An Airbus A320 flying over a busy taxiway in San Francisco served as an example of the serious risk of pilots being overloaded with NOTAMs, an ICAO forum heard when the organization made efforts to reduce unnecessary NOTAM information.
The crew of the Air Canada jet, who wanted to land on runway 28R at night in July 2017, accidentally stood on parallel runway C, which was occupied by four aircraft.
The National Transportation Safety Board investigators found that the pilots misidentified the runway because they did not remember the closure of runway 27L contained in a NOTAM.
The flight clearance package from the crew was 27 pages long, and the NOTAM, which announced the closure of the runway, was on the eighth, in the middle of the second page of the NOTAMs.
Although the entry had a red ‘NEW’ mark with asterisks and bold text for ‘RWY’ and ‘CLSD’, the investigation read, “This emphasis was not effective in getting flight crew members to review [or] Save this information, especially given the NOTAM’s location, which was not optimal for information retrieval. “
It has been suggested that a psychological trait known as the “serial position effect” makes people remember the first and last elements of a series better than the ones in the middle.
“The failure to see this NOTAM was essentially the main cause of this serious incident. That was a wake-up call, “said Mark Zee, founder of the OpsGroup and former pilot and air traffic controller, during an ICAO event on April 8 that initiated a global campaign to overhaul the NOTAM system.
Zee presented the example of a typical briefing package for an Airbus A330 flight from Munich to Singapore, which contained 24 pages of operational information – fuel, route and weather data, all clearly arranged – followed by around 120 pages of NOTAMs.
“This is not a special case,” he said. “It happens routinely. Every flight, every day receives a very large package of NOTAMs. “
Lauri Soini, Captain of the Finnair A320, pointed out that there will be around 10-15 NOTAMs on each side.
“For each and every one of us we should read, understand and decide if it is relevant to our flight,” he said. But even if he only reads 5 seconds for each NOTAM, the process could take over 90 minutes, while the crews may only have 20 minutes for pre-flight briefing.
Twenty years ago, the entire briefing package would have been “usable” in less than 20 pages, Soini said, but the increase in NOTAM data was “mind-boggling.”
The ICAO’s campaign will initially focus on eliminating the number of obsolete NOTAMs that are still circulating in the system.
During the event, several ICAO regional offices underlined the problems of inadequate regulatory oversight and slow implementation of quality management systems for aeronautical information services.
According to Shane Sumner, ICAO regional representative for the Asia-Pacific region, only 19 out of 42 countries and administrative regions in the Asia-Pacific region have implemented quality management systems and there are indications of poor maintenance, even in the implementing countries.
Only 12 countries have formal agreements with data producers, and there is “insufficient knowledge and awareness” of regulations among those authors, he added.
This situation is exacerbated by the fact that aviation information services within civil aviation authorities are often given “low status,” Sumner said, and are not empowered to refuse to accept raw data or non-compliant data provided at a later date.
Keziah Ogutu, ICAO Regional Representative for East and South Africa, pointed to similar problems across the continent, including inadequate information dissemination infrastructure, lack of expertise and poor training.
“As expected, many of our NOTAMs come from outside service providers, including government agencies,” she said. “Some of them have little or no knowledge of the requirements for issuing a NOTAM.
“Most of the time, they want a message to end as it’s worded and to stay in place for much longer than the standard that is set.
The ICAO campaign aims to examine not only the quantity of NOTAMs, but also their quality.
Investigators investigating the Air Canada incident in San Francisco mentioned the need for “more effective presentation” of flight operations information to improve pilot loyalty.
“The way information is presented can have a significant impact on how information is reviewed and retained, as a pilot may miss more relevant information if less relevant information is presented to him,” the investigation said.
Although the NOTAM of the runway 28L closure had been given to the A320 crew, the presentation did not effectively convey its meaning, adding, “Several events in [NASA’s] The Flight Safety Reporting System database has shown that this issue has affected other pilots, indicating that all pilots could benefit from the improved display of flight operations information. “