Safety Review based on Tier 2 indicators

In addition to higher-level indicators for the safety performance, (tier 1; accidents, serious incidents and fatalities), various lower-level indicators (tiers 2 and 3) are used to monitor the development of operative risk factors. Tier 2 indicators include the most significant causal factors of accidents; Runway excursions (RE) Runway Incursions (RI-VAP) Airprox incidents (MAC) CFIT incidents (CFIT) Losses of control in air (LOC-I) Ground collisions (GCOL) Below the situation for 2019 is analysed based on these tier 2 indicators. Definitions of the indicators can be found further below.

Runway excursions (RE)

In 2019, eight runway excursions that occurred in Finland or involved Finnish aircraft were reported. This was less than in 2018 (12) and slightly below the average for 2013-2018 (9.5). Three of these cases resulted in an accident and two in a serious incident. On average in 2013-2018, runway excursions have led to 1.3 accidents, and in this respect the safety performance in 2019 was poorer.

Most runway excursions occurred in general aviation, which has been typical in recent years. The runway excursions usually happened while landing. In many cases, challenging wind conditions, which resulted in a steering error on landing, were a contributory factor. In two cases, a technical fault also had a role in the event, and in one, excessive speed after landing when exiting the runway was a contributory factor.

The runway excursion cases were more or less equally distributed around Finland. Two runway excursions each occurred at Malmi and Jämijärvi.

In January, a Latvian aircraft in commercial air transport was involved in a runway excursion in Savonlinna. The Safety Investigation Authority completed its investigation  (Ulkoinen linkki)of this incident in December.

Runway excursions (RE) by aviation domain 2004-2020 (not including drones, state aviation or foreign operators)

Runway incursions (RI-VAP)

The number of these cases increased clearly compared to the year before (64), ending the decreasing trend of runway incursions which had continued since 2016. This number also exceeds the average for 2013-2018 (64).
One runway incursion was classified as a serious incident. In this situation, a general aviation aircraft landed over a vehicle at the end of the runway with a small height clearance.

n 2019, 79 runway incursions (incidents where an aircraft, a vehicle or a person was incorrectly present on the runway) were reported.

A typical runway incursion in 2019 happened as the aircraft landed on the runway incorrectly in some way, for example while another aircraft or vehicle was still present on it.

The number of runway incursions by aircraft (51) thus increased alarmingly compared to the year before (35) and also clearly exceeded the average for 2013-2018 (41.3).
Increases from the year before were recorded particularly at Helsinki-Vantaa (5 cases in 2018 vs 12 cases in 2019) and Malmi (3 cases in 2018 vs 11 cases in 2019).

Foreign and Finnish commercial air transport operators were both equally often involved in the cases at Helsinki-Vantaa airport. Some cases involved failing to stop at holding position markings or stopbar lights. In five cases, however, an aircraft either approached for landing or took off without ATC clearance. The Safety Investigation Authority completed in December its investigation  (Ulkoinen linkki)of a case which occurred at Helsinki-Vantaa airport in early 2019 (an Irish aircraft in commercial air transport came in for landing while a Turkish craft, which had landed before it, had not fully exited the runway).

The runway incursions at Malmi airport occurred in general and recreational aviation.
A runway incursion is defined as any situation where an aircraft, vehicle or person is present on the runway or its protected area, without clearance or otherwise incorrectly. Malmi is an uncontrolled airport. It has no air traffic control that would give aircraft clearance to enter the runway. Situations at uncontrolled airports have also been classified as runway incursions, when the conclusion is that another aircraft had otherwise entered the runway incorrectly (including misjudging the location of an incoming aircraft).
In a typical situation at Malmi, an aircraft was in the final stages of landing when another aircraft taxied onto the runway, forcing the approaching aircraft to abort the landing.
Compared to a few previous years, runway incursions were more often caused by general aviation aircraft. Over the long term, however, the number of occurrences caused by general aviation has not been significantly higher.

The number of runway incursions caused by military aviation also increased significantly in 2019 compared to 2018. On the other hand, their number was low in 2018. All runway incursions in military aviation occurred at controlled airports, usually in Jyväskylä or Rovaniemi. In most cases, a taxiing aircraft crossed the runway holding position markings without clearance for one reason or another. The level of seriousness of these cases was typically low.

The number of runway incursions caused by ground vehicles and persons (26) increased slightly compared to 2018 (19) and exceeded the longer-term average (16.2). While the safety performance was good in this respect in 2019, more frequent than usual runway incursions caused by vehicles occurred in its last few months.

