MODULE 19

RUNWAY INCURSIONS

Table of Contents

Session plan ........................................................................................................................ 2

Runway Incursions ............................................................................................................. 3
Defining runway incursion ......................................................................................... 3
Case study - Milano-Linate runway incursion ........................................................... 5
Runway incursion risk factors ........................................................................................ 11
Actions to prevent runway incursions ..................................................................... 12
References ........................................................................................................................ 13
Web ........................................................................................................................... 13

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Module 19

Runway Incursions

Session plan

Module no 19

Module title Runway Incursion

Duration 1 hour

Optimal class size 6 to 12

Learning On completion of the module the student will understand the hazards of runway
Objectives incursion, be able to identify risk factors and strategies for reducing the risk.

Delivery method Facilitation

Trainer Trainer to have completed 5 day CRM Trainer core course.

qualifications

Student None
prerequisites

Trainer materials PowerPoint

Whiteboard
Flipchart

Participant Handout: N/A

materials

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Runway Incursions
Slide – Header slide

Slide - Objective

Defining runway incursion

The definition of runway incursions determined by ICAO and generally accepted by leading
Regulators since 1st January, 2007 is:

“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 an aircraft.”

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Slide - Definition

The cost of runway incursions is sometimes measured in human lives. This is a particularly
valid CRM subject as it involves effective liaison with ground personnel that may or may
not have been trained in Human Factors awareness and the subsequent
miscommunications that could result. Also, incursions may occur in relatively unfamiliar
airports and reduced environmental conditions.
An accident often cited as one of the pivotal events in the development of CRM resulted
from a runway incursion in 1977, in Tenerife.
We may classify runway incursion incidents into three types:

Slide – Classified into 3 types

In some circumstances safe principles may be forgotten as we become captured by

events, or may have become the accepted operating practices away from our base. An
incursion may be the result of a combination of misunderstandings, incomplete or
inadequate communication, procedural failures or greater systemic and latent
breakdowns.
Nobody ever sets out to have this form of accident.

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Case study - Milano-Linate runway incursion

Slide - Case study - Milano-Linate runway incursion

On 8th October 2001. A brand new Cessna 525A Citation Jet 2, D-IEVX, arrived at Milano-
Linate International Airport following a flight from Köln, Germany. The Cessna was to carry
out a return flight to Paris-Le Bourget, with two pilots, a Cessna sales manager and a
prospective customer. The plane arrived at 06:59 and was taxied to the general aviation
apron, also known as “West apron” (See diagram below). It was a foggy morning at Milano-
Linate International Airport and one of the passenger flights parked on the “North apron”
was SAS MD-87 flight SK686, which was being prepared for a flight to Copenhagen,
scheduled to depart at 07:35 local.

Slide – Overview

At 07:41, the pilot of the MD-87 SK686 contacted Linate Ground Control for engine start
clearance, as the boarding of 104 passengers had been completed. The Ground Controller
cleared the pilot to start engines and advised that the slot time for takeoff of the flight was
at 08:16. Thirteen minutes later flight SK686 was cleared to taxi to runway 36R:
“Scandinavian 686, taxi to the holding position Cat III, QNH 1013 and please call me back
entering the main taxiway.”

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At 07:58, the Cessna Citation pilot requested permission to start the engines. The Ground
Controller then gave start-up clearance. The Ground Controller then requested flight
SK686 to contact the Tower Controller. From this moment on, the MD-87’s crew and the
Cessna’s crew were tuned on two different radio frequencies. At 08:05 the pilots of the
Cessna received taxi clearance: “Delta Victor Xray, taxi north via Romeo 5, QNH 1013, call
me back at the stop bar of the main runway extension.”
The pilot acknowledged by saying: “Roger via Romeo 5 and ... 1013, and call you back
before reaching main runway.”
The Cessna started to taxi from the general aviation parking position, following the yellow
taxi line. After reaching the position where the yellow taxi line splits into two diverging
directions, the pilot erroneously took the taxi line to right and entered taxiway Romeo 6
(South-east bound not Northbound).
Opportunities were missed to clarify the current position of D-IEVX with unexpected
stop/hold sign (S4) reports and also communication with another taxing aircraft occurring
in Italian. At 08:09 the Ground Controller cleared the Cessna to continue its taxi on the
Main Apron.

