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Gatwick LRST – 12th May 2010

Gatwick Local Runway Safety Team – 12 May 2010
CE Meeting Summary


Action Log Review dated 12 May 10

  • Report on CAT D Runway Incursion at J2 – caused by a vehicle involved in barrier removal for a runway change. Resulting mitigations:
    • Night drivers to be briefed on need for more vigilance
    • Audit of the current driver trg package
    • Runway holding points to be re-briefed and marked on driver map
    • Specific and clear ATC calls to drivers to reinforce the restrictions
    • Pattern A paint markings to be co-located with stop-bar and wig wags
  • 1. Charlie Holdinterim measure is to reduce risk of a vehicle induced Runway Incursion at C1 by placing red reflective studs to east of stop-bar
    • Long term solution to be permanent grass over at runway edge
  • 2. Safety Survey – Northern Runway Ops during Main Runway maintenance
    • Airlines asked to consider their preferred solution – designate Northern taxiway as permanent runway always or just when required
  • 3. Runway Stop-Bars
    • Review of vehicle crossing runway stop-bars required in line with the CAP 493
    • Workshop to be held between NATS and GAL
      • Drivers may be asked to adopt a sterile cab technique when on the runway – radios turn down appropriately and mobiles not answered
    • Review of Heathrow ‘full length’ inspection process
  • 4. Airport Charts
    • AIP to be corrected by the GAL Compliance team after a NATS audit identified errors
    • Jeppeson are not too keen to change the chart information – a brief from Jeppeson would be requested for the LRST
  • 5. Manoeuvre Area Driving Map – Update
    • Driving map is being developed for airside driving
    • Draft map in circulation has generated useful comment
    • A more formal lost procedure for drivers is to be developed
    • Map to be re-sized and simplified – for drivers only
    • Instructions on ATC approval requirements to be included when Northern runway in use as a taxiway
    • Separate maps to be developed for birds/wildlife, block map and a drivers’ map
    • Recommendation that the new maps be shown to new drivers for their comment and degree of understanding
  • 7. List of Actions from other airports – to be considered at next meeting
  • 11. Vehicle Transponders – being fitted gradually – Ops vehicles next
  • 12. On Runway Incursions – a summary of incursions at Gatwick since 2007 indicates that there are no hotspots at this stage
    • J2 may become a hotspot – to be monitored
  • 13. LVP Presentation – Background Brief
    • Vehicle free ranging rules
      • Definition is vehicles can move anywhere but must seek radio clearances
    • Airfield safeguarding – for vehicles only!!
      • To protect the runway in Cat 3 – covering landing aids and Runway Incursion prevention
      • It is Not LVPs!!!!!!!!!!! – it is the preparation to go into LVPs
      • Free ranging is cancelled – vehicle barriers put in place and traffic signs switched on
      • Safeguarding takes up to 20 mins to put in place
      • Conditions for instigating safe guarding are RVR less than 1000m and it is expected to go below 600m or cloud base is 300’ and going below 200’
      • GAL Ops vehicles can free range by exception at 200’ cloudbase or below butvis must be at least 1500m
      • Every 5 mins, safeguarding is transmitted on ATC frequencies until safeguarding instigation is complete
    • At full LVP – maximum of 12 aircraft movements per hour possible
    • It is the drivers responsibility to know that safeguarding is in force
    • Even though LVPs may be lifted, safeguarding may still be in force
    • 3 incidents in LVPs during 36 LVP periods last year
  • AOB
    • Latest runway incursion occurred during a full emergency on the airport
    • Fire vehicle remained on the active runway after getting confused about which runway he was positioned on.
    • NATS have a runway incursion questionnaire for drivers and are lodged on a database for human factors

Rich Jones
Chief Executive
UK Flight Safety Committee

Gatwick LRST – 30th June 2010

Gatwick Local Runway Safety Committee – 30 June 2010

CE Meeting Summary


Action Log Review

  • Charlie Hold- Interim solution to reduce risk of a vehicle induced RI at C1 is to fit red reflective studs to east of stop bar
    • Permanent solution will be to grass over at runway edge
  • Free Ranging – Safety Survey of airline users underway to seek preferred solution to North Runway ops during main runway maintenance period
    • Options are to nominate and manage taxiway as a permanent runway throughout maintenance period or only when it is being used as a RW.
  • Runway Stop-Bars
    • Review of vehicles crossing runway underway in line with CAP 493
    • AGL control stop-bar upgrade being awaited and tie in with Uniorm ramp work in progress
    • Vehicle workshop between NATS and GAL to be arranged in due course
    • Arrival runway inspection in a 12 mile gap with 2 vehicles to be introduced on the arrival runway initially
    • Best practice advice on runway inspection methodology being sought from Heathrow
    • View being taken from Drivers on the adoption of a sterile cab technique when vehicles on the runway – radios turn down appropriately and mobiles not answered
  • Airport Charts
    • AIP to be corrected after a NATS audit by the GAL Compliance team
    • Jeppeson are not too keen to change information –
    • Seek a brief from (EAG/NavTech) on how it co-ordinates it chart work
    • Possible add-on to a LGW website and review LHTW MAST site
  • Manoeuvre Area Driving Map
    • Aim is to develop map for airside driving
    • Draft in circulation which has generated useful comment
    • Lost procedure for drivers to be developed for possible inclusion on map
    • A resize and simplification of map underway – for drivers only
    • Consideration of separate maps for birds/wildlife – block map – driver map
    • New map to be shown to new drivers for comment and understanding check
  • CGA Markings
    • Work in progress but may not make it until after RW maintenance programme is finished
    • Wig wags in smaller access roads to be fitted in due course
  • Amalgamated Actions List from other airports
    • Vehicle runway crossing numbers- reduce to a minimum and allow mainly emergency vehicles and safeguarding
    • New tug drivers being trained – reminder on LVP and runway driving to be included
    • Audit review of those drivers who are trained and cleared on the RW
    • Visit to the ATC
    • Nil RIs noted at Birmingham – potential for best practice?
    • Driver training on RT guidance and trg standardisation to be investigated
    • New driver CAP progress at the CAA was briefed
  • Vehicle Transponders
    • Being fitted gradually to ops and rescue vehicles as funds are being made available but costs are £2000 per vehicle – but bulk buy being considered for economic advantages
  • Runway Incursion Comms
    • On hotspot candidates for Gatwick charts- No specific hotspots identified at this stage but J2 may become one in due course – to be monitored
    • A 1 page summary of 2009 Runway Incursions to be issued

