Presentation to the Canadian Airports Council's Operations, Safety and Technical Affairs Committee
Transportation Safety Board of Canada
Victoria, British Columbia
18 May, 2010
Slide 1 - Runway Safety
Thanks for the introduction Andy and thank you very much for this opportunity to speak today on three significant safety issues identified by the Transportation Safety Board of Canada as posing the greatest risk to Canadians.
Slide 2 - Outline
First I'd like to give you some information about the TSB, our mandate and investigation processes.
After that, I will talk about our recently-released Watchlist, and the safety issues of greatest concern to the TSB which are of particular interest to airports. I will also outline what action the Board would like to see.
Finally, I look forward to hearing your perspective and answering any questions you may have.
Slide 3 - About the TSB
- The Transportation Safety Board was formed in 1990 with the passing of the Canadian Transportation Accident Investigation and Safety Board Act. We conduct independent, expert investigations of selected marine, pipeline, rail and air occurrences.
- A transportation occurrence can be an incident or accident. Incidents generally involve events such as engine failures or risks of collisions, while accidents are more serious, involving serious injury, loss of life or significant equipment damage. The reportable types of occurrences are defined for each transportation mode in the CTAISB Regulations.
- We have approximately 230 employees across the country. The Board currently consists of 5 Board Members, including the Chair.
Slide 4 - TSB Mandate
The TSB's mandate is to advance transportation safety in the air, marine, rail and pipeline modes of transportation . We are not a court, and we do not assign fault or determine civil or criminal liability. We aren't a regulator and we don't have powers of enforcement.
During an investigation, TSB investigators identify safety issues by assessing the technical, operational and human factors related to an occurrence. They then determine what the unsafe acts and conditions are as well as any other underlying factors that might have an influence on safety. From there, they assess the risks, analyze the defences in place as well as any other existing risk control options.
The TSB issues Safety Advisories and Safety Information Letters to notify the industry and regulators as soon as possible when significant safety risks are found during an investigation. The Board issues recommendations to handle more difficult, systemic issues.
Slide 5 - Watchlist
In March 2010, the TSB launched our Watchlist.
These are nine critical safety issues, some of which are mode-specific and some of which apply to all the transportation modes.
These safety issues are tough issues to solve. They are based on our thorough review of accident investigation reports, in particular for recurring incidents/ accidents, Canadian and worldwide statistics, TSB safety communications and outstanding Board recommendations. These are the safety issues which have not yet been fully resolved and which pose the greatest risk to Canadians.
For the purpose of today's meeting, I will concentrate on two of the aviation issues and one multimodal: landing accidents and runway overruns, risk of collisions on runways and Safety Management Systems or SMS.
First, let me talk about landing accidents and runway overruns.
Slide 6 - Watchlist: Landing Accidents and Runway Overruns
Landing is one of the most critical phases of flight and every year millions of aircraft land at Canadian airports. Accidents can happen on the runway or aircraft can fail to stop in time and run off the side or end.
Many of these accidents happen in bad weather. Typically these crews are faced with a dynamic and quickly changing environment requiring split second decision making. In these situations, it is crucial that pilots receive timely information about weather and runway surface conditions to help them make the safest decisions.
Aircraft running off the end of runways is a problem worldwide. The latest figures from the Flight Safety Foundation (May 2009) reveal that almost thirty percent of aircraft accidents between 1995 and 2008 were runway excursions - either overruns or veer offs.
And here in Canada, we have the vivid reminder of the Air France aircraft running off the end of runway 24L at Toronto's Pearson Airport in 2005. Fortunately, nobody died. But this accident taught us hard lessons, which should not be forgotten.
Slide 7 - Runway Overruns: A Worldwide Challenge
According to a 2009 report from the Flight Safety Foundation, between 1995 and 2008, there were 435 landing excursions around the world where an aircraft either overran the end of the runway or veered off to the side.
This translates to roughly 30 runway excursions per year and accounts for 29% of total accidents. Excursions can occur both during takeoff and landing.
Slide 8 - Approximate Runway Overrun Accident Rates
Let's focus now on landing runway overruns.
A 2008 study commissioned for Transport Canada showed that Canada has almost twice the rate of runway overruns per million landings than the world average. Compared with the US, we have almost 3 times the rate of overruns. Note that these statistics are based on transport category aircraft only (jet and large turboprop aircraft over 5700kg./12,500 lbs.)
When it comes to wet runways, Canada has 4 times the number of overrun accidents per million landings than the world average.
While these numbers may not appear to be very big, remember that the consequences can be horrific particularly when a large passenger carrying jet is involved !
