcement Purposes
• Part 193 – Protection from Release of Voluntarily Submitted
Safety Related Information
– FAA ATSAP and T-SAP reports protected under Part 193
• Part 13.401 – Flight Operational Quality Assurance Program:
Prohibition against use of data for enforcement purposes
Federal Aviation 59
Administration
FAA Example: Event Review
• An Event Review Committee (ERC)
determines the appropriate response for each
voluntary safety report
– Reviews and analyzes the information provided
– Conducts interviews of reporting personnel when
required
– Gathers additional information as available
– Investigates all safety related reports to the extent
appropriate
Federal Aviation 60
Administration
FAA Example: Event Review
• The ATSAP ERC:
– Includes members from each party to the program:
• Regulator
• Service Provider(s)/Certificate Holders
• Labor union(s)
– Requires members to sign confidentiality and non-
disclosure agreements
– Meets at least twice a month
– Uses both informal and formal methods to resolve reports
• May recommend additional training to address an employee’s
performance that demonstrates a lack of qualifications
• May issue a formal Corrective Action Request requiring
response from the service provider
Federal Aviation 61
Administration
References
• Voluntary Reporting Resources:

– FAA Order JO 7200.20
– FAA Order 7200.22
• ICAO Safety Management Manual, Doc 9859
Federal Aviation 62
Administration
Next Up:
Surface Event Definitions
Federal Aviation 63
Administration
Safety Assurance: Federal Aviation
Administration
Surface Events and

Severity
Classifications
Worst US Runway Incursion Accident
• Comair flight 5191
• August 27, 2006

Lexington, KY
• Wrong runway takeoff
• 49 fatalities
• 1 survivor
• https://www.youtube.com/watch?v=yIq-zzISH18
Federal Aviation
Administration
August 2006
COMAIR Flt 5191
49 Fatalities
Federal Aviation 66
Administration
2013
Federal Aviation 67
Administration
Surface Incident
Unauthorized or unapproved movement
within the designated movement area
(excluding runway incursions) or an
occurrence in that same area associated
with the operation of an aircraft that affects
or could affect the safety of flight.
Federal Aviation
Administration
Surface Incident
Example
Taxiway
Vehicle/aircraft crosses this
marking:
Entering a taxiway without
communicating with (or
receiving permission from)
the tower.
Ramp
“SOLID LINE = STOP”
Federal Aviation
Administration
Runway Incursion
An occurrence at an aerodrome
involving the incorrect presence of an
aircraft, vehicle or person on the
protected area of a surface designated
for the landing and take-off of aircraft.
Federal Aviation
Administration
Runway Incursion Example
Pilot acknowledges “HOLD SHORT”

of the runway,
but crosses this marking anyway,
entering the Runway Safety Area
(RSA).
“SOLID LINE = STOP”
Federal Aviation
Administration
Primary Causes of Runway Incursions
• Breakdown in communications
• Lack of airport familiarity
• Loss of situational awareness
• Complacency
• Normalization of deviance from
process, procedures, regulations
Federal Aviation
Administration
Pilot Deviation
A Pilot Deviation
(PD) is an action
by a pilot that
violates any
Federal Aviation
Regulation (FAR).
For example, a
pilot fails to
comply with air
traffic instructions
to hold short of an
active runway.
Federal Aviation
Administration
Three Types of Runway Incursions
Operational Incident
(OI)
An Operational Incident
is a surface event
attributed to ATCT
action or inaction.
Federal Aviation
Administration
Vehicle / Pedestrian
Deviation (V/PD)
A vehicle or
pedestrian deviation
(V/PD) involves
pedestrians or
vehicles interfering
with aircraft
operations by
entering or moving
in the runway safety
area without
authorization from
air traffic control.
Federal Aviation
Administration
Runway Incursion Definitions
A Runway Incursion is…“Any occurrence at an aerodrome involving the incorrect
presence of an aircraft, vehicle, or person on the protected area of a surface
designated for the landing and takeoff of aircraft.” (ICAO Doc 4444 - PANS-ATM)
Severity Categories:
Serious incident in which a collision is narrowly avoided
Incident in which separation decreased and there is a significant

potential for collision, which may result in a time critical corrective/
evasive response to avoid a collision
Incident characterized by ample time and/or distance to avoid a

collision
Incident that meets definition of a runway incursion but with no

immediate safety consequences
Federal Aviation
Administration
Runway Excursion (RE)
A veer off or overrun off the runway surface.
Federal Aviation
Administration
Runway Excursion Types
• Overrun on Take Off: A departing aircraft fails to become airborne or
successfully reject the take off before reaching the end of the runway.
• Overrun on Landing: A landing aircraft is unable to stop before the end of

the runway is reached.
• Veer Off: An aircraft taking off, rejecting a take off or landing departs the
side of the runway.
Federal Aviation
Administration
Question
If something like this were to happen at one your

airports, how would your organization respond?
Federal Aviation 79
Administration
Federal Aviation
Administration
Next Up:
Data Collection and
Severity Classification
Federal Aviation 81
Administration
Federal Aviation
Administration
Safety Assurance:
FAA Data Collection
and Analysis
Data Collection
- Mandatory Occurrence Report (MOR)
FAA Order JO. 7210.632 – Air Traffic Organization