North West Zone Layout – New Ramp Area

  • 6 new stands available from 1July 10 (230-235) – A380 capable with Code F
  • New Uniform and Tango holds being brought in (with stop bars) as a result
  • New feeder road to the new stand area cannot be closed off in LVPs since servicing vehicles will need to support NW operations
    • This road has lights on it but it does run close to the taxiway
  • 2 wash down stands in the NW area coming in November

Potential Runway Incursion Incident Enquiry – 4 May 2010

  • A Thomson B737 crew raised an ASR on an Emirates B777-ER which stopped on the run-off to RW 08 with the tail of the ac still on the runway
  • He was instructed by ATC to contact gnd before vacating the runway
    • This may have been to early and it may have been better to instruct ac to contact gnd once runway is vacated
  • Heathrow group through NATS has formed to discuss the definition of ‘vacated’
  • B777ER – longest ac currently – was the Emirates pilot awareness of its length?
  • Several safety considerations thrown up by this incident :
    • High speed incident –RTOs – ICAO rules – selection of RT

Other RIs

  • Take offs and landing on taxiways briefed
  • Luxembourg airport van strike by B747 on approach/landing


  • New ATIS coming on line at Gatwick in 2 weeks – feedback welcomed
    • Wind shear time range to be included
  • Checker /Ops callsign confusion on runway discussed – not seen as an issue for the flightdeck- but possible confusion for ATC ops
  • Engineer ingestion incident in US – during an engine examination – 70% power run on the ground 40 years an engineer! Bent down to pick his hat and was killed

Rich Jones
Chief Executive
6 July 2010

Gatwick LRST – 23rd February 2011

Gatwick Local Runway Safety Team Meeting – 23 February 2011
CE Meeting Summary


Action Log

Key Issues from the Log:

  • Safety survey undertaken in preparation for Northern Runway Ops whilst the Main runway is resurfaced. Outcomes include:
    • Explicit runway 26R/08L crossing clearances will not being introduced during this work – a pilots forum was held to explain the various elements involved in the project. Onlyonly 1 runway will be active at any one time.
    • A NATS safety assessment has also been carried out which agrees with the above finding inspite of this being MATS part 1 non-compliant
    • A mag strip will be produced for all GAL vehicles free-ranging on the affected work areas on the airfield
    • Some vehicle driver re-training will be undertaken to ensure all the rules and issues related to the resurfacing work are widely understood
  • Runway Stopbars – SRG agreement for non compliance reached to allow vehicles to cross red Runway Guard Bars whilst new control software is installed – to be completed by 9 May 11
  • Some controller training on the sim for the new software and on the new RGB protocol from May 11 is also being undertaken
  • Drivers need to understand new protocol on runway guard lights
    • Formal training to be undertaken with all drivers involved including the fire service
  • A review of the method used for runway inspections is being undertaken at Gatwick.Feedback is being sought from Heathrow on their full length inspection process.

Airfield Charts – AIP

  • Jeppeson have been invited to brief on their airport chart production process
  • Awaiting Jeppeson to attend

CGA Markings

  • Burnt line (weedkiller) on the grass edge near the runway surface to identify the runway proximity for grass cutters is being considered.Planning has been done and now just needs approval to go ahead
  • Wig Wags to be added to all road access points to the runway as part of the runway project

Amalgamated action list from other Airports

  • NATS airports action lists are available but other airports would be useful to identify best practice across the UK
    • The CAA RISG could help out with this intention

Vehicle transponders

  • All available Vehicle transponders have been fitted now to GAL vehicles


  • No specific Gatwick hotspots identified at this stage but it will be continuously reviewed in the LRST.
  • The more complex taxying routes are included on the operator airport briefs as standard

LHR Mast website

  • The Heathrow Mast website is being reviewed for ideas for Gatwick

Runway Incursions

  • All RIs plus resulting actions now added to the LRST Action Log to increase awareness amongst all organisations at Gatwick

Airfield Van Tour in Oct 10

  • The Gatwick Van Run included aircrew and resulted in the following changes:
    • Signage improvements
    • Change the angle of signage to align with the field of view
    • Align wig wags perpendicular to runway edges
    • Align signage arrows with precise taxi directions
    • Include current taxiway arrows with alternate turns onto adjoining taxiway

Review of the recent Runway Incursion

  • Ac instructed to move from J7 to hold at the J1 holding point with an ac on approach. Ac passed J1 but stopped to recheck the clearance before entering the runway.
    • Ac on approach was sent on precautionary go-around
  • Likely Causes
    • Expectation bias and repetitive use by Gatwick based crew
  • Valuable discussion on whether clearing ac to J1 from J7 should continue – instead hold at J7 until clearance to line-up is possible
    • NATS Gatwick SMG to discuss the possibilities
    • Op analysis to be sought on operational effects on line-up time
    • Focus article on RIs to be circulated to the LRST as required

Airfield WIP/Projects

  • Plans for Main runway closures in 2011 will be considered by the LRST in due course
  • Main runway rehab 2012/13 draft also to be considered by the LRST