The number of runway incursions with ATC contribution (6), on the other hand, decreased compared to 2018 (10) and was on par with the longer-term average (5.5).

Runway incursions (RI-VAP) per causal domain 2004 (in some cases several domains may have a contribution)

Traficom’s work to reduce runway incursions
Traficom has published a number of safety bulletins concerning runway incursions over the years.
In 2013, an information letter (Ulkoinen linkki) was sent to all aviation licence holders, and in November 2018, a safety bulletin (Ulkoinen linkki) was published, which reminded the operators about typical cases of runway incursions. A safety bulletin (Ulkoinen linkki) published in October 2019 discussed the events of summer 2019, including runway incursions. The bulletins also contain useful tips for avoiding runway incursions.

The European Plan for Prevention of Runway Incursions (EAPPRI) (Ulkoinen linkki) was updated by the European aviation organisations in late 2017. EAPPRI contains numerous recommendations, and all parties should thus go through this document and attempt to implement its recommendations as far as possible. Traficom conducted a survey on the status of implementing the recommendations in Finland in September 2018.

Collisions and near misses in mid-air (MAC/Airprox)

A mid-air collision between aircraft would be a highly exceptional occurrence, and none were recorded last year, either. On the other hand, 82 Airprox incidents that occurred in Finland or involved Finnish aircraft were reported.

This represents a clear increase compared to the 71 cases in 2018 and also by far exceeded the average for 2013-2018 (49). Eight of the cases were classified as serious incidents, which means that the number of particularly serious incidents went down slightly year on year. In 2018, 11 events were classified as serious incidents. However, the number of serious incidents clearly exceeded the average for 2013-2018 (5.3). In six of these cases, the parties were a drone and an aircraft in commercial air transport; in one, two gliders; and in one case, military aircraft and a general aviation aircraft.

Finnish commercial air transport was a party to 42 Airprox incidents in total during the year. This number is clearly higher than in 2018 and also exceeds the average for 2013-2018. The most significant reason for the increase in the number of these situations is the growth in drone operations. In 2019, drones and commercial air transport aircraft were involved in Airprox incidents more or less as frequently as in the year before, in which 24 of such incidents were recorded. Most of these situations occurred in the vicinity of Helsinki-Vantaa airport.
In addition to Airprox incidents with drones, aircraft in commercial air transport were party to infringements of a separation minimum between manned aircraft slightly more often than in previous years, both in Finland and abroad.

The number of Airprox incidents in general aviation was higher than in the year before and more than double the average for 2013-2018. On the other hand, the number of these cases in recreational aviation was clearly lower than in 2018.

Most of the cases occurred at Malmi airport. The cases at Malmi typically were situations were general or recreational aviation aircraft had to perform an evasive manoeuvre on the landing circuit. Based on the reports, in quite a few cases one of the aircraft had failed to announce their intentions on the radio, or they had been misunderstood.
A few near misses were also reported from Spain, where the parties involved had been Finnish training aircraft and local aviators.

While the number of infringements of a separation minimum with ATC contribution was slightly higher in 2019 than in the year before, this figure remained at the same level as the average for 2013-2018 (19.5).

The reduced number of airspace infringements last year was a positive trend. An airspace infringement refers to a situation where an aircraft enters a controlled or restricted airspace or an ADIZ without appropriate clearance or permission. Whereas this situation does not inevitably cause an Airprox incident if no other aircraft is found in the vicinity, it increases the potential for such incidents. A total of 133 airspace infringements was reported. In 2018, there were 176 cases, and the average for 2013-2018 is 162.
In particular, the number of airspace infringements caused by general and recreationalaviation was reduced.

While drone operations have been the most significant factor in the increased number of near misses, this year their growth appears to have stopped. During the year, 22 Airprox incidents caused by a drone were reported (of which 15 in Finland), whereas the year before, this number was 27 (of which 23 in Finland).

MAC/Airprox incidents per participans 2004-2019 (drones include only incidents in Finland)

Traficom’s work to reduce near misses
Drone operators have been informed of the rules applicable to them on different channels.
EU rules on drone operations will enter into force in July 2020. These rules require all operators to complete a specific training package. It is believed that this will contribute to improving the safety of drone operations. Read more about the new Regulation here (Ulkoinen linkki).

Drone operators should remember Traficom’s Droneinfo  (Ulkoinen linkki)site, where you can find the most recent information about the rules applicable to operating drones and download the Droneinfo application onto a mobile device. On Droneinfo, you can check if drone operation is allowed at your planned location and find out the greatest permitted height. 

