Controller and pilot error in airport operations : a review of previous research and analysis of safety data

Cardosi, K. M.; Yost, A. · 2001 · ROSA P / United States. Department of Transportation. Federal Aviation Administration

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Summary

This report addresses the growing safety threat posed by runway incursions and surface incidents in airport operations. Motivated by a steady increase in reported incursions since 1995, despite stable rates of near mid-air collisions, the study aims to identify "shortfalls" in Air Traffic Control Towers (ATCT) and propose remedies. The authors note that nearly all such incidents are caused by human error, driven by the complexity of terminal environments and the unforgiving nature of split-second timing requirements. The scope is limited to tower operations and system integration, explicitly excluding training, procedures, and work schedules. The methodology combines a comprehensive review of existing literature on surface incidents and tower system integration with an empirical analysis of safety data. The data analysis examined 256 tower operational errors and deviations, 67 pilot deviation reports, 326 reports from the Aviation Safety Reporting System (ASRS), and 23 National Transportation Safety Board (NTSB) final reports of accidents and incidents. The literature review covered studies ranging from the first comprehensive runway incursion study in 1978 to recent surveys of tower controllers, focusing on causal factors and potential technological or procedural solutions. The findings indicate that the primary factors contributing to controller errors are memory lapses (forgetting about aircraft, runway closures, or issued clearances), communication errors (readback/hearback issues or instructions issued to the wrong aircraft), and incomplete coordination between controllers. The data supports previous literature suggesting that the absence of a supervisor, or a supervisor simultaneously working a control position, is a significant risk factor, as supervisors often prevent situations from escalating. Additionally, radio frequency congestion was identified as a critical strain on controller-pilot communication, leading to blocked transmissions and reduced safety margins. The analysis also highlighted the need for better surveillance equipment and consistent use of memory aids. The significance of this study lies in its specific recommendations for mitigating these identified shortfalls. The authors call for improved surveillance and monitoring equipment, such as ASDE-X and Airport Movement Area Safety System (AMASS), to assist in determining aircraft positions. They recommend better memory aids for controllers, improved means of controller-pilot communication to reduce frequency congestion, and enhanced coordination tools among controllers, such as shared displays. Furthermore, the report suggests revising methods for recording operational errors to better identify causes, surveying towers for effective "homemade" aids to disseminate best practices, and encouraging individual towers to perform specific risk analyses. These measures aim to prevent errors and mitigate their consequences, thereby enhancing the safety and efficiency of airport surface operations.

Key finding

The most common factors contributing to controller errors in the tower were forgetting about an aircraft or clearance, communication errors such as readback mistakes, and lack of or incomplete coordination between controllers.

Methodology

review

Provenance

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Topics

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• pre crash contributing factors