5-2 Manual on the Prevention of Runway Incursions
controller should have scanned the runway before clearing another aircraft to land on the same runway. Stating that the controller “forgot” that the aircraft was there captures the nature of the controller’s error, but
not the factors that induced it. 5.2.4
Due consideration must be given both to the circumstances under which the error occurred e.g. the tasks the individual was performing at the time and relevant environmental conditions and to the
latent conditions that originate deep within the organization e.g. complex aerodrome layout, inadequate signs and markings, and high workload. Identifying the circumstances under which certain types of errors
are likely to occur, such as at night or when the controller is working more than one control position, points to possible mitigating measures.
5.3 A STANDARD APPROACH TO RUNWAY INCURSION INCIDENT REPORTING AND DATA COLLECTION
5.3.1 Annex 13 — Aircraft Accident and Incident Investigation, 8.1, requires States to establish a
mandatory incident reporting system to facilitate collection of information on actual or potential safety deficiencies.
5.3.2 Annex 6 — Operation of Aircraft, Annex 11 — Air Traffic Services, and Annex 14 —
Aerodromes require States to establish safety programmes in order to achieve an acceptable level of safety in the provision of services. Use of standard definitions, reporting formats and error taxonomy will facilitate
data sharing among States. The larger the data pool, the more robust the analysis of common causal factors will be and, thus, a better understanding of the nature of the problem.
5.3.3
The Procedures for Air Navigation Services — Air Traffic Management PANS-ATM, Doc 4444, 2.4.1.2, requires ATS authorities to establish a formal incident reporting system for ATS
personnel to facilitate the collection of information on actual or potential safety hazards or deficiencies related to the provision of ATS.
5.3.4
The initial runway incursion notification form see Appendix F requires the inclusion of data to describe the event and to classify its severity.
5.3.5 The runway incursion causal factors identification form see Appendix G establishes the
how, what and why concerning the event and is to be completed once the detailed investigation into the event has been completed.
5.3.6 Since there are few reported runway incursions per thousand aircraft movements, such
incidents may appear to be unique to a particular aerodrome. It is only by pooling data that patterns of common causal factors can emerge.
5.3.7 The pooling of data requires that all participating organizations adopt a common, reliable
and robust method of data collection. Furthermore, methods used to analyse the results should be harmonized to ensure the comparability of assessment results.
Note.— The quality of the investigations has a direct impact on the assessment of the risk of collision, the severity of the outcome, and the identification of causal and contributory factors.
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Chapter 6 CLASSIFICATION OF THE SEVERITY OF
