AIR TRAFFIC BULLETIN Issue 00-2

Air Traffic Bulletin

Issue 00-2 MAY 2000

Reducing Operational Errors Related to Runway Incursions

/*T/ In recent months, there has been a significant increase in operational errors (OE) that resulted in runway incursions. In March 2000 alone, there were 11 errors that resulted in a runway incursion compared to three in March 1999. One of those 11 runway incursions resulted in an accident with fatalities. This was the first runway incursion accident since 1994.

Of the 11 March 2000 OE's, only three occurred at night, and only one occurred in IFR conditions. The chart below shows that 73 percent occurred during daytime hours with VFR conditions.

The paragraphs following the chart contain brief synopses of some of the recent operational errors.

Operational Errors for March 2000

A Cessna C172 landed Runway 24 and was instructed to exit at taxiway W. The C172 was still on the runway when a Delta B737 was cleared for takeoff and started takeoff roll on the same runway.

Deficiency - Scanning

An MD80 was cleared for takeoff Runway 23R with a PAZT still on the runway after landing Runway 23R. Closest proximity reported was 300 feet vertical and 100 feet horizontal.

Deficiency - Scanning

A B737 was cleared for takeoff Runway 25R and approximately 30 seconds later, a B737 was cleared to cross Runway 25R. The taxiing aircraft was not clear of the runway when the departing aircraft was rolling for departure, closest proximity 4,125 feet.

Deficiency – Scanning

Flight progress strip scanning

A PA28 departed Runway 8 and had not cleared the intersection of Runway 15 when a B737 commenced takeoff roll on Runway 15. Closest proximity reported was 4,000 feet.

Deficiency – Scanning

Flight progress strip scanning

A PA31 and a B737 came within 3,000 feet horizontal separation on Runway 35L. The PA31 landed Runway 35L and was instructed to exit at the reverse high-speed taxiway. The pilot acknowledged but 35 seconds later advised the tower he could not find the high-speed taxiway. The controller attempted to send the B737 around; however, the B737 advised it was already on the runway.

Deficiency – Position determination, scanning.

Did not get verification from the pilot that the aircraft was clear of the runway and failed to use the aid of the ASDE.

A DC9 was cleared for takeoff Runway 33L while a B727 had been cleared to cross 33L at Taxiway Delta. The DC9 aborted takeoff and stopped prior to the Runway 27 intersection. Aircraft came within 2,600 feet horizontal separation on Runway 33L.

Deficiency – Scanning

Runway incursions caused by operational errors can be prevented, even eliminated, by getting back to the basics:
Scan effectively.

Scan with a purpose. Scanning involves more than mechanical head movement.

Scan the arrival or departure runway with a focus on known problem areas.

An effective scan helps the controller correlate what he or she hears with events seen happening on the surface.

Look for things that do not belong.

Anticipate pilots/vehicles not doing what is expected and be prepared for it.

Use the memory aids provided. Many times memory aids are provided but are not used. The same applies to flight strip management. Follow the facility's ritual of strip management. Train yourself to use memory aids and strip management, not because they are mandated, but because they ensure the safety of the operation. Remember that complacency can lead to errors.

REVIEW THE FOLLOWING 7110.65 PARAGRAPHS:

2-10-3 TOWER TEAM POSITION RESPONSIBILITIES

a. 1. There are no absolute divisions of responsibilities regarding position operations. The tasks to be completed remain the same whether one, two, or three people are working positions within a tower cab. The team as a whole has responsibility for the safe and efficient operation of that tower cab.

3-1-12 VISUALLY SCANNING RUNWAYS

Local controllers shall visually scan runways to the maximum extent possible.

b. Ground control shall assist local control in visually scanning runways, especially when runways are in close proximity to other movement areas.

3-1-4. COORDINATION BETWEEN LOCAL AND GROUND CONTROLLERS

Local and ground controllers shall exchange information as necessary for the safe and efficient use of airport runways and movement areas. This may be accomplished via verbal means, flight progress strips, other written information, or automation displays. As a minimum, provide aircraft identification and applicable runway/intersection/taxiway information as follows:

a. Ground control shall notify local control when a departing aircraft has been taxied to a runway other than one previously designated as active.

b. Ground control shall notify local control of any aircraft taxied to an intersection for takeoff, unless departure from that intersection is specifically designated via prior coordination or facility directive as the standard operating procedure for the runway to be used. When standard procedures require departures to use a specific intersection, ground control shall notify local control when aircraft are taxied to other portions of the runway for departure.

c. When the runways in use for landing/departing aircraft are not visible from the tower or the aircraft using them are not visible on radar, advise the local/ground controller of the aircraft's location before releasing the aircraft to the other controller.

3-1-5. VEHICLES/EQUIPMENT/ PERSONNEL ON RUNWAYS

a. Ensure that the runway to be used is free of all known ground vehicles, equipment, and personnel before a departing aircraft starts takeoff or a landing aircraft crosses the runway threshold.

3-1-7. POSITION DETERMINATION

Determine the position of an aircraft before issuing taxi instructions or takeoff clearance.

NOTE- The aircraft's position may be determined visually by the controller, by pilots, or through the use of the ASDE.
(ATP-20)

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