National Academies Press: OpenBook

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

Chapter: Chapter 8 - Improving Airport Investigations

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Suggested Citation:"Chapter 8 - Improving Airport Investigations." National Academies of Sciences, Engineering, and Medicine. 2022. Airside Operations Safety: Understanding the Effects of Human Factors. Washington, DC: The National Academies Press. doi: 10.17226/26779.
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Suggested Citation:"Chapter 8 - Improving Airport Investigations." National Academies of Sciences, Engineering, and Medicine. 2022. Airside Operations Safety: Understanding the Effects of Human Factors. Washington, DC: The National Academies Press. doi: 10.17226/26779.
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Page 53
Suggested Citation:"Chapter 8 - Improving Airport Investigations." National Academies of Sciences, Engineering, and Medicine. 2022. Airside Operations Safety: Understanding the Effects of Human Factors. Washington, DC: The National Academies Press. doi: 10.17226/26779.
×
Page 53
Page 54
Suggested Citation:"Chapter 8 - Improving Airport Investigations." National Academies of Sciences, Engineering, and Medicine. 2022. Airside Operations Safety: Understanding the Effects of Human Factors. Washington, DC: The National Academies Press. doi: 10.17226/26779.
×
Page 54
Page 55
Suggested Citation:"Chapter 8 - Improving Airport Investigations." National Academies of Sciences, Engineering, and Medicine. 2022. Airside Operations Safety: Understanding the Effects of Human Factors. Washington, DC: The National Academies Press. doi: 10.17226/26779.
×
Page 55

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51   Improving Airport Investigations This chapter discusses how airport leaders benefit from improved incident investigation techniques. The chapter starts by explaining why improvement efforts should be considered. The discussion continues with the advantages that airports can realize, not only regarding the data collected on V/PD human factors but on how the requirement to investigate V/PD translates to investigating other airport safety events, serving to support or act as a starting point for an airport SMS. The chapter also discusses the FAA’s role in the V/PD investigation process, dis- cusses investigation training that is available to airport personnel, and presents information airport investigators can use immediately to begin the improvement process. Enhancing the quality of human factors information captured during airport V/PD investi- gations will, over time, improve the ability to study and identify human factors trends, both locally and ultimately at a national level. Achieving this improvement in the quality of investi- gations and thus the quality of human factors data will take years and the participation of a large majority of airports. So, in the near term, the analysis of the FAA V/PD database will only show changes year over year rather than reveal additional details of the human performance causes behind these critical safety incidents. Reducing the number of V/PDs nationwide year over year is achievable. Realizing this goal would mean that these events would become rarer and the number of investigations conducted would decline, slowing the flow of information to the FAA. There needs to be a local incentive to improving investigations to drive the change. To spur more thorough and informative inves- tigations, there must be value for local airport leadership to drive a demand for better data on human factors. 8.1 Why Invest in Improving Airport Safety Investigations? The analysis of the V/PD investigation reports performed for this project found that during the 2-year period studied, all of the events had a human performance element. It would therefore follow that putting in the effort and dedicating resources to ensure that investigations capture the human factors involved are important to not only completing a thorough investigation, but to providing key, actionable information to airport leaders. 8.1.1 V/PDs as a Unique Safety Hazard V/PDs are just one of the safety incidents that occur airside, but a V/PD is a unique event in a couple of respects. As discussed in Chapter 3, V/PDs where those involved are employed by the airport or an airport stakeholder rarely result in damage or injury. With that in mind, it can C H A P T E R   8