Reporting
It is the responsibility of all Air Traffic Organization

employees who are engaged in and support air
traffic services to report all suspected unsafe air
traffic occurrences.
- FAA collects MOR data on runway incursions,

runway excursions, and surface incidents
Federal Aviation 83
Administration
Data Analysis
-Severity classifications
-Runway Incursion Assessment

Team (RIAT)
-Runway Safety Team
Federal Aviation 84
Administration
FAA Runway Incursion Assessment
Team (RIAT)
- Determines runway incursion severity classifications
- Takes place once a week
- Comprised of either one or more members from Air Traffic Organization Terminal
Services, Flight Standards, and Office of Airports
- Flight Standards Member - qualified aviation safety inspectors or

equivalent experience with either general aviation and/or air carrier
background and field experience. Broad knowledge of various aircraft types,
models, and performance characteristics
- Office of Airports Member - Qualified airport certification safety inspector,

or knowledgeable of airport operations
- Air Traffic Organization Terminal Services – Experienced Certified

Professional Controller in one or more FAA Airport Traffic Control Towers
Federal Aviation 85
Administration
Runway Incursion Assessment
Team (RIAT) Exercise
Federal Aviation 86
Administration
Runway Incursion
Assessment Team
Exercise
Federal Aviation Administration

Federal Aviation
October 21-25, 2019 Administration
Exercise Overview
• Work as a team to review each incursion an
Incident Type and one Severity Classification to
each incursion
• Each Voting Member assigns Severity
Category to each incursion based on the
Guidance document and his/her area of
expertise
• Scribe records the agreed upon Severity
Category
Federal Aviation 88
Administration
Exercise Overview
• Work as a multidisciplinary team to assign an
Incident Type and a Severity Classification to
each incursion
• Scribe records the agreed upon Severity
Category
Federal Aviation 89
Administration
Preparation
• Groups of 8 (one group of 9)

• Assign roles
– 1 Facilitator
– 1 Scribe/Timekeeper
– 2 Airport safety experts (voting members)
– 2 Flight Safety experts (voting members)
– 2 Air Traffic experts (voting members)
Federal Aviation 90
Administration
Preparation
• Groups of 6-8
Federal Aviation 91
Administration
Preparation
• Groups of 6-8
• Assign roles
– 1 Facilitator
Federal Aviation 92
Administration
Preparation
• Groups of 6-8
• Assign roles
– 1 Facilitator
Federal Aviation 93
Administration
Preparation
• Groups of 6-8
• Assign roles
– 1 Facilitator
Federal Aviation 94
Administration
Preparation
• Groups of 6-8
• Assign roles
– 1 Facilitator
Federal Aviation 95
Administration
Preparation
• Groups of 6-8
• Assign roles
– 1 Facilitator
Federal Aviation 96
Administration
Preparation
• Groups of 6-8
• Assign roles
– 1 Facilitator
Federal Aviation 97
Administration
Files Needed
• SSFA Mock RIAT Data (Excel)

• SSFA Mock RIAT Airport Diagrams (pdf)
• RIAT Guidance (Word)
Federal Aviation 98
Administration
Files Needed
• Mock RIAT Data (Excel)

• SSFA Mock RIAT Airport Diagrams (pdf)
Federal Aviation 99
Administration
Files Needed

• Mock RIAT Airport Diagrams (pdf)
Federal Aviation 100

Administration
Files Needed

• Mock RIAT Airport Diagrams (pdf)
Found here:
https://www.icao.int/NACC/Pages/meetings-
2019-wrst.aspx

Administration
Activity
• Each Voting Member reviews incursions and decides
his/her opinion on the Incident Type and the Severity
Category, based on the Guidance document and
his/her area of expertise
• Facilitator asks each Voting Member for his/her vote on
the Incident Type and the Severity Category
• Group works to establish agreement among all voting
members
• Scribe records the agreed upon Incident Type and
Severity Category
• Repeat process for each incursion listed

Administration
Activity
members
Severity Category

Administration
Activity
members
Severity Category

Administration
Activity
members
Severity Category

Administration
Activity
members
Severity Category

Administration
Activity
members
Severity Category

Administration
Federal Aviation
Administration
Incursion #1, Rocky Mountain Metro

Administration
• Aircraft 1 landed Runway 12R and was then instructed to turn off
the runway at Delta3 to Delta, then make a left turn onto Runway 3
and hold short of Runway 12R. The pilot correctly read back the
instructions. Aircraft 1 was then observed to have crossed Runway
12R while a departing aircraft had just become airborne on
Runway 12R. There was no over flight. Controller estimated
proximity of 150 vertical and 150 lateral as Aircraft 1 crossed the
hold short line.
• SSFA Assessment - ?
• FAA – Category C, Pilot Deviation

Administration
hold short line.

Administration
hold short line.

