on commercial aviation safety summer 2002 - past issues/focus 47.pdf · sumo fork integrated damage...
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O N C O M M E R C I A L A V I A T I O N S A F E T Y
ISSUE 47 THE OFFICIAL PUBLICATION OF THEUNITED KINGDOM FLIGHT SAFETY COMMITTEE ISSN 1355-1523
SUMMER 2002
This issue of Focus sponsored by Cascade Kenhar Ltd.Sole European Distributors for the
SUMO Fork Integrated Damage Protection System
This issue of Focus sponsored by Cascade Kenhar Ltd.Sole European Distributors for the
SUMO Fork Integrated Damage Protection System
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The Official Publication ofTHE UNITED KINGDOM FLIGHT SAFETY COMMITTEE
ISSN: 1355-1523 SUMMER 2002 ON COMMERCIAL AVIATION SAFETY
contentsEditorial 2
Chairman’s Column 3
Its not the one thing that gets you, 4its when they gang up against you
How do you view Ramp Damage? 6
ATC Options 7
Aircraft damaged by de-ice rig. Port stabiliser wing tip 8damaged beyond repairDean Godfrey, KLM uk
A Ramp Related Incident 9Nicole Stewart, bmi regional
Confidential Reporting for Cabin Crew 10
Stand Discipline - Does your Organisation have it? 11
UKFSC List of Members 12
The JAA’s operations standardisation team visit programme 14Captain Tim Sindall
CRM training needs measures and remeasures 16if it is to succeedKeith Bedingham
New Human Factors Requirements for JAR145 18Approved Maintenance OrganisationsFiona Merritt, CAA
Frontline Defences? Safety on the Ramp 19Colin Brown, CHC Scotia
The Dangers of Tyre Failure 21
Helicopter Ramp Incident & Ground Damage at Zurich 22
Implementation of HSE’s Aircraft Turnround 23Guidance Note HSG209 at Heathrow
Ramping-up Safety 26Dr Simon Bennett FICDDS
Just Another Ramp Incident 29
Thoughts on Ramp Safety 30Wg Cdr Dave McCormick, DASC
FOCUS on Commercial Aviation Safety is published quarterly by The UK Flight SafetyCommittee.
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FOCUS on Commercial Aviation Safety iscirculated to commercial pilots, flight engineersand air traffic control officers holding currentlicences. It is also available on subscription toorganisations or individuals at a cost of £12(+p&p) per annum.
FOCUS is produced solely for the purpose ofimproving flight safety and, unless copyright isindicated, articles may be reproduced providingthat the source of material is acknowledged.
Opinions expressed by individual authors or inadvertisements appearing in FOCUS are thoseof the author or advertiser and do not necessarilyreflect the views and endorsements of this journal,the editor or the UK Flight Safety Committee.
The mention of specific companies or productsin articles or advertisements does not imply thatthey are endorsed or recommended by FOCUSor its publisher in preference to any others.
1
UK FLIGHT SAFETY COMMITTEE OBJECTIVES
■ To pursue the highest standards of flight safety for public transport operations.
■ To constitute a body of experienced aviaition flight safety personnel available for advice and consultation.
■ To facilitate the exchange of urgent or significant flight safety data.
■ To maintain a liaison with all aviation authorities on matters affecting the safety of the flight-crew, ground-crew, the aircraft
and passengers.
■ To provide advice and assistance to operators setting up a flight safety organisation.
Editorial
2
Ramp Damage - Time for Action
There are strong indications that theairline business is returning to the pre11th September 2001 level. I am certainthat many are breathing a sigh of relief.This should be good news for all thosewho were made redundant. Many havealready found jobs and returned to workand I am sure they feel much happier,even if less secure, in their new positions.Others are still frantically looking forsuitable employment.
For those, unlike the aircrew, who are notreliant for employment in the aviationindustry, many have found positions inother industries, vowing never to return toaviation. Some feel there is a total lack ofloyalty by management to their staff. Theloss of experienced aircraft engineers toother industries is certainly not good forthe aviation industry. They shouldhowever be a little cautious, as working inanother industry does not make themimmune to staff cutbacks.
One of the byproducts to redundancyaction is the effect that it has on the workof the employees. Low moral has a directimpact on work practices and employeemotivation and can ultimately lead to alowering of safety sandards within anorganisation. It is therefore necessary forall managers to be aware of this and tomanage accordingly.
On a brighter note the increasing numberof air travellers means that the industrywill soon be expanding again and therewill be an even greater need for goodreliable staff at all levels. The rate at whichthe air operators expand may well be
limited to the availability of suitable staff.
Damage to aircraft on the ramp remains amajor concern and the uninsured lossesto air operators continues to grow. Someairlines are starting to pay more attentionto the monitoring of these losses as theirprevention would lead directly to anincrease in the profit. Some estimatethese losses to be in excess of $4 billionannually.
The Health and Safety Executive (HSE) isvery concerned about the number ofinjuries on the ramp and the ever growingloss of working time. (Some believe theaviation industry injury record is nowhigher than that of the building industry.)
Safety on the ramp must be improved,but how?
It has become clear that making the airoperator responsible for the safety of theircontractors, as required by JAR-OPS, isnot working. Perhaps it would make bettersense for the airport to be responsible forsafe operation of all contractors on theirairport. The airport operator is in a farbetter position to monitor how thecontractors are working, than an airlinebased in another city or country. Inaddition they have the ultimate sanctionof withdrawing the right of the contractorto work on that airfield if they fail toperform in the correct manner.
Has the time come to introduce someform of certification for the many workerson the ramp? Pilots and engineers arerequired to be properly qualified in order
to work on aircraft. Whilst they do causesome damage to aircraft on the ramp it isfar less than the damage caused to theaircraft by the thousands of unqualifiedramp personnel.
The cost to the aviation industry due toinjury and damage on the ramp hasreached a point where we can no longerignore it. The current system ofemployment of ramp personnel will haveto change in order to bring the number ofinjuries and cost of damage undercontrol. Should we therefore not “graspthe nettle” and introduce some form ofground handling certification before theproblem gets even worse?
UK FLIGHT SAFETY COMMITTEE OBJECTIVES
■ To pursue the highest standards of flight safety for public transport operations.
■ To constitute a body of experienced aviation flight safety personnel available for advice and consultation.
■ To facilitate the exchange of urgent or significant flight safety data.
■ To maintain a liaison with all aviation authorities on matters affecting the safety of the flight-crew, ground-crew, the aircraft
and passengers.
■ To provide assistance to operators setting up a flight safety organisation.
Amendment to ‘Angle ofAttack’ article in Spring2002 Issue:
“Key Points to emphasise in training”bullet point 3, last sentence, 3rd tolast word should read ‘inappropriate’
Chairman’s Column
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Challenges for the Industry
2001 had all the makings of a good yearfor aviation safety until 11th September.Since then a greater emphasis has beenplaced on new or revised securityinitiatives. Many of these were, arguably,rushed into place.
Historically safety initiatives in our industryhave always been carefully thoughtthrough to ensure that “improvements”don’t contain any latent problems. Longqueues of passengers at securityscreening posts within the terminals havebecome the norm at airports. Recentpress reports have hailed the securityinitiative as a success, quoting the numberof Swiss army knives and other“dangerous” items detected - we trustthat they don’t lose sight of the realobjective.
John Heimlich, Director of Economics atthe US Air Transport Association is quotedas saying “we’ll never be able to stop theweapons, so we have to go after thepeople”. The recent airside robberies atLondon Heathrow have illustrated that notall the “bad guys” are necessarily going tosubmit themselves to inspection at thepassenger security checkpoints inside theterminal building.
I strongly concur with Tom Croke’smessage in the Spring 2002 issue of
FOCUS that security measures against thetype of attacks of 11th September restentirely with the state agencies.
Prior to the 11th September the aviationindustry was already in a state of a steadybut slow decline. Since then passengernumbers have fallen dramatically andCompany Executives were faced withenormous survival challenges. Difficulttimes call for difficult measures, steadynerves and acute business skills.
We have all seen budgets slashed, aircraftparked up and colleagues and friendslaid-off. Even the areas of Flight Safetyand Quality which are considered to beessential to the safe operation have notbeen immune to the deep cuts. All areasof airlines are being forced to make painfulcuts, and make rapid changes in policyand direction to keep pace with anuncertain market. Senior Managers needthe eyes and ears of their Quality andFlight Safety departments to ensure thattheir organisations, now more than everwill emerge intact, safe and ready for thechallenge of the upturn.
