Airside Operations Safety: Understanding the Effects of Human Factors (2022)

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1   1.1 Background In 1997, James Reason observed that it was “. . . fashionable to claim that human error is implicated in 80 to 90 percent of all major accidents. While probably close to the truth, this statement adds very little to our understanding of how and why organizational accidents happen” (Reason, 1997, p. 61). As technology advances and the machines involved in aviation become more and more reliable, the contribution of humans to aviation incidents likely makes up a greater percentage. Some safety professionals will argue that there are no accidents without a human- cause factor in that humans design, build, and maintain the equipment involved in flight. It is therefore logical and critical to study human factors in order to discover the root causes that lead to injury, damage, and undesirable outcomes in aviation and airport operations. One particular safety event that takes place solely at airports is the runway incursion. The prevention of runway incursions has been a focus area of the FAA for decades, and rightly so. A runway incursion is defined by the FAA as follows: Any occurrence at an airport involving the incorrect presence of an aircraft, vehicle, or person on the protected area of a surface designated for the landing and takeoff of aircraft. (FAA, 2022a, p. 1–10) Such an event could result in and has resulted in catastrophic accidents. A single accident following a runway incursion could lead to the loss of hundreds of lives, the destruction of massive passenger aircraft, and severe damage to airport facilities. 1.1.1 The Frequency of Runway Incursions Despite dedicated efforts involving changes in technologies and procedures, the number of annual runway incursions in the United States has shown little to no improvement. Table 1-1 depicts the annual runway incursions at U.S. airports for the 7 years ending in 2020. These data were obtained using the FAA Airport Safety/Runway Incursions web page (https://www.faa.gov/ airports/runway_safety/statistics/). The table depicts the incursions as a result of operational incidents (OI) or those resulting from air traffic control (ATC) errors, pilot deviations (PD), vehicle/pedestrian deviations (V/PDs), and other causes. According to the FAA statistics, between 2014 and 2018, the number of reported incursions increased by nearly 50%. These year-over-year increases could be the result of more vigorous reporting due to an increased awareness of the importance of such events, improved knowledge of what an incursion entails, and breakdowns in the mitigations implemented. The 2019 statistics C H A P T E R   1 Why Examine Airside Human Factors? Given that humans design, build, and maintain the equipment involved in flight, it can be argued that there are no safety events or accidents without a human cause.

2 Airside Operations Safety: Understanding the Effects of Human Factors showed a small reduction in incursions as compared to the previous year, but the number of events remained near the high marks for the time period. In 2020, the number of incursions dropped to occurrences near those recorded in 2014. The reasons for this reduction are yet to be released, but a safe bet is that the reduction in air operations during the pandemic is one factor. 1.1.2 Vehicle Pedestrian Deviations and Airside Safety Management The FAA defines a V/PD as follows: Pedestrians or vehicles entering any portion of the airport movement areas (runways/taxiways) without authorization from air traffic control. (FAA, 2020) While the number of reported V/PDs followed the overall trend of total runway incursions, the percentage of V/PDs remained relatively consistent. Regardless of the year, roughly 18% of incursions were V/PDs. In fact, in 2020 (the most recent year’s data available for this report), the percentage of V/PDs was the highest of the 7 years shown in the table. Thus, nearly one in every five runway incursions fall under the purview of the airport and the personnel who work in the airside environment. Research performed by the Volpe Institute and reported in a December 2016 Technical Report entitled Runway Safety Analysis: Runway Incursion Characteristics and Mitigation Recommendations (John, 2016) confirms this and reveals that most V/PDs, just under 80%, are Class D (posing no immediate safety consequences), with the others falling primarily under Class C (ample time or distance to avoid a collision) incursions. While V/PDs rarely result in Class A (a collision was narrowly missed) or Class B (a time-critical corrective/evasive response was needed to avoid a collision) incursions, putting focused effort into an area of airport activity under the control of those that work on the airfield could result in a significant contribution to improved airport safety and the reduction of these deviations. 1.1.2.1 The V/PD as an Airside Safety Hazard The International Civil Aviation Organization (ICAO) defines a safety hazard as a condition or an object with the potential to cause or contribute to an aircraft incident or accident (ICAO, 2018, p. vii). A V/PD (condition) may lead to a collision with an aircraft taking off or landing (aircraft incident or accident); therefore, a V/PD can be considered an airside safety hazard. Expanding this into the realm of safety risk management, the V/PD and its causes present a level of safety risk (potentially a high risk) to the airport. 1.1.2.2 Investigating the V/PD as a Safety Hazard From a safety management system (SMS) perspective, at least at this point of SMS adoption by U.S. airports, the V/PD is a unique safety event in that it rarely results in damage or injury, Year OI Other PD V/PD Total V/PD % 2020 161 19 841 241 1,262 19.1 2019 318 25 1,120 294 1,757 16.7 2018 345 10 1,142 335 1,832 18.3 2017 306 7 1,142 293 1,748 16.8 2016 332 8 943 278 1,561 17.8 2015 323 2 881 252 1,458 17.3 2014 258 8 764 234 1,264 18.5 Totals 2,043 79 6,833 1,927 10,882 17.7 Note: Based on data from the FAA Runway Safety web page (FAA, 2022b). Table 1-1. Runway incursions at U.S. airports.