Slide – Divergent taxiway markings

At the same time the Tower Controller cleared the MD-87 for takeoff: "...Scandinavian 686
Linate, clear for takeoff 36, the wind is calm report rolling, when airborne squawk ident."
The pilot advanced the throttles and acknowledged the clearance: "Clear for takeoff 36 at
when...airborne squawk ident and we are rolling, Scandinavian 686." When the MD-87
was speeding down the runway, the Cessna crossed the runway holding sign and entered
the active runway 18L/36R.
At 08.10:21 the nose landing gear of the MD-87 had left the ground and main gears were
extending the shock absorbers but the main wheels were still on the ground at airspeed of
146 kts.
At that moment the MD-87 crew probably saw a glimpse of the Cessna through the fog and
reacted with additional large nose-up elevator. At that moment the MD-87 collided with the
Cessna Citation Jet. The right wing of the MD-87 sustained damage at the leading edge
and the right hand main landing gear leg broke off. It damaged the right flap and struck
the number 2 engine which then separated from the pylon.

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The pilot of the MD-87 gradually advanced the throttles and then the aircraft was airborne
for a total of 12 seconds, reaching an estimated height of about 35 feet (11 metres). The
left hand engine suffered a noticeable thrust reduction as a result of debris ingestion,
which became insufficient to sustain flight.
The airspeed had increased up to 166 kts, but the MD-87 descended abruptly making
contact with the runway with the left hand main gear, the truncated right hand main gear
leg and the tip of the right hand wing. Prior to touch down the pilot reduced engine thrust
and after ground contact the engine reverse levers were activated and deployed. Only the
left hand engine functioned. Maximum available reverse thrust was selected and the
brakes applied. The plane skidded past the grass overrun area, across a service road,
crashing sideways into a baggage handling building, which partly collapsed. This building
was located 20m to the right of the runway and 460m from the runway end.

Slide –MD 87 after the event

Both aircraft were destroyed and all 114 aircraft occupants died. In the baggage handlng
building, 4 people died and another 4 people suffered serious injury and burns.

Slide - Diagram of the sequence of events

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 Flight SK686 taxied to the holding point for runway 36R. Heavy fog had
delayed the flight by more than one hour. The visibility was improving,
but RVR was still only 225 metres.
 The Cessna Citation parked at the West Apron was cleared to taxi via
taxiway Romeo 5 and to report reaching the first holding point. The pilot
read the clearance back correctly, but entered taxiway Romeo 6.
 The Cessna Citation’s pilot called for clearance to proceed from the
Romeo 5 holding point though it was in fact at the Romeo 6 holding
point.
 Flight SK686 was cleared for take-off.
 The Cessna Citation crossed the holding point for runway 36R-18L.
 The two aircraft collided.
 The MD-87 skidded off the runway into a baggage handling building
adjacent to the passenger terminal.

Slide Sequence of events

Slide Sequence of events

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The primary cause for the accident was the runway incursion into the active runway by the
Cessna Citation. However the human factor related actions of the Citation crew during low
visibility conditions must be considered in the context of the situation that prompted this
course of events that led to the fatal collision. The system in place at Milano Linate Airport
at the time was not effective to trap misunderstandings, let alone inadequate procedures,
human errors and faulty airport layout.

Slide – Immediate causes

Slide – Immediate causes cont.

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Slide – Systemic causes

Slide – Systemic causes cont.

The following list highlights the immediate and systemic causes that led to the accident:
 The ground visibility was low, between 50 and 100 meters.
 The traffic volume was high.
 The lack of adequate visual aids.
 The Cessna Citation crew used the wrong taxiway and entered the
runway without specific clearance.
 The failure to check the Citation crew qualification enabling operations
in low visibility (IFR Rated to ILS Cat I approach down to minimum
visibility of 550m).
 The nature of the flight might have exerted certain pressures on the
Citation crew to commence the flight despite the prevailing weather
conditions.
 Official documentation failed to report the presence of unpublished
markings (S4, S5, etc.) that were unknown to air traffic managers, thus