Slide 9 - Landing Runway Overrun Accidents Involving Airplanes Over 5,700 kg in Canada, 1989-2006
In the TSB database, there are a total of 11 accidents involving aircraft over 5,700 kg between 1989-2006 where there was at least substantial aircraft damage and, in many cases, injuries.
In Canada, including incidents and accidents, runway overruns occur at a rate of about 2.7 per year for these larger aircraft. So even though the numbers are small, we are all exposed to the possibility of a runway overrun, with as I said earlier, potentially catastrophic consequences.
Slide 10 - Runway Overruns: A Complex Problem
The Board recognizes that runway overruns are a complex problem. Numerous lines of defence are needed to both
- prevent overruns from occurring in the first place, and;
- to prevent injury, loss of life or damage to property or the environment in case an overrun occurs.
To prevent runway overruns from happening in the first place, the Board issued 3 recommendations to enhance operational standards, pilot training and operational procedures as follows:
- That regulators establish clear standards to limit landings in bad weather;
- That pilots receive mandatory training to better enable them to make decisions about landing in deteriorating weather; and
- That crews be required to establish the margin of error between landing distance available and landing distance required before conducting approaches in deteriorating weather.
Our Watchlist also highlights the need for pilots to receive timely information about runway surface conditions in bad weather, as these can significantly affect landing distance calculations.
Slide 11 - What Else Can We Do?
But even if training and procedures go some distance to preventing overruns, they will not eliminate them entirely. James M. Burin of the FSF said that: ...
So what else can be done?
TSB spent considerable time thinking about this very question as have our American counterparts. The Board weighed the risks against the consequences of a large aircraft overrun. The terrain off the end of Canada's runways is not always hospitable.
Slide 12 - Board Recommendation on RESA
Therefore, the Board recommended an additional line of defence. When all else fails, adequate runway end safety areas, or RESAs will greatly increase the chances for an aircraft to stop safely in case of an overrun.
We need a balanced approach. We know that all runways do not present the same risks and that is why the Board's recommendation focused on Code 4 runways at Canada's largest airports. We also understand that it may not be possible to build a 300m RESA (inclusive of 60m runway strip) at the end of all these runways. That is why the Board gave careful consideration to the equivalent level of safety provided by engineered material arresting systems or EMAS.
Slide 13 - Why a 300m RESA?
A 1987 FAA study shows that 90 % of aircraft that overrun runways stop within 1000 feet or approximately 300 metres from the runway end. This conclusion was also re-confirmed in a 2009 study by the ATSB.
The more serious runway overrun accidents occurred because of the insufficient size of overrun areas and a close proximity of urban developments to runway ends. This was a factor in 4 overrun accidents since 1999 in the US, which resulted in 12 fatalities and 185 injuries.
If almost all aircraft stop within approximately 300m from the end of the runway, it only makes sense that we make that area safe for aircraft to stop in case of an overrun.
The 300m RESA also provides additional protection in the event of an under-shoot on final approach or a rejected take-off at high speed.
Slide 14 - RESAs: ICAO Standards
There are a number of different standards for runway end safety areas.
- Today, TC's TP312 only REQUIRES a 60m strip at the end of Code 3 and 4 runways and RECOMMENDS a 90m RESA starting at the end the 60m strip for Code 3 and Code 4 runways (red area).
- The current ICAO STANDARD is for a 90m RESA starting at the end of a 60m strip (red area). Their RECOMMENDATION is for a 240m RESA at the end of the 60m runway strip (blue area).
- The current FAA STANDARD is for a 300m RESA from the end of the runway.
- So let's be clear, TC does not yet meet the current International Standard. Furthermore, TC's response to the Board's recommendation to date has been to say that it plans to consult industry on meeting the 150m requirement (i.e. 90m RESA plus 60 m strip).
- It's unusual for Canada to lag the world in safety. And while we appreciate that TC is taking some action, the Board is disappointed that Canada is still only proposing to go to the current ICAO standard, and only following a lengthy rulemaking process, even as many (e.g. IFALPA) are encouraging ICAO to require a 240 +60= 300m standard. That is why the Board has assessed TC's response as only Satisfactory in Part.
Slide 15 - Engineered Materials Arresting System
An alternative to a RESA, where terrain features don't permit one, is an Engineered Materials Arresting System, or EMAS.
In the United States, EMAS is installed at 44 runway ends at 30 airports, with plans to install 4 EMAS systems at 4 additional airports.
