A18-05 – “The Board recommends that: the Department of Transport 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.”
Transport Canada's response to recommendation A18-05
Transport Canada (TC) agrees in principle with the recommendation.
Given the potentially catastrophic consequences associated with runway incursions, TC believes that continued efforts to further reduce the likelihood of these serious occurrences are warranted. The report identifies actions already taken by multiple stakeholders, including operators, the airport authority and NAV CANADA to mitigate the risks of runway incursions in the South Complex. The report also states that, post-landing checks are “usually brief and occupy only a small amount of one or both of the flight crew member’s attention” (Section 4.2.2) and there are many factors that crews will take into account in managing the timing of these checks.
As such, a blanket provision requiring crews to delay post-landing checks could also introduce additional risks to the system. For example, during winter weather, delaying the retraction of flaps and spoilers could lead to issues related to contamination of retraction mechanisms.
TC believes that the most effective means to prevent these and other incidents is to provide crews with the information to proactively manage threats in their operating environment. To this end TC has:
- Incorporated Threat and Error Management (TEM) as a key component of AC 700-042 Crew Resource Management (CRM)Footnote 1. In keeping with the latest developments in CRM training, crews will receive regular training in threat and error management to assist with the identification and analysis of potential hazards and the implementation of appropriate strategies to handle threats.
- Consulted with airline operators on this recommendation to ensure they are aware of the potential for runway incursions in the South Complex at CYYZ and continue to monitor the situation through their Safety Management Systems (SMS). These consultations served to confirm that operators have best practices for preventing runway incursions incorporated into their SOPs (e.g., briefing of hot spots in the taxi route; both crew members to be heads up approaching and crossing a runway). These consultations also indicated that several major operators SOPs already include provisions for timing checks once cleared of both parallel runways. TC will continue to work with operators to monitor the effectiveness of operator SOPs in the prevention of runway incursions in the South Complex.
- Consulted with counterparts at the Federal Aviation Administration (FAA). TC facilitated identifying the United States operators who were predominantly involved in these occurrences so that the FAA flight operations inspectors were able to effectively target their follow up activities.
Furthermore, the report identifies the role of flight crew expectancy as a principal contributor to these runway incursions. Simply stated, the crews involved were aware of the need to hold short of runway 24R/06L and were planning to do so, but were not expecting to reach the hold line as quickly as they did. Section 3.1.2 identifies the following contributing factors:
- All crews involved were aware of need to stop but did not recognize the hold line position (Finding 1);
- Airport charts included general warnings of incursions in these locations but “lacked sufficient information to impart a clear understanding of the risk or lead the crews to take effective mitigating measures.” (Finding 2);
- Operator SOPs did not require crews to discuss how situations would be addressed in approach briefs (no management of threats) (Finding 3). As a result, crews did not adjust normal routines and one crew member was heads down when approaching the hold line (Finding 4);
- Many operators had SOPs requiring both crew members to be heads up approaching hot spots and runway crossings (Finding 5);
- Due to the uncommon location of runway holding positions crew members who were looking outside were not looking in the right place for hold lines and available visual cues were dismissed because they did not conform to the crew’s mental model of the situation (Findings 6 and& 7).
These findings emphasize that being heads up is important, but not sufficient, to prevent these types of runway incursions. Crews must be anticipating the need to stop at the appropriate hold location. The role of crew expectations is also demonstrated by the fact that Canadian operators were under-represented in these occurrences with only 5 of the 27 occurrences examined involving Canadian operators.
Recognizing the multiple causal factors that contribute to this safety issue, TC recognizes the importance and will continue to work with airports, NAV Canada, and airlines to look at other opportunities to reduce the number of incursions.
We thank the TSB for their comprehensive work on this important issue and we continue to work with stakeholders to reduce the risks associated with runway incursions.