Runway Excursion Risk Management Process (RMP)

Transcription

1 Runway Excursion Risk Management Process (RMP)

2 NOTE DISCLAIMER. The information contained in this publication is subject to constant review in the light of changing government requirements and regulations. No subscriber or other reader should act on the basis of any such information without referring to applicable laws and regulations and without taking appropriate professional advice. Although every effort has been made to ensure accuracy, the International Air Transport Association and the contributors to this publication shall not be held responsible for any loss or damage caused by errors, omissions, misprints or misinterpretation of the contents hereof. Furthermore, the International Air Transport Association and the contributors to this publication expressly disclaim any and all liability to any person or entity, whether a purchaser of this publication or not, in respect of anything done or omitted, and the consequences of anything done or omitted, by any such person or entity in reliance on the contents of this publication. The International Civil Aviation Organization (ICAO) and other contributors opinions expressed in this publication do not necessarily reflect the opinion of the International Air Transport Association. The mention of specific companies, products in this publication does not imply that they are endorsed or recommended by the International Air Transport Association in preference to others of a similar nature which are not mentioned. International Air Transport Association 20. All Rights Reserved. No part of this publication may be reproduced, recast, reformatted or transmitted in any form by any means, electronic or mechanical, including photocopying, recording or any information storage and retrieval system, without the prior written permission from: Senior Vice President Safety, Operations and Infrastructure International Air Transport Association 800 Place Victoria, P.O. Box 3 Montréal, Québec Runway Excursion Prevention (RMP) 2 RERR 2 nd Edition

3 RUNWAY EXCURSION RISK MANAGEMENT PROCESS Introduction This document provides an example process for an operator to use in assessing, and more significantly, reducing their risk of a runway excursion. A fundamental element of an effective Safety Management System is the development and utilization of a Safety Risk Management Process (RMP). The International Civil Aviation Organization (ICAO) Safety Management Manual 2 (SMM) states that: Safety risk management is a generic term that encompasses the assessment and mitigation of the safety risks of the consequences of hazards that threaten the capabilities of an organization, to a level As Low As Reasonably Practicable (ALARP). The objective of safety risk management is to provide the foundation for a balanced allocation of resources between all assessed safety risks and those safety risks where the control and mitigation are viable. There is no expectation that all safety risks can be mitigated 00%; however, hazards can be systematically identified, risks assessed and mitigated to a low level of residual risk through analysis. As such, an operator should strive to identify hazards, measure their risk and (if applicable) implement mitigation strategies to eliminate or reduce the risk to a tolerable level. In some cases, hazards can be completely eliminated (e.g., removing an obstacle near a runway), or avoided (e.g., prohibiting use of a specific runway). In any case, safety risk management should become a routine process in normal operations. The RMP in this document is focused on the risk of a runway excursion. This RMP can also be used as an example process for assessing any type of risk in many operational arenas. The identified hazards in these tables are not an exhaustive list, nor do all of the potential hazards apply to all operators, operations, or airfields. This RMP provides guidance for a systematic approach to the identification, assessment and management of static and dynamic factors, which have historically been shown to increase the risk and/or severity of runway excursion events. A number of different areas contribute to the total risk of a runway excursion. These areas have been divided into the following categories: A. Organizational risk factors B. Airfield strategic risk factors (planning factors) C. Day of operations risk management D. Tactical Interventions for Pilots in Response to Changing Risk Factors Runway Excursion Prevention (RMP) 3 RERR 2 nd Edition

4 This guidance is not exhaustive and is designed to be used as the basis for an operator to optimize a risk management system tailored to their operation, and suited to the unique characteristics of their specific operation. Use of this guidance constitutes a significant step in understanding and managing the runway excursion risks associated with approach, landing and take-off. In any case, the lists in these example tables should not be considered as the only conditions that need to be assessed, as every operator may experience a different set of conditions. Please note that operational personnel (e.g., flight crews and dispatchers) are an essential component in reducing risk. Each operator should look at their own data (or industry data such as provided by the IATA Global Safety Information Center, or GSIC) or other industry sources to determine the probability of specific risks. Pair this with the estimated severity of the occurrence and a qualitative index can be created that identifies when mitigations are required. This prioritizes the risks for the carriers based on their own observations. Data, whether internal or external, is to be used to determine both probability and severity for the calculation of a risk score. The Risk Scores may be determined by different means; however it is critical that they are applied consistently throughout an organizational risk factor assessment. The risk scores in the following tables were estimated to provide a relative value, and are categorized below: Risk Score Risk High 2 Medium 3 Low Runway Excursion Prevention (RMP) 4 RERR 2 nd Edition