The UK Flight Safety Committee has beenencouraged to continue its good work. Itis the only Aviation Safety body in theworld where Operators, Regulators, Pilots,Air Accident Investigators, Airport
Authorities, Trade Unions, Air TrafficControllers, Ground Handlers, Engineers,Lawyers and Insurers meet on a regularbasis in order to discuss Flight Safetymatters. We do make and will continue tomake a positive contribution to theimprovement of Flight Safety.
To date 2002 has seen a number ofaccidents or incidents whose causaleffects have included: CFIT; landingoverrun; icing; engine flame-out in rain;autopilot mode confusion; failure of largediameter fan blades; hostile acts. Theseillustrate that we can never afford to becomplacent.
We are all responsible for Flight Safety andwe can all make a difference.
by John Dunne, Airclaims
4
This is an account of what happenswhen several things conspire against you,to make an ordinary flight into somethingmore dangerous. All the problems thatare described here are manageable ontheir own but added together made quitean evening.
The flight was planned to go to MilanLinate, it was to be the first line trainingflight for a new first officer, and it iscompany policy to carry another firstofficer on the jump seat for safetyreasons. The pilot flying was a line-
training captain with eight yearsexperience on type.
At the pre-flight stage the weather for LINand its alternates looked OK, just achance of rain and snow on the forecastbeing the worst and further down Italy,two diversions had a quite good stableforecasts. Enough fuel to hold for 30 minsor divert a long way away was loaded.
The trip down was uneventful; theweathers all remained as forecast.Crossing the Alps that all changed.
As soon as we contacted Italian ATC wewere sent to hold over Bergamo, alsobeing informed that the two Milan airportswere snow clearing and closed untilfurther notice. We rechecked our otheralternates, Turin and Genoa. Both ofthese were reporting good weather.A diversion to Genoa was requested,‘sorry’ came the reply ‘they are unable toaccept diversions because of overcapacity’ ‘OK, request diversion to Turin’,same reply ‘overcapacity’.
Now we had a problem, nowhere to go.Just as it was looking quite bad ATCasked if we had a fuel problem, well, twominutes ago we hadn’t, now we did, Theyoffered us the just cleared, Malpensa.
While all of this had been unfolding wewere burning fuel, precious fuel. Nowseemed a good time to change firstofficers to maximise the experienceavailable.
We anticipated the northerly runway andbriefed, it was not to be, the wind hadswung round 180 degrees, that was ourfirst clue as to what was in store for us.Then a third rebrief, as the ILS for thesouth runway was unserviceable.
Down wind the flaps decided tomalfunction and stick at zero, I flew aVOR DME approach while the first officerdid the relevant calculations and drills,these were all finished as we turned ontofinal approach, at last a runway ahead.
At 1000 feet on final approach all hellbroke loose, with the wind roaring andhowling, the aircraft went into anuncontrolled descent, WINDSHEAR GO-AROUND was shouted and the aircraftwas put into the recovery attitude with fullpower. ‘Gear up’ was called, but twicethe reply ‘still descending’ came back.How could this be? The aircraft waspitched up and full power was applied.The GPWS joined in, ‘WHOOP WHOOP,PULL UP, TERRAIN’.
The aircraft data recorder noted that we
It’s not the one thing that gets you, it’s when they gang up against youAn account of a windshear event - December 2001, Milan, Jet aircraft
5
had gone down to 250 feet radio beforerecovery.
As we climbed away the TCAS went redin the whole of the climb segment; welevelled off, guessing that we mayimpinge on the holding traffic above and
declared a PAN, as we had to go toanother airfield. Turin was nominated, andATC, with renewed interest in us, turnedus en-route.
Fuel and MSA’s where now high on theagenda as the route would take us alongthe foot of the Alps, although, as weapproached Turin snow once againraised its head. Turin had a long runwaybut the wind was straight across at 20knots and the runway was covered insnow! Just ideal for a flapless!
The aircraft performed well on therunway, stopping two thirds down andtaxiing off normally.
I always thought beer tasted best inHolland, but it tastes much better in Turin!
What did we learn?
Things happen in threes and fours notjust on their own.
Weather forecasts are somebody’s bestguess, but not a certainty.
Airports close for a variety of reasons notjust weather.The quality of ATC varies with theworkload they have.
The term windshear is often used todescribe a loss of 10 knots or 100 feet,but don’t forget it can be much worse.
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6
How do you view Ramp Damage? Is itbecause poorly trained, poorly paid,workers are employed to carry out theirwork with heavy vehicles close toexpensive aircraft? Is it because trainingstandards are low and quality assurancepoor? Is it the fault of the airlines whowant everything for almost nothing? Is itdue to unrealistic time pressures duringturn-rounds?
This is a tale of a short turn-round at aSpanish airfield on a Charter AirlineBoeing 757. The aircraft has been de-identified in the photographs to protectthe innocent.
The Captain had followed the signalsfrom a marshaller and stopped theaircraft in accordance with his orders.The parking brake had been applied,shut down checks carried out and thepassengers had deplaned. The APU wasrunning in accordance with normal SOPs.A tremendous jolt was felt throughout theairframe and some of the crew left theaircraft to check for the cause. A set ofpassenger steps, that were being towedby a vehicle, had impacted the APUexhaust and caused part of the exhaust
structure to separate from the aircraft. TheAPU continued to run but was shut downimmediately the Captain returned to theFlight Deck.
An investigation was initiated and severalinteresting points emerged. The stepswere being towed in an unauthorisedconfiguration i.e. sideways rather thanlengthways and although the Captain hadstopped the aircraft following instructionsfrom the marshaller, the tail of the aircraftextended by a few inches beyond the‘yellow line’.
Who was held to be at fault? Yes youguessed it, THE CAPTAIN. Although hestopped in a position ordered by themarshaller, it was his responsibility toensure the aircraft was suitably parked.Who paid for the damage? You canimagine the sloping shoulders on thisone. The handling agent and airportauthority claimed that they wereblameless in spite of the obvious failingsin their performance but ultimately abargain was struck.
What are the lessons learnt followingsuch an incident? The Captain is theCaptain and is likely to be blamed foranything. Be aware of ramp markingseven if you have followed externalinstructions correctly. Do not expectexternal agencies to put up their hands toaccept blame, at least not without a fight.
Ramp Damage remains one of the mostsignificant areas of airline loss.Isn’t it about time we got our acttogether?
How do you view Ramp Damage?An account of a windshear event -December 2001, Milan, Jet aircraft
7
8
Weather at the time of the incident:Freezing, dry.
Lighting: Dark, stand lights.
Surface conditions: Dry, no contamination.
Aircraft damaged by de-ice rig. Portstabiliser wing tip damaged beyondrepair. This occurred whilst repositioningthe de-ice rig from the port to thestarboard side of the aircraft; the rigboom came into contact with the rearport tail plane wing tip.
Due to congestion between thepassenger air-bridge and the port wing, itwas discussed and agreed between
driver and bucket operator, that the bestapproach would be to de-ice the wing
and the rear tail plane, from theone position between wingand tail plane. The driverapproached the aircraft at 90degrees to the main fuselageand de-icing commenced,by spraying the root of thewing and working backtowards the wing tip. Thiswas completed by reversingthe rig to allow the bucketoperator the best angle ofattack possible. Oncompleting the wing, the rigwas driven forward again at90 degrees to the fuselageand the rear tail plane wasde-iced using the samemethod.
While the de-icing operationof the port side wasunderway, a fuelling bowserhad parked on the adjacentstand, to refuel anotheraircraft. The position that thefuel truck had taken blockedthe normal reversing route
taken by the rig to pull away from theaircraft and to manoeuvre to the otherside of the aircraft. It was discussed andagreed between the driver and bucketoperator, what the best means tomanoeuvre clear of the aircraft andreposition on the other side were. Themanoeuvre would involve a reversestraight back as far as possible, beforecoming into contact with the bowser andthe use of a hard right lock to turn awayfrom the aircraft.
The bucket operator guided the rigstraight back as far as possible and thenthe driver turned full right lock and movedforward. As the de-ice rig moved forwardand right, the boom came into contactwith the port rear tail plane wing tip,causing a crumple and tear to the wingtip approximately twelve inches in length.As a result of the investigation theprocedures for moving from one side tothe other for this aircraft were changed:Whilst manoeuvring, the boom should bepositioned below the level of the tail planeto avoid any possible contact with theaircraft.
Aircraft damaged by de-ice rig. Port stabiliser wing tip damagedbeyond repairby Dean Godfrey KLM uk
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9
During turnaround at a UK Internationalairport, the number 1 cabin attendantnoticed that the viewfinder in the reartoilet, that allowed sight into the hold, wasobscured.
She informed the Captain who asked theloaders to have the blockage removed.He then, during his walk-round, checkedto make sure this had been done. It wasobvious to him that something sticky hadbeen put there due to adhesive stillremaining on the lens.
