Torqued: In Safety Reports, the Devil Is in the Details

 - March 4, 2019, 6:00 AM

I know we all face such a daily torrent of information that it’s difficult to keep up with our own work information, let alone the news of what’s happening around us. That includes the aviation career fields that we are in or even the airports we fly into. Some people have described the information overload as trying to drink water out of a fire hose. Sometimes I feel like I’m trying to drink straight out of the hydrant. Yet, even with all this gush of information, it’s important to stay up-to-date with what’s happening in the world of aviation and sometimes to seek out even more information to get an accurate picture. It might help our own operations avoid a costly or even tragic error.

I encourage my students at Vaughn College of Aeronautics and Technology to look beyond news reports and, if it’s a subject they’re interested in, to try to find the original source documents. The media’s depictions have their own particular slant and shortcuts and usually do not give enough technical information for those of us in the field. I was thinking of the importance of reading original reports as I was reading an article sent to me by a Canadian friend. It discussed the unusual number of runway incursions at Pearson International Airport in Toronto involving its parallel runways and a Transportation Safety Board report analyzing the problem and proposing recommendations. The Canadian TSB is an independent safety agency, the equivalent of the U.S. NTSB.

A few things caught my attention in the article. One was the high number of runway incursions over a five-year period. Both the U.S. and Canada use the International Civil Aviation Organization’s definition of runway incursion: 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.

According to the article, between June 2012 and November 2017, there were 27 runway incursions at Pearson, Canada’s busiest airport, involving its parallel runways. As a student of human factors, I was intrigued by the quote from the chairwoman of the TSB: “All 27 incursions examined involved flight crews who understood they needed to stop, and that they were approaching an active runway.” Even though they had this critical information, they still failed to avoid entering an active runway without air traffic control clearance. This made me curious to find out what exactly was going on with the flight crews in the cockpit that this happened so many times. 

I was also curious to see that one of the three recommendations made by the TSB was specifically directed at the FAA. So I sought out the Board’s actual report on runway incursions for more information. The incursions studied in the TSB report related only to aircraft and specifically to aircraft that landed on the outer runway, exited on one of the rapid-exit taxiways, and did not hold short of the inner runway at the designated holding position. These incursions were deemed to pose the highest risk of collision between aircraft. While there were other runway incursions at Pearson during this time frame, they were not analyzed in this report. The TSB chose to analyze these specific runway incursions because of their numbers and similarities. And to determine their “systemic underlying causes and contributing factors and to assess the degree of ongoing risk.” 

Specific Crews Involved

What struck me immediately on reading the report was this note in the executive summary: “Regional airlines that are based in the United States and that operate regional jets were involved in a disproportionate number of the incursions, both in total and in terms of the rate of incursions per landing. This was likely due to foreign flight crews being unfamiliar with the uncommon taxiway layout between the parallel runways at CYYZ and to the increased speed at which their smaller aircraft types often approached the runway holding positions.”

Nowhere in the media reports that I had seen was this fact mentioned—that the overwhelming number of these incursions (22 out of the 27 studied)—were by U.S.-based airlines. Of the most recent incursions, 10 out of 11 were by U.S. regional airlines. And, of course, that’s why one of the recommendations was addressed to the FAA. I’m not sure why this was not highlighted in the Canadian news reports. 

The report found that notwithstanding the fact that all the flight crews had been instructed by air traffic control to hold short of the runway, and despite intending to stop, the crews “had missed the visual cues identifying the respective locations of the runway holding positions.” To pass the runway holding positions, the flight crews had missed the runway “elevated signage, elevated stop bars, runway guard lights, painted mandatory hold signage, enhanced taxiway centreline lighting, enhanced holding position markings, and illuminated stop bars.” That’s a lot of visual cues to miss.

The TSB recognizes the number of changes made over the years to try to reduce the number of runway incursions at this location, including all the visual cues referenced above. However, since implementing all these strategies has not been successful, the TSB believes physical changes to the taxiway layout are necessary to reduce the risk.

Since any physical changes to the airport will take time, if they’re ever made, the TSB recommends additional, interim measures including the recommendation that the FAA: work with operators to amend standard operating procedures so that post-landing checks are sequenced only after landing aircraft are clear of both active runways when closely spaced parallel runway operations are in effect, rather than the current common practice of sequencing the checks once landing aircraft are clear of the landing surface.

It seems to me that this is information regional airlines, especially those flying to Toronto’s Pearson International Airport, should know and consider; notwithstanding what the FAA ultimately decides to do. It’s never too early to implement safety recommendations that could improve your operations and avoid a catastrophic runway incursion.


Interesting to learn that the TSB has jurisdiction over the US-"TSB was specifically directed at the FAA."

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