5 Table A Organizational Risk Factors The policies and practices of an organization and its management directly impact upon the magnitude of runway excursion risk exposure, and the ability to identify and manage that risk. Front line personnel are uniquely qualified to observe and report potential threats before they manifest themselves as events, and lessons can be learned from errors which did not actually translate into events, but could if repeated in the future. Neither of these valuable sources of information will be available to management or to other personnel if the prevailing corporate culture does not actively encourage open reporting in a non-punitive environment. Corporate policies with regard to go-arounds and on-time performance will directly affect the behavior of personnel in the way they make operational decisions. The value of flight data analysis and line employee reporting as a risk identification and management tool cannot be over-estimated. It is vital that they are utilized in a non-punitive manner. Note that each of these conditions includes one or more suggested mitigations which are by no means the only solution. Table A Organizational Risk Factors Condition Effect Risk Score (add) A. Potentially punitive response to reporting of errors, incidents and operational threats Diminished access to front line information on threats and errors, which increase the risk of runway excursions Potential mitigations: Corporate policy supporting an open reporting culture and education process to mitigate punitive responses A2. Potentially punitive response to Increased likelihood of approaches and go-around landings continued when the conditions indicate a go-around Potential mitigations: Eliminate required go-around reporting; or go-around reporting provided only to the safety organization, who follow up on causual factors A3. Strong corporate emphasis on on-time performance (without a balanced message regarding safe operational limits) Increased likelihood of approaches and landings continued when the conditions indicate a go-around, or take-offs commenced when the conditions indicate a delay Runway Excursion Prevention (RMP) 5 RERR 2 nd Edition

6 Potential mitigation: Corporate policy recognizing a safety first culture where weather conditions requiring delays are categorized as un-avoidable A4. No flight data analysis (FDA) No empirical feedback of operational program or FDA does not include performance during approach, landing and critical excursion risk factors take-off, from which to identify and manage (touchdown point/attitude, approach risk speed, use of retardation devices etc) Potential mitigation: Implement a FDA program that identifies these risk factors and utilizes flight crew expertise in identifying areas of risk A5. No feedback to pilots from FDA Diminished risk awareness program Potential mitigation: Implement a FDA program that identifies these risk factors and provides direct feedback of performance to line crews, identifying runways with the highest risk A6. No on-going process to identify airfields with inherent critical excursion risks Diminished risk awareness and strategic excursion risk management opportunity Potential mitigations: Implement a two tier process. First step is to assess all runways against all types of aircraft, identifying where takeoff and landing margins are lowest. Operational changes may be necessary. Second step is to ensure that changes in the operation are identified and addressed (such as runway construction, new types of operations, etc). A7. No process to promulgate up-todate identified critical excursion risks personnel Diminished risk awareness by line (NOTAMs, company bulletins) Potential mitigations: Feedback process established for flight dispatch and line crews identifying and tracking increased risks; for high risks, a direct link should be established, such as a required chief pilot briefing or a call to flight dispatch A8. No reporting system, or no follow up system, for line personnel to report hazards Diminished risk awareness. Management may be unaware of the hazards and unable to proactively reduce risk Potential mitigation: Establish effective reporting systems for all operational employee groups, and ensure that there is adequate follow up to reports Total score Goal: The goal in this area should be zero. Runway Excursion Prevention (RMP) 6 RERR 2 nd Edition

