Runway incursions – Part 1 of 2

Voiceover 0:17

Welcome to the CAA Safety Files podcast

Nathan Lovett 0:30

Welcome to the Safety Files podcast from the UK Civil Aviation Authority. I'm Nathan Lovett from the CAA's Communications team. And in this series, we look at a occurrence, incident or accident reports that have been published throughout the different areas of the UK aviation industry. We look at a different report in each episode to find out what can be learned from it, and also to hear from aviation experts to explain the relevant safety guidance. Now, this is the first episode in a two part series where we'll be looking at runway safety at commercial airports. Specifically, we're going to be talking about runway incursions, what the risks are in this area, and what procedures are in place to help mitigate against them. Joining me now is Neil Gray from the CAA who's going to be with us throughout these two episodes. So welcome, Neil. Please, can you start by introducing yourself and the type of work that you do?

Neil Gray 1:15

My name is Neil Gray. I'm a Principal Aerodrome Inspector in the CAA's Safety and Airspace Regulation Group. My role is to lead a team whose collective responsibility is to ensure UK aerodromes or airports comply with organizational and operational safety regulations and manage aviation safety effectively. One of the most significant hazards faced by all aerodromes is that of runway incursions.

Nathan Lovett 1:44

And for those that haven't heard that term, what do we mean by it? What is a runway incursion?

Neil Gray 1:49

A runway incursion in simple terms is the incorrect presence of a person or a vehicle or an aircraft on the runway or the protected areas around the runway. And we know that there are many factors that could cause or contribute to that incorrect presence. Effective management of the runway incursion risk requires a collaborative approach by all of those concerned so that we can identify the possible causes, and take the necessary joined up steps to mitigate them. And we need to recognize this as an ongoing process because things don't stand still in aviation. Change is perpetual, whether that's infrastructure changes or changes in personnel, or changes in the type of operations taking place at the aerodrome. It might be new operators, the changes might be permanent, or there might be temporary changes, but they can all introduce new causal factors or reduce the effectiveness of mitigations. It's right that we should all always feel uneasy about the prospect of a runway incursion, so that we don't become complacent. And we should consider the associated safety management of the risk to be a high priority, whether we're an aerodrome operator, or an organization operating at or undertaking work at an aerodrome, or an air traffic control unit, or maybe a provider of Aeronautical Information, or an aircraft operator or airline or the regulator, but doing it in a collaborative way will yield the best results.

Nathan Lovett 3:14

Are there any particular incidents that stand out to you that involved a runway incursion?

Neil Gray 3:19

Very recently, at Jorge Chavez International Airport in Peru, a collision between a departing Airbus 320 and an emergency vehicle that had entered the runway into its path resulted in the deaths of two firefighters. That incident is still under investigation, so I'm not going to speculate on causal factors. But something has clearly gone wrong, and mitigations have been breached. Perhaps two of the most catastrophic aircraft accidents at European aerodromes in the last 50 years have been the result of runway incursions. In '77 two Boeing 747 aircraft collided on the runway at Tenerife's northern airport, leading to the deaths of five hundred and eighty three people. And in '01, at Milan Linate airport, a departing MD 87, collided with a Cessna Citation that had entered the runway into its path, leading to 114 fatalities on board the two aircraft and the deaths of four airport workers on the ground. Now poor visibility was a factor in both of those catastrophic events. The investigations identified all the weaknesses and failings and things like communications, infrastructure maintenance, equipment availability, accuracy of information and training, all things that we would consider to be barriers or mitigations. As I've said, effective runway incursion prevention requires collaboration, and we as the regulator have our part to play. Part of our regulatory role is to establish oversight programs. And a key part of those programs is to assure ourselves that aviation organizations whether they're aerodromes, air traffic control units or airlines have put in place systems to help them identify their hazards, and effectively mitigate the risks and to do and review this continuously. Whilst my teams and teams from other areas of the CAA go about their oversight separately, we have a way of internally reviewing what they find. What we're looking to do is identify where the activities of one organization may introduce risk for another. We also feed into this what the data from occurrence reports is telling us so that we can develop a risk picture of the overall operation that can be shared with the Accountable Managers, and if necessary, can be acted upon. Thankfully, catastrophic accidents like those at Tenerife and Milan, and more recently, Lima are extremely rare when you consider the magnitude of global runway activities. But runway incursions and precursor events continue to be reported. So the threat still remains.