The Captain then asked the loader whowas walking away from the aircraft, whatexactly had caused the blockage. Theloader said that a sticker had come offone of the bags and had stuck to the lens.
Knowing the height to which the bags werestacked in the hold and likewise the heightof the lens itself, the Captain surmised thatthe sticker would have needed to grow itsown wings to get up there!
The incident was discussed amongst thewhole crew and it was decided to contactthe police and the duty ground manager.
The police agreed that there was a strongpossibility that the bags had beentampered with. Whilst unlikely thatanything had been placed in the bags, itcould not be eliminated without furtherscreening.
The Captain,conscious of notinviting bogus theftclaims, told the now-boarded passengersthat he had receivedinformation that theirbags may not havebeen 100% screenedduring the check-inprocedure. Thepassengers were thendisembarked whilst
their bags were removed and rescreened.
Whilst the aircraft was empty, the policeboarded and inspected the cargo holdviewfinder from inside the toilet and insidethe hold. They found a new, still sticky‘FRAGILE’ label on the floor of the hold.It matched the marks stillevident on the lens andadjacent bulkhead.
The police agreed withthe crew that it was adeliberate attempt toprevent the loading staffbeing observed fromwithin the aircraft.
The following day thesame Captain had asimilar incident at aEuropean Internationalairport. Again a labelappeared to have beenstuck over the lens toprevent the crew insidethe aircraft seeing intothe hold.
Certainrecommendations weremade:-
1. Advise all crews toinspect the viewer onwalk-rounds.
2. Captains to brief cabin attendants tocheck prior to pushback that theviewer is clear.
3. Crews to file ASR’s in all instances toassess the scale of the problem.
4. Cabin Services to issue crew directiveto be aware of this problem.
5. That a label be produced in English,German and French to state that thisarea must be kept clear of luggage atall times. The lens itself to be at thecentre of the label and attached to thebulkhead.
A Ramp Related Incidentby Nicole Stewart, Embraer Fleet Safety Officer, bmi regional
Scarman Centre
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Course AdministratorScarman CentreUniversity of LeicesterThe Friars154 Upper New WalkLeicester LE1 7QA, UKTel: +44 (0) 116 252 3946Fax: +44 (0) 116 252 5788Email:[email protected]: www.le.ac.uk/scarman/Please quote ref FOC/06 in allcommunication
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10
The UK Confidential Human FactorsIncident Reporting Programme (CHIRP),has been operating since 1982 andreceives confidential incident reports fromprofessionally licensed pilots, air trafficcontrollers, licensed engineers andapproved maintenance organisationsemployed within the UK Air Transportindustry along with individuals involvedwith General Aviation. CHIRP wasestablished in its present form, as anindependent charitable company limitedby guarantee in 1996. The Programmereceives a Grant of Funding from the CivilAviation Authority.
Reports are validated as far as is possiblethrough a callback process. Ifappropriate, report information is broughtto the attention of the relevant operationalmanagement or CAA (SRG). Onlydisidentified information is used in anydiscussions with third party organisations.The confidentiality of the reporter isassured and the reporter’s permission isalways sought before any action is taken.No personal details are retained fromreports received and on closing a reportall personal details are returned to thereporter with a letter notifying them of theaction that has been taken. Each reportis allocated a unique referenceidentification. The reporter may, if theywish, contact the CHIRP office foradditional information by using the reportreference identification.
The Programme was extended in July
2001 to include Cabin Crew, for a trialperiod of one year. Recently, with theagreement of CAA (SRG) the trial hasbeen extended to March 2003. It hasbeen emphasised that CHIRP should notbe seen as a replacement for CompanyConfidential Reporting Schemes and thatit is important that safety-related mattersbe reported to the Company in the firstinstance, whenever possible. A separatenewsletter, Cabin Crew FEEDBACK,containing disidentified reports isdistributed to companies participating inthe Trial; these are pigeon-holed or sentdirect to bases/crew rooms.In the period 1 July 2001 - 1 May 2002,78 reports were received. Of these, 23were represented to the relevant operatorand 25 were made available to the CabinSafety Office of CAA (SRG). Issuesraised have been in the followingcategories; Standard OperatingProcedures/Safety EmergencyProcedures (21); Rosters/dutytime/breaks (21); Faulty Equipment/Health& Safety (9); Security (9); AbusivePassengers (7); Potential Health Risks (4);Experience/Training (3);Dismissal/Discipline Due Sickness (3);Company Discipline (1).
Typical issues raised have been:
Standard Operating Procedures(SOPs)/Safety Emergency Procedures(SEPs) - Incidents reported in whichSOPs/SEPs have not been followed,leading to potentially unsafe operations.Examples are; take-off/landing withoutreceiving ‘Cabin Secure’ report andwithout notifying Cabin Crew; emergencyexits blocked during ground operationsby drinks trolleys, equipment not used inaccordance with correct procedures(portable oxygen bottles/crash axe), cabincrew seating allocations not inaccordance with SEPs.
Rosters/Duty Time/Breaks - Reportsinclude misinterpretation of Company FTLschemes by either Company or AircraftCommander leading to onerous dutyperiods and/or requirement to work into
‘discretion time’, lack of time/opportunityto take rest/meal breaks (short-haul multi-sector and charter operators). Somereports allege pressure/coercion by eitherflight crew or Company.
Faulty Equipment/Health & Safety -Reports of unserviceable/faulty cabinequipment interfering with normal dutiesand/or giving rise to safety concerns.Examples are; galley/catering equipmentin a potentially dangerous condition,fumes in cabin, crew rest area unusabledue to excessive temperature on an ultralong-haul sector, insect infestation incabin crew rest area.
Security Procedures - Reports ofbreaches/lapses in airport/airline securityprocedures, such as a potentiallydangerous passenger permitted to boardat foreign stopover, segregation/screeningof crew baggage, procedures for carry-onbaggage during transit stops, screeningof airport personnel.
For further information on the CHIRPProgramme please contact:
The CHIRP Charitable Trust BuildingY20E, Room G15Cody Technology ParkIvely Road, FarnboroughHampshire GU14 0LX
Tel: 01252 395013 or Freefone 0800-214645 (UK only)Fax: 01252 394290e-mail: [email protected]: www.chirp.co.uk
Confidential Reporting for Cabin CrewAn account of a windshear event -December 2001, Milan, Jet aircraft
11
Human error may be the dominantcontributor to incidents and accidentstoday, it is probably also the mostmisunderstood. How do you reconstructthe human contribution to system failure?Human error investigations must oftenfollow a path of intuition or commonsense, but can fall into the biases andtraps inherent in understanding past,puzzling performance.
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understand human error in complex,dynamic domains and offers concreteguidance for reconstructing orinvestigating human error – not to find outwhere people went wrong, but why theirperformance made sense to them at thetime.
Contents:Human Errors as a Cause of Mishaps:The bad apple theory; Reacting to failure;What is the cause?; Human error - in thehead or in the world?; Put data intocontext. Human Error as a Symptom ofTrouble Deeper Inside the System:Human error - the new view; Humanfactors data; Reconstruct the unfoldingmindset; Patterns of failure; Writingrecommendations; Learning from failure;Rules for in the rubble; Index
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Book Review
The Field Guide to Human Error Investigationsby Sidney Dekker, Linköping Institute of Technology, Sweden
Apparently it is lacking on the standillustrated in the picture and has causedproblems and danger for the cateringoperators.
The correct approach line for the cateringvehicle should have been from thephotographer’s position followingapproximately the black line at the middleof the bottom edge. However, otheroperating staff have failed to park ground
equipment in the marked areas and leftthem overhanging, thus blocking thecorrect approach path.
Note the errors:
The mobile conveyor belt wheels justinside the line but the boom is stickingwell out.
The container/pallet loader with most ofits main platform over thewhite line.
Behind that, an AKH containerlying on the ground on thewrong side of the line.
In this situation, the cateringoperator, trying to help theairline to achieve an on timedeparture has elected to breakthe operating procedure rulesand come in at an angle
instead of waiting for the other equipmentto be moved.
Positioning the vehicle like this increasesthe risk of injury to staff and damage tothe aircraft.
Only the day before this picture was takena similar angled approach had resulted inthe catering vehicle striking the openedforward hold door.
What instructions are given to groundstaff on your station when they find theirroute blocked?A. "Do not approach until the
obstructions are cleared"B. "Get in there somehow and
don't delay the service"
Which is the correct answer in keepingwith one of your goals to be a safe andsecure airline?