Administration
hold short line.
• Assessment - ?

Administration
hold short line.
• Assessment - ?

Administration
Incursion #2, Falcon Field
• Aircraft 1 landed Runway 22R and was instructed to turn left on
Taxiway Bravo and holdshort of Runway 22L. Readback was
correct. Aircraft continued to taxi onto Runway 22L and stopped on
the runway. Aircraft 2 had been cleared for takeoff on Runway 22L
and overflew Aircraft 1 on the runway. Closest proximity
approximately 100 feet.
• FAA – Category B, Pilot Deviation

Administration

Administration

Administration

Administration
• Assessment - ?

Administration
• Assessment - ?

Administration
Incursion #3, Portland-Hillsboro

Administration
• A C172 landed on Runway 31L, exited onto Taxiway Alpha and
contacted Ground Control (GC) to request taxi back to Runway
31L. GC advised the aircraft that Runway 2 was in use. The
aircraft advised it wwas unable to accept Runway 2 and requested
taxi back to parking. The aircraft was instructed to taxi via Alpha
and hold short of Runway 2. Read back was correct. The aircraft
taxied past the Runway 2 hold short line and stopped
approximately 25 feet from the Runway 02 edge. No other aircraft
in conflict.
• FAA – Category D, Pilot Deviation

Administration
aircraft advised it was unable to accept Runway 2 and requested
in conflict.

Administration
in conflict.

Administration
in conflict.

Administration
in conflict.
• Assessment - ?

Administration
in conflict.
• Assessment - ?

Administration
Incursion #4, Hilo Intl
• At 0700 the airport authority delayed Runway 8 shortening for construction until 0830
due to weather. During this time, the shortened-runway NOTAM was not amended,
however the full length of the runway was available and utilized. At 0830, the shortened
runway went into effect. The construction crew was still setting up the displaced
threshold when a B717 reported that it was on approach. The ATIS was turned off while
numerous NOTAM's were being adjusted. The approach controller advised A/C 1 that
the runway was shortened. At this time, Local Controller (LC) was being relieved. During
the relief briefing it was conveyed to the relieving controller that the full length of Runway
8 was available. After initial contact, the new LC told the aircraft that there were no
runway closures. After landing, when the aircraft was passing Taxiway E, it asked LC if
the whole runway was open and LC replied that it was. The aircraft responded that there
were sand bags on the runway. The aircraft made a 180 to back taxi and exited the
runway at Taxiway E. Closest proximity from the aircraft to the sandbags was
approximately 1000 feet. There we no personnel or equipment operating on the runway
or in the RSA at this time.
• FAA – Category D, Operational Incident

Administration
• At 0700 the airport authority delayed Runway 8 shortening for construction until
0830 due to weather. During this time, the shortened-runway NOTAM was not
amended, however the full length of the runway was available and utilized. At 0830,
the shortened runway went into effect. The construction crew was still setting up
the displaced threshold when a B717 reported that it was on approach. The ATIS
was turned off while numerous NOTAM's were being adjusted. The approach
controller advised A/C 1 that the runway was shortened. At this time, Local
Controller (LC) was being relieved. During the relief briefing it was conveyed to the
relieving controller that the full length of Runway 8 was available. After initial
contact, the new LC told the aircraft that there were no runway closures. After
landing, when the aircraft was passing Taxiway E, it asked LC if the whole runway
was open and LC replied that it was. The aircraft responded that there were sand
bags on the runway. The aircraft made a 180 to back taxi and exited the runway at
Taxiway E. Closest proximity from the aircraft to the sandbags was approximately
1000 feet. There we no personnel or equipment operating on the runway or in the
RSA at this time.

Administration
RSA at this time.

Administration
RSA at this time.

Administration
RSA at this time.

Administration
RSA at this time.

Administration
RSA at this time.

Administration
RSA at this time.

Administration
RSA at this time.
• Assessment - ?

Administration
RSA at this time.
• Assessment - ?

Administration
Incursion #5, New Century
Aircenter
• A vehicle proceeded on Taxiway Alpha and crossed Runway 22 without
ATC authorization while a GALX was on landing roll. An airport vehicle
observed an unknown vehicle traveling northbound on Taxiway Alpha and
notified ATC as the aircraft was touching down on Runway 22. The
vehicle crossed Runway 22 at Taxiway Alpha when the aircraft was 1500
feet from the taxiway. ATC advised the aircraft that the vehicle was
crossing the runway and that they were not in communication with the
driver. The pilot advised that he had the vehicle in sight. The controller
instructed the aircraft to turn right and taxi to parking. Airport management
followed the vehicle off the airport. The closest proximity was
approximately 1500 feet when the vehicle cleared Runway 22. This event
occurred in Hotspot 1.
• FAA – Category C, Vehicle/Pedestrian

Administration
Aircenter

Administration
Aircenter

Administration
Aircenter

Administration
Aircenter

Administration
Aircenter

Administration
Aircenter
• Assessment - ?

Administration
Aircenter
• Assessment - ?

