Runway

Runway
Runway Excursion
Runway Excursion
Excursion
Excursion
Risk
Risk Management
Risk Management Process
Management Process (RMP)
Process (RMP)
(RMP)
 NOTE
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Senior Vice President

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800 Place Victoria, P.O. Box 113
Montréal, Québec

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 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 System1 is the

development and utilization of a Safety Risk Management Process (RMP). The
International Civil Aviation Organization (ICAO) Safety Management Manual2
(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 100%; 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

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 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

1 High
2 Medium
3 Low

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 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

Risk
Condition Effect Score
(add)

A1. Potentially punitive response to Diminished access to ‘front line’ information 1

reporting of errors, incidents and on threats and errors, which increase the
operational threats 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 1
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 Increased likelihood of approaches and 1
on-time performance (without a landings continued when the conditions
balanced message regarding safe indicate a go-around, or take-offs
operational limits) commenced when the conditions indicate a
delay

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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 1
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 1
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 Diminished risk awareness and strategic 1
airfields with inherent critical excursion risk management opportunity
excursion risks
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-to- Diminished risk awareness by line 1
date identified critical excursion risks personnel
(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 Diminished risk awareness. Management 1
follow up system, for line personnel may be unaware of the hazards and unable
to report hazards 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.

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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

Risk
Condition Effect Score
(Add)

B2. One regularly active runway Potential for catastrophic 3

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
outcome from overrun
Potential for deep (long) 2
touchdown
No choice for landing or take-off 3
direction; may result in tailwind
operations
Limited choice for landing 1
direction
Difficulty judging final approach 1
trajectory and touchdown point
Potential for water contamination, 1
or slow draining following rain

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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
B10. Visual approach only to at
least one regularly active runway
(no approach aids)
B11. Airfield elevation > 3,000 feet
amsl
B12. Density altitude > 5,000 feet
amsl
B13. No approach lighting
xx. No touchdown markings
B13. Airfield subject to severe
weather
Xx Unreliable or inaccurate winter Potential for unexpected low
contamination reporting (apply friction conditions
seasonally)
Runway Excursion Prevention (RMP)
Potential for unknown 1
crosswind/tailwind conditions
Increased likelihood of 2
unstabilized approach
Potential for NPA 1
Increased likelihood of 3
unstabilized approach
Increased inertia, increased 1
TAS/groundspeed, and difficulty
controlling flare/touchdown
Increased inertia, increased 1
TAS/groundspeed, and difficulty
controlling flare/touchdown
Difficulty establishing runway 1
centerline early
Difficulty achieving touchdown at 1
the desired point
Potential for turbulence, 2
windshear, strong surface winds,
heavy rain, poor visibility, runway
contamination
2
Total score
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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.

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Table C – ‘Day of Operations’ Risk Management

Condition Effect Score

C1. Airfield identified as having Inherent airfield risk 1

increased excursion risk from Table
B
C2. Pilot not familiar with airfield and Reduced threat awareness and 1
no adequate airfield briefing facility increased workload
C3. Pilot new to aircraft type and/or Reduced threat awareness and 1
new to role increased workload
C4. Approach or take-off scheduled Reduced alertness/increased 1
during circadian low likelihood of error
C5. Approach or take-off scheduled Reduced alertness/increased 1
following long duty period likelihood of error
C6. Landing planned at or close to Increased inertia, increased 1
MLW (eg. fuel tankering) approach speed, greater landing
distance required
C7. Retardation systems partially Increased landing and 1
inoperative (spoilers, accelerate/stop distance
autobrake/brakes, antiskid, both
reversers)
C8. One reverser inoperative Impaired directional control, 1
increased landing and
accelerate/stop distance
C9. NOTAMS affecting serviceability Degraded approach quality not 1
of approach aids/lighting identified by strategic risk
assessment
C10. NOTAMS affecting runway Reduced choice of runways not 1
closures identified by strategic risk
assessment
C11. NOTAMS for work in progress Increase in excursion risk not 1
affecting declared runway distances identified by strategic risk
assessment

Total Score

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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

D1. En route system Increased landing distance Recalculate landing

failure affecting retardation
devices (spoilers,
autobrake/brakes, anti-
skid, 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
performance, consider
availability of longer
runway, brief changes to
landing SOP
Impaired directional Recalculate landing
control, increased landing performance, consider
distance 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

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D5. Assigned runway Reduced landing distance Maximize retardation and
landing distance < margin brief for immediate
calculated landing deployment on touchdown
distance required + 25%
D6. Crosswind component Directional control and Brief crosswind take-
> 15 knots attitude during flare, off/landing and roll out
touchdown and roll out technique
D7. Tailwind component > Increased groundspeed, Maximize retardation and
5 knots increased landing/take-off brief for immediate
distance, risk of long flare deployment on
touchdown/RTO, define
conditions for go-around
from long flare
D8. Visibility < half runway Generic metric relative to Brief anticipated visual
length judging trajectory on final picture on final approach
approach
D9. Reported windshear Control of final approach Brief windshear recovery
and/or turbulence on final trajectory and landing, and define conditions for
approach increased go-around, recalculate
approach/landing speed, landing performance
increased landing distance
D10. Any meteorological Possibility that local Consider delaying
condition within 20% to variations include approach/take-off if
minima or operating limits conditions below minima conditions forecast to
or outside operating limits improve
D11. Wet runway Impaired stopping Consider maximizing
performance retardation and brief for
immediate deployment on
touchdown/RTO
D12. Contaminated Impaired stopping Maximize retardation and
runway performance brief for immediate
deployment on
touchdown/RTO, brief for
directional control on
slippery runways
D13. Unplanned extension Reduced alertness and Consider implications for
of duty period potential for error human performance and
increased likelihood of
errors

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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 Score
Table A: Corporate risk factors

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 Score
Table A: Corporate risk factors

Table B: Airfield strategic risk factors (planning factors

Table C: Day of operations risk management

Total score for a specific operation before risk reduction