Stand Discipline - Does Your Organisation Have It ?by Sidney Dekker, Linköping Institute of Technology, Sweden
12
Full members
ChairmanAirclaimsJohn Dunne
Vice-ChairmanBritish EuropeanStuart McKie-Smith
TreasurerAir 2000Capt. Martin Pitt
External Affairs OfficerRAeSPeter Richards
Aer LingusCapt. Tom Croke
Aerostructures HambleDr. Marvin Curtiss
Air ContractorsCapt. Tony Barrett-Jolley
Air MauritiusRoy Lomas
Air ScandicPaul Ridgard
Air SeychellesCapt. Curtis Allcorn
Air Transport AvionicsColin Buck
ALAEDave Morrison
BAA plcFrancis Richards
BAC ExpressCapt. Steve Thursfield
BAE SYSTEMS Reg. A/CDan Gurney
BALPACarolyn Evans
bmi regionalCapt. Steve Saint
British Airways CitiExpress LtdCapt. Ed Pooley
British InternationalCapt. Terry Green
British Mediterranean AirwaysRobin Berry
CAADave Lewis - MRPSChrys Hadjiantonis - Safety Data Dept.Brian Synnott - Flight OperationsAlison Thomas - Intl. Services
Cardiff International AirportAlan Whiteside
CargoLuxCapt. David Martin
Cathay PacificCapt. Richard Howell
Channel ExpressRob Trayhurn
CityJetCapt. Mick O’Connor
Cougar LeasingShaun Harborne
DHL AirPeter Naz
DragonairAlex Dawson
Eastern Airways UK LtdCapt. Jacqueline Mills
EasyJetCapt. John Broomfield
Emerald AirwaysCapt. Roley Bevan
European Aviation Air CharterDavid Wilkinson
EVA AirwaysAlex Reid
Excel AirwaysPeter Williams
FlightLineCapt. Derek Murphy
GAB Robins AviationRob Burge
GAPANCapt. Chris Hodgkinson
GATCORichard Dawson
GO FLY LtdCapt. Simon Searle
HeavyLift CargoCapt. Mike Jenvey
Independent Pilots AssociationCapt. Mike Nash
Irish Aviation AuthorityCapt. Bob Tweedy
JMC AirlinesCapt. Graham Clarke
LAD (Aviation) LtdSteve Flowers
LoganairDoug Akhurst
London-Manston AirportWally Walker
Maersk AirCapt. Robin Evans
Manchester Airport plcPeter Hampson
Middle East AirlinesCapt. Mohammed Aziz
Monarch AirlinesCapt. Gavin Rowden
Members of
13
MyTravelCapt. Tom Mackle
NATSPaul Jones
PrivatAirCapt. Boris Beuc
RyanairCapt. Gerry Conway
SBACJohn McCulloch - SecretariatBryan Cowin - BAE SYSTEMSVic Lockwood -FR Aviation
Schriener AirwaysArnoud Schriener
ServisairEric Nobbs
Shell AircraftCliff Edwards
The Boeing Co.Edward Berthiaume
TRW Aeronautical SystemsKeith Joyner
Virgin Atlantic AirwaysCapt. Jason Holt
Willis AerospaceIan Crowe
Group members
bmi british midlandCapt. Ian Mattimoe
bmi british midland Eng.Peter Horner
Bristow HelicoptersCapt. Derek Whatling
Bristow Helicopters Eng.Richard Tudge
Britannia AirwaysJez Last
Britannia Airways Eng.Adrian Vaughan
British AirwaysSteve Hull
British Airways Eng.Penny Barltrop
British EuropeanStuart McKie-Smith
British European Eng.Chris Clark
CHC ScotiaCapt. David Bailey
CHC Scotia Eng.Colin Brown
EurocypriaCapt. Constantinos Pitsillides
Cyprus AirwaysCapt. Spyros Papouis
FLS Aerospace (IRL)Frank Buggie
FLS Aerospace (UK)Andrew Hoad
Ford AirF/O Paul Stevens
Ford Motor Co. EngF/O Paul Stevens
GB AirwaysCapt. Aaron Cambridge
GB Airways Eng.Terry Scott
KLM ukDean Godfrey
KLM uk Eng.Andy Beale
Lufthansa Cargo AGCapt. Nigel Ironside
Condor/Lufthansa & CityLineF/O Paul Stevens
MODDASC Col. Arthur GibsonDASC Eng. - Wg Cdr Dave McCormickHQ STC MOD - Sqn Ldr Jeff Collier
RAeSPeter Richards
RAeS Eng.Jack Carter
Co-opted Advisers
AAIBPhil Gilmartin
CHIRPPeter Tait
GASCoJohn Campbell
Royal Met. SocietyDr John Stewart
14
Romania, Switzerland, Finland, theUnited Kingdom, the Republic of Ireland,and Austria – these are the first sixEuropean States whose national aviationsafety authorities have been listed toreceive audits from the Joint AviationAuthorities’ (JAA) OperationsStandardisation Team (OPST).
JAA audits are not new: maintenance andlicensing already have well-establishedvisit programmes, but operations – the‘sharp end’, some might say – hashitherto been spared. One reason for thedelay has been the relative immaturity ofJAR-OPS 1 and 3, which containrequirements and guidance materialaddressing commercial air transportoperations by aeroplanes and helicopters,respectively. However, recentamendments to both documents,correcting omissions, creating alleviationswhere the early rules were unnecessarilyonerous, and accommodating recentICAO Standards and RecommendedPractices, have done much to improvethe acceptability and reasonableness ofboth sets of JARs. In turn, this hasremoved many objections toimplementation from States that hadundertaken to do so for all requirementsadopted by the JAA Committee. The fewyears that have passed since adoption ofJAR-OPS 1 and 3 has also given manyStates the time they needed to develop orto elaborate their national legislation toaccommodate their provisions, and tocomplete text translation into nationallanguages.
Implementation in national legislation orequivalent arrangements that result in allcommercial air transport operatorscomplying fully with JAR-OPS is the aimof Central JAA’s Operations Division,which is masterminding the OPST visitprogramme. Unless either solution isachieved, the much-desired ‘level playing
field’ will not be realised. Whilst acommon compliance level is, perhaps,the most sought-after ‘prize’ expected bythose who have had to invest heavily tomeet the standards required for the issueof a JAR-OPS Air Operator Certificate(AOC), the true beneficiaries will be thecustomers, those who pay for theservices on offer. It is they who shouldhereafter be assured of a common, highlevel of safety whenever they travel orsend cargo in an aircraft operated by anyAOC holder regulated by a JAA MemberState, wherever in the world their flightmay take place. However, the levels ofsafety established in JAR-OPS 1 and 3will be effective only when the operatorsconcerned have implemented fully therequirements they prescribe.
It is thus appropriate that Central JAAshould now begin the process ofsatisfying itself that States that haveissued AOCs based upon JAR-OPS 1and 3 have ensured full compliance, thatthere are no National Variants from therequirements, and that no long-termExemptions or Exceptions have beengranted. The means by which the JAAdoes this is by the formation of OPSTs,each of which comprises three inspectorsseconded temporarily from three differentStates – the team composition beingdifferent for each audit – working to acommon set of procedures. This is toensure that all audits are conducted inlike fashion and that a fundamental set ofquestions of critical importance is put toall States. One State will be visited everymonth until all full members of the JAAhave been audited.
The OPST audit process begins in themonth before the visit is due to takeplace, with the ‘host’ State being invitedto complete a questionnaire, the contentsof which will assist team members tounderstand the organisation within itsflight operations authority/inspectorate.
Questionnaires are sent also to threeoperators who have been issued with anAOC based upon JAR-OPS, typically onelarge aeroplane operator and one small,and one helicopter operator.
In the week prior to the visit, the threeteam members travel to Hoofddorp,where Central JAA is based, to meet thenational co-ordinator of the ‘host’ Stateand to be briefed by the OperationsDivision visit programme manager on theobjectives and procedures concerningthe audit. The audit programme isdiscussed and agreed, and any queriesarising from information provided inanswers to the questionnaires areanswered or noted for later investigation.Team members collect copies of thechecklists they will use and theassociated forms on which they can notetheir observations. One checklistcontains questions targeted directly at therequirements to be observed by States ashave been published in JointImplementation Procedures - Operations(JIPs). Others have been designed toindicate the level of compliance with JAR-OPS, and do this through queriestargeted at selected requirements thathave been prescribed in all the relevantSubparts.
In the week following the briefing, on themorning after their arrival, team membersare usually first given a welcome by theauthority of the State they have come toaudit. The OPST leader, orspokesperson, then explains the processthat the team will follow before they beginto work their way through the ‘NationalAviation Authority’ checklist. By the endof the day, the team will probably havemade a few observations that might laterbe confirmed as non-compliances, andmany others that will have indicated fullcompliance. On the second and thirddays, the OPST visits each of the threeoperators in turn, not to carry out any
The JAA’s operations standardisation team visit programmeby Captain Tim Sindall
audits (that activity is the function of theState), but to ascertain whether anyapplicable requirements of JAR-OPS havenot been implemented. So-called‘Operator’ checklists are used for thispurpose.