NB. Collisions and near misses are monitored as total numbers of cases and in terms of the parties involved in the incidents. Consequently, the figures in the graphs for total numbers and ‘parties involved’ are not the same. The figures in the ‘parties involved’ graph only include situations that occurred in Finland for the part of drones.

Controlled flight into or towards terrain and similar situations (CFIT/near-CFIT)

In 2019, nine cases were classified as CFIT. This is clearly more than the average for 2013-2018 (6.2) and almost double the number of cases in 2018.

These situations mainly occurred in recreational aviation and drone operations. Three out of the four situations reported in sport aviation were classified as accidents. Two of them occurred in glider operations as a glider collided with obstacles in an off-field landing, and one took place as an ultra-light aircraft collided with some trees on the edge of the runway when taking off.

Three situations classified as CFIT took place in drone operations, which is on par with the figure for 2018. If these unmanned aviation incidents are excluded, the total number of cases is comparable to the average for 2013-2018.

CFIT/near-CFIT incidents 2004-2019 by aviation domain (not including drones, state aviation or foreign operators)

Loss of control in flight (LOC-I)

In 2019, 21 cases of loss of control in flight were reported. This number was slightly lower than in 2018 (31) but clearly higher than the average for 2013-2018 (13.7). As in the previous year, the growth in the total number is explained by situations that occurred in drone operations (14). However, the number of reported drone incidents dropped in comparison to 2018 (22).

In commercial air transport, LOC-I cases are rare, and not a single one was reported last year.

In general and recreational aviation, there were seven LOC-I situations, of which four were classified as accidents. Three of these occurred in recreational aviation, and a life was lost in one of the cases. One case was classified as a serious incident. These figures are on par with the accident and serious incident numbers of previous years.

The Safety Investigation Authority launched an investigation (Ulkoinen linkki) of a situation at Tampere-Pirkkala airport which occurred in July and in which a student pilot’s life was lost, as well as of a situation that occurred in Eura (Ulkoinen linkki) in September. In both cases, a student pilot was flying an ultra-light aircraft, and according to the initial information, control was lost during take-off.

If we exclude cases that occurred in drone operations, the number of LOC-I cases in manned aviation was slightly lower (8) than in 2018 (10) and similar to the average for 2013-2018 (8.4).

Many of the cases involving drones resulted in the loss of the drone. However, the number of these cases was slightly lower than in the year before. The most common reason for loss of control was technical faults, including loss of radio link, or the pilot’s steering error.
The RPAS newsletter (Ulkoinen linkki) published by Traficom in the summer discusses the reasons for these events and the lessons learned from them at greater length. Droneinfo.fi is also a good source of information.

LOC-I incidents per aviation domain 2004-2019 (not including drones, state aviation or foreign operator)

Ground collisions while taxiing to or from a runway in use (GCOL)

In 2019, one collision was reported while an aircraft was taxiing to or from the runway or the area used for taking off or landing. This number is significantly lower than in the year before (5) and also less than the average for 2013-2018 (2.5). In this case, the propeller of a general aviation aircraft hit the ground while taxiing.

At airports, aircraft often need to reverse from the gate before they can start taxiing towards the runway. For this, either the aircraft’s engines or a pushback tractor is used.
Last year, 90 incidents in which pushback was disrupted were reported in Finland. This is more than twice the average for 2013-2018 (42.8).
Almost all of these cases occurred at Helsinki-Vantaa airport.

Typically, a bus or another vehicle crossed behind the aircraft, and the pushback had to be interrupted. These situations may contribute to a collision. This is why it is important that both vehicles operating in the apron area and the aircraft comply with the airport’s right-of-way rules.

Ground collisions (GCOL) 2004-2019 per aviation domain (not including state aviation or foreign operators)

Laser interference

aser interference with aircraft and helicopters is a continuous risk factor in air traffic. Laser beams can interfere with the pilot’s vision in critical flight stages, including take-off and landing, or when flying at low altitudes. Laser pointers disrupt the pilot's concentration and interfere with their vision, including temporary loss or blurring of sight and even permanent damage to the retina.

Cases of laser interference
In 2019, 32 laser interference cases were reported (14 in Finland and 18 in other countries), which is significantly below the average for 2013-2018 (53.7).

Traficom published a safety bulletin about laser interference (Ulkoinen linkki), which reminded the readers of its dangers, in September 2019. The bulletin also discussed the first sentence imposed by a court for laser interference.

