An Investigation Of Runway Risks Using A Systems Approach

Abstract

The purpose of this study was to explore and determine if Causal Analysis Based on System Theory (CAST) could divulge differing underlying causes in the Taxiway overflight incident of Air Canada Flight 759 at San Francisco International Airport, as compared to traditional investigation methods used by the National Transportation Safety Board (NTSB). Investigations tend to focus on trying to establish the probable cause of an accident or incident, and as a result, the systemic components tend to be overlooked which leads to the common underlying causes of the event left unsolved. Adopting a systems approach to assessing runway risks helped identify flaws in the aviation system and generated viable recommendations for fortifying a system and mitigating the risks mitigated. The CAST analysis generated a range of different underlying causes to the incident and identified factors related to runway risks. CAST determined organizational failure in procedures and policies to be the underlying cause of the Taxiway overflight incident of flight AC759. The identified factors related to runway risks included: misleadingly configured airfield lighting, a lack of automation, landing parallel to a taxiway, and improper application of Crew Resource Management.