It then remains for the team to discusstheir observations with the national co-ordinator, who has accompanied themthroughout their visit, to obtainclarification, to correct anymisunderstandings, and to obtainacceptance or agreement by the authorityof any apparent non-compliances thathave been observed. All relevantobservations are transposed onto anelectronic report form, and any thatappear to require remedial action maythen become ‘findings’. Before membersof the team depart on the third or fourthday, they debrief the ‘host’ State on thecontents of the report. Finally, the reportis first printed and then signed by eachmember of the OPST.
Once completed, the report is handedover to the JAA Operations Division, whowill first review it and then formally send itto the State that has been audited. Thelatter is then required to construct anAction Plan that will include proposals foraddressing all items listed in the reportand show time scales within whichcorrective action will be completed.When the Plan has been accepted byCentral JAA, staff there will monitorprogress until they are satisfied that allremedial action has been fulfilled.Now, what has been found so far from thefirst States to have been made subject toOPST visits? Well, this is for theOperations Division to declare at theirdiscretion and to share with all the otherJAA Member States in a manner of theirchoosing. As may be expected, theOPST has concentrated on ‘high profile’issues such as implementation of JAR-
OPS in national legislation, the absenceof National Variants or long-termExemptions/Exceptions, and fullimplementation by operators ofcommercially sensitive items such asperformance degradations associatedwith operations on contaminatedrunways, and the existence of a flight timelimitations scheme that satisfies therequirements of Subpart P. Many readerswill know that the JAA Committee neveradopted Subpart Q, which had beendesigned to accommodate requirementsfor a JAA FTL scheme. However, SubpartP requires operators to have a schemebased upon that prescribed by their Stateauthority and to specify how crews shouldmanage exceedences of flight duty andreductions of rest. The OPST checksthese points.
Although still in its infancy,the OPST visit programmehas got off to a very goodstart thanks largely to theenthusiasm shown by allwho have been involved. Allparties seem to share in thebelief that time andresources allotted to thisexercise are well spent if theyensure that operationalsafety standards have beenraised to the levels containedin JAR-OPS 1 and 3, andthat compliance levelsapplied by JAA MemberStates to their operators arenot below the required level.
The author, Tim Sindall, wasformerly Head of the FlightOperations Inspectorate(Aeroplanes) in the UK CAA’sFlight OperationsDepartment, and the UKmember of the JAA’sOperations
Committee/Sectorial Team responsible fordeveloping JAR-OPS 1 and 3. He helpedthe Operations Division to establishprocedures for use by the OPST, andparticipated as a member of the first threeaudit teams.
15
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16
CRM can help prevent accidents causedby human error, but it must be measuredor it could continue to fail, writes KeithBedingham, Chairman, Verax.
Crew Resource Management (CRM) issometimes touted as a quick fix forsituations where people are not workingwell together, or where an improvement incommunication is required. Training isthe deliverer of CRM, but is the trainingeffective? If CRM training achieved itsobjectives, we wouldn’t continue to hearstories of communication lapses betweenmembers of the flight crew and/or airtraffic control. Nor would we continue tohear apocryphal stories of grumpy,taciturn or arrogant pilots creatingpotentially dangerous situations.
It’s common knowledge that allcommercial flight crew are obliged toattend CRM training, although it is largelyleft to individual airlines as to the form ittakes. Yet there is very little evidence toshow that increases in the frequency ofCRM training - where it is practised -results in a reduction of accidents.
However, there is evidence from themilitary that with the current level oftechnical reliability and sophistication,over 90 per cent of current aircraftaccidents are due to human error. Fiftyyears ago the percentage of accidentsattributable to mechanical failure was very
much higher. So, things have movedsubstantially in the right direction, butthere is a problem - and it isencapsulated in human nature, whichhasn’t changed as rapidly in the sametime frame.
What is the solution?
If we believe that flight deck crew, airtraffic controllers and all others involved inthe communications process intend to doa good job -and intend to impart the rightkind of information in the right way and atthe right time - we can only assume thatthe reason things don’t happen properlyis because individuals are unaware oftheir communication failings, or don’tknow how to communicate.
No training, however good, is of any useunless the trainees see a personal benefitto them. CRM or communicationstraining has little impact because mostpeople think they are already good at it -just like everyone is a good driver (exceptthe others on the road). Only bydemonstrating real and personallyspecific need, will individuals take CRM orcommunications training seriously. Thiscan only be done through feedback, notfrom the classroom - because we can allfake it for a short while - but from theflight deck or workplace.
One of the findings of a feedback and
measurement tool (Personal EffectivenessProfile, or PEP) - which is used fordiagnosing and analysing individuals’preferred communication and influencingstyle -is that around half the populationsystematically has difficulty understandingtheir own style, compared to how it isexperienced by others.
This research has covered about 7,500individuals and there is no reason tobelieve that flight crew are any differentfrom the rest of the population. Indeed,work that Verax carried out five years agowith the RAF indicated exactly the sametrend.
How do we break through this impasse ofpoor self-knowledge in key areas such ascommunication? The solution lies in eachindividual who attends CRM trainingagreeing to submit to analysis of his/hercommunication and behaviour styles.The analysis is of their own view ofthemselves and the views of thecolleagues who fly with them i.e. of selfand peer views of an individual’scommunication and behaviour styles.Such a holistic, or ‘helicopter’, view isalso known as a 360 degree view.
A tool such as PEP provides informationfrom - and analysis of - the various‘views’. It allows individuals (users) toidentify their own communicationstrengths and identify their ownweaknesses and work to improve them.It also allows users to understand thekinds of people they are likely to ‘turn off’by their communication style and to learntechniques for communicating moreeffectively with this latter group.
Re-measures (i.e. post trainingmeasures) provide a means ofmonitoring the extent to which air creware actually applying these new acquiredcapabilities in the cockpit. Training alonemay be counter-productive, whereascontinuous assessment improvescommunication performance.
by Keith Bedingham
CRM training needs measures and remeasures if it is to succeed
17
Why may training be on the negativescale of things? Someone may sailthrough training on ‘how to be a goodlistener’, or ‘how to be a good teammember’, because he is ‘listening’ well inorder to show a good result. However, ifhis attitude to the world is ‘everybody’s anidiot’, he will revert to type when he getsback to the flight deck. He can thus fooleverybody with short term behaviour whileon CRM training, but his underlyingattitude to people is unchanged.Measures and re-measures should give atruer picture, certainly where his peers’views of his behaviour are concerned.Direct objective feedback is likely to bethe start point for real behaviour change.
When the RAF adopted a 360 degreemeasure approach (with re-measures) inthe 1990s, the number of aircraftaccidents attributed to human errorreduced to zero for more than two years.When the programme ended, havingsucceeded in its aim of reducing thenumber of accidents, human error-ledaccidents re-occurred. It does seem thatarchetypal human behaviour will re-assertitself unless we are regularly reminded ofhow things should be!
A tool like PEP could be included in thetraining and performance review of flightcrew members. But let’s not point thefinger of bad behaviour solely at flightcrews. Similar CRM-led issues are foundon board warships and in civvy street -for example, in the control units ofnuclear power stations, where thedangers of ‘I know what I’m doingbecause I’m always right’ could translateinto disaster.
360 degree measures are simpleobjectively phrased questionnaires aboutbehaviour and communications thatguarantee anonymity and can thereforenot lead to ‘comebacks’. The exceptionmight be where an individual learns that amajority of the people he/she works withare critical of him/her. But in that casethe individual should then realise prettyquickly that positive change isparamount. Analysis of questionnairefeedback can be carried out by anairline’s own HR people who have beentrained to do this job, or by an authorisedthird party, or a combination of the two.
Summary
What everybody on CRM training reallyneeds is 360 degree measurement andre-measurement. This gives anonymousfeedback from everybody the crew workswith, from among themselves on theflight deck to ground support/ATC.Because the measurement includes
individuals’ view of how they seethemselves, those views can becompared to how others see them.
Many airlines don’t use any measurementor re-measures after training, while thosethat do tend to use rather antiquated andless effective measurement tools. I do notargue that all aircraft accidents arecaused by human error, but I do knowthat human error is often blamed whenfatal incidents occur: e.g. a number ofAirbus incidents and the crash in SouthKorea in April.
I cannot be sure that human error-ledincidents would cease totally if all airlinescarried out measures and re-measuresafter CRM training, but I do know aboutthe RAF’s experience, as I was involved inthe measurement programme.
Old methods of measurement do need tobe phased out and replaced by modern360 degree measures. These show whypeople hold particular attitudes...and canhelp in changing those attitudes. Until thishappens and until re-measures are morewidely taken up, CRM training willcontinue to disappoint.