Nathan Lovett 5:43

So as I mentioned earlier, we focus on a different real life incident in every episode of this series to see what can be learned from it, and also to highlight the relevant guidance in that area. So in a few minutes, we're going to hear about runway incursion incident that happened in the UK. The details were originally sent to the CAA as part of what's called a mandatory occurrence report, also known as an MOR. But first we're going to speak with Chantelle Holtom who is part of the CAA team that works with these reports. Welcome, Chantelle, please, can you tell us about your role here?

Chantelle Holtom 6:10

My name is Chantelle Holtom. I'm part of the Safety Intelligence team which is a team of 12. We're part of the Safety and Airspace Regulation Group based here in Aviation House close to Gatwick airport. We work in pairs covering the data and intelligence need for each area of the business. Each pair consists of a Safety Analyst who looks after our data and an Intelligence Lead who focus on providing the insight from that data. I'm an Intelligence Lead and I work for airspace, air traffic management and aerodromes. Our team produce safety intelligence using data from multiple sources and one of our biggest sources is the mandatory occurrence report database. Reporting is mandated by UK regulation three seven six, twenty fourteen which requires the reporting of safety related occurrences involving UK airspace users. During an average year prior to the Coronavirus pandemic we received around 30 thousand mandatory occurrence reports this reduced to around 18 to 20 thousand in '20, and '21. These reports help us to work proactively helping us to identify safety concerns and allowing measures to be implemented before they escalate. It's not to attribute blame or liability but supports continued learning to make flying safer.

Nathan Lovett 7:18

Thanks Chantelle. And how many of these reports relate to runway incursions?

Chantelle Holtom 7:22

in the UK we receive on average around 220 runway incursion reports per year. They are split into four types: runway incursion by an aircraft which is about 63%, a vehicle or equipment around 28% and by a person 8%. For those that don't come under those categories, there is an other category where we get very, very few reports. We see more runway incursions by aircraft than any other categories, on average 90% of these reports assessed by the UK CAA as low severity. And for '22 some of the reasons for the reports include for aircraft, crossing the red stop bars or taxiing past the clearance limits, taxiing errors. For vehicles we see ops fire or engineering vehicles on the runway or other vehicles crossing the runway without permission. And for people at smaller aerodromes, pedestrians or walkers being unaware of their surroundings straying onto the grass runways.

Nathan Lovett 8:14

Thank you. We're going to hear now about a runway incursion incident that took place at one of the UK's international airports. So just to let you know before we hear it, the report has been de identified. Chantelle, please can you read through what it says?

Chantelle Holtom 8:27

Reported by air traffic control. I was operating with medium workload at the time of the incident. Aircraft A landed on the runway and was vacated to the north because another aircraft was pushing back from the stand and preparing to leave. At this time there was one aircraft rolling out to the runway and aircraft B was on a short final approach to land. I asked aircraft A to hold its position and the pilot read this back to confirm. Through the window I could see the most recent aircraft to land had vacated the runway. I was ready to pass a landing clearance to aircraft B when I noticed that aircraft A was no longer holding its position. It had crossed the stop bar and was now infringing the runway and continuing to roll forwards. I immediately sent aircraft B around which was late in the approach. Aircraft B conducted a missed approach and once it had established in climb, I instructed aircraft A to cross the runway, which it did without further incident.

Voiceover 9:23

You're listening to the CAA safety files.

Nathan Lovett 9:25

Thanks to Chantelle for covering that report. So just to recap on what we heard there. The report was sent to the CAA by a tower controller, who saw an aircraft infringing onto a runway while another aircraft was coming in on approach to land. The tower controller saw the danger and told the second aircraft to carry out a go around so that the runway could be cleared before it landed. We're going to hear Neil's views about what happened. And we're also going to get perspectives from a tower controller and a commercial airline pilot. So joining us now is Alex Rattray and Vicky McKevitt who both work here at the CAA. Alex, please can we start with you? Can you tell us about your role and background?