Why Examine Airside Human Factors? 3   yet an investigation is required by the FAA each time one occurs. When a different type of safety incident without damage or injury (a close call) occurs, it is likely that the event will not be reported, and an investigation is rarely initiated. How airports respond to a V/PD may therefore be a model for how to address any safety hazard—by viewing each incident or identified hazard as a triggering event for an investigation and an initiation of the safety risk management (SRM) process. Investigation techniques from a human factors perspective are explored in Chapter 8. 1.1.2.3 Mitigating the Safety Risks All safety hazards present the airport with certain levels of risk. In order to ensure the safety of airside operations, the risks must be mitigated to eliminate or lower the risk level. In Runway Safety Call to Action, the FAA called for focusing on improving familiarity of vehicle drivers with their given airports; having vehicle drivers alert ATC if they are new to the airport; and airports deploying vehicle alerting systems as mitigations to the risks presented by airside drivers (FAA, 2015a). These recommendations are aimed at improving communications between airside vehicle drivers and ATC and improving the situational awareness (SA) of airside drivers. These are considered risk mitigations that address key airside human factors and are discussed later in this report. However, little information is available on whether such changes address the underlying human factors that result in V/PDs. 1.1.3 Human Factors: The Common Element in Airside Operations and V/PDs Humans are involved in all aspects of airside operations at airports. In order to discover the underlying human factors that affect both the efficiency and the safety of airside operations, examining the events for which human factors data are collected using a consistent methodology is a logical starting point. For airport safety incidents, the V/PD is such an event. 1.1.3.1 The V/PD as the Catalyst for the Research The catalyst for this research was the increasing number and steady rate of V/PDs that occur at airports of all sizes around the United States. The statistics are shown in Table 1-1 and were discussed previously. The research problem statement requested the research team take a focused look at V/PDs and the human factors behind these occurrences. V/PDs are in nearly all instances the result of humans making decisions or taking actions that result in a violation of FAA regulations and airport rules regarding access to runways. As will be discussed in Chapter 3 and Appendix A, the research revealed that all of the V/PDs analyzed had human factors as the underlying causes. Additionally, these events are perhaps the only airport airside event that is investigated in a relatively consistent manner and where a standardized set of data is captured on each event. In studying V/PDs, the research team was able to analyze a type of event that, while rare at individual airports, occurs with a regular frequency nationally, involves human factors, and has data on the events contained in a consistent database with consistent data sets and captured using a consistent reporting method that is required both in content and format for every airport across the country. 1.1.3.2 The Influence of Human Factors Across Airside Operations Ideally, all the safety incidents and accidents that occur in the airside environment would be investigated using a standard process, and data would be captured on the causes. At present, this is not the case. Therefore, the research team needed to make some assumptions in order to develop recommendations that airport management could use to improve airside safety.