  • Review of any changes to the airport to be reflected on the official chart
    • Pier number changes in March 2011
    • AIP cycle is unhelpful in allowing accurate info to be updated
    • New Stand numbers to be covered up when not in use

Exeter Incident Review

  • The recent AAIB Report on an Exeter Runway Incursion was discussed by the LRST
  • Applied the errors and lessons to the Gatwick situation and considered the likelihood of it happening here
  • A similar review to take place at the NATS Gatwick SMG

Rich Jones
Chief Exec
265 Feb 2011

Gatwick LRST – 28th March 2012

Gatwick Local Runway Safety Team Meeting – 28 March 2012

CE Meeting Summary

Action Log

Action Log Key Issues

  • (5) Vehicle transponder trial had been extended, final outcome still unclear.
    • ICAO requirements on PID needed to be satisfied.
    • Question on whether new process generated more risk than it mitigated due to changes in callsigns etc?
    • Satisfactory performance required for runways and LVP protected areas.
    • ATCO comment that radar + transponder would be primary means of ensuring that vehicles or aircraft were clear of protected areas under LVPs, crew calls would not be relied on.
    • Squids are hard-wired to vehicles, callsigns registered with DAP, so local/temporary changes not possible.
    • Further survey of ops and ATCO teams required.
  • (12) Helicopter aim point (north-west, Zone J) submitted to CAA for approval, daylight only.

Runway Incursions Review

  • Now 14 months since last aircraft incursion, Oct 11 since last vehicle incident.
  • An LGW operator had an incursion at Frankfurt following a “cross all stops” clearance.CRM factors contributed.

Airfield Layout

  • Taxyway and pavement markings 90% complete. Minor changes to viewing angles for some direction arrows and fascia boards.
  • Changes to layout at C1/C2 would retain concrete originally planned for removal.
  • No AIP changes or airfield hotspots identified.
  • DONM 30 May 2012.

Dai Whittingham
Chief Exec
26 April 2012

Gatwick LRST – 25th July 2012

Gatwick LRST – 25 July 2012
CE Meeting Report


Action Log items

  • Van runs to be scheduled in Nov.
  • Scratchpad survey (hotspot identification) to be re-run in Sep 12.
  • Helicopter aim point at Juliet (North end of taxiway U) awaiting clearance from CAA.Hels will have Northerly arrival/departure.Removes risk arising from use of runway.Air and ground taxy still available from proposed site.
  • Operations briefing video to be developed.6-9 month project.
  • Use of specific transponder code for ac under tow has been proposed (LHR already uses).General airfield SQID use is still technically on a trial basis, formal endorsement for continued use awaited from CAA.
  • NOTAMs.Main runway rehabilitation is under way.GAL will NOTAM daily list of individual outages (lighting etc) and operators will then be responsible for determining type of approach. Plan will be to maintain at least 85% of lighting capability at all times.

Zurich ATR42 Incident (2010)

  • Discussion of ATR 42 conflict with A340 both on take-off from Zurich as cleared, from different but intersecting runways.Incident averted by BA crew who intervened to bring conflict to controller’s attention, ATR42 instructed to stop.Full details here.
  • Lessons include encouragement for all personnel to intervene if in doubt or if a hazard is identified, and the relevance to drivers – conflicting clearances were issued to aircraft but could equally have been aircraft vs vehicle.

Start of Roll indication

  • LGW RW 26R has a 400m displaced threshold.TODA is calculated from the end of the full runway width where it meets the adjoining taxyway.
  • Existing ‘start of roll’ board may not provide adequate indication, consideration to be given to additional markings to avoid early roll (on taxyway) or late (loss of TODA).
  • Chart differences apparent.Jeppeson airfield chart does not include full AIP entry mentioning start of roll point.
  • Recommendation (from BA rep) that GAL subscribes to main chart providers to ensure that data for crews matches expectations of airport operators, ie data owners (the airfield operator) should have a feedback loop with chart providers.Valid also for SIDs/STARs.


  • Fire signals and lithium batteries raised as issues (already discussed by UKFSC).

DONM: 26 September 2012.

Dai Whittingham
Chief Executive
26 July 2012

Gatwick LRST – 28th November 2012

Gatwick Local Runway Safety Team – 28 November 2012
CE Meeting Report

Dave Matthews has replaced Andy Taylor as co-Chairman.

Action Log

  • Runway refurbishment work will be completed by end Jan 13, including drainage and gulleys. Wig-wags will be installed at all runway access points.
  • New holding points will be effective from late Feb; infrastructure will be in place but unmarked until go-live date.Activation will be promulgated with AIP update.
  • Taxyway Unavailability Bar System (TUBS) now in place, first in UK.Provides switchable stop bar system to mark closed RETs.
  • Swissport tug drivers will undergo competency tests following training courses.New system will require logging of 3 x runway crossings per month for currency, system will be extended to all airfield drivers.
  • RET design speeds are all being revalidated prior to the next AIP update and will be in the new LGW briefing packs.
  • Operation of ac transponders while towing to be tested: will not have a unique ID but should improve awareness for ATC (system already in use at LHR).Will reduce the need for fixed transponders for tugs.Training on IFF power-up and code selection required for brake men.