Table of communicationskills seen as importantto CRM, and measuredby PEP.
1: Communication style (open andhonest or otherwise)
2: Advocacy (willing to state aposition or point of view)
3: Enquiry (happy to question inorder to understand)
4: Critique (i.e., analyse one’s own- and the team’s - performance)
5: Assertiveness (willing to speakup, so that your point of view isheard)
6: Synergy (able to ensure that thecrew’s performance is betterthan that of any individual in it)
7: Acknowledgement (able toconfirm commands, questionsand observations)
8: Crew co-ordination/observation(i.e. ability to clarify tasks, rolesand responsibilities)
18
Many of you will be aware of accidentsand incidents where ‘human factors’, froma maintenance standpoint, have beenidentified as having contributed to theevent. Some issues, such as poorprocedures or maintenance data,engineers signing off tasks without havingseen or checked the work, informationmisinterpreted at handover, etc. can bedescribed as ‘human factors’ since it ispeople who write the procedures,engineers who sign off work not seen,human beings who become complacent,or make assumptions, etc.
The UK CAA has invested time andresources encouraging industry to adoptmethods of minimising the risksassociated with human factors during thelast few years. Whilst this has beensuccessful in some areas the CAAconsider that a change to requirements,underpinned by organisations adoptinghuman factors best practice andprinciples, will raise standards resulting ina reduction of maintenance errors. In anycase recent amendments to ICAO Annex6 standard states that “the design andapplication of the operator’s maintenanceprogramme shall observe human factorsprinciples” and “the training programmeestablished by the maintenanceorganisation shall include training inknowledge and skills related to humanperformance”. Therefore in order tocomply with ICAO Annex 6, there was aneed to have an appropriate national orJAA requirement.
Consequently there has been an initiative,driven by the JAA, to mandate goodsafety practice, with the emphasis uponhuman factors.
Some of you will already be aware thatthere are new human factorsrequirements round the corner, forJAR145 organisations, in the form ofNPA12 to JAR145. These proposedchanges were drafted by the JAAMaintenance Human Factors WorkingGroup (MHFWG), with representation
from both industry and regulators,specifically formed for the expresspurpose of looking at human factors inmaintenance. The group has published,on the JAA website (www.jaa.nl), a reportexplaining the background to NPA12 andproviding additional guidance material.
The scope of issues addressed by NPA12include:
■ publication of a safety and qualitypolicy, signed by the AccountableManager
■ an internal occurrence reporting,investigation and analysis system
■ reporting of inaccurate andambiguous maintenance data
■ reporting of poorly designedprocedures and work instructions
■ shift and task handovers
■ implications of fatigue on humanperformance
■ planning of work to take account ofhuman factors
■ error capturing mechanisms andduplicate inspections
■ signing off tasks not seen
■ human factors initial and continuationtraining
The UK CAA has published a document,entitled “CAP 716: Aviation MaintenanceHuman Factors (JAR145)” containingmore comprehensive guidance material insupport of human factors requirements,both existing and proposed, in JAR145. Itis available from the CAA website(www.caa.co.uk), in the publicationspage. Also recently published is CAP715“An introduction to aircraft maintenanceengineering human factors for JAR66”which is study material in support ofJAR66 module 9.
In order to inform industry about NPA12,and the rationale behind it, the UK CAAhave recently run a ‘roadshow’ across theUK, at 7 different venues and with over400 attendees from UK JAR145companies, JAR147 training schools andother organisations which expressed aninterest.
The aim of NPA12 is to create a levelplaying field by requiring all JAR145organisations to adopt the good safetypractices already implemented by moreconscientious companies. Therequirement proposals allow enoughflexibility to enable organisations to applythe changes as appropriate to the sizeand nature of the company, and not toimpose an excessive financial burdenupon industry.
The CAA remains committed to thesuccess of this requirement change andconsiders the implementation of NPA12,can minimise the likelihood ofmaintenance error being cited as a factorin aircraft incidents and accidents.
New Human Factors Requirements for JAR145 ApprovedMaintenance Organisationsby Fiona Merritt, CAA Human Factors Specialist, Operating Standards Division
19
Formula-One motor racing pit stops areplanned, rehearsed and monitored toextract the best from a team performancefor safety, accuracy and speed. The racecan be won or lost purely on whattransposes in a very brief period asmultiple operations take place in aseverely limited time frame. Is thisanalogy comparable to that of frontlineflight receipt and dispatch – Rampoperations?
In a way yes, but the systems beinglinked are more diverse and multiple.Similar determined objectives can beobserved by aircraft/airport operators aswell as handling agents as they areforced to meet commercial/contractualand ATC deadlines. With a touch of drivererror thrown in for good measure onoccasion.
An industry axiom echoes that the AirportRamp is the last area still to beaddressed by many operatives with thesame enthusiastic safety protocolsutilised for core business SafetyManagement System (SMS) activities.
In the UK civil aviation industry we haveenviable safety and quality initiatives
through our obvious responsibilities,utilising our individual internal SMS andhardware. However, the airport Ramp is ajigsaw of systems trying to function underextreme pressures for a common goal.Mike Seller’s article “How safe is yourdestination airport” (FOCUS, Spring2002), touched on a few of the issues thatcan affect ramp operations worldwideand pointed out the valuable direction ofauditing. The problem with Rampincidents is the diversity of possible errorsituations/events resulting from overlapactivities. Thus it is harder to ensurerealistic and practical controlling barriersare in place.
This is not a new awareness problem.The UKFSC voiced concern about AirportRamp operations early in 1994 and will doso again this year, basing its 2002 AnnualSafety Seminar in September on RampSafety issues.
Two relevant CAPs are available;
■ CAP 642 - Airside Safety Management
■ CAP 700 - Aerodrome Safety Management Operational Safety Competencies
However, as Ramp personnel relatedaccidents have increased over the last 5years the UK’s Health and SafetyExecutive (HSE) have advised their graveconcerns to the industry. They haveidentified that Airport Ramp workers aremore exposed to serious injuries thanagricultural workers and equal to themining industry for minor incidents.
Such concern has prompted theirguidance document titled;
■ Aircraft Turnaround (Publication ID# -HSG209)
This guide is suitable for airport andaerodrome operators, airlines and serviceproviders. It offers advice on control, co-operation and co-ordination ofturnaround activities performed bycompanies and contractors to reducestaff risks.
As with many failings that can culminateinto an accident, communication errorsare a key failing. Lack of, mistaken orfailure to communicate in partnership withother cross boundary services is a causeof concern if safety could becompromised.
Through CRM & MRM teachings thebenefits of education on the HumanFactors affecting communication andother important tenets are recognised.This level of knowledge though is notwidely available to other labour skillsfound with access to the ramp area. Safeworking practices require specific stafftraining, procedures and terms ofreference. However, considerable conflictand dissonance could result if anindividual in charge of ramp functionprocedures also had overridingconstraints to perform goals on-time.
Since the horrific events of September11th 2001 higher pressures have beenplaced on all aspects of flight operationsto ensure their operations maintain qualitywhile being efficient, secure and
Frontline Defences? Safety on the Rampby Colin Brown, CHC Scotia
20
economically effective. The ramp now hasgreater challenges to deal with becauseof possible shortfalls in staffing numbers,heightened security awareness, etc.
Everyone including the general public isaware of the hazards of overcrowding theskies but are we not in danger ofovercrowding the aprons?
Do we or our contractors take it forgranted that someone else hasresponsibility for overseeing basic safetyconcerns that are not actually even flightrelated?
Embarrassingly other industries externallyremote to aviation have tackledoverlapping error management, thoughsometimes through experiencing a severecost first. One US airline did overcomesome ramp exposures perhaps
unintentionally byeducating companystaff in each othersroles with activeparticipation wherepossible. Thisincluded aircrewexperiencing groundstaff duties willinglyand allowedawareness andappreciation to all.
The aim was toproduce faster turn-arounds but didproduce beneficialside results and ateamwork respect.
Personnel,Vehicular/Equipment,FOD, Manoeuvringand Jet Blast hazardsare prolific andamongst the mostcommon incidentsglobally. They may bein danger of beingjust acceptedexposures if
awareness is not constantly enforced andfailure to adopt safe practices controlled.Incident diversity is restricted only to theimagination as the Ramp has apersonality culture of its own. Carefulplanning of appropriate ground hazardanalysis and risk assessment methods isrequired and these must be periodicallyre-evaluated.