The case numbers have dropped since 2015, which was the peak year of the decade (74 cases). The case numbers tend to go up especially as the dark season approaches. Typically, laser interference is reported in the vicinity of Helsinki-Vantaa airport, and two cases out of three occur as an aircraft is approaching.

While no aviation accidents caused by laser pointers have been reported, incidents have been reported around the world. The increase in laser interference is partly due to technological advancement and partly to pure ignorance. The number of cases in Finland has been low compared to other countries, and the trend has also been declining in recent years.

Country20192018201720162015201420132012201120102009
Finland3247384074665762573515
UK  12321258143914421394157119121500742
USA 5663675374427703389439603482359228361527
Canada 211379527590502461357273187108
Switzerland       1001508040
Germany 113
(30.6.)
123
(30.6.)
   32234227927336
Sweden 628811914811114612312211366
Norway32405654751177595115155119
Netherlands         470270
Belgium       23317110713
France         600 
Italy     1189885450 479 
Ireland   50134153158    
New Zealand  16915210437
(15.5.)
116    
Australia 228541544502466587667570521211

Hand-held laser pointers are inexpensive and easily accessible, and many people thus treat them as toys. One milliwatt is the highest permissible output of an individual laser pointer in Finland. An audio-visual equipment package may have a laser pointer with the maximum output of 5 milliwatts. If a pointer of this type has a green beam, it may interfere with pilots from a distance of up to three kilometres. With 125 mW lasers, this range may extend to up to 18 kilometres. The human eye is more sensitive to green light than to red or blue light.

Pointing a laser towards an aircraft is punishable
Pointing a laser towards the crew in an aircraft cockpit is punishable even if no actual damage or concrete danger has been caused to the aircraft, its crew or its passengers.

If, for example, the beam hits a crew member in the eye at a critical stage of the flight, such as during take-off or landing, dazzling the pilot or even partly blinding them, a serious dangerous situation may develop. This may constitute an offence titled ‘imperilment’ or, in some cases, ‘criminal traffic mischief’ or ‘negligent endangerment’.

If the use of a laser pointer causes actual damage, the situation would naturally be assessed quite differently. In that case, all Criminal Code provisions which safeguard human life and health, including those on negligent bodily injury and negligent homicide, would be applicable. The person who caused the damage would of course also be liable for significant financial losses.

The first court sentences for laser interference have also been passed in Finland. The Lapland District Court sentenced to a fine a man who had interfered with a medical helicopter with a strong laser pointer. The helicopter pilot had lost their sight for a moment. The incident occurred in Rovaniemi on New Year's Day 2017. In its sentence, the court found the man guilty of causing a serious traffic hazard, thus putting aviation safety at risk.

Punishable actPotential punishmentConsequences of the act; danger or damage caused
Aviation violation
Sections 159 and 178 of the Aviation Act
a fine– a violation of the Aviation Act
– causing danger or damage is not a requirement
Interfering with traffic
Chapter 23, section 11a of the Criminal Code
ranges from a fine to imprisonment for 6 months– the act disrupts traffic, for example a flight is delayed
Causing a traffic hazard
Section 159 of the Aviation Act and Chapter 23, section 1 of the Criminal Code
ranges from a fine to imprisonment for 6 months– the act's potential to put other people's safety at risk is sufficient
Criminal traffic mischief
Chapter 34, section 2 of the Criminal Code
imprisonment
4 months to 4 years
– the act must have put the safety or health of several other people at risk
– an abstract danger is sufficient, no concrete incident is required
Negligent endangerment
Chapter 34, section 7 of the Criminal Code
ranges from a fine to imprisonment for one year– the act must have put the safety or health of several other people at risk
– an abstract danger is sufficient, no concrete incident is required
Imperilment
Chapter 21, section 13 of the Criminal Code
ranges from a fine to imprisonment for two years– the act poses a concrete risk to other people’s life or health
All Criminal Code provisions safeguarding human life and healththe penal sanctions depend on the category of offence
liability for financial losses
– other people incur actual losses as a result of the act

Definitions

ACAS (Airborne Collision Avoidance System) refers to a system which warns pilots of the threat of collision and which meets the requirements for ACAS II systems set out in Appendix 10, Volume IV Chapter 4 (version 7) of the Convention on International Civil Aviation. This system relies on information exchanges between aircraft transponders, based on which pilots are given advisories and alerts of the presence of other aircraft nearby. A system that meets the ACAS II requirements is known as a TCAS (Traffic Collision Avoidance System). The system issues either Traffic Advisories (TA) or Resolution Advisories (RA).