4 Airside Operations Safety: Understanding the Effects of Human Factors For the foreseeable future, humans will be involved in all aspects of airside operations. Regard- less of the activity, with the exception of the specific skills and unique physical environment associated with operating specific equipment, the factors that influence human performance are constants. With this in mind, the research team made the assumption that the human factors discovered to influence V/PDs can be extrapolated across the entirety of the airside environment. Therefore, while readers will be presented with information related to V/PDs, they should infer that the analysis and recommendations apply to any airside activity. 1.2 Goals and Objectives of the Research With the background just presented in mind, and as a lead into the discussion of human factors in airside operations, having a view into the research goals and objectives established for the project gives the reader a view into the research methodology and the presentation of the findings. Based on the history of V/PDs, the problem statement for this project stated the following goals: Research is needed to identify best practices to improve airside operations safety through better understanding of human factors as well as improve each individual’s SA within the airside environ- ment. The research should heighten vehicular and pedestrian safety throughout the airfield and should (1) inform airport decision makers of the human factors related to airside operations and (2) make a justifiable case for allocating resources to mitigate the risks from human elements operating in the airside environment. The following specific objectives were developed as an initial guide to achieving the research goals: • Abilities of Airside Personnel: Identify and describe the cognitive tasks and required abilities used in airside operations (e.g., vehicle and pedestrian activity inside the fence). • Situational Awareness: Describe the demands that can limit or complicate SA and thus increase the risk of runway incursions and V/PDs. • Human Performance Risks: Identify risks associated with reduced cognitive ability and SA caused by fatigue or overload. • Process and Technology Mitigations: Discuss how technologies and processes could be used to reduce or mitigate risks from reduced human performance. • Technology Use for Heightened SA: Identify and describe the most effective technologies and processes that affect and could improve SA for airport employees and others working airside. • Resource Requirements: Estimate resource requirements, including the costs of technologies and process introductions. • Mitigation Limitations: Discuss the limitations and complications that technology intro- ductions and process changes may add to the demands of people working in the airside environment. These objectives served as the foundation for the research methodology used and the manner in which the findings are presented in this report. 1.3 Research Methodology The research for this project was conducted in three phases, with the latter two building on the findings of the previous phase. The research team delivered a report on the progress and findings at the end of each phase.

Why Examine Airside Human Factors? 5   1.3.1 Phase 1: Foundational Knowledge Development The research in Phase 1 developed the foundational knowledge on which the follow-on phases were built. Two primary tasks were performed in Phase 1: an extensive literature review and an analysis of the FAA’s runway incursion database. Figure 1-1 depicts the key Phase 1 tasks. 1.3.1.1 Literature Review The goals of the literature review included identifying past and ongoing human factors and airport safety research projects conducted by the airport industry and identifying past and current human factors and airport safety research pertaining to airport operations being con- ducted by key airport stakeholders, such as airlines and air traffic management organizations. In total, 223 resources were reviewed during the literature search. Of those, 45 were selected and used as references. The results of the literature review can be found in Appendix C of this report, which provides a number of additional resources for those airport personnel interested in further researching the topic. The appendix is the white paper prepared to report the findings of Phase 1 to the ACRP Project Panel and is available as a separate document on the National Academies Press website. 1.3.1.2 Runway Incursion Database Analysis – Getting to the “Why’s” An analysis of the FAA Runway Safety Office Runway Incursions database was performed during Phase 1. With the assistance of the FAA, the research team asked for and received the records for V/PDs for the fiscal years 2017 through 2018. During this 2-year period, 847 V/PDs were reported to the FAA and investigated by the airports where the events occurred. The reason this time period was chosen was that it mirrored the time period for the latest complete study of V/PDs done by the Runway Safety Office. In order to determine what human factors led to each V/PD, the analysis was performed using the Human Factors Analysis and Clas- sification System (HFACS) when evaluating the event investigation narratives for each event. Using the HFACS methodology, the analysis revealed that every event examined had a human-factor cause that led to the V/PD. Following the HFACS methodology, a V/PD is classified as an “unsafe act.” A key goal of the data analysis was to determine the “why’s” behind the reasons these unsafe acts occurred. Additional analysis was performed to gain insight into additional factors related to the events, such as the size of the airport, the time of day, what type of vehicle was involved, and whether training was available and completed by the persons involved in the event. The HFACS methodology and key findings from the analysis are presented in Appendix A. Figure 1-1. Phase 1 research tasks. Using the HFACS methodology, the analysis revealed that every event examined had a human-factor cause that led to the V/PD.