■ In November last year a large piece ofaircraft staging (used for tail work onSAAB 340s) “took-off” with anassisting 35knot wind gust along themain taxi-way of a northern airport inScotland. The taxi-way was closeduntil the staging was cut up and hadbeen removed from the area by theAirport Fire Service. The staging hadbeen stored outside in the lea of alarge Hangar, following cessation ofmaintenance. It is still unclear
whether or not the brakingmechanism had failed, or if the windjust proved too strong even withproven adequate, serviceable brakes.As a result of that incident,approximately £6000 worth of aircraftstaging is now in several pieces andconsequently scrapped. By chanceonly the staging came to rest beforedamaging anything else; it had thepotential to hit at least two fixed wingaircraft, which were parked nearby atthe time.
■ Recently a ramp worker got lost in fogon an airfield. Finally suppressingembarrassment to use the vehicleradio and requesting assistance hereturned safely. Fortunately, nothingelse was moving around at the timeand his manoeuvrings were extremelycautious.
■ A helicopter crew mistakenly becamemisled by the attending ground staffhand signals and lifted into the air.(Physical miscommunication is acommon error). Unfortunately thecargo boot was still in the process ofbeing loaded and a handlerexperienced a very brief 2m lift intothe air.
■ Rodents have stowed away in freshunsecured freight and chewed theirway through navigation computerwiring, crippling two independentsystems. In sunnier climes largelizards have strayed aboard and,exploring new found territories,discovered the cockpit, “and so thetails go on.”
Ramp incidents will continue to take placewithout concerted efforts by all in theindustry. An adage circulates amongst usthat states, “If it is on the ground it costsmoney”. This is now truer than ever but, itis not necessarily the safest anymoreeither!
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21
In our manuals, staff are warned againstapproaching hot aircraft wheels from thesides, in case they explode. Althoughthey are fitted with fusible plugs whichmelt if they become too hot and allowthe tyres to deflate, there is a risk thatthey could fail.
If a wheel did fail what could be theresult?
I, for one, did not appreciate thepotential danger until a recent incidentoccurred to one of our aircraft. Strangelyenough, it was not an aircraft wheelwhich failed but one fitted to an aprondrive jetty.
The design of the jetty wheel was similarto that of many aircraft wheels with thetyre held between two halves of the wheelhub. The two halves of the split hub werebolted together with 12 bolts and thewheel hub was attached to the axle with afurther 12 bolts.
The pressure of the air in the tyre wasnominally 16 bar (235 psi) which isslightly higher than the pressure of mostaircraft tyres.
The jetty had been retracted from theaircraft following completion of boardingand the wheels were turned to allow the
jetty to be driven to its parking position. Atthis point a loud bang was heard. Theouter half of the split hub flew across theramp and struck the B737 aircraft justbehind the nose undercarriage causing alarge hole in the fuselage.
Why the wheel failed is still underinvestigation. The jetty had been inservice less than three months. Thepotential risk, particularly to staff, of sucha failure is more fully appreciated whenone realises that the split half of the hub,which weighed 52kg (115lb), travelled17m (55ft) through the air withouttouching the ramp and struck the
fuselage some 1.3m (4ft) above theground.
Only the ground engineer was near theaircraft at the time. He was checking theremoval of the nose wheel steering pin.Fortunately he was located on theopposite side of the aircraft. Had he beenon the left hand side of the aircraft it isprobable that the hub would have hit himcausing serious injury or even death.
Aircraft and air jetty wheels are not theonly ones utilising high pressure tyres. Beaware of the risks of any equipment fittedwith them.
The Dangers of Tyre Failure
Split hub lying below the hole in the fuselage
Position of air jetty to aircraft when jetty wheel failed
22
A helicopter was taxied from themaintenance area to a position outsidethe terminal building where it was due toembark its passengers.
The crew were aware that whilst thepassengers were being loaded, abaggage vehicle approached the aircraftand later departed from the aircraft. TheFirst Officer was given the manifest andwhilst he was checking it the passengerswere given the normal briefing.
With all the preparations completed theCommander called for pre-taxi checks. Atthe time no ground personnel were insight. The checks were completedwithout either pilot noticing an illuminatedbaggage bay warning light.
At this stage the aircraft was taxiedforward and commenced a gentle rightturn towards the taxiway.
When the tower controller saw thehelicopter for the first time he noticed thatthe baggage door seemed to be openand advised the Commander of theaircraft. The aircraft came to a halt andthe First Officer was dispatched to securethe door. On his return the aircraftcontinued to taxi. The Tower controllerreceived a telephone call from theoperator regarding the baggage that hedid not understand and so advised theaircraft to return to the stand forclarification.
Once on stand , another helicopteradvised the Commander that thereseemed to be some damage to thefrangible fairing below the tail.
The aircraft was shut down, thepassengers disembarked andengineering support requested.
On arrival in the hangar the crew wereadvised that the aircraft had collided withthe baggage truck and the baggageloader.
It transpired that the baggage loader wasstill busy loading the aircraft and thebaggage compartment door was open.The crew had missed the illuminated doorlight during their checks. When theCaptain taxied forward and started histurn he crushed the baggage loaderagainst the baggage truck, causing injuryto the baggage loader and damage tothe frangible fairing on the aircraft.
Helicopter Ramp Incident
The aircraft was parked on one of theremote stands and was being preparedfor a night departure to Turin. The crewhad operated an earlier flight andremained on board during the turnaround.
The passengers were bussed out to thestand and were boarded from the frontand rear steps. When boarding wascompleted the rear steps were removed
and the front stepsremained in placeuntil the ‘head count’was completed andthe paperworkhanded off.
The front steps werethen removed, first byreversing from theaircraft and then bydriving away from theaircraft to drivearound the port wing.The parking area is
quite tight. There is a manoeuvring areafor vehicles which forms the boundary ofthe parking area for aircraft anddesignates the parking area for vehicles.The stairs had not been fully retractedwhen they were pulled from the aircraftand the driver turned too early whenturning onto the parking area and drovethe steps into the port wing, about twofeet in from the wing tip. The vehicle wasnot being driven quickly but the left rail of
the steps became imbedded in the wingand was stopped by the leading edgespar.
The aircraft was grounded for two weekswhile the repairs were carried out with thehandling agents accepting fullresponsibility for the ‘downtime’ and forthe cost of a replacement aircraft duringthis time.
In the final report there were no realextenuating circumstances given either bythe driver or by the airport authorities asto what caused the incident other thanperhaps inattention by the driver. Therewas a lot of rebuilding going on at thetime. The stands had aircraft positioningpast them on both sides, but were fairlywell lit and had been in use for someconsiderable time. A local curfew was inplace but was not a factor in this incident.
Ground Damage at Zurich
23
The Health and Safety Executive’s AircraftTurnround Guidance Note HSG209 firstpublished in 2000 came straight to thepoint in its introduction by stating‘currently, accident rates in the industryare well above the national average for allindustries, and for ground handling andairport workers, accident rates exceedeven those of the construction industryand the agricultural sector’.
These are strong words for an industrythat can rightly pride itself on an aviationsafety culture which has deliveredunparalleled safety performance in theskies but why has this not been translatedonto the ramp? To outsiders it may seema strange anomaly but those within theindustry will be able to recognise that inthe past a task culture was nurtured thatfocused on getting the job done ratherthan how it was done.
The HSE document raises manyimportant issues. It focuses on theresponsibilities of the airport operator, theairline or aircraft operator and the serviceproviders as individuals and also actingcollectively. Under existing Health andSafety Legislation, all companies haveresponsibility to protect the health andsafety of their employees and to protectthem from risks created by the activitiesof other airport users. If others are likelyto be affected by a company’s activities,the HSE define three guidelines thatcompanies should follow:-
1. Co-operate and co-ordinate withother employers
2. Control your contractors
3. Assess and control the risks to otherpeople from your activities and informthem of any risks still left
Under the first point the HSE recognisesthat the airport or aerodrome operator isbest placed to develop co-operation andco-ordination on an airport wide basis,but can only do so with the active
involvement of the whole airport oraerodrome community. A simple but veryimportant message inherent to the newdocument is that success can only bedelivered by all parties working together.
Control of contractors has become more ofan issue over the years. Services at onetime provided in house by airlines havebeen divested and are now carried out byseparate companies. The HSE documentstates that legal safety responsibilitiescannot be delegated and that it is notpossible to merely rely on standardclauses requiring contractors to complywith relevant health and safety legislation.While companies are responsible forchecking their prospective contractors’arrangements for health and safety, theyshould also co-ordinate and control thework they carry out on the company’sbehalf and monitor their performance.One of the key recommendations is thatcompanies should appoint a supervisor tocontrol the turnround, who could be amember of the airline or handling agentstaff. This supervisor should havesufficient authority to control the activitiesaround the aircraft and should work to anagreed turnround plan.