To date, there have been six occurrences in the US where the technology has worked successfully to stop aircraft which overrun the runway and in several cases has prevented injury to passengers and damage to the aircraft.
KGMU= Greenville, S.C. KCRW = Charleston, WVA
Slide 16 - Stopping Aircraft Safely
The Board realizes that RESAs or EMAS involve a significant capital investment, especially in the current economic climate. However, a Flight Safety Foundation study found that between 2005 and 2007, runway excursions cost the aviation industry as a whole $1.5 billion, or $506 million per year. Some of this cost is also shouldered by airports to repair damage, in delays due to downtime and in litigation.
The Board believes it is important for airport operators to assess the risks at each airport with a Code 4 runway and take appropriate action to reduce the potential for serious injuries or deaths.
The Board wants to ensure that the next time we have a large aircraft overrun - and we will - that the aircraft will stop safely without passenger injury or death.
Slide 17 - Watchlist: Risk of Collisions on Runways
Our other airport-related Watchlist issue is the risk of collisions on runways, or runway incursions.
The likelihood of a collision on runways at Canada's airports is low. However, should two aircraft collide, or an aircraft collide with a vehicle - the consequences could be catastrophic. That is why this issue is on our Watchlist.
Slide 18 - Runway Incursions
ICAO defines a runway incursion as:
"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 take-off of aircraft."
Slide 19 - Runway Incursions
There were 3831 runway incursions between 1999-2008 in Canada. That's approximately one per day.
Slides 20 - Runway Incursions: Causes
There are many causes and contributing factors for runway incursions. Many stakeholders, including airports, play a role in reducing them.
Runway incursions can be caused by factors such as:
Lack/loss of situational awareness
- Circling approaches at night (e.g. only one precision approach at airport);
- Intersection of multiple taxiways and runways;
- Visual contrast taxiways vs. runways
- Use of oblique or angled taxiways to line up or cross runway by both aircraft and ground vehicles
Deficiencies in signs, markings and lighting
- Snow covered signs and markings
- "Sea of lights" at night
Unclear or non-standard communications/phraseology
Lack of warning systems
- Incursion alerting on ASDE not used or not available
- Stop bars used only during low visibility operations or not available
Slide 21 - Runway Incursions: Potential Defences
In our Watchlist, we called for improved procedures and enhanced collision warning systems to reduce runway incursions in Canada.
Some available options
- Runway status light systems
- Final approach runway occupancy system
- "Low cost" surface surveillance technology
- Using tools/procedures from low-visibility operations, such as stop bars.
Runway safety teams
Two (or more) heads are better than one
"The primary role of a local Runway Safety Team, which may be co-ordinated by a central authority, should be to develop an action plan for runway safety, advise the appropriate management on the potential runway incursion issues and to recommend mitigation strategies." (ICAO Manual for Preventing Runway Incursions)
Slide 22 - Watchlist: Safety Management Systems
The last safety issue, which is related to the others I spoke about earlier, is the implementation of Safety Management Systems, or SMS.
SMS is an internationally recognized management tool to proactively manage safety risks. A well-functioning safety management system integrates sound risk management policies, procedures and practices into a company's day-to-day operations.
Put simply, SMS is a tool that help organizations find trouble before trouble finds them. They help companies foresee what might go wrong so they can take pre-emptive action.
The Transportation Safety Board has emphasized the advantages of SMS. However, we have found during our investigations in all the modes that their implementation and regulatory oversight of SMS has been problematic in the transportation industry.
The Board believes that airport operators can and should apply your SMS to thoroughly assess the risks of runway overruns and runway incursions. This will help you clearly quantify the risks and decide how best to manage and mitigate those risks.
Slide 23 - Summary
- The Board is pleased with how the lessons learned from the thousands of accidents we have investigated have made transportation safer.
- We know these outstanding safety deficiencies are complex and require a multi-faceted approach from multiple stakeholders. However, we also know from hard experience that if a persistent safety problem is not addressed, there will be another accident.
- Airports can play an important role in reducing runway overruns and runway incursions and we believe a well implemented SMS can help you get there.
Slide 24 - More Action Required
In conclusion, the Board believes more can be done to improve runway safety.
We would like to see Transport Canada and airport operators undertake a formal risk assessment of all Code 4 runways in Canada to see which ones pose the greatest risk, and then develop appropriate mitigations to reduce these risks.
With respect to runway incursions, the Board would like to see more pro-active steps taken to reduce the risk such as avoid vehicle crossings mid-runway.
These are two areas where we believe you could make very effective use of your SMS to quantify the risks and develop mitigation strategies in concert with other stakeholders.
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