52 Airside Operations Safety: Understanding the Effects of Human Factors be argued that the V/PD is the only safety event where no damage or injury is present where an investigation is mandatory. Thus, the V/PD stands as a unique safety hazard. In the vernacular of an SMS, a safety hazard is a condition that could foreseeably cause or contribute to an accident. A V/PD is a safety hazard that presents a risk of a collision with an aircraft, which could result in a catastrophic outcome. The potential severity of the outcome, even with the likelihood of such an event occurring being extremely low, makes runway incur- sions of any kind a high-priority safety issue for the aviation industry; thus, the mandatory investigation. 8.1.2 V/PD Investigations as a Model for Airport SRM Processes When viewed from the SMS perspective, the requirement to investigate a V/PD and the need to improve the quality of such investigations from a human factors standpoint presents a model for the effective execution of airport SRM and SA processes. The improvement of V/PD investigations might serve as a catalyst for implementing and executing effective SMS processes at the airport. For those developing and implementing an SMS, the key operational component is SRM. SRM and SA provide airport leaders with safety data on which risk-mitigation actions can be formed and put into place. One of the first steps of any SRM process, and in many cases the trigger for the initiation of a formal safety risk assessment, is the identification of a safety hazard. While the V/PD itself is technically not a safety hazard but the result of a hazard, the investigation of the event reveals the underlying safety hazards. Since all the V/PDs analyzed were the result of human factors causes (see Appendix A), it follows that an effective investigation will reveal human factors safety hazards prevalent in airside operations. Following through with the logical aspects of SMS pro- cesses, the identification of the human factors hazards will lead to the assessment of key airport risks, the development of risk mitigations, and ultimately monitoring, through SA processes, the frequency of the hazards and the effectiveness of the mitigations. Thus, airport leaders can rely on effect investigations to ultimately provide human factors data on which risk-based resource allocation decisions can be made. 8.1.3 Trained Investigators Are Value Added for the Airport Interviews with airport representatives across the country revealed that few airports have personnel on staff with formal training in safety investigations. It is highly likely that the person assigned to investigate a V/PD may have no training in performing the investigation other than having performed one in the past or having observed a teammate perform an investigation. Thus, lacking any formal airport guidance, the person assigned to investigate a V/PD is likely to conduct the investigation by simply searching for the information needed to complete FAA Form 8020-25, Investigation of Vehicle or Pedestrian Deviation Report (form can be found in FAA Order 5200.10 – Appendix A, https://www.faa.gov/document library/media/order/safety_5200_10.pdf). While this form covers the required data elements that the FAA collects for inclusion in the runway incursion database, it is left to the investigator to delve into the human factors involved and include them in Block 11 of the form (Description of V/PD and Comments with Recommendations). One airport was an exception to this rule. LEX in Kentucky put one of its airport operations personnel through the National Transportation Safety Board (NTSB) accident investigation course. The catalyst for The only human factors data made available for analysis and national trending are those that the airport investigator provides in narrative form in Block 11 of FAA Form 8020-25.

Improving Airport Investigations 53   this decision was the airport’s experience with an aircraft accident. The airport’s after-action discussions resulted in a determination that having a well-trained safety investigator on staff would have helped significantly during the response phase of the accident. Subsequently, LEX has found that its trained investigator has been used on multiple occasions despite that fact that there have been no additional aircraft accidents. The airport has found that the skills and techniques its investigator learned added great value to the airport’s ability to discover the root causes of all manner of safety issues and therefore improve airport safety as well as operational effectiveness. In Appendix B, a sample list of available courses, both online and in person, is presented so that airports may consider taking advantage of these training opportunities to improve the expertise of their personnel and the quality of their investigations. If an airport is in the vicinity of a university that has an aviation program, that program may include safety courses that cover accident investigations and could be an option worth exploring. 8.2 The Role of the FAA in V/PD Investigations The process and requirements for investigating a V/PD are covered in FAA Order 5200.10, Procedures for Conducting Investigations of Vehicle/Pedestrian Deviations. While an Airport Certification Safety Inspector (ACSI) is assigned to oversee the investigation of reported V/PDs, the order states that most V/PD investigations “. . . will not involve a site visit” (https://www.faa. gov/documentlibrary/media/order/safety_5200_10.pdf, p. 1). It further states that, for Part 139 certificated airports, the ACSI will in most cases send the airport operator a letter of instruction that informs the airport that an investigation is being conducted but that still places the respon- sibility for the conduct of the investigation on the airport operator. 8.2.1 FAA Investigator Training The assigned ACSI for each V/PD may reside at FAA headquarters in the office of airports or may be in the FAA regional offices with which each airport interacts. Assigned investigators have completed training required by the FAA that allows them to oversee the investigation. This training is done primarily online and does not provide them with a background in investigating human factors and human performance causes of the V/PDs. The training courses focus on the V/PD reporting and investigation process and the requirements that must be met to close out the investigation. The training prepares the ACSI to walk the member of the airport staff assigned to perform the investigation through the administrative steps of completing the process. 8.2.2 Capturing Human Factors Data During the Investigation As discussed in Chapter 1 and Appendix A, the only data available for analysis were found in the FAA’s runway incursion database. Additionally, due to the structure of the FAA investigation form from which the database is populated (FAA Form 8020-25), the only human factors data made available for analysis and national trending are those that the airport investigator provides in narrative form in Block 11. Those in the airport community who have had to investigate a V/PD are aware that the completion of FAA Form 8020-25 is only part of the process. Additional investigative informa- tion may be requested by and provided to the FAA in the form of a letter. On receipt and review of the Form 8020-25, the ACSI may ask additional questions. The questions come to the airport via a formal letter. The airport researches and answers the questions and responds to the FAA by formal letter.