A CFIT/near CFIT situation (Controlled flight into or towards terrain, CFIT) is a situation where an airworthy aircraft under the complete control of the pilot is inadvertently flown (or nearly flown) into terrain, water or an obstacle.

Recreational aviation refers to the operation of a glider, motor glider, ultra-light aircraft, autogyro and hot-air balloon, hang gliding and paragliding, as well as parachuting. NB. If a hot air balloon is used to transport passengers against a fee, this constitutes commercial air transport. This publication does not deal with hang gliding, paragliding or parachuting.

Loss of control in flight (LOC-I) means a situation where the pilot loses control of an airborne aircraft, resulting in a significant deviation from the aircraft’s intended flight path. The loss of control may be total or momentary and caused by such factors as human error, mechanical faults or external factors.

The International Civil Aviation Organisation (ICAO) is a civil aviation organisation operating under the auspices of the United Nations.

Commercial air transport refers to using aircraft for transporting passengers, cargo or mail against payment or other compensation.

Runway excursion (RE) refers to uncontrolled exit by an aircraft from a runway during take-off or landing. This may be unintentional or intentional, for instance as the result of an evasive manoeuvre.

Runway incursion (RI-VAP) is any situation where an aircraft, vehicle or person is present on the runway or its protected area, without clearance or otherwise incorrectly. This includes low approaches executed without clearance or otherwise incorrectly.

An accident refers to an occurrence associated with the operation of an aircraft which, in the case of a manned aircraft, takes place between the time any person boards the aircraft with the intention of flight until such time as all such persons have disembarked, or in the case of an unmanned aircraft, takes place between the time the aircraft is ready to move with the purpose of flight until such time it comes to rest at the end of the flight and the primary propulsion system is shut down, in which

a) a person is fatally or seriously injured as a result of

• being in the aircraft, or

• direct contact with any part of the aircraft, including parts which have become detached from the aircraft, or,

• direct exposure to jet blast,

except when the injuries are from natural causes, self-inflicted or inflicted by other persons, or when the injuries are to stowaways hiding outside the areas normally available to the passengers and crew; or

b) the aircraft sustains damage or structural failure which adversely affects the structural strength, performance or flight characteristics of the aircraft, and would normally require major repair or replacement of the affected component, except for engine failure or damage, when the damage is limited to a single engine, (including its cowlings or accessories), to propellers, wing tips, antennas, probes, vanes, tires, brakes, wheels, fairings, panels, landing gear doors, windscreens, the aircraft skin (such as small dents or puncture holes) or minor damages to main rotor blades, tail rotor blades, landing gear, and those resulting from hail or bird strike, (including holes in the radome);

or

c) the aircraft is missing or is completely inaccessible.

serious injury means an injury which is sustained by a person in an accident and which involves one of the following:

a) hospitalisation for more than 48 hours, commencing within 7 days from the date the injury was received;

b) a fracture of any bone (except simple fractures of fingers, toes, or nose);

c) lacerations which cause severe haemorrhage, nerve, muscle or tendon damage;

d) injury to any internal organ;

e) second or third degree burns, or any burns affecting

more than 5% of the body surface;

f) verified exposure to infectious substances or harmful radiation.

Foreign commercial air transport means the transport of passengers, cargo or mail against payment or other compensation using other than a Finnish aircraft, or under an operating licence not issued in Finland.

serious incident means an incident involving circumstances indicating that there was a high probability of an accident and is associated with the operation of an aircraft, which in the case of a manned aircraft, takes place between the time any person boards the aircraft with the intention of flight until such time as all such persons have disembarked, or in the case of an unmanned aircraft, takes place between the time the aircraft is ready to move with the purpose of flight until such time it comes to rest at the end of the flight and the primary propulsion system is shut down. A list of examples of serious incidents is set out in the Annex to Regulation 996/2010 (EU).

mid-air collision (MAC) and a near miss/AIRPROX is a situation where airborne aircraft come into contact with one another or in which the distance between aircraft as well as their relative positions and speed have been such that the safety of the aircraft involved may have been compromised.

A ground collision while taxiing to or from a runway in use (Ground collision, GCOL) is a situation where an aircraft comes into contact with another aircraft, a vehicle, a person, an animal, a structure, a building or any other obstacle while moving under its own power in any part of the airport other than the active runway, excluding power pushback.

General aviation refers to all other domains of aviation apart from commercial air transport and aerial work. NB. In this publication, general aviation and aerial work are dealt with as a single category. Recreational aviation is also handled as a separate category.