6 Airside Operations Safety: Understanding the Effects of Human Factors 1.3.2 Phase 2: Risk Assessment and Mitigation Research The next step of the project was to examine airside human factors from the standpoint of risk. As the industry has acted to reduce V/PDs, the focus of the efforts has been on procedural, technological, and airport infrastructure changes, primarily led or directed by the FAA. The research team took the approach of examining human factors from the perspective of an airside driver or line worker. Additionally, the research focused on what airport management can do at the local level, with all the different budgetary and resource considerations in mind, to mitigate the safety risks associated with airside human factors. 1.3.2.1 Human Factors Risk Assessment Armed with the results of Phase 1, a risk assessment was performed on the human factors discovered during the V/PD data analysis. Chapter 3 discusses the risk assessment process used and the findings of the analysis; Figure 1-2 depicts the risk assessment process. The information presented to airport leadership on the variety of human factors discovered during event investi- gations and analysis of the captured data can be used as the basis for making risk-based decisions on safety resource allocation. The results of the risk analysis provided the needed knowledge to investigate various risk mitigations available to airport managers, as well as to develop recommendations for changes to airport processes that could better manage airside human factors risks. 1.3.2.2 Human Factors Risk Mitigations The risk mitigations explored and for which recommendations were developed fell into five areas. These areas, as well as the associated chapters that discuss them, are as follows: • Airside personnel hiring and development (Chapter 4) • Airside driver training programs (Chapter 5) • Fatigue risk management (Chapter 6) Figure 1-2. Phase 2 human factors risk assessment process.

Why Examine Airside Human Factors? 7   • Technology solutions (Chapter 7) • Airport investigations (Chapter 8) The research explored practices in these areas that were in place at airports and had been used successfully by other aviation organizations or organizations with specialized expertise. Again, the focus was on practices and solutions airports of various sizes could implement to positively influence human performance. 1.3.3 Phase 3: Follow-Up Research and Report Writing During the final phase of the project, additional research to cover gaps was conducted, and the project deliverables were created. Among the more important topics explored during Phase 3 was how airports managed personnel during irregular operations. The focus was on managing fatigue risk during times of extended working hours and during extensive airport operations and maintenance in the early morning hours when it is still dark. 1.3.4 Airport Outreach Airport outreach was conducted during all three phases of the project to examine effective practices that were in place in the field and solicit the views of practitioners regarding the findings of the research team. A list of the airports contributing to the research is provided in Table 1-2. Altogether, the research team visited or interviewed representatives from 18 airports of various sizes and geographic locations, along with one department of transportation representative. Of these, there were five large-hub airports, three medium-hub airports, three small-hub airports, five non-hub airports, and two general aviation (GA) airports. In addition, the team researched and examined airport driver training program documents from 11 airports: seven large-hub airports, one small-hub airport, two non-hub airports, and one GA airport. Airports Visited (Phase I) Airport Driving Program Reviews (Phase II) Airport Interviews (Phase III) Daytona Beach International Airport (DAB) Coeur d’Alene Airport (COE) Alaska Department of Transportation Orlando Melbourne International Airport (MLB) Dallas–Fort Worth International Airport (DFW) Centennial Airport (APA) San Antonio International Airport (SAT) Erie International Airport (ERI) Dayton International Airport (DAY) Airport Interviews (Phase II) Fort Wayne International Airport (FWA) Denver International Airport (DEN) Detroit Metro Airport (DTW) Honolulu International Airport (HNL) Idaho Falls Regional Airport (IDA) El Paso International Airport (ELP) Los Angeles International Airport (LAX) Jackson Hole Airport (JAC) Hollywood Burbank Airport (BUR) Memphis International Airport (MEM) Lebanon Municipal Airport (LEB) Lexington Blue Grass Airport (LEX) Miami International Airport (MIA) Portland International Airport (PDX) Spirit of St. Louis Airport (SUS) Minneapolis–Saint Paul International Airport (MSP) Sacramento International Airport (SMF) Toronto Pearson International Airport (YYZ) Philadelphia International Airport (PHL) Salt Lake City International Airport (SLC) Washington Dulles International Airport (IAD) Table 1-2. Airports and transportation departments visited, interviewed, or researched during the project.

