Consequences 6.1

Consequences

Because this has not happened before, your principle assumption is that the procedures as specified normally work and are understood by everyone. Perhaps for this particular person the rules were not clear and well understood? Or perhaps the person did not know about the existence of this procedure?

What are you correcting:

The person needs to understand how important it is that the available rules match the operational practice. He also needs to understand that operational practices are supported by rules and procedures. So, he or she should feel uncomfortable when there is an inconsistency between rules and operational practice, or when he or she is doing things for which there seem to be no procedures available. He or she needs training to report any inconsistencies in the rules when it would not be possible to safely complete the work following the procedures and should be coached on the risk of the ego-trap.

How are you correcting:

In the first instance this is all about training, but you are training at two levels:

Content: make sure the person gets trained in the procedure
Attitude: Address the issues of "I can do it without" as a factor the person should be mindful of

Also, investigate how it could be that somebody ends up in a situation for which rules and/or procedures are available, but were not known.

Wrong intersection

The crew crossed the runway at number W11, in stead of continuing to taxi all around the runway at the south end, using taxiway Zulu, as they had been cleared to do by the traffic controller.

This certainly was not the intention of the crew. But what they found perhaps confusing, was that the tower controller cleared them "to cross 36C at Zulu". Although the wording "Zulu" could not possibly be misunderstood about where they were supposed to be (Z->Z2->Z1->Z), it was the word "cross" that confused them. To them, this meant they had to physically be on the runway to "cross" it. But in correct ICAO language, the word "cross" is also used when the aircraft needs to taxi around the south end of this runway and needs to cross the holding line at Z2.

In a telephone discussion between the controller and the captain, the controller pointed out to the captain that there was an extra sheet of paper in the airport diagrams, laying out this particular "hotspot" situation. Over the phone the controller heard papers shuffling and then the captain sigh "Oh.. .buggars... If I had seen that, I would have never made this mistake"

Many solutions have been tried to solve this. In the end, the aiport physically blocked both entries W12 and W11. End of problem.

Consequences

Examples Rule not Followed

Wrong intersection