7 Table B Airfield Strategic Risk Identification The guidance in Table B allows for the identification and evaluation of individual and cumulative static airfield factors, which contribute to increased runway excursion risk. It only addresses factors specific to excursion risk but could also be used as the starting point of a system to identify critical airfields from an overall risk perspective, by including high terrain, limited ATC capabilities, or other environmental risks. The risk scores for each condition are totaled to determine the overall inherent risk score. In some cases the scores should probably be multiplied to more accurately reflect the impact of cumulative risk factors but the variables are too complex to quantify easily. The total score is indicative of the magnitude of the risk and thereby the caution with which operations to or from the airfield should be approached (from an excursion risk perspective only). Note: These scores are IATA recommendations; and may be modified by operators to suit the specifics of their unique operations based on objective data. Table B Airfield Strategic Risk Identification Condition B2. One regularly active runway with short or no RESA, and/or critical overrun characteristics (water, cliff, buildings etc) xx. Vertical obstacles on the approach (buildings, ships, etc), or required turns on short final B3. Single one-way runway (obstacle at one end) B4. Local restrictions (e.g., noise) require non-optimum landing runway choice B5. No PAPI/VASI or glide slope visual reference B6. Runways not grooved, runway subject to flooding due to grading Effect Potential for catastrophic outcome from overrun Potential for deep (long) touchdown No choice for landing or take-off direction; may result in tailwind operations Limited choice for landing direction Difficulty judging final approach trajectory and touchdown point Potential for water contamination, or slow draining following rain Risk Score (Add) Runway Excursion Prevention (RMP) 7 RERR 2 nd Edition

8 B7. Unreliable wind indication from ATC or airfield meteorology office B8. Non-precision approach only (no ILS available) B9. Non-precision approach (NPA) only to at least one regularly active runway B0. Visual approach only to at least one regularly active runway (no approach aids) B. Airfield elevation > 3,000 feet amsl B2. Density altitude > 5,000 feet amsl Potential for unknown crosswind/tailwind conditions Increased likelihood of 2 unstabilized approach Potential for NPA Increased likelihood of unstabilized approach Increased inertia, increased TAS/groundspeed, and difficulty controlling flare/touchdown Increased inertia, increased TAS/groundspeed, and difficulty controlling flare/touchdown B3. No approach lighting Difficulty establishing runway centerline early xx. No touchdown markings Difficulty achieving touchdown at the desired point B3. Airfield subject to severe Potential for turbulence, weather windshear, strong surface winds, heavy rain, poor visibility, runway contamination Xx Unreliable or inaccurate winter Potential for unexpected low contamination reporting (apply friction conditions seasonally) Total score Runway Excursion Prevention (RMP) 8 RERR 2 nd Edition

9 Table C Day of Operations Risk Management Starting with the inherent risk category from Table B, Table C lists a number of dynamic conditions likely to further increase the runway excursion risk, which can be identified on the day of operations. In isolation the increased risk from each individual condition can probably be regarded as small, although it should never be ignored, but in combination the cumulative risk should be seen as significant. Once a group of contributory conditions has been identified, efforts should be made prior to dispatch to mitigate and manage as many of the conditions as possible, by changing aircraft, changing crew or updating the airfield runway excursion risk category to reflect the situation. The crew should be made aware of the risk assessment and any operational changes made in response to it, in case there has been an unforeseen or inadvertent associated increase in risk as a result. Note: These scores are IATA recommendations; and may be modified by operators to suit the specifics of their unique operations based on objective data. Runway Excursion Prevention (RMP) 9 RERR 2 nd Edition

10 Table C Day of Operations Risk Management Condition Effect Score C. Airfield identified as having Inherent airfield risk increased excursion risk from Table B C2. Pilot not familiar with airfield and Reduced threat awareness and no adequate airfield briefing facility increased workload C3. Pilot new to aircraft type and/or Reduced threat awareness and new to role increased workload C4. Approach or take-off scheduled Reduced alertness/increased during circadian low likelihood of error C5. Approach or take-off scheduled Reduced alertness/increased following long duty period likelihood of error C6. Landing planned at or close to Increased inertia, increased MLW (eg. fuel tankering) approach speed, greater landing distance required C7. Retardation systems partially inoperative (spoilers, autobrake/brakes, antiskid, both reversers) Increased landing and accelerate/stop distance C8. One reverser inoperative Impaired directional control, increased landing and accelerate/stop distance C9. NOTAMS affecting serviceability of approach aids/lighting C0. NOTAMS affecting runway closures C. NOTAMS for work in progress affecting declared runway distances Degraded approach quality not identified by strategic risk assessment Reduced choice of runways not identified by strategic risk assessment Increase in excursion risk not identified by strategic risk assessment Total Score Runway Excursion Prevention (RMP) 0 RERR 2 nd Edition

