ANSV Italy Agenzia Nazionale per la Sicurezza del Volo PRESENTATION

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ANSV - ItalyAgenzia Nazionale per la Sicurezza
del VoloPRESENTATION

• EC RWY Inc. TF Workshop
• BRUSSELS Sept, 9-10 2002

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Air Transport Safety and Runway incursions

• bruno d'alba for

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Introduction

• This presentation has been made possible through
  courtesy of Eurocontrol RWY Inc. TF
• ANSV is pleased to participate in the Workshop
  and contribute to the agenda and ensuing
  discussions
• Speaker presentation

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Case items

• Two events have been chosen to elaborate on the
  concept of Runway incursions Event A and Event B
• Event A - Accident, lead to 118 casualties,
  extensive catastrofic destruction
• Event B - Incident, no casualties, no damage

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Similarities and Differences

• Runway incursion event
• Different outcome
• Same lesson to learn

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Event A - Linate AirportOct, 08 2001

• MD-87 and Cessna Citation collide at Runway
  intersection, heavy toll in casualties, extensive
  destruction and damage
• Human error?
• Other causes and contributory factors?
• Details in separate presentation to follow

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Event B - Linate AirportFeb, 28 2002

• Runway incursion without damage (traffic delay
  only)
• Human error?
• Other causes and contributory factors?
• Details to follow

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Analysis and conclusions

• Both instances share common genesis
• Human error? YES
• Other causes and contributory factors? YES
• Margin erosion leads to consequences

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The perception is

• Air Transport Safety starts on the ground, with
  sound prevention measures
• ICAO, JAA and FAA provide the aeronautical
  community with the necessary regulatory and
  technical framework, SARPs, etc,
• Improved Air Transport Safety is achievable
  through education and prevention

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Let us act !!!

• Accident investigation teaches lessons
• Analisys allows recommendations to be issued to
  responsible national and international competent
  organisations
• Recommendations translate into safety minded
  regulations and recommended practices
• National regulatory organisations are URGED to
  inform, to monitor and to correct

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Coming next.

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Linate Oct, 08 2001Accident, Interim 2
Factual Reportsee workshop FolderLinate
Feb, 28 2002Incident, Final Reportsee
workshop Folder Review of Reports
Other considerations
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Linate Oct, 08 2001Accident Excerpts from
Interim 2 Factual Report

• Summary
• On the 8th of October, 2001, at 06.10 UTC, an
  MD-87, SE-DMA operated by SAS, while on takeoff
  run on Rwy 36R, collided with a Cessna 525A
  registration marks D-IEVX which taxied into the
  active Rwy coming from West apron (General
  Aviation)
• After the collision the MD-87 continued
  traveling (the aircraft was airborne for a short
  while) down the Rwy and came to a stop impacting
  a baggage building beyond the Rwy
• The Cessna remained on the Rwy and was totally
  destroyed
• All occupants of the two aircraft and four ground
  staff suffered fatal injuries. Four more ground
  staff suffered injuries and burns of various
  entity
• Excerpts
  from findings on next slide..

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• On Oct 8, 2001 at Milano-Linate airport
• D-IEVX crew taxied not respectful of the taxi
  clearance issued by controller.
• -40 seconds after having instructed D-IEVX to
  taxi, the same taxi instruction was given
• to LX-PRA parked on the same apron, but the
  communication was in Italian and
• could not be perceived by the German D-IEVX
  crew.
• -The controller remained unaware of the crew
  mistake.
• (..)
• -West apron and on R5 and R6 taxiways lacked most
  of the required visual aids
• -Existing visual aids were degraded and not
  consistent with ICAO requirements.
• -Airport information in AIP Italy incomplete
  and not descriptive of actual conditions.
• -Instruction/information in Jeppesen charts not
  consistent with instruction in AIP.
• -Procedures mandated for LVO, in the absence of
  ASMI, were not enforced.
• -Tower controller supervisor was not at his
  working position when the accident occurred.
• -Air-to-ground phraseology comms not in
  conformity with the ICAO recommendations.
• -Controllers did not implement read-back
  confirmation procedures consistently.
• -Controller(s) ignored the presence/location of
  S4 (a marked location along taxiway R6).
• -Air-to-ground comms conducted in Italian and
  intermixed with English.

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Linate Feb, 28 2002Incident Excerpts from
Final Report

• Summary
• At 08.36 UTC, flight BE 400A, registration marks
  OY-SIS, was at holding position for CAT III at
  runway 36R of Milano Linate, in the takeoff
  sequence.
• The Tower controller, instructed the BE 400A
  pilot with hold short 36 the pilot replied
  short 36 and started to taxi towards the runway
  maintaining in sight the approaching traffic, a
  PA-34 light aircraft, registration marks I-MIRK
  who was on final.
• After the aircraft landing, OY-SIS entered the
  runway without clearance
• Excerpts from Final report
  on next slide..