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preventing the ATC staff from interpreting the ambiguous information

from the Cessna Citation crew, a position report mentioning S4.
 The Citation crew was not aided properly with correct publications (AIP
Italy- Jeppesen) lights (red bar lights and taxiway lights), markings (in
deformity with standard format and unpublished, S4) and signs (non-
existing TWY R6) to enhance their situational awareness.
 Radio communications were not performed using standard phraseology
(readback) or were not consistently adhered to (resulting in untraced
misunderstandings in relevant radio communications).
 Operational procedures allowing high traffic volume (high number of
ground movements) in weather conditions as were current the day of
the accident (reduced visibility) and in the absence of technical aids.
 Radio communications were performed in Italian and English language.
 ATC personnel did not realize that Cessna Citation was on taxiway
Romeo 6.
 The ground controller issued a taxi clearance toward north (main)
apron although the reported position S4 did not have any meaning to
him.
 Instructions, training and the prevailing environmental situation
prevented the ATC personnel from having full control over the aircraft
movements on ground.
 The aerodrome standard did not comply with ICAO Annex 14; required
markings lights and signs did not exist (Romeo 6) or were in dismal
order and were hard to recognize especially under low visibility
conditions (Romeo 5 - Romeo 6), other markings were unknown to
operators (S4).
 The competence maintenance & requirements for recent experience
for ATC personnel did not comply fully with ICAO Annex 1.
 The Low Visibility Operations implementation by ENAV did not conform
to the requirements provided for in ICAO Doc 9476.
 No functional Safety Management System (SMS) was in operation.

Runway incursion risk factors

Most Runway Incursions are caused by Human Error, but we can identify significant risk
factors:
 Low visibility.
 Night.
 Operations at complex and/or unfamiliar airports.
 Poor airport geometry.
 Cockpit distractions.

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Actions to prevent runway incursions

Question

What can prevent other incursions at airports?

Answer

Significant research and activities by National Authorities continue to address the issue. A
survey of incursion factors from UK CAA data September 2006-2007 expressed specific
aspects of incursions, including the failure to ensure correct ground vehicle movements:
 34% Pilot failed to follow clearances.
 20% Driver failed to follow procedures.
 7% Driver – no R/T contact.
 6% ATC – incorrect/missed readback.
 5% Pilot – erroneous expectations.
 4% Pilot – poor/lack of ability/airmanship.
 3% Driver – no R/T available.
 2% Pilot – ignored indications/clearances.
Whilst the factors involved in each accident or incident factors vary, particularly highlighted
is the need for disciplined vigilance on behalf of flight crews, ATC and ground staff to
ensure effective communication and adherence to correct procedures.
Suggested actions to reduce the risk of runway incursion include:
1) Disciplined use of correct terminology.

2) Eliminate distractions in the operational area.

3) Obtain and use airport diagrams.

4) Conduct “Clearing Turns” prior to entering ANY runway.

5) Maintain a sterile cockpit when taxiing.

6) Maintain appropriate taxi speed.

7) Have a “heads up” and “eyes out” policy when taxiing.

8) Attend safety seminars and programs on runway safety.

9) Improve safety by teaching, advocating, stressing and understanding

situational awareness.

10) Distribute runway safety materials to all aviation entities.

11) Recognise that every airport is unique and presents its own set of
runway safety challenges.

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12) Positively identify/state runway identifying markings early.

13) Question information that seems to contradict your thinking.

14) Refresh training and knowledge of airport markings and procedures.

15) Check runway heading is consistent.

16) Check scenery is expected runway scenery (lights and markings).

Slide – Any Questions

References
1) Final ASNV Report N.A/1/04 dated 20th January 2004.
2) Runway Incursions Summary September 2008,
United Kingdom Civil Aviation Authority.
3) FAA Video ‘Airport Signs, Markings and Procedures’.
4) ICAO Manual for Preventing Runway Incursions.
Doc 9870 AN/463

Web
1) ALPA Runway Safety Program. (CBT)
http://flash.aopa.org/asf/runway_safety_alpa/
2) FAA Runway Safety Office.
http://www.faa.gov/runwaysafety/
3) Eurocontrol web site for the Prevention of Runway Incursions
http://www.eurocontrol.int/runwaysafety/

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