Review of Incursions

  • 5 total in 2012
  • 18 Sep: ADM handed runway back to ATC post-night refurbishment work (0430-0530) without realising that friction runs were in progress.Cat D incursion.
  • Single-manned grip-test vehicle, driver had not noticed radio volume had been turned down.
  • ADM saw vehicle on runway after handover to ATC but assumed it had been given clearance.
  • Radio in grip-test vehicle badly sited and will be relocated.
  • Other lessons: Non-standard vehicle (one-off) with different SOPs increases risk.Vehicles transmitting on VHF can’t always hear other transmissions, hence reduced SA and increased risk (VHF connectivity a wider issue for LGW surface ops).Long project, self-imposed pressures to complete on time…
  • Remedial action included a review of SOPs and manning levels plus delivery of additional briefings.
  • 24 Oct:Night, 08R, lots of WIP.U/T ATCO cleared departing ac for T/O with previous landing traffic still on the runway.RIMCAS alert, screen controller opted to let departing traffic continue given separation and ‘expedite’ instruction issued to landing traffic.Operator subsequently endorsed the decision.Probable Cat C incursion (still under assessment).
  • U/T controller assumed that as ac had slowed it was turning off at RET (expectation bias…) but crew had actually opted to continue to next RET.Ac had already been transferred to GND freq and so didn’t hear T/O clearance being given.
  • Lesson: Landing traffic should not have switched to GND freq before it had vacated the runway.If you are on the runway, you should be talking to TWR!

RISG Update

  • ‘Runway ahead’ markings are seen as positive but they are not possible at all locations.Unworkable at LGW.
  • Single Cat I and Cat III holding points under discussion, aim would be to standardise on Cat III.Favoured by ATC but not by airfield operators because of capacity implications.
  • 24/7 ‘Ring of Reds’ not in operation at all UK airfields (incl LGW), but operators need to check charts for accuracy.Some charts include the info, others don’t.CAA needs to provide direction to chart suppliers.
  • Visibility of 3rd party (TCO) MORs and ASRs required for improved data quality.
  • Feasibility of annual runway incursion seminar being considered.
  • LGW examining use of new TUBS lighting for incursion warning.

LGW Layout

  • TODA signs will shortly replace ‘Start of T/O roll’ signs.
  • New helicopter aim point will be promulgated in next AIP supplement.


  • Taxyway error scratchpad exercise reported 84 events in 2 months
  • 82 incorrect pilot routings at 28 different locations, though only 3 errors at night (presumably because there are greens to follow).
  • Main hotspot is J/P/Z junction with 10 events then P/A/N with 5.

DONM: 30 Jan 2013

Dai Whittingham
Chief Executive
5 December 2012

Gatwick LRST – 30th January 2013

Gatwick Local Runway Safety Team – Gatwick – 30 January 2013
CE Meeting Report

  • No incursions in previous two months
  • Work on Charlie hold will be complete by end Mar
  • TRM training going well, focusing on runway incursions, routings and human factors.
  • Helicopter aiming point now live and included in AIP.
  • Feasibility study is next step for potential move to 24/7 ‘ring of red’.
  • Implementation of new Cat III hold points is imminent (G3/C3).Y2 has moved to meet Cat III requirements.
  • TUBS (taxyway unavailable bar system, unique to LGW), unidirectional lights will only be seen from runway.Being examined for potential modification as additional stop bars for runway incursions.
  • Review of Luxembourg incursion (Jan 2010), landing 747 hit the roof of a contractor’s van.Poor internal coordination and inadequate procedures the root cause.Ground controller cleared van (with no comms) onto the runway, tower controller was unaware.Emphasises the importance of: “On the active runway – on Tower freq”.

DONM: 27 March 2013

Dai Whittingham
Chief Exec
15 February 2013

Gatwick LRST – 27 March 2013

Gatwick Local Runway Safety Team – 27 March 2013
CE Meeting Report

Action Log update

  • Charlie Hold will be changed to reflect LRST input, changes incorporated in runway rehabilitation project.Likely to include flush wig-wags, which will also make snow clearance easier.
  • Van run needs to cross-check with AIP entry.Night run to be carried out later in the year.
  • RISG technology group is looking at RI alerting systems, one system under trial at Aberdeen.TUBS (Taxyway Unavailable Barrier System) is now active and has the potential to be modified as an RI light barrier also, and a trial is under consideration.
  • Revised holding points are being included in the airside driver training syllabus.
  • Bases for the new ‘start of TODA’ signs had been installed and installation of signs was imminent.Wording for the AIP entry was agreed.
  • 24/7 RGB operation was under active consideration but was a major change and needed to fit into overall airport strategy.Procedural and infrastructure change and associated training would be required.

Review of Runway Incursions

  • Aircraft holding at night at J8 for RW 26R was given clearance to route N-K-P with a green route lit.Crew turned left instead of right (for J8-N) and headed for runway, breaching protected area. ATC clearance was aimed at facilitating parking for another aircraft, which was a complicating factor.Crew expected to go from holding point towards the runway as normal.Expectation bias in play…?
  • Ops vehicle incursion during rehabilitation works at B, with 4 working groups active.Driver was in process of handing back runway to ATC.Stop bar was not illuminated, veh tracked towards a contractor’s veh already on the runway edge amd over-ran the hold.Lots of RT chat, breakdown in situational awareness.
  • LGW is reiterating ‘basics’ to its ADMs, who have been told to call a halt of workload becomes too high.Basic lesson is that if you don’t need to conduct WIP in proximity to ops, don’t!LGW has also identified the need to include adequate time and distance buffers in major infrastructure projects.(Comment: another incident occurring at shift change or other handover…)
  • Helicopter carrying out an ad hoc airfield filming task (ironically, as part of the RI prevention work) mad a low approach and go-around with a departing aircraft lined up.No risk of collision, but an ‘incorrect presence’.Communication issue – controller had not been made fully aware of the plan.Lesson: make sure any unusual activity is briefed to all players.

Airfield layout

  • RISG had identified that changes to holding points increased the risk of RI and recommended that information notices were used to bring changes to the attention of flight crews.This had been completed at LGW.
  • Stand 110 was now available for A380 ops.Taxyway Q had been modified for Code F traffic, procedures had been successfully demonstrated but further work was required prior to any scheduled ops (expected later in the year).A380 diversions from LHR could now be accepted.
  • Runway rehab work was almost complete, all LED lights had been installed and re-seeding of grassed areas was planned for the autumn.