Administration
Incursion #6, Monroe Regional
• A C172 was cleared for takeoff on Runway 22 while an airport
vehicle was on the runway edge. The vehicle was cleared to
conduct a full-length inspection on Runway 4 from Taxiway
Foxtrot. Approximately 4 minutes later the aircraft called ready for
takeoff on Runway 22 at Taxiway Charlie (full length of runway).
Local Control then cleared the aircraft for takeoff while the vehicle
was sitting off the east edge of Runway 22 at Taxiway Charlie 1.
The facility estimated the closest proximity as 0 feet vertical, and
75 feet lateral.
• FAA – Category B, Operational Incident

Administration
75 feet lateral.

Administration
75 feet lateral.

Administration
75 feet lateral.

Administration
75 feet lateral.

Administration
75 feet lateral.
• Assessment - ?

Administration
75 feet lateral.
• Assessment - ?

Administration
Incursion #7, Smyrna Airport
• A PA28 departed Runway 01 and lifted off
approximately 1,700 feet down the runway. The pilot
informed the tower that a pedestrian was walking in the
middle of Runway 01 towards the approach end. The
person was approximately 200 feet south of the
Runway 32/14 hold short lines. The closest proximity
was 150 feet vertical and 0 Lateral.
• FAA – Category B, Vehicle/Pedestrian

Administration

Administration

Administration
• Assessment - ?

Administration
• Assessment - ?

Administration
Incursion #8, Montgomery Field

Administration
• An SR22 landed Runway 28L and had a runway excursion to the
left, before reaching Taxiway Golf 1. The aircraft came to rest in
the grass between Runway 28L and Taxiway Hotel, just east of
Golf 1, within the Runway Safety Area (RSA). ATC attempted to
contact the pilots but received no response, then both passengers
were observed jumping out of the aircraft. A few moments later a
pedestrian ran across Taxiway Hotel to assist the aircraft and
entered the RSA without ATC authorization. Subsequently, the
pedestrian called the tower phone line and reported no injuries, but
the aircraft was leaking fuel.
• FAA – Category D, Vehicle/Pedestrian

Administration

Administration

Administration

Administration
• Assessment - ?

Administration
• Assessment - ?

Administration
Incursion #9, Chicago O’Hare

Administration
• ATC cleared Aircraft 2, a CRJ2, for departure on
Runway 28R with Aircraft 1, also a CRJ2, less than
6,000 feet downfield. The first CRJ2 rolled and was
airborne when the second CRJ2 began departure roll.
Closest proximity based on FALCON replay was 5,370
feet lateral and 200 feet vertical. No ASDE analysis
available because of 45-day retention.
• FAA – Category C, Operational Incident

Administration

Administration

Administration
• Assessment - ?

Administration
• Assessment - ?

Administration
Incursion #10, Reno/Tahoe Intl

Administration
• An A319 was on departure roll Runway 16R and reported to ATC
that it had almost hit a pedestrian. ATC could not initially see
anyone but then observed a pedestrian who appeared to be
walking along the edge of Runway 16R near Taxiway Juliet. ATC
advised airport maintenance of the individual's location to escort
the pedestrian from the runway. The person was apprehended and
taken into custody by airport police. An interview with operations
personnel and law enforcement indicated the individual was only
partially coherent. He reported to authorities that someone off
airport was chasing him and the only escape route was across the
airport. Police reports show that this individual has a history of
trespassing. Closest proximity was 15 feet.
• FAA – Category A, Vehicle/Pedestrian

Administration

Administration

Administration

Administration
• Assessment - ?

Administration
• Assessment - ?

Administration
Incursion #11, Springfield-
Branson National

Administration
Branson National
• A vehicle crossed Runway 14 while an E145 was departure roll. Ground Control
(GC) owned Runway 14 which was closed to landing traffic. The aircraft called for
taxi and GC issued instructions to taxi to Runway 20. The aircraft requested
Runway 14. GC issued instructions to taxi via Taxiways Foxtrot and Whiskey to
Runway 14 and advised the aircraft that it had a release time of 1751Z. Local
Control (LC) instructed the aircraft to line up and wait on Runway 14. The vehicle
called GC at the intersection of Taxiways November and Charlie and requested to
proceed to an area on the south west side of the airfield. GC instructed the vehicle
to cross Runway 20 at Taxiway Charlie and proceed via Taxiways Uniform and
Echo. LC cleared A/C 1 for takeoff on Runway 14. GC looked and did not see the
memory aid showing Runway 14 hot and instructed the vehicle to cross Runway 14
at Taxiway Uniform. GC had forgotten that the the aircraft had taxied to Runway 14
to wait for release. The aircraft was rolling on Runway 14 when the vehicle crossed
the runway. The pilot said "Truck Truck Truck" over the frequency. The aircraft
began to lift off just prior to Taxiway Uniform. The pilot reported that the closest
estimated proximity was 500 feet lateral.
• FAA – Category A, Operational Incident

Administration
Branson National

Administration
Branson National

Administration
Branson National

Administration
Branson National

Administration
Branson National

Administration
Branson National
at Taxiway Uniform. GC had forgotten that the aircraft had taxied to Runway 14 to
wait for release. The aircraft was rolling on Runway 14 when the vehicle crossed

Administration
Branson National

Administration
Branson National

Administration
Branson National
• Assessment - ?