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The Tower controller, who was checking Ground
movements on the ground radar which was on trial
basis and used for evaluation and familiarisation
purposes, observed that OY-SIS was entering the
runway At the same time, another aircraft,
HB-VMZ reported Outer Marker on his approach for
landing to runway 36R The Tower controller
informed I-MIRK of the landing time and cleared
him to vacate the runway at its end and asking
him to speed up. The pilot of I-MIRK
acknowledged and requested confirmation about
exiting on R1, since R2 and R3 were closed as per
NOTAM. After a short while I-MIRK reported runway
vacated, but the Tower controller noticing that
the aircraft had entered the (closed) R2 on the
ground radar monitor, advised the pilot that he
was on the wrong taxiway and suggested him on how
to exit from that position re-entering the runway
and proceed to R1. The Tower controller also
advises HB-VMZ to continue the approach and that
he would receive clearance to land on short
final. A few seconds later Tower controller
instructed HB-VMZ to Go-around and perform the
missed approach procedure.
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ANSV conclusions Although comparing the two cases
that ANSV has presented seems inadequate from
many points of view (the severity of consequences
entailed in terms of life toll and catastrophic
damage are not comparable) and considering other
known occurrences, the following is
noted. According to available statistics
regarding the incidence of active Runway
incursions, the following comment becomes
pertinent.   Among other very basic
considerations regarding Airport layout, Airport
Safety Management, ATC procedures and adherence
to strict professional standards by all actors
involved, to prevent active Runway intrusion
occurrences, especially in LVO, the lack of
electro-optic Runway anti-intrusion equipment can
only be substituted by efficient and modern
technology Surface Movement Radar.
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• Safety recommendations issued by ANSV in
  connection to the two
• occurrences described in this presentation dealt
  with
• Usage of the English language in Air/Ground
  communications / Read-back
• Consistency of Aerodrome approved and published
  information with International Standard and
  correspondence between the information published
  and the physical state of Airports - Follow-up
  to a previous Safety Alert issued immediately
  after the accident
• Reporting and registration by ATC of abnormal
  Operational Safety related events
• Professional qualification proficiency and
  recurrence of training for Air Traffic
  Controllers
• Criteria for Aircrafts Ground Movement routing -
  Follow-up to a previous Safety Alert issued at
  first stage of the enquiry
• Applicability of Mandatory Low Visibility
  Procedures
• Recommending the presence of a ground radar to
  avert a potential traffic conflict involving
  aircrafts
• Comment regarding ICAO phraseology as suggested
  in Rules of the Air Traffic Services Hold short
  of may have triggered a mental association
  (mechanism) that lead to the runway incursion

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The following is a statistic of runway
incursion events recorded at Italian airports
over the period Oct 2000 Aug 2002 ANSV
assumes that the list of cases analysed (23) is
not exhaustive of all events that may have
occurred. This may be attributed to operators
reluctance in declaring events and/or lack of
(mandatory) reporting procedures thereof.
Furthermore classification of cases is
sometimes difficult due to lack of sustaining
evidence/information (also attributable to
procedural deficiency in data collection).
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(No Transcript)
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Milan AccidentOctober, 8 2001

• Based on Preliminary information,
• the following has been produced
• in cooperation with SHK-Sweden

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Content
LINATE Airport
Airport markings
Airport view points
Aircraft involved
D-IEVX arrival
Aircraft movements
Wreckage
Preliminary summary
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LINATE Airport
North Apron
West Apron
Main Taxi way
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Airport Markings
North Apron
Main Taxi way
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Aircraft involved
Main Taxi way
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D-IEVX arrival
Main Taxi way
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Aircraft movements
Ground Frequency 121.8 GND DVX taxi north via
romeo five QNH1013 call me back at the stop bar
at the main runway extension DVX Roger via
romeo five and 1013 and call you back before
reaching main runway
Tower Frequency 118.1 TWR scandinavian 686 line
up and wait 36 rightSK686Line up and wait 36
right scandinavian 686(conversation in italian
between TWR and Meri.023)060929 TWR //
scandinavian 686 Linate, cleared for take off 36,
the wind is calm, report rolling. When airborne
squawk ident SK686 Cleared take off 36 set, when
airborne squawk ident and were rolling
scandinavian 686
Ground Freqency 121.8 DVX delta victor xray
approaching sierra four GND delta victor xray
confirm..... your position? 060831 DVX
approaching the runway .... sierra fourGND
delta victor xray roger maintain stop bar I call
you DVX roger hold position (italian
communication with other aircraft) GND delta
victor xray continue your taxi on the main apron
follow the alpha line DVX roger continue taxi on
main apron alpha line delta victor xray GND that
is correct please call me back when entering the
main taxi way DVX will call you on the main taxi
way
Main Taxi way
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Wreckage
North Apron
Reconstruction Hangar
West Apron
Main Taxi way
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Scatter Path
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Park stand
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R5 / R6
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S4 Hdg W
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Romeo 6 - RWY 36R
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Scatter path RWY 36R
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Tracks
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RWY view
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MD87 Cockpit
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Citation wreckage