Pushback Errors

  • No change in rate of errors, with wrong direction and/or comms issues being the most common cause.

DONM:29 May 2013

Dai Whittingham
Chief Exec
25 Apr 2013

EASS – European Air Safety Seminar – 10-12 March 2008 – Bucharest

European Aviation Safety Seminar – Bucharest – 10-12 March 2008

CE Meeting Summary

  • Click here for EASS Programme. The entire proceedings papers are only available on payment through the Flight Safety Foundation, however, the UKFSC holds a copy of the proceedings in the library and individual papers can be transmitted on request. The Key Messages and highlights from the sessions follow in this report.
  • In the Opening Ceremony, Bill Voss, the CE FSF described the outcome of his review of the FSF and the way it will go about its business in future. The AeroSafety World magazine sells 2000 hard copies (FOCUS – 11000) and has now introduced a soft copy on its website with an 18000 circulation. FSF aim to influence through establishing global partnerships and exploiting the ICAO Global Air Safety Road Map. They have joined IATA in addressing the shortage of qualified aviation safety personnel, engineers and pilots and joined with Eurocontrol to sponsor an aviation safety encyclopaedia website known as ‘Skybrary’.
  • Eurocontrol ATM Dep Director raised the issue of a 10% AT Controller shortage with high number of retirees approaching. The intro of CESAR was exacerbating this leading to a 20% shortfall soon. He addressed the threat of legislation on open reporting culture.
  • Mike Ambrose, ERA, highlighted the need for action from the regulator on aircraft icing on supercritical wings and the unacceptable pressures being exerted on crews by airlines to fly with technical problems. He also raised concerns about multinational crews, the need to harmonise in-flight procedures and the need for protection of safety critical data and just culture. Finally, he expressed the desire for common EU-wide safety standards and aircraft registration and for emergency response plans to be strengthened.
  • David Learmount (FLIGHT) reviewed the past year in flight safety terms. Fatalities were down (744) whilst hull loss (25) was up.
  • The entire afternoon of Day 1 involved a panel discussion on criminalisation and safety with a distinguished panel of legal and safety experts from a number of key nations. The discussion was based around a fictitious scenario designed to draw out the complex multinational issues that surround an aircraft accident – both in the immediate and longer term. The Key outputs from the discussion included:
    • Corporate Manslaughter legislation will be introduced in the UK from 6 April 2008 which will have significant consequences for UK airline management boards. Fines of 1.5% of turnover and 4 years in prison for directors).
    • A sea-change in legal attitudes – in the past a pilot was blamed for an accident, in future, the company will be blamed for not training the pilot appropriately.
    • Scapegoating of aircrews involved in aircraft accidents can be expected in certain countries. Duty of care considerations for crews by airlines need to be in place for such events.
    • Crews should have separate dedicated legal advice to that available to their airline.
    • Evidence that an airline has a positive just and open culture on safety carries significant weight with courts of law.
    • Airlines should employ a single professional spokesman to handle media in the event of accidents- and identify who in their emergency plan beforehand.
    • Personal protection and counselling for those involved in an accident- both victims and families – needs prior consideration.
  • The Dutch AT Safety Institute presented on an investigation into SID deviations. They found 3 significant deviations (300’ vertical/300’ horizontal) for every 100K SIDs carried out. Major factor was the wrong SID being taken by the crew. This was caused by a similar sounding name, lack of crew preparation, read-back error, late changes and crew expectation. Conclusion was that SID names should be chosen carefully and late runway changes should be avoided.
  • The Head of Norwegian Air Safety described their methodology for assessing the risks involved in approaches and departures for Norwegian airfields. Through analysis of past accidents and applying knowledge of the wide number of threats – weather, terrain, obstacles, ac performance variations, nav aids and visual references – a comprehensive model has been built that can be applied to any airfield.
  • > style=””> The Swiss DFT Civil Aviation Safety Officer presented on his serious concerns with the lack of interoperability between ACAS and STCA, using the Uberlingen mid-air accident as his model. His major issues were that over Europe there are 30 TCAS RAs per flying day – 2 per hour and contradictory indications were common between TCAS and STCA which needed resolution. He pointed out that TCAS had been developed independently from STCA.His conclusions were that action on training and education was essential and protocols to introduce interoperability between both systems should be developed urgently.
  • The presenter from the University of Texas briefed on the principles of NOSS – Normal Ops Safety Survey. The aim of NOSS was to develop a threat recognition and error management system or framework that identified threats, events and errors that occurred beyond the influence of ATC. Ultimately, the objective of NOSS is to predict the margin or point at which normal operations move to a higher threat environment. This is achieved through observing the routine error management being undertaken by the crew before the error becomes gross or significant. A LOSA is an application of NOSS principles.
  • Ratan Khatwa from Honeywell presented on his findings from an investigation among airline crews about the utilisation of Weather Radar to identify CB. His pitch was that aircrew knowledge and training was inadequate. Examples of gaps included poor tilt and gain management, earth curve effect, interpretation of ground returns, radar attenuation, system limits at high altitude and poor technique generally.His recommendations were for operators to formalise initial and continuation training on fundamental concepts, system limitations, tilt management and overscan of storm cells.
  • James Burin from FSF presented on the FSF Runway Safety Initiative which is aimed at addressing incursions, excursions and confusion. The former two are well documented but the latter is not.The output from the Initiative will be a catalogue of Runway Safety Products.He went on to suggest that the majority of excursions were being caused by unstable approaches and that the French were in the process of introducing regulations on approach criteria. He concluded that the lack of statistics on ‘confusion’ events around airports and airfields required attention in order to highlight and prevent confusing taxi procedures before they were introduced.
  • Michel Masson from EASA covered the ESSI programme and then briefed on the establishment of the 3 main co-ordinating groups in EASA – ECAST, EHEST and EGAST. Over 150 external organisations and interest groups are now represented across these fora.