11 Table D Tactical Interventions for Pilots in Response to Changing Risk Factors Table D recognizes that notwithstanding any assessment of static and dynamic risks prior to the flight, the final assessment and management of risk lies with the crew. By this stage of the flight it is probably too late to make substantial operational changes and the management of risk becomes heavily dependent upon recognition, awareness and preparation. The recommended pilot interventions rely heavily upon accurate and appropriate calculation of take-off and landing performance and maximizing the use of retardation devices in a timely manner. They also focus on ensuring a shared understanding of what parameter values are acceptable and the intended course of action should they become unacceptable. Table D Tactical Interventions for Pilots in Response to Changing Risk Factors Condition Effect Intervention D. En route system failure affecting retardation devices (spoilers, autobrake/brakes, antiskid, both reversers) D2. En route system failure affecting one reverser D3. En route system failure affecting high lift devices (slats/flaps) D4. En route failures affecting serviceability of approach aids or lighting Increased landing distance Recalculate landing performance, consider availability of longer runway, brief changes to landing SOP Impaired directional control, increased landing distance Recalculate landing performance, consider availability of into wind runway, brief changes to landing SOP Increased Recalculate landing approach/landing speed, performance, consider increased landing distance availability of longer runway, brief changes to landing SOP Potentially degraded Consider and brief impact approach quality on approach type, approach stabilization and excursion risk Runway Excursion Prevention (RMP) RERR 2 nd Edition

12 D5. Assigned runway landing distance < calculated landing distance required + 25% D6. Crosswind component > 5 knots D7. Tailwind component > 5 knots D8. Visibility < half runway length D9. Reported windshear and/or turbulence on final approach D0. Any meteorological condition within 20% to minima or operating limits Reduced landing distance margin Directional control and attitude during flare, touchdown and roll out Increased groundspeed, increased landing/take-off distance, risk of long flare Generic metric relative to judging trajectory on final approach Maximize retardation and brief for immediate deployment on touchdown Brief crosswind takeoff/landing and roll out technique Maximize retardation and brief for immediate deployment on touchdown/rto, define conditions for go-around from long flare Brief anticipated visual picture on final approach Control of final approach Brief windshear recovery trajectory and landing, and define conditions for increased go-around, recalculate approach/landing speed, landing performance increased landing distance Possibility that local variations include conditions below minima or outside operating limits D. Wet runway Impaired stopping performance D2. Contaminated runway Impaired stopping performance D3. Unplanned extension Reduced alertness and of duty period potential for error Consider delaying approach/take-off if conditions forecast to improve Consider maximizing retardation and brief for immediate deployment on touchdown/rto Maximize retardation and brief for immediate deployment on touchdown/rto, brief for directional control on slippery runways Consider implications for human performance and increased likelihood of errors Runway Excursion Prevention (RMP) 2 RERR 2 nd Edition

13 Total Score: One technique in reducing risk is to perform an initial assessment, and then a second assessment, after risks have been mitigated. Note that the table below allows an operator to determine where in the operation the remaining risk, and risk reduction opportunities, remain. Initial Risk Assessment Risk Table A: Corporate risk factors Score Table B: Airfield strategic risk factors (planning factors Table C: Day of operations risk management Total score for a specific operation before risk reduction After risk reduction actions, the scores can be reassessed again to determine the areas where risk remains. Final Risk Assessment Risk Table A: Corporate risk factors Score Table B: Airfield strategic risk factors (planning factors Table C: Day of operations risk management Total score for a specific operation before risk reduction