Alex Rattray: 10:07

My name is Alex Rattray, I work for the Civil Aviation Authority as a flight operations and training inspector. I've been flying for over 30 years now. And I'm currently a pilot on the 787 fleet with one of the major airlines to keep my hand in. I'm also an examiner and instructor on the 787 type. Prior to that, my first flying job was in Loganair and so I started with that sort of flying. And then a lot of my time was with companies like Air two thousand, so I was flying the North Atlantic and the holiday routes mainly. I joined the CAA about 10 years ago and my job is partly overseeing airline AOCs and also quite a lot of flight crew training and authorizing examiners that kind of thing.

Nathan Lovett: 10:50

Excellent. Thank you. And Vicky, please can you introduce yourself too?

Vicky McKevitt: 10:53

Hello, I'm Vicky McKevitt, I work for the CAA. I'm an Air Traffic Services inspector and ATS inspector operations with the CAA now for just over three and a half years. Prior to that I started my air traffic career at age 18 as a baby, I joined NATS, National Air Traffic Services and I worked initially at Manchester as an en-route controller at Manchester that was just about under 10 years actually, which was fantastic. I then left Manchester and I went to work at Leeds Bradford Airport. So I went on the tower and approach side and did another 10 years tower and approach. Throughout that career. I've gone through all different job roles, not just being an ATCO. But being a SATCO watch manager, unit training officer, unit competency assessor, all those things. So it's good. I've got hopefully a good background both from the tower and approach and the enroute sides. So I can put the puzzle in the picture all together.

Nathan Lovett: 11:52

Great. Thanks to all of you for joining us. We're going to speak about experiences from each of your own careers. But first, I wanted to focus on the MOR incident that Chantelle read through a few minutes ago. Now the tower controller played a key role here both in identifying the problem and then taking quick and decisive action to remove the risk. Vicky having worked as a tower controller yourself, was there anything particular that stood out to you about this incident?

Vicky McKevitt: 12:13

First thing that springs to mind really is obviously the aircraft A when it first landed, and it was vacated to the north, which appears unusual because there was another aircraft pushing back from the stand preparing to leave. So reading that I was kind of wondering whether if they were vacated to the north when they're perhaps used to vacating to the south. So is that area of expectation, complacency, especially from base crews, potentially, if this was a base crew that they expect to vacate left on to alpha or whatever it may be, because that's what they do day in, day out. But this time, for whatever reason, they've had to go the other way and go to the other side of the airfield potentially. So it's kind of become out of the norm and more of a non standard event. Similarly, it could be if it was a foreign crew, that they've obviously been studying the aerodrome chart looking where they're going on landing potentially, and then being told to go in a different direction. And as an ATCO, you're always very aware that if you are doing something that's like it's not non standard, but out of the ordinary, potentially for everyday ops that you make sure that it's very, very clear first off, where exactly you're wanting them to go. So that was my kind of first thoughts on that. The other bit was, and again, there's not much detail in this MOR. So when the ATCO said I asked aircraft A to hold its position, again, phraseology is always very, very important. It should be clear, it should be concise. It should be as to in our world in the UK, CAP 413. So did they say, you know, was it holding position? Did they say the designators? Or was it holding at delta one? Or did they just say hold position? You've got to be very careful. Again, if it's foreign crew, making sure was that the only thing they said in that transmission? Or was it quite a long transmission with other information. And, again, if it's a foreign crew, you kind of restrict the amount of information provided in each transmission, you'd knock it down. So you get the read backs and you make sure they're understanding. But similarly, for any crews really, you don't want a very, very long transmission with lots of pertinent information in it because it can get lost, they can forget about it. So those are the kind of thoughts initially, the good thing was obviously the ATCO, they were doing their job in the VCR, they were looking out the window, which I love to see. There should be that scan, you know, and they've been watching exactly where the aircraft were going. They were in medium workload so, you know, obviously moderate workload is what they probably I would assume are dealing with at this particular airfield. And I think they obviously noticed when the aircraft A infringed and went on to the runway and they took the appropriate action to prevent aircraft B from landing and sending the aircraft around. Questions again, all sorts of things pop into my head, but we don't know are there ring of reds, are there H24 stop bars in play here? Always a good thing if there are. Have to consider again from the pilots perspective was there fatigue involved? you know, length of flight, how many rotations had they done? was it at the end of the day they were looking to get back quick in, you know, who knows similar call signs, is it a hotspot, where they were vacating to is it a known hotspot on the airfield, you know, complexity of the runway and taxiway designs, this all can play a part when it comes towards runway incursions. So there's, I have lots of questions really, from the very basic MOR, but those were from an ATCO point of view, they were kind of my first initial thoughts on reading this.