IASS 61st – 28-30th October 2008 – Hawaii Seminar

61st International Air Safety Seminar (IASS)Honolulu, Hawaii – 28-30 October 2008



  • The Pres and CEo FSF offered the following keynotes in his introduction:

o Importance of continuing rigorous SMS Implementation across Govt/Regulator/Boardroom and Operations
o Finance and trust difficulties causing serious concerns in the industry
o There is a danger that safety reporting and focus would be moved off the agenda
o In the US, there are 13000 standards and 30000 specs to be adhered to in the airline industry – this may be as far as we can go with compliance using rules and regs!
o The industry needs to get ready for the next generation:
§ Demographics and middle class growth
§ Middle class will grow by 2Bn and they will want to travel
§ 28% increase in air travel predicted
§ Insufficient numbers of regulators in many States
§ Shortage of numbers in pilots, engineers and regulators
o We must break the cycle of repetition of the same mistakes by sharing information in ever growing amounts
§ 1986 and MD 80 crashed – no slats then 2009 Spanair happened!
§ ATR icing incidents just keep on happening
§ Smoke and fire incidents
§ Runway excursions

  • IFA President addressed the following in his keynote speech:

o Human Factors needs much more work in engineering
o SMS Implementation is fundamental
o Fatigue management must improve in maintenance
o Rigour required in contract writing when outsourcing
o ‘Safety costs’ and ‘Quality costs’ – but failure is even more costly!
§ For example – ETOPS has meant safer and cheaper operations

  • FAA Administrator –Safety

o When identifying risk, it is essential that an internal examination of your organisation is undertaken
o Low accident rates do not mean we can not get any lower.
o Sharing of safety information is vital for effective risk assessment
o Through trends we must ident accident precursors
o Prior to Lexington, there were 116 type incidents in 5 years
o Data analysis models and tools are essential but fused analysis of all sources is the key to a full understanding
o ‘Data will set us free’ but we must mange risk but we must do it together!

  • Accident Review2008 – Jim Burin FSF

o Full Presentation
o Commercial Jet Aircraft flying-20,933 of which 19277 are western built
o Commercial Turbo prop – 6418 of which 4830 are western built.
o Business jets – 15055

o Commercial Jet Accidents this year – 16 major(6 ALAR, 5 LOC and 2 CFIT)
o 27 Turbo (25% CFIT)
o 10 Business Jets

o ALAR accident trends – 7 in 96 and 11 in 07!
o 5 icing accidents this year

o The Challenges:
§ Safety Culture
· What we do round here!
· What you do when no one is watching!
· Everyone has one – some good some bad!
· You can’t buy one – it must be cultivated/built/positive!
· SMS does not mean you have a positive culture

o Summary:
§ An average to poor year so far!
§ Loss of Control dominate the fatalities
§ Where have the lessons learnt gone?
§ Make aviation safer by reducing the RISK of an accident!

  • Global Safety Initiatives

o CAST – aim is to offer world leadership in air safety
o CAST is seeking to establish regional safety teams – ECAST
o Helicopter safety team HEST – EHEST in Europe
o FOQA TAWS Analysis
o ALAR Team activities

o Global Aviation Safety Roadmap
o GASR and GASP – (Safety Plan)

  • Criminaliation of Aviation Accidents

o It is vital that just culture is established and preserved
o Medics reported 2% of errors in the 1980s
o To Err is human – but so is not to report!
o Criminalisation is not an effective safety tool – except in cases of sabotage or wilful or reckless misconduct
§ In the Spanair case, 3 engineers have been charged
§ Concorde – numerous people are still being targeted after 7 years
§ Uberlingen – the ATC controller was murdered
§ Accident info is going directly to court in the Helios case
§ The Lexington case continues

o There is precious little protection to prevent prosecutors from using safety info in criminal cases
o Aviation suffers in the long run
§ Is there enough protection for those collecting safety data?
§ When does a bad mistake turn into gross negligence?
§ Should we be educating courts and the law enforcers?

Day 1 – 28 Oct 08 – PM Session- LOSS OF CONTROL

o Spatial disorientation examples were used by the NTSB to advocate the need for Upset Recovery Training to be made mandatory in the US.

o The senior safety pilot at Boeing reported on a programme of simulator work to evaluate the effectiveness of Upset recovery training in the simulator training. The programme used 10 pilots to fly 3 events and consisted of a 30 minute slot per pilot.
§ The outcome of the trail indicated significant value from the training in terms ofconsistency and timing of responses to Upset recovery

o Fedex reported on the introduction of Upset Recovery training to counter LOC. They have an academics phase which addresses the critical knowledge required before they demonstrate the appropriate techniques and procedures in the sim and during in-flight training.
§ The sim has the right look in terms of instruments but does not provide the right feel!

  • ADS-B Safety Strategies

o The ADS-B Co- chair of the FAA ARAC briefed on ADS-B. He covered the following points:
§ The technology is proven and capable with demos shown positive benefits – analysis indicates the possibility of reducing accidents by 40%.
§ The Committee Report on ADS-B has 36 recommendations.
§ In the current business case, the benefits barely met the costs.
§ Key safety benefits are:
· Improved situational awareness
· Increased operational assurance
· Enhanced weather avoidance
· Reduced surface movement errors
§ The challenges are:
· Frequency spectrum alignment
· Antennae diversity requirements
· Avionics costs
· TCAS/FMS upgrades
· Investment capital is in short supply

Day 2 – 29 Oct 08 – AM Session- DATA ANALYSIS AND SHARING

  • Accident Classification

o A new form of accident classification was introduced by IATA in 2007 which takes a USC model where human factors are included in a threat and error management framework. Click here for the detailed paper.