8 Airside Operations Safety: Understanding the Effects of Human Factors Three airport visits were conducted during the first phase of the project. During those visits, the team was able to interview a variety of airport and tenant personnel, observe airport operations, and examine airport publications that contained information related to human factors. More airport visits were planned during Phases 2 and 3; however, travel plans changed following the start of the COVID-19 pandemic. 1.4 Using the Report This report is organized so that the information presented in one chapter sets the stage for what follows. With that said, each chapter contains information that is related to that provided in other chapters. Thus, while it is ideal to start at the beginning and read to the end, readers can benefit from going directly to the chapters that address specific issues relevant to their airport or to those chapters that present topics of individual interest. 1.4.1 Goals of the Report This report has three primary goals. The first goal is to communi- cate the research findings to the airport industry. These findings include the results of the analysis performed on the FAA database to discover the human factors that underlie V/PDs. The breakdowns of the data provide actionable knowledge along with practical recommendations airport leaders can use for the improvement of safety and the manage- ment of the specific risks that exist on their own airports. The second goal is to provide ideas, information, and recommenda- tions that will allow airport leaders to link their airside safety practices and the human factors that influence them with SMS processes, including SRM and safety promotion in the realm of training for airside workers. The third goal is to provide information to airport leaders on the risk mitigations that may lower or eliminate human factors risks that can lead to V/PDs as well as provide information that will help guide decisions on resource allocation and airport safety improvement efforts. 1.4.2 Organization of the Report The report is designed to define the issue of human factors and inform the industry on mitiga- tion strategies airports could implement. It wraps up the discussion by listing areas where more detailed information is available but beyond the scope of this project, and where additional research could benefit the industry. In short, the report can be considered in four parts: • Assessing Human Factors: Chapters 1 through 3 set the stage with background information on human factors at airports and include defining key terms and topics and presenting a human factors risk assessment based on the analysis of V/PD data. • Mitigating Human Factors: Chapters 4 through 8 provide information on mitigations to reduce the risks presented by humans performing airside operations, along with tools available to improve the identification of human-factor safety hazards. • Conclusions and Recommendations: Chapters 9 is a wrap up of the material presented in the report and includes conclusions, direction to additional resources, and recommendations for future research. • Tools for Airports: The appendices provide airports with tools and additional information aimed at adding to the human factors knowledge base and improving safety processes used in the airside environment. The goals of this report are: • Communicate the research findings • Link the findings to safety management processes • Provide recommendations and mitigations to reduce human factors risks

Why Examine Airside Human Factors? 9   1.4.3 Additional Resources Associated with the Report Two additional publications are available through ACRP that work in concert with this report but in two distinctly different ways: the Human Factors and Airside Operations Executive Summary and the Human Factors Research White Paper. 1.4.3.1 Executive Summary The executive summary presents the key points of this report in a bulleted, quick-reference format for ease of use by airport leaders. The information presented in the executive summary references the specific paragraph numbers in this report. The user is pointed directly to the source of the information should added detail on the topic be needed. The executive summary is available on the National Academies Press website (www.nap.edu) by searching for ACRP Research Report 246: Airside Operations Safety: Understanding the Effects of Human Factors. 1.4.3.2 Research White Paper The research white paper written at the conclusion of Phase 1 of the project is provided as Appendix C so that a summary of the more than 200 resources reviewed for the project is available should airport personnel desire to add to their knowledge base. The white paper also includes the results of the V/PD database analysis (much of which is included in Appendix A) along with a lengthier discussion of technologies developed to address human factors and runway incursions at airports. Appendix C is available on the National Academies Press website (www.nap.edu) by searching for ACRP Research Report 246: Airside Operations Safety: Under- standing the Effects of Human Factors.