Nathan Lovett: 15:36

Thanks, Vicky. And moving on to you now, Alex, this took place at a major international airport in the UK, you're very familiar with flying into this type of environment. Was there anything from this MOR that stood out to you as a pilot?

Alex Rattray: 15:49

There are a few things that did jump out, one of the things I was thinking of was, and again, we don't know whether the crew was familiar with the airfield or not. And we don't know, if they therefore sort of followed some kind of environmental capture for getting back to where they thought they should be. But the thing that mostly struck me and we quite often get this, and it's particularly an issue, if you're not that familiar with an airport, is quite often at some airports, there's a tendency for the after landing instruction clearances to be issued, while you're still completing a landing roll. I suppose the key thing for me was was the instruction issued, perhaps during a fairly dynamic maneuver, which of course, is the landing roll. So that could have been a factor. Again, if a crew are using threat and error management properly, then modern briefings should include the threats that are likely to be encountered on whatever you're doing, be it a takeoff or a landing or an approach or whatever it happens to be. And one of the things you should always cover off, say for a landing is, you know, what are the risks of runway excursion particularly, but of course, any risk of ground collision and what could possibly lead to that? So I suppose just looking at the, because the data isn't particularly detailed, the main question I'd be interested to know is when the instructions were issued, and what was going on at the time?

Nathan Lovett: 17:05

Thanks, Alex. And coming to you now, Neil, your role covers airport and aerodrome safety as a whole. What were your takeaways from the incident?

Neil Gray: 17:12

I think for me, the interesting thing here is that, at an aerodrome, there are going to be a number of safety nets in place to prevent a runway incursion from happening. And I think you can see from the limited data available about this MOR that there will have been a number of those safety nets in place, such as ground markings, signage, aeronautical ground lighting, the instructions of the air traffic controller, to convey that aircraft from its landing position to the stand, and including that runway crossing. And whilst it may appear that a number of those safety nets haven't prevented this runway incursion, there is still that final safety net that was effective. I think, for me, I would be sort of interested to know, at this stage in the flight, what was the workload like on the flight deck of the aircraft? And how might that have impacted on the pilots attention to where they were on the ground or where they were headed, and also familiarity. We don't know who the airline was or what familiarity the crew had with their surroundings. But when you've got a complex aerodrome layout, just how familiar can a visiting or a foreign pilot be with that layout? And how much could that contribute to them becoming disorientated?

Nathan Lovett: 18:39

Vicky with your experience in air traffic control and your work both as an approach controller and a tower controller. How have you managed the risk of runway incursions? And have you ever experienced a similar situation to the one in this incident?