  • Non Punitive FOQA Programme

o The FOQA Manager from Shanghai Airways described the challenges of introducing a non-punitive FDM/FOQA programme into the Chinese culture

  • The ASIAS Programme

o This CAST Initiative was described by the Senior Director Safety at Continental Airlines. His key points on ASIAS were:

§ Air safety has never been better but we need to continue
§ Accident rates are low but flying is on the increase
§ ASIAS is the response to these challenges

o The benefits of ASIAS are to identify and monitor trends, evaluate risks and formulate interventions
o The outputs are directed studies on concerns identified and setting of priorities -already identified runway safety and Terrain awareness warning
o Known risks included – ATC procedures, flight deck automation, training on advanced manoeuvres, aircraft state awareness, precision approaches
o Benchmarking underway on unstable approaches, TCAS RAs and TAWS
o In the US, the ASAP – aviation safety action plan is being established with MITRE, and independent data gathering company, acting as the analytical arm and safeguard of the data.
o Under ASAP, each airline will provide its FOQA data to MITRE who will fuse it.

  • Risk Management Choices – Head of Research CAAUK

o The method used by the CAA to identify risk and then manage it was briefed. Click for paper .
o The process is as follows:
§ A strategic analysis pyramid is constructed from MORs received by the CAA
§ World fatal accidents are then factored into the UK fatal reports
§ The main risks areas are then identified and prioritised and a view taken of world risks against UK specific risks
§ Analysis teams are assembled to produce action plans to address the risks identified.
§ Data is also analysed to attempt to identify precursor events for future risk assessment purposes.
o The CAA work does incur cultural battles along the way:
§ Increasing numbers of safety reports does not indicate increasing risks
§ Money spent on safety initiatives does not mean dead money
· Insurance premiums are reduced
· Fewer high profile events means less spent of marketing to attract customers back.
· Regulatory oversightcan focus on compliance and real performance

  • Skybrary – Aviation Safety Website
  • The Skybrary Project – the production of a Safety Knowledge Website was briefed.

Day 2 – 29 Oct 08 – PM Session – PANEL DISCUSSION ON SMS

  • The SMS Panelists each offered the following perspectives on SMS as it applied to their company or situation:

The Moderator

  • SMS is a proactive, predictive mode approach to safety
  • From Jan 2009, SMS is to be implemented in accordance with the ICAo SM Manual
  • Individual States will be responsible for oversight
  • If you can’t measure, you can’t manage!

Cathay Pacific

  • An airline is a system of systems
  • The negative approach to SMS is that it costs money, time and effort and will take several years to install.
  • Many airlines already have the basic building blocks in place – IOSA provides them
  • Having a Ferrari does not make you a good driver! Effective SMS requires a positive safety culture
  • In simple terms, SMS requires you to:
    • Identify risk – incident and accident reports
    • Assess risk – no need for great complexity
    • Manage risk – form an action plan to mitigate it
    • Integration and communication – bring the relevant people together


  • In Qantas it has been evolutionary and needed to be engineered
  • The initial focus is on data
    • Multiple feeds into the database
    • Manage the risks through action plans
    • Measure the outcomes of the action plans
    • Integrate the information
  • Very similar to an Enterprise Risk approach with a causal framework

Transport Canada

  • From the Regulator’s view, it is a hard journey.
  • Significant changes were needed to the regulations
  • Audits are out and assessments are in.
  • With 1200 AOCs and 2000 airports, the TCCN approach had to change.


  • Airports have needed an SMS since 2005.
  • Standardisation is a vital component for airports

Panel Discussion

  • The basic components of SMS are already available in most companies; just some minor re-alignment is required with the help of the Regulator.
  • The Regulator’s FOIs need to trained to do a different job – need to focus on systems – and change management to organisations is fundamental.
  • Integration of SMS across the entire organisation is key. Motivation and leadership will be required.
  • Data is essential to take informed decisions, take effective action and to report on the success of the action.
  • SMS must be simple to follow and be understood right across the organisation.


  • Moving from a Penalty Driven Culture – the Manager’s Dilemma
  • How do your managers measure success – aircraft availability, turn-round times?
  • How does the workforce see it – make the bottom line, do it for less?
  • How does a Manager get an accurate assessment of the risks being taken?
  • Does your company want to know what’s going on?
  • Isn’t that what safety and quality people are for?
  • It may be time for a Management Review!

Actions to Consider

  • Develop a reliable data set and identify the need for change
  • Determine your organisation’s cultural maturity
  • Ensure the Accountable Manager understands his role
  • Provide Safety Mangers with a consistent understanding of SMS
  • Get safety and quality improvements aligned with the cost of errors in the business plan
  • Evolve a just culture
  • Management must commit to change to achieve change
  • Senior management must emphasise safety.
  • Senior management must accept criticism and encourage feedback
  • Do safety culture surveys
  • Take a candid look inside your organisation
  • Are We Learning the Lessons? – Mick Skinner CHIRP UK

· Maintenance errors and MEDA investigations show that the number of errors being made has not reduced in the past 10 years.

· Aircraft are still being delivered to the line with serious defects – cross controls, servo disconnects for example

· Factors are varied but include individual technique and procedural errors, poor supervisory levels, soft copy manuals, inaccurate manuals.

· The CHIRP MEMS Group has undertaken a Management review covering engineering capability, trust and safety performance. The results show that the higher the level of management targeted for questions the higher the effectiveness of the companies’ SMS.

· The Issues revealed by the SMS Review are as follows:
o Leadership – They are business people not safety orientated. Safety should be part of the business plan along with the error costs.
o Trust of the employee in a company’s SMS is reflected in the just culture and the value and trust placed in an individual.
o Effectiveness of training and the confidence of the work force to use new skills – this is often not measured and a Tick Box ttaining is used.
o Line Management – has a poor understanding of of the safety role and what the standards of safety should be.
o Risk Assessment – carried out by specialists only , when it should be done by everyone involved.