Administration
Branson National
• Assessment - ?

Administration
Incursion #12, North Las Vegas

Administration
• Aircraft 1, a C182, taxied onto Runway 12R without ATC
authorization. Aircraft 2, a BE36, was cleared to land Runway
12R. Aircraft 2 droped off of the radar leaving 2300 feet at .34
miles from Runway 12R, FALCON. Twenty seconds later Aircraft
2 reported aircraft on the threshold. Aircraft 2 initiated a go
around. Over flight at an estimated 100 feet. NOTE: Elevation of
VGT Runway 12R threshold is published as 2,205 feet. Local
Control did not see Aircraft 1 on Runway 12R threshold until
informed by Aircraft 2.
• FAA – Category A, Pilot Deviation

Administration
12R. Aircraft 2 droped off of the radar leaving 2300 feet at .34

Administration
12R. Aircraft 2 dropped off of the radar leaving 2300 feet at .34

Administration

Administration

Administration
• Assessment - ?

Administration
• Assessment - ?

Administration
Administration
FAA Runway Safety Metric
• Monitors all types of surface events that

occur in runway environment
• Helps FAA to understand what is driving
risk in the system
• Data shared with runway safety
stakeholders

Administration
FAA Runway Safety Metric

Administration
Runway Incursions By The Numbers

Administration
Assessment of A, B, & C Runway
Incursion Data
As a result of the annual increase in the
number of reported RIs of all Categories,
the FAA identified runway incursions as a
safety issue in FY17.
To identify the contributing factors and

mitigations, Subject Matter Experts (SMEs)
and panel members from Lines of
Business (LOBs) across the agency, along
with three representatives from various
pilot organizations (e.g., Aircraft Owners
and Pilots Association, the Air Line Pilots
Association (ALPA), and the National
Business Aviation Association) reviewed
the data.

Administration
Analysis Summary 361 FY16 Pilot Deviations (PD)

Administration
Runway Safety Team Process

Administration
Local Runway Safety Process
• Runway Safety Teams are our primary tool at the
airport level to reduce surface risks at an airport
• Towered airports in the U.S. are required by the
FAA to conduct an RST meeting at least once each
fiscal year

Administration
Runway Safety Teams
• Recommendation from the first ICAO Global Runway
Safety Symposium in 2011
• Effective means of reducing runway related accidents

and incidents
• Have helped significantly reduce the runway safety

related risks globally since 2011
• Over 200 airports internationally have registered an

RST with ICAO

Administration
RST Planning
- Meet at least annually
- Carefully consider timing (possibly coincide with pilot meetings)
- Notify participants with sufficient lead time
- The sooner the RST is planned, the better the chance of stakeholder
engagement!!
- Consider inviting stakeholders to make presentations – keeps meeting
interesting and facilitates engagement!!
- Prepare meeting materials
- Agenda, specific event data, any information that needs to be
communicated with aerodrome users
- Adjust meeting duration to agenda – don’t make meeting longer than it
needs to be!!!
- Ensure an appropriate environment (meeting room
acoustics, technology, etc)
- Review previous RST’s action plan and achievements
- Identify a note taker/recorder for action plan

Administration
Team members
• Air Traffic Control • Union representatives
representatives
• Wildlife biologists
• Airport operator and their
• Governmental regulators
employees (mower operators,
airfield inspectors, etc.) • Local flying clubs and pilots
based on the field
• Airline representatives
• ARFF or local Fire
• Fixed Base Operators (FBOs)
Department (whoever
and flight schools
responds to emergencies on
• Navigational aid technicians the field)
ANYONE WHO OPERATES ON THE

AERODROME!!!

Administration
RST Success
• Active facilitation and make it interesting
• Stakeholder participation
• Clear explanation of potential hazards
• Review of previous RST’s action plan
• Development of new action plan
• Follow up to ensure action plan goals are
met
• Celebrate safety successes!!
Administration
Facilitation Tips
• Prepare in advance
• Plan and distribute agenda
• Establish community expectations
• Practice active listening
• Encourage and balance participation
• Guide the group in presenting and sharing
information and to finding resolutions
• Provide closure and reiterate action items

Administration
How do we identify
potential hazards?