Vicky McKevitt: 18:50

I think for me, personally, we were very keen at Leeds for ensuring that this kind of defensive controlling aspect where there would be, you know, an aircraft approach and if you knew there was something on short finals, etc. You didn't want them where you had that feel you didn't want them to, you know, to enter the runway at all that you would just reconfirm Hold it, hold at delta one on reaching, for example, you know, just reapply, reconfirm, make sure they know you're obviously got you're looking out the window. And it's that monitoring capability. And the busier you get, potentially the harder that is to do because you're looking at multiple aircraft in very different places across your airfield, and airborne as well. That's one thing that we do on a regular basis. I think the other that we did introduce is like I said before, the ring of reds and H24 stop bars. Again, not every airfield. I think if this was a major airfield, they will have I'm sure but not every airfield has this at the moment. But again, it's another mitigating factor and another way to try and hopefully prevent such runway incursions occurring because you should have a visible red stop bar there. So even if they are unsure they might look at that and hopefully say, Oh, hold on, and check with ATC before going any further. I know that there are issues sometimes at other airfields potentially on the location of the holding points, again, we don't know, with this one where that comes to but, you know, some holding points are quite a way back from the runway. Can it be a little bit confusing? Do they think they were somewhere else? Not so sure, but that can come into play. But yeah, from my own personal experience, I've not had any runway incursions. So it's a case of monitoring, if you get that feel reconfirming with the aircraft, getting them to, you know, just confirm they are holding where you want them to hold. And I would always say, re-emphasize just not hold position, but hold at that designator to make sure that they know what they're doing.

Nathan Lovett: 20:46

Thanks, Vicky. Alex, how do you manage this risk as a pilot? And are there any challenges that you want to highlight that people should be aware of?

Alex Rattray: 20:53

Yeah, thank you, Nathan. So it's interesting, actually, that we were talking using the word defensive earlier. And I think that's such an important thing. And up until very recent times, briefings have tended to centre around actually what the clearance is likely to be, be it an approach or a landing or taxi clearance, and that kind of thing. Whereas now, the briefing, will also include the risks around again, whatever you're about to do. So I think the thing that's probably one of the best defences around this now is that crews, if they're doing it correctly, and it's been quite a lot of work to get this established in the industry, and some are better than others at it. But essentially, you've got to always say, well, what's the thing here, that could bite us. And you know, and that should be pre briefed as much as possible so that you've got some sort of plan and mitigation to prevent it. The red light system, the ring of red lights around the runway, that's an extremely effective barrier. And again, looking at the MOR, I guess, we don't know whether that existed, and we don't know where this incident took place. And the other thing, of course, we don't know with this particular incident is again, visibility. Now, in my own experience, if you have, say, quite a bit of rain that is falling, or has fallen, particularly at night, the surface becomes extremely shiny. And it's very difficult to certainly read any markings, the ring of reds, of course, or WigWag, lights will always be a huge help. But sometimes it can be very, very difficult to find your way around. A particularly good thing that's come along now if I talk about the aircraft that I'm particularly familiar with at the moment, and operating is the 787. On that if you turn the range down on your map on board, on your screens, which are fortunately, very large on that, it zooms in all the way to give you a full map of the taxiway system wherever you are. So you can see precisely where you are. And you can see where the runways are. So as well as being dependent on what you've heard and looking out and reading a paper chart, you have a physical presentation of precisely where you are. And I think that probably going forward will be one of the future very good mitigations. Interestingly enough, for example, for pilots converting from the triple seven, so onto the triple seven from the seven, eight. There's nothing wrong with the triple seven, but because it doesn't have that moving map, if you like of the aerodrome, one of the things it talks about on the differences course is, essentially be aware of the significantly less information you'll have displayed to you to sort of build your situational awareness. So I think it's partly a technology thing. So the runway lighting is very important. But again, it's those natural phenomena, isn't it like rain, like mist like time of day, that can get to you and I think probably the best way to deal with that is again, using the threat and error management I mentioned earlier, of saying, well, what could go wrong? What could get us here? And how do we make sure we stay out of trouble, essentially.

Nathan Lovett: 23:45

Thank you, Neil, the same question for you please, what is the most effective way to mitigate against runway incursions happening?