54 Airside Operations Safety: Understanding the Effects of Human Factors 8.2.3 The Challenge to Thorough V/PD Human Factors Analysis and Trending At present, the data provided to the FAA in the form of response letters are not entered into the runway incursion database. The letters remain in hardcopy form in the archives but are not digitally scanned. Thus, additional human factors data that may have been uncovered during the course of the investigation are not easily analyzed. Therefore, from an airport industry perspective, in order to be able to fully analyze V/PD causal factors, airports should provide as much detailed information as possible regarding events in a complete and understandable description in the narrative in Block 11 of Form 8020-25. 8.3 Improving Airport Investigations from a Human Factors Perspective Not all airports will choose to develop an expert safety investigator by putting a staff member through a formal investigation course. However, having a formally trained safety investigator on the staff of a large airport may prove to be a sound investment because of potential airside safety issues given the tempo of operations. Regardless of the size of the airport, V/PDs are still rare events. For smaller airports, safety incidents that need a full investigation may also be rare. Airports can benefit from having guidance readily available to aid those members of the staff assigned to perform investigations in capturing all the information available on the human factors involved. 8.3.1 Researching Human Factors Investigation Techniques When looking to provide information and tools to assist airports in improving their ability to capture complete data on human factors during safety investigations, it made sense to examine the techniques used by the professionals who regularly investigate aviation accidents and inci- dents. Once a number of techniques were identified through interviews and reviews of guidelines, the goal was to craft a simplified guide that first-time investigators could use to ensure that the first investigation they performed captured the highest-quality information possible. Representatives from four investigative organizations were interviewed regarding the methods they used to capture human factors information. These organizations were: • NTSB, • Boeing Corporation, • U.S. Naval Safety Center, and • United Airlines. While the approaches used by each of these organizations varied slightly, all agreed that the primary means of capturing human factors data is through interviews with the people involved in and witnesses to the event. Investigators who can put the interviewee at ease and begin by asking simple, open-ended questions about the incident, thus allowing the person with direct knowledge of the incident to describe it, end up getting the best information. 8.3.2 Capturing Personal Histories for Multiple Days A key element of the human factors information the professional investigators capture is the recent histories for those involved in a safety incident. A common period of time these organiza- tions examine is the activities of those involved in the incident during the preceding 72 hours.

Improving Airport Investigations 55   This allows the investigator to study contributing circumstances, such as issues on or off the job that might serve to distract the person, or the amount of sleep obtained to see if fatigue might be a consideration. More information on fatigue is included in Chapter 7. Collecting personal histories on those involved in V/PDs is not required for completion of FAA Form 8020-25 and closing out the investigation, but it is a technique that can greatly benefit the investigation of human factors for any safety incident. 8.3.3 Investigation Information and Data Capture Template Appendix B provides information to airports for preparing staff members for conducting investigations, and it provides a template investigators can use to ensure that more complete human factors data are captured during an investigation. The appendix is in three parts: • Part 1 provides information and tips on the conduct of an effective investigative interview. • Part 2 presents a checklist for the capture of human factors data. • Part 3 presents a representative list of the types of investigation training courses airports might consider for developing a greater level of expertise in those staff members assigned to conduct safety investigations. The information in Appendix B does not have a V/PD focus. It was created for airport use based on tools developed and used by the professional organizations previously discussed.

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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.

The TRB Airport Cooperative Research Program's ACRP Research Report 246: Airside Operations Safety: Understanding the Effects of Human Factors provides a review of the current state of human factors research and the related resources that are available to U.S. airport operations personnel.

Supplemental to the report are an Executive Summary (to be released soon) and a White Paper.

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