Day 3 – 30 Oct 08 – AM Session- EMERGING CHALLENGES

  • A Collective Approach to Aircraft Maintenance

· Design Engineers must work together with Maintenance Engineers to address safety issues in each other environment.
· Accidents have proven that Maintenance schedule extension is not an advisable strategy for maintainers, particularly when it comes to fatigue.
· Incorrect parts or correct parts incorrectly fitted lead to failure and accidents.
· The demise of Ansett Airlines resulted from a poorly written maintenance schedule change on the 767 by Boeing.
· The following recommendations were offered:
o Use both design and maintenance engineers in manufacturers and airlines
o Use Human Factor experts to examine maintenance schedule changes
o Respect time-specific inspection schedules

  • Errors and Influence of Working Patterns and Fatigue

· There is no clear answer on the part played by fatigue in maintenance error (ME)
· FAA figures indicate that 8.3% of accidents in the US and 26% worldwide are caused by ME.
· No accident reports state the rosters or degree of night working that may have been involved prior to the accident.
· Under Annex 13, Flt crew work patterns are always covered as are their licenses, experience and duty times – but NOT for the maintainers involved.
· There are some working time rules around; ICAo mentions them in its SMM but not specifically targeted at maintenance crews.
· Night working has limitations:
o Lack of facilities – many are closed at night
o Less supervision and mentoring
o Working environment and lighting is poorer
o Circadian effects increase susceptibility to error
o Schedule pressures
o Distraction
· Measures required to reduce tiredness:
o CRM is not as effective in maintenance
o Support for nights ops needs to increase
o Critical repair items need more care
o Remuneration for longer overtime has established bad habits
o Shift patterns lead to excessive fatigue
o Tiredness can lead to over confidence and lowering of standards
· What are regulators doing about it?
o Maldives is setting time limits – NZ and Canada are following suit

  • Organisational Design for Safety Oversight Effectiveness

· Major challenges are emanating from changes in automation, the complexity of the environment and dynamics of technology.
o These challenges can be met through SMS since the answers lay in organisational support, relationship development and motivation
o The Next Gen and SESAR era will bring much greater interdependencies of data and voice exchange and the part that the human plays in it. Safety needs to heed these changes.
o The aim must be to augment human performance with an increased situational awareness and minimisation of errors. – human factors, organisation, technology and environment all need attention in SMS – it is not just data!
o SMS means leadership, people management, policy, resources. Process and results
o Inter-organisational vulnerabilities will be key to identifying the dangers. SMS needs to recognise vulnerabilities, identify sensible actions and manage and monitor implementations

Unmanned Aerial Systems; Mitigating Hazards


  • FSF Runway Safety Initiative

· Click for Paper.

· The initiative is divided into 3 areas; Incursions, Excursions, Confusion and is a 2 year programme of work which involves the manufacturers and includes:

o Unstable approaches
o Airport design, lighting and markings, runway conditions
o ATC – their influence on stable approaches

· Accident Data involving Runway safety -1995 – 2007
o 1323 accidents not including GA
· 10 incursions (0.7%)
· 379 excursions (28.5%)
· 4 confusion (0.3%)

o The major target is therefore excursions.

· The way ahead is to ident high risk areas and formulate action plans
· There is much going on with incursions, some activity on excursions and nothing on confusion

  • Technical Aspects of the Initiative

o Full Briefing Paper.

· Over $500M is being spent each year on Runway safety measures including:
o Airfield lighting and indictators
o GPS voice advisories and moving maps
o Ground based ASDE_X to provide in-cockpit alerts
o Weather radar modifications to detect conflict on runways/approach.
o Stabilised approach monitoring
o Deep land and distance to go advisories
o Improving runway infrastructure
o Improning ATC and cockpit procedures
o Go-rounds – No fault go-round encouragement
o Low cost cockpit tools

  • Direct –to –Pilot Warnings

· Full briefing paper.

· CAASD/MITRE Corporation are undertaking trials to identify effective warnings direct to the pilot. Examples of systems under investigation:
o Take –off hold lights on runways – in trial these have led to a 90% reduction in incidents
o Additional red lead on lights prior to the runway
o Runway intersection lights
o Final approach lighting and audio systems to warn of potential conflict

· Results so far indicate positive benefits from runway lighting mods, but that audio systems on final approach are more effective than lights.

  • NTSB Most Wanted List of Runway Warning Systems

· ImprovedHazard Detection and warnings to crews
· Improved control over runway crossings
· Tell the pilot where he is on the airfield
· Landing performance indications
· Specifically:
o A ground movement safety system to prevent runway incursions which feeds directly to the crew
o Runways should only be crossed when cleared specifically to do so, and at one runway at a time.
o An alert tied into the moving map of the airport which audibly alerts the crew if they go wrong – including runway length available.
o Distance to go information on landing

· The Current Status of Recommendations with the FAA is as follows:
o Ground safety systems are being installed in 35 largest US airports
o Runway crossing procedures have yet to be accepted
o Moving map alerts not yet cleared but are being closely considered
o Landing distances not yet accepted

· Key Factors in runway related accidents are:

o Night time operations
o Low experience tower personnel
o Readily identifiable conflict situations being overlooked

· Where to next:
o Lower cost conflict warning systems for smaller airports
o Fully automated hazard detection and warning for vehicles and aircraft
o An evolution of ADS-B
o Better control of runway crossings
o Move awareness and warnings to the cockpit for quicker response times
o Conduct performance calculations for each arrival using best data available – and do not be afraid to reject a landing

A copy of the IASS 2008 CD is available from the Fairoaks office.

Rich Jones
Chief ExecutiveUK Flight Safety Committee
26 November 2008