Neil Gray: 23:51

In my experience, the best way to deal with the threat of a runway incursion is to understand what the contributory factors are, and try to manage those precursor events. One of the mitigations of a runway incursion is the ring of red that we've been talking about, and the use of red stop bars. That is a mitigation that is fairly well into the process of that aircraft moving or that vehicle moving around the airfield. There may well be many other contributory factors upstream of that, and I'm thinking about things like the complexity of the aerodrome layout, or the aerodrome in question might have things like free ranging vehicles. Alex mentioned weather and visibility that can be contributory factors, and other things like work in progress where perhaps you've got aircraft taking unusual routes to work their way around areas of the taxiway network that might be closed for a period of time. So I think if the approach to managing runway incursions takes into consideration, those contributory factors. And that can only be done by having a good knowledge of the aerodrome, and it's lay out and the risks at that particular aerodrome. And that in turn, I think can only be properly understood when you adopt a collaborative approach where not only have you got aerodrome operations personnel involved in that conversation, but also the operators of the aerodrome, the flight crew of the aircraft, the air traffic control service provider at that aerodrome, and anybody else who contributes to that movement of aircraft, or vehicles, so that we really understand where we're exposed or where we're vulnerable to runway incursions happening, and then we can properly start to put in place stronger mitigating measures.

Nathan Lovett: 25:50

We're going to move on now to the safety guidance that's available in this area. Neil what should people be aware of here in terms of overall guidance and resources?

Neil Gray: 25:58

There are two sets of regulatory requirements for aerodromes in the UK so there is the UK retained regulation 139/2014 which applies to the larger aerodromes in the UK. And then there is CAP 168 civil aviation publication 168 licensing of aerodromes, which is applicable to the smaller aerodromes. There's also a number of other relevant CAPS such as CAP 790, which is the requirements for an air side driving permit system. So that's all about ensuring the competence of people who drive on the maneuvering area of an aerodrome. But perhaps the most significant piece of guidance is the Euro control document the European Action Plan for the Prevention of Runway Incursions. Before, when I was talking about understanding the vulnerabilities at an aerodrome to runway incursions, I talked about a collaborative approach. And the European Action Plan for the Prevention of Runway Incursions very much adopts that principle that everybody has a role to play. And that includes airlines, aerodrome operators, air traffic control units, it also includes regulators and the providers of Aeronautical Information. So it very much focuses on that collaborative approach. And just picking out a couple of the pieces of guidance from there that I think are particularly important. One is the development of local runway safety teams, which again, adopt that collaborative approach to ensuring runway safety. And I think it's worth saying that at Heathrow, they've expanded that runway safety team to be a movement area safety team, recognizing that the taxiway network needs equal levels of protection from incursions, as does the apron and stand area. The other thing for me that's important in that document is ensuring that when you are maybe planning some work in progress, or positioning signs or lighting, that you consider the perspective of the pilot, it's very easy to judge things from ground level from the level of say, the driver's seat of a vehicle. But the perspective of the pilot from up there on the flight deck of a large aircraft can often be very different. And therefore there's guidance around addressing that as well.

Nathan Lovett: 28:27

Vicky, is there anything that you'd like to add to that in terms of guidance for air traffic control?

Vicky McKevitt: 28:31

I think Neil's stolen all my points! The EAPPRI, the European Action Plan for the Prevention of Runway Incursions, that was going to be the main one that ATC I think have done a lot of work on. I know for people that are interested Eurocontrol publish some really good stuff as well. They've got runway safety newsletters, and I think they did a section there was a few hindsight publications on different runway incursions. So if you search on Eurocontrol, you also find some really good stuff. And this is something that we use in ATC for our annual training for unusual circumstances and emergency training. So lots of units kind of dip into that. Anything they can get their hands on really. It's all good stuff to learn from.

Nathan Lovett: 29:15

Great. Thank you and coming to you now Alex, is there anything that you want to highlight for pilots?

