Purdue University Graduate School
2021.7.29 Bhargava_Divya_Thesis_.pdf (5.68 MB)

Learning Lessons from Incidents to Improve Runway Safety: What helps controllers create information-rich reports that improve our knowledge of runway incursions and their causes?

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posted on 2021-07-29, 23:53 authored by Divya BhargavaDivya Bhargava

A runway incursion occurs when an aircraft, ground vehicle, or a pedestrian is present on a runway when they were not supposed to be there. Runway incursions are a decades-old and continuing problem. The runway incursion between two Boeing 747s at Tenerife airport in 1977 is still the worst accident in aviation history. Despite the aviation community’s efforts to mitigate runway incursions, the number of incursions has not decreased. Though most of the runway incursions that occur today are near-misses or incidents, and do not result in injuries or aircraft damage, we cannot count on fortune to prevent another deadly accident.

While the COVID-19 crisis has slowed air traffic, the industry is optimistic about recovery and return to the growth in air traffic we have seen over the past decade. With this growth comes the potential for more runway incursions. Therefore, we must develop better ways of preventing incursions. Runway incursion incidents are one way to learn more about how we can prevent similar incidents in the future and reduce the probability of serious accidents. Unfortunately, most incident reports lack detailed information on the causes of runway incursions. In the United States, trained investigators at the National Transportation Safety Board investigate aviation accidents, but not most incidents, including incursions. Air traffic controllers on duty at the time of incursion report the incident to the FAA. While most controller reports explain what happened, they often do not explain why the incident happened. We need deeper insight into why incidents occur so that we can develop more effective measures to reduce incursions.

After controllers submit their incident reports, reviewers at the FAA go through the controller-generated reports and determine the need for further investigation. They may contact the controllers for more information or talk to the pilots involved. This research considers one aspect of the reporting process — the reporting form. The research hypothesis is that an alternative reporting form that asks detailed questions and guides the controller to look deeper into an incident can provide more details on human error and causes of these errors than the current form, which does not necessarily prompt controllers to gather all the details of the incident.

The design of the alternative reporting form is based on the theoretical framework of expert systems. Expert systems, which provide tailored questions and guidance to medical doctors and others, have proven useful in other fields. The resulting alternative tool aims to guide controllers into answering three major questions: what happened (which aircraft were where, and when), how it happened (e.g., controller gave the wrong instruction), and why it happened (e.g., controller was fatigued).

To investigate how controllers interact with different reporting formats and what helps them or detracts them from creating useful reports, the research experiment involved controllers reporting two hypothetical runway incursions either using the alternative reporting tool or an online survey based on the current FAA form. The experiment used surveys, think-aloud protocols, observations, and interviews to collect data on what controllers included in their reports and how controllers generated these reports. The findings helped compare the type of information we get from the two reporting formats, and how the reporting formats affected the quality of the incident reports.

Overall, the alternative tool-generated reports provided more information than the online survey based on the current FAA form. Each controller who participated in the experiment approached preparing an incident report differently and different factors motivated them to specify details of the incident. While the format of the alternative reporting form helped one controller talk to the pilot and learn more about why the pilot made an error, the format did not have the same impact on another controller.

This research identifies ways of helping controllers prepare more useful reports. This research may help the FAA improve data collection. More useful reports in the future can help the aviation community identify the cause of human errors leading to incursions, and develop more effective mitigation strategies, ultimately saving lives.


Degree Type

  • Doctor of Philosophy


  • Aeronautics and Astronautics

Campus location

  • West Lafayette

Advisor/Supervisor/Committee Chair

Karen Marais

Additional Committee Member 2

Steven Landry

Additional Committee Member 3

Denny Yu

Additional Committee Member 4

Colin Gray

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