Administration
Airport Geometry
Does the airport have any of these common geometry
problems?
• Crossings in middle third of runway (high-energy areas)
• Unusual marking and/or signage placement
• Absence of a full length parallel taxiway
• Direct/short ramp to runway taxi routes
• Aligned taxiways (in-line)
• Intersections with more than three ways to go
• Wide expanse of pavement at a taxiway/runway intersection
• Entrance taxiways at other than 90º to runway
• Taxiway coinciding with the intersection of two runways
Federal Aviation
Administration
Airport Geometry
• Are there airport geometry changes planned
aimed at reducing the risk of runway
incursions?
• Are there procedural or other mitigations

needed to reduce risk?
• Prohibiting crossings in high energy segment of
runways
• Runway Guard Lights at difficult intersections
• Surface painted signs at difficult intersections
Federal Aviation
Administration
Example: MLI

Administration
Construction Discussion
• Is construction planned that impacts aircraft
surface operations?
• Back taxi or extra runway crossings
• Shortened or closed runways
• Unusual or temporary hold line locations
Federal Aviation
Administration
Hot Spots
What is a Hot
Spot?
Any area on the

aerodrome where
the team feels
there is an
increased risk of a
runway incursion.

Administration
Hot Spots
Are there any areas which pilots have difficulty
navigating?
• Wide expanses of pavement
• Extra wide hold lines
• Taxiways on the edge of an apron (direct access or short taxi
distance)
• Complex intersections
• Runway confusion – landing on the wrong runway (or a taxiway)
• Closely aligned runway ends
Designating an area as a Hot Spot can help increase pilots’

awareness of areas where incursions are more likely to happen
Federal Aviation
Administration
Effects of Weather
Are there any areas on the airport where

weather could impact surface safety?
• Water ponding and covering markings
• Sun conditions making visibility difficult
• Areas not visible from the ATCT due to
weather
Federal Aviation
Administration
D6 13
Hold Sign Hold Line
Federal Aviation
Administration
Vehicles
For drivers in the movement area…
• Is training adequate to ensure safe
operations?
• Are there taxi-qualified mechanics who
operate on the field?
• Do procedures provide for maximum safety?
• Are distractions controlled? (ie: cell
phones/texting prohibited while on the
airfield?)
Procedures… • Are improvements possible?

• Do vehicle drivers always use access
roads – or do they cross runways for
convenience?
• Do the ATCT and airport encourage
crossings in low energy portions of the
runway?
• Right at landing threshold
• Last third of runway surface
• Are access roads well maintained?
Federal Aviation
Administration
Wildlife control and vehicles
• Do procedures at your airport
• Ensure drivers addressing wildlife know to keep clear of runways?
• Employ risk mitigations? (closing runways and/or sending traffic
around when animals are near operational runways)
Federal Aviation
Administration
How do we document and
Follow up?

Administration
What are Action Items?
• Action items developed during an RSAT meeting are
voluntary, consensus driven, and are not regulatory.
• You must have agreement from the party who will be

responsible for implementation.
• If the responsible party is not present at the meeting,

ensure coordination prior to finalizing the action
plan.
Federal Aviation
Administration
Action Plans
• After each RST meeting, the Air Traffic

manager (or person leading the meeting)
creates the Runway Safety Action Plan
(RSAP).
• This is a document that outlines the RST’s

plan for the coming year for improving
runway safety.

Administration
Action Plans
Sections to include in the RSAP:
• Airport statistics
– Identifier / Airport name
– Towered / non-towered
– Hours of operation
– Type and number of operations
– Number of flight schools / FBOs

Administration
Action Plans
Sections to include in the RSAP (cont):
• Incident history
• Meeting overview
• Action items
• Best practices
• Review of previous action items
• Current airport diagram
• List of attendees
Administration
RUNWAY SAFETY ACTION ITEMS
Suggested detail for Action Items
Number : XXX ATCT-2013-001

Define Issue:
Proposed Solution:
Responsibility of : ATCT, Airport, etc.
Point of Contact :
POC email:
Estimated Start Date:
Estimated Completion Date:
Federal Aviation
Administration
Runway Safety Team Activity
Atlantis International Airport
Federal Aviation
Administration
2019 Runway Safety Team (RST)
Atlantis International Airport (AIA)
October 24, 2019
Introduction
Welcome to the Runway Safety Team (RST)

Introduction of team members:
• Cheri Walter, AIA Air Traffic Manager, AIA ATCT

• Juan Manuel Manriquez, Airport Director, AIA
• Bart Simpson, Air Traffic Controller Association, AIA ATCT
• Stakeholders - Self Introductions (please sign roster)
Please enter name, organization, and contact information

on the sign-in sheet
Agenda
• Runway Safety Briefing
– Overview of the RST Process
– Definitions and National Statistics
– National Trends and Topics
• RST Open Discussion
– Local Incidents
– Local Action Item Review
– Identify local risk factors and/or current initiatives
– Stakeholder / User Perspectives/Discussion
• Outcome: Develop RSAP and Action Items
RST Process Overview
• Purpose: To bring local stakeholders together at least

once per year to identify and mitigate the risks of
significant surface events at your airport
• Process:
– Review Incident History
– Discuss Current Concerns
– Create 2019 Runway Safety Action Plan and Action
Items
Basic Definitions
• Runway Incursion: The incorrect presence of an

aircraft, vehicle or person on the protected area of a
surface designated for the landing and take-off of
aircraft, including the Runway Safety Area (RSA).
• Runway Excursion: A veer off or overrun off the
runway surface
• Surface Incident: Unauthorized or unapproved
movement within the designated movement area
(excluding runway incursions) or an occurrence in that
same area associated with the operation of an aircraft
that affects or could affect the safety of flight
Definitions Cont’d
Types of Surface Events:

• Operational Incident (OI) – A surface event attributed to
ATCT action or inaction
• Pilot Deviation (PD) – A surface event caused by a pilot or

other person operating an aircraft under its own power
• Vehicle or Pedestrian Deviation (VPD) – A surface event

caused by a vehicle driver or pedestrian
• Other – Surface events which cannot clearly be attributed to a

mistake or incorrect action
Incursion - Severity Category
The following scenarios are all classified as runway incursions, but with
different severity categories.
In each case, the taxiing aircraft penetrated the runway safety area (crossed
the holding position marking).
Category D runway incursions involve little or no risk of a collision. There is either no other
aircraft involved, or other aircraft are further than a mile away (greater than a 1 mile final).
Category C runway incursions involve another aircraft, but there is ample time and distance to
avoid a collision.
Category B runway incursions involve significant potential for collision.

Category A runway incursions are events in which an accident occurred or was barely avoided.
Usually characterized by aggressive evasive maneuvers.
National Statistics
Total Runway Incursions by Fiscal Year
Data current as of October 1, 2019

National Statistics
Data current as of 1/1/2018
What Does the Data Show?

National Trends - Wrong Surface
Landings / Departures
National Trends –
Wrong Surface Landings / Departures
• Wrong Surface Landings include

wrong runway, taxiway, and
wrong airport landings
• Common factors include:
– Parallel runways 700’ apart
– Parallel taxiways confused for
runways
– RWY 10R / 28L is hard to see
AIA has all these risks

National Trends –
Wrong Surface Landings / Departures
• Pilot expectation bias the most common
contributory factor in wrong surface landings
• Examples of “bias”:
– Last minute runway change
– Always expecting the same clearance
– Not confirming airport layout
– Falsely “hearing” what is expected opposed to
what is actually happening
– Not “seeing” taxiway / runways marking
– Examples and discussion?
National Trends - Communication Challenges
• Communication continues to be a contributing factor in

many runway incursions, wrong surface landings surface
incidents
Communication Best Practices
• Complete Read back / Hear back loop

• Use Prescribed Phraseology and Standard
Format by pilots and controllers
• Maintain Situational Awareness including
transmissions to other aircraft / vehicles
• Use appropriate Speech Rate
• Ask for clarification anytime!
Local Incidents #2
March 29, 2018
AC #2
Terminal
Both aircraft cleared to land.

Aircraft 1 had not yet crossed RWY 14
ARFF
hold line when Aircraft 2 crossed RWY
14 Threshold. RWY 14 HOLD SHORT BARS
ATCT did not issue a go around. ON RUNWAY 10L.
AC #1
Local Incidents #3
April 29, 2018
A/C lined up for wrong parallel at the last minute with a Jet crossing RWY 10L
AC# 3 SR22
Cleared to Land
10R and correct
pilot read back
Aligned to RWY 10L
Short final Go Around

AC# 2
AC #3 GC Freq crossing AC# 1
10L Blown tire
RWY 10R
Local Incidents #4
May 3, 2018
Terminal
AC# 2
ATCT advises Op
midfield
Vehicles “Proceed to
roll out
RWY 10L via A” ARFF
TWY A AC# 1
Disabled on RWY
Sweeper with blown tires + FOD
(no radio)
RWY 10L Closed. RWY14 Active.

Sweeper Cleaning tire debris
crosses R14 hold bars by
accident.
Local Incident #5
• AIA had 1 excursion on RWY 28L no injuries or damage
• PA28 student pilot, unstable approach at night and went

into grass at the end of the runway
2018 Action Item Review
2018
AIA-001: Runway 10L L hold bars are placed further
back than expected. Info is now on ATIS + Hot
Spot #1
AIA-002: TWY R3 entry directly from ramp to RWY 10R

and then TWY L1 to RWY 10L. Now - TWY L1 is now
TWY P after re-labeling plan. Direct entry issue
pending.
Action Item Review cont’d
2018
AIA-003: Taxiway re-labeling plan.

Completed in June 2018
AIA-004: Strategic pushback plan during

construction (Mentioned by Atlantis Airways at
last RST).
Construction phase completed in late 2018.
Risk Factors - AIA Hot Spots
Risk Factor - You are Cleared to Land
RWY 28L = Where is it?
Risk Factor - RWY 10R/28L is Hard To See!
DRAFT
RWY 10R has been major concern area for ATC and Airport Authority
Risk Factor - RWY 10R/28L is Hard To See!
DRAFT
RWY 10R has been major concern area for ATC and Airport Authority
Risk Factor - Runway Excursions
• Number # 1 cause of
accidents
• Estimated annual cost
$900 Million
• Causes
- Unstable Approaches
- Runway Contamination
- Adverse Weather /
Wind Conditions
- Mechanical Failure
- Pilot Error
Risk Factors - Flyover Events
SAFETY IN SECONDS
YOU HAVE LESS THAN A MINUTE TO DO THE RIGHT THING
SAFETY IN SECONDS
AA1234
Line up
And wait
SAFETY IN SECONDS
AA5678
Cleared
to land
1.5 Miles
Approximately
45 Seconds
AA1234
Line up
And wait
SAFETY IN SECONDS
What is a Flyover Event?