Alex Rattray: 29:19

Yes, so we used to call it airmanship and it's been better now defined I think as what we now term as pilot competencies. And there are generally nine competencies we look at but I think the main thing is as ever, just to start with precise RT you know, precise RT is really important I think because it's one of our best defences against misunderstanding and avoids things like level busts or runway incursions that kind of thing. So precise, RT very important. Properly following the company's SOPs. And then whenever you're operating of course maximizing situational awareness as best you can, and any aids you've got to help you with that, you know, good look at these on board EFBs now using the iPad, you can zoom in quite well on the aerodrome diagram and get a proper understanding of where you're supposed to be. I think an area you need to be a little bit careful of is, every now and again, particularly at quieter times of the day, at otherwise busy airports, you can sometimes find the frequencies. I believe the term is band boxed. So sometimes you may not hear something's been told to another aircraft, or you might hear conversations that are say, on ground and tower together, it's not a great problem, it just means the dynamic of the radios a little bit different, I think you need to be mindful of that. The other thing is that, again, I come back to threat and error management, which we're really trying to major on at the moment. And often we tend to roll up the terms of runway incursion and runway excursion under the generic term of ground collision. But nonetheless, they're really important. I'll give you an example of where the risk of for example runway excursion is not as well understood as it could be. Let's take for example. So we obviously use reduced thrust or whenever we can we use reduced thrust. And of course, the software that comes up with a thrust setting is titrating, the thrust down until it hits the performance limit, be the that runway length, be it obstacle, be it brake energy, whatever it happens to be. And so it's always worth bearing in mind that when you have a D rated thrust, depending on the topography around the airport, quite often that will translate into the thrust being set at a position whereby in the worst case, engine out stop case, i.e. just before v1, that stop is calculated to be exactly in the remaining distance available. So ironically, using reduced thrust, it doesn't seem the case when you first look at it, but if you've got reduced thrust, it may very well be that the thrust setting has turned a nice long runway at say something like Heathrow, actually into a limiting runway, which you will only you will be able to stop but that will be dependent on a very accurate execution of the RTO maneuver. And again, threat and error management is that you need to recognize that when you calculate your performance and say, well, actually, the performance D rate itself puts us on the doorstep of a runway excursion. So with that in mind, let's just remind ourselves to do very accurate drills, very accurate calls rather for V one, and so on. And also let's just rehearse with a touch drill exactly what the RTO drill will be. So if we need it, we get it right, simply because the performance calculation has made that the limiting factor.

Nathan Lovett: 32:28

Great, thank you. It's also important to mention that this incident was highlighted to the CAA because the tower controller made an MOR or mandatory occurrence report. Neil, why are these types of reports so important in helping identify safety risks, and what should someone do if they want to make a report themselves?

Neil Gray: 32:44

What's really important is for us to be able to identify the causal factors, and to be able to put in place effective mitigations. It's critical that people report as is so often in aviation, the human elements in any system is potentially vulnerable to mistakes to making errors. But they're also a very important part of us identifying our risks and managing them effectively through a reporting process. So the mandatory occurrence reporting system requires certain events by certain people to be reported, and that does include runway incursions. But also we should be encouraging people to report those other precursor events, and also encouraging them to perhaps self report if they feel that they've made an error that could have contributed to a runway incursion. And to get to that maturity of safety management where people feel confident to report their own errors or their own failings requires a really effective just culture within that organization, where they know that they can confidently report something without any fear of action being taken unnecessarily against them. So the occurrence reporting process does allow for individuals to report confidentially. One of the things that we've said on a number of occasions during this podcast is that we had very limited detail of the mandatory occurrence report that sits behind our conversations. And part of that is because that MOR has been redacted to protect the confidentiality of reporters and of some of the identifying information that might have been contained in that MOR. So everybody should be able to confidently report. If they can't report as an individual, then their organization will have a process more often than not through the air traffic control provider for making a mandatory occurrence report.

Nathan Lovett: 34:53

Thanks very much to Vicky, Neil and Alex for speaking to us about that runway incursion incident, and also to Chantelle for speaking with us earlier. You can find links to the guidance and resources that they spoke about in the Episode Notes. So that's it for this episode, but if you have any feedback or suggestions for things that you'd like us to cover in future episodes, please get in touch by emailing safetyfilespodcast@caa.co.uk Thanks for listening

Voiceover: 35:27

Thanks for listening. This is the CAA Safety Files