SAFETY IN SECONDS
What is a Flyover Event?
Less than
1000 Feet
Flyover Risk Mitigations
Air Traffic Control:
• Maintain situational awareness & immediately issue ATC recovery
control instructions
Pilots and Vehicle Drivers:

• Maintain situational awareness, actively monitor radio, listen for
potential threats/mistakes
• Look out the window. Continually scan the taxiway and runway
environment for potential threats
• Know where you are, know what airport signage you should see
and find it. If unable stop and contact ATC immediately
• Be vigilant. If you see something - say something – broadcast on

the radio.
Runway Safety Best Practices
To mitigate the risk during surface operations,

every user of the airfield should, must and can:
To mitigate the risk during surface operations,

every user of the airfield should, must and can:
• Review Airport Diagram & NOTAMs in advance
• Review & find visual cues you need to be safe
• Use prescribed phraseology and deliver an

accurate read back of ATC instructions
• Use your call sign

New Action Items 2019
• Action Items are a local plan to improve safety in

our operation
• Our action items must be achievable within local

resources
• Each action item should be specific, include a

point of contact and anticipate an estimated
completion date
Reminder – Action Items
Action items may include, but are not limited to:
• Changes in physical features/facilities of the

airfield
• Air traffic control procedures
• Airfield access requirements
• Pilot/vehicle operator awareness

Lets identify our ACTION ITEMS
• Identify AIA runway safety concerns and develop

excellent mitigations:
RUNWAY SAFETY ACTION ITEMS
Suggested detail for Action Items
Number : AIA ATCT-2018-001

Define Issue:
Proposed Solution:
Responsibility of : ATCT, Airport, etc.
Point of Contact :
POC email:
Estimated Start Date:
Estimated Completion Date:
Wrap Up
Comments, questions?
Please provide feedback to meeting host
Also, please ensure your contact information

is on the sign-in sheet.
THANK YOU FOR YOUR PARTICIPATION!

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Why SMS?

• Heinrich’s Triangle illustrates the number of incidents,

Other benefits of SMS include:

Safety Risk Management

Safety Risk Management

Safety Risk Management Safety Promotion

• The State (regulator) is responsible for the

ICAO SARPS Annex 19

FAA Order FAA Order 8040.4, FAA Order

FAA Air Traffic

Safety Risk Management Safety Promotion

• There is great potential for disaster when large,

• 2 Boeing 747s collided on the runway at Los

• One of the primary causes was

• Over 15 million flights handled in 2016, with more

• More than 2.5 million passengers flying in and out of

• FAA Air Traffic Services are part of the aviation

• Based on the pillars of Safety Management

– Requires adopting a common approach to

 Provides government and industry

 Data-driven, risk-based, integrated

Surface Safety  Governs the work of the Surface Safety

 National Runway Safety Plan

Runway Incursion Assessment Team and

 Determines runway incursion severity

 Comprised of one or more members from

 Identify and understand the contributing

 Analyze risk factors

 Develop safety strategies and mitigations

Surface Safety  Collect, find, fix, monitor work that is

 Serve as a forum for the identification,

 Develop a standardized, data-driven

 Promotional materials (signage,

• Every aspect of Runway Safety program

Safety Risk Management Safety Promotion

• Safety culture is the way safety is perceived,

SKYbrary: Category: Safety Culture (http://www.skybrary.aero/index.php/Category:Safety_Culture)

• An organization with a negative safety culture:

• An organization with a positive safety culture:

• Holds employees accountable for deliberate violations of the rules but

• Adapts effectively to changing demands and allows quicker, smoother

• Willing to change based on safety indicators and hazards uncovered

• To develop a positive safety culture:

SKYbrary: Toolkit: Safety Culture (http://www.skybrary.aero/index.php/Solutions:Safety_Culture)

• Strategies for conducting a safety culture

SKYbrary: Toolkit: Safety Culture, B1.2 and B1.3 (http://www.skybrary.aero/index.php/Solutions:Safety_Culture)

Example safety culture

Safety Culture in Air Traffic Management: A White Paper; FAA/EUROCONTROL AP 15

SKYbrary: Assessing Safety Culture in ATM (http://www.skybrary.aero/index.php/Assessing_Safety_Culture_in_ATM#Data_Collection:_The_Safety_Culture_Questionnaire)

• A safety culture assessment may suggest

• Strategies for managing culture change:

• Voluntary safety reporting programs are a

– Learn from mistakes

Make safety Learn from

• FAA (regulatory) perspective:

Using Root Cause Analysis to Drive Process Improvement (http://intland.com/blog/safety-engineering/using-root-cause-analysis-to-drive-process-improvement/)

• Voluntary Reporting Resources:

Surface Events and