Interestingly it can be argued that theintroduction of the EU Directive forGround Handling at Heathrow created theneed for a changed environment whereairport users took on responsibilitythrough collaborative decision making forshaping how the market would bestructured and managed. Initially HALsaw the introduction of an open marketas contrary to maintaining a safe andefficient airside working environment. Foran airport that already had 8 groundhandlers it was difficult to see that therewould be any benefits from having more,as more handlers almost inevitably meantmore equipment and congestion.
Further to HAL’s request for a restriction, aruling by the CAA in December 1998 infavour of an open market thrust all theparties involved into forming the AirportUsers Committee (the body described inthe legislation) and putting in place all themeasures necessary to support theimplementation of the new legislation fromApril 1999. The work was undertaken bythe AUC Licensing Sub Group which hassince become a model for developingproposals that have wider communitybenefits. It was this sub group that was
Implementation of HSE’s Aircraft Turnround Guidance Note HSG209at Heathrow
24
reconvened in October 2001 at therequest of the AUC to examine the HSEdocument and identify if a Heathrowframework could be developed.Membership of the AUC Licensing SubGroup was comprised of 5 nominatedairlines, 5 airlines who were also handlersand 5 independent handlers. A series ofweekly meetings was established to movethe task forward rapidly with HSE invitedto attend. Their presence proved verybeneficial and maintained a focus onavoiding the risk of injury to people whichis now a consistent theme in the Heathrowdocument. It is probably significant thatbefore this work, safety data on aircraftdamage incidents and vehicle incidentswas widely monitored and while significantimprovements have been achieved overthe last year (a reduction of 16% and 20%respectively), there was not the samefocus on personal injuries. That is not tosay that companies were not monitoringand reporting personal injuries as requiredby legislation, but as a community wefound it difficult to share the data and useit to target improvement.
The document developed was titled ‘TheAircraft Turnround Plan (Heathrow Airport)’and describes the activities involved in thegeneric aircraft turnround process which
should be considered at each stagetogether with checklists. The plan can berepresented as four key sub processes asshown at Figure 1.
a) Resource Planning ProcessThis sub process requires companiesto have all necessary riskassessments, trained staff, equipmentand resources in place together with aco-ordinated turnround plan for anyparticular aircraft movement. It alsoidentifies the need for a Turnround Co-ordinator (TCO), and the need toanalyse performance against theturnround plan and review ifnecessary, communicating anychanges to all parties.
b) Preparation and Arrival ProcessThe preparation sub process containsall the checks that are necessary priorto the arrival of the aircraft, while thearrival sub process describes theground procedures for the safe arrivalof the aircraft onto stand.
c) Turnround Servicing ProcessThe turnround servicing sub processinvolves all the core activitiesundertaken while the aircraft is onstand and is further divided into four
sub processes: off load, coreservicing, on load and departure.
d) Make Ready for Next TurnroundProcessThis final sub process importantlydescribes the activities which shouldbe undertaken after the aircraft hasleft the stand to ensure everything isin place for the next turnround.
The second part of the Aircraft TurnroundPlan (Heathrow Airport) containsappendices which have been collated asexamples of current good practice, toassist airlines and service providers in thedevelopment of their own morecomprehensive Turnround Plans.
The AUC has now approved the final draftof the document and the licensing subgroup has been stood down. Thedocument will now be issued under aGeneral Notice and will effectivelyembody relevant safety requirements intothe licence documentation.
The success of the new document hasyet to be proved although it should resultin decreasing personal injuries andaircraft and vehicle incidents. Thedocument is an important starting pointbut will be reviewed and improved as feltnecessary. What is clear is that throughthe airside community involvement awide range of expertise from variouscompanies has been brought together tocreate a simple document that willprovide a common framework forcompanies working airside at Heathrow.
Changing Safety Culture
While the Aircraft Turnround Plan(Heathrow Airport) has been produced toprovide a generic template for specificaircraft turnround plans, anotherimportant initiative has been runningalongside, based initially on workundertaken by Dupont Safety Specialists.Previous experience has shown that ithas proved difficult to sustain safety
Figure 1
improvement and while variouscampaigns have had some impact, thebenefits tended to dissipate fairly quickly.It was recognised that to make asignificant change in safety performanceit would require a step change in thesafety culture which affected everyone’sbehaviour. As a result Dupont SafetySpecialists were commissioned to carryout a ‘peg in the ground’ safety study witheight significant ramp operators.
Separate individual company reports wereproduced but also a communal report
which sought to identify how we as anairport community could lead a changeprogramme. Dupont found that 95% ofinjuries and incidents were caused by‘unsafe acts’ as opposed to ‘unsafeconditions’ which focused attentionstrongly onto behaviour and developing asafety culture where people identify andeliminate ‘unsafe acts’. Their studies alsofound that there was a strongcommitment towards aircraft andpassenger safety, while staff, vehicle andinfrastructure came significantly lower asshown in the Safety Curve at Figure 2.
Behavioural auditing training hascommenced so that line managers caninteract with the front line teams tosupport good safety performance butalso to address areas where furtherimprovement must be made.
A Safety Leadership Group has beenformed and membership expanded,sharing a vision of zero incidents and
injuries. While everyone accepts there ismuch to do, there is a communityapproach being developed with commonstrategies for sharing data andimprovement. It clearly will take time tochange a task culture particularly one thathas been built over many years but thereis a growing commitment to wanting toact as part of an airport community tomake a sustainable safety culture changethat will be for everyone’s benefit.
Copies of the Aircraft Turnround Plan(Heathrow Airport) are available fromGeorge Cook, General Manager Airside,Heathrow Airport Ltd
Tel: 020-8745 [email protected]
25
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Figure 2
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Ramp safety is of importance to all thoseinvolved in commercial air operations — ifonly because the economic and publicrelations fallout of a mishap involvingpassengers transiting the ramp couldeasily cripple the airline involved, its rampservice provider and the airport authority.This article will look at safety issuespertaining to passenger embarkation anddisembarkation using stairs (either carriedor provided by ground handlers).
The rise of the ‘low cost’ carrier has meanta greater focus on turnaround time. Thelow cost business model requires thataircraft spend as little time as possible onterra firma. An airframe’s profitability ispartly a function of its utilisation level(although numerous other factors act onthe bottom line). The embarkation ofpassengers across the ramp to, say, a 737has a number of advantages. First, itobviates the use of a (potentially) morecostly air bridge. Secondly, passengerscan be embarked via L1 and L2simultaneously. Thirdly, carriers practised inthis method are free to choose secondaryor tertiary airports where air bridges are notprovided. Fourthly, because of theirtechnical complexity air bridges are proneto failure. In this context a carrier thatbecomes reliant on air bridging mayencounter operational problems. (Ofcourse a 737’s integral air stairs can alsojam, although redeploying the groundstairs from L2 to L1 is always an option).As a consequence of such factors ramploading is attractive to low cost operators.
Resident pathogens
The ramp is an example of whattechnologists call an ‘open system’. In anopen system people, technologies and thenatural environment may interact inunpredictable and potentially unsafe ways.These potentially dangerous interactionsconstitute ‘resident pathogens’ or‘problems waiting to happen’ (seeReason’s book Human Error for a fullerexplanation. Details below). The most
obvious problem is a passenger, possibly apoorly or non-supervised infant, runningacross the ramp and sticking her arm intoa revolving compressor blade (the 737’sCFM-56 is a low-slung engine that almostinvites the curious and naive to crawlinside). As we all know children areunpredictable, supervising adults are notalways attentive (especially when tired, wet,cold, disorientated and/or intoxicated) andcompressor fans freewheel in the wind.
Having worked as a safety consultant to anairline for two years I can attest to both theunpredictability of children and their(nominal) guardians. I have witnessednumerous near misses. On occasion, whenmanaging the ramp on turnaround, I havefound myself monitoring thenapprehending wayward children. Findingthe supervising adult is not always easy.
Of course, airport designers use suchdevices as barriers and markings to imposea measure of discipline on the ramp. AtStansted, for example, all ramps are markedto mandated standards, with the usualgreen and white lines indicating passengerways, the red and white lines indicating theramp equipment park (REP) and the doublewhites indicating the aircraft manoeuvringarea (prohibited to all except those workersdirectly involved in push-back, start-up andrelease). Of course the obvious problem isthat while such markings mean – or shouldmean – something to ramp workers, theycarry no meaning for passengers. Hencethe need for the supervision of passengerson the ramp.
This creates potential problems:The low cost business model requires thatoverheads be minimised. To pare downcosts aircraft are usually operated with thelegal minimum number of cabin crew. Inthe case of a 148-seat 737 this meansthree. Ideally, one cabin crewmembershould, in concert with the dispatcher,supervise the ramp. In practice, due to on-board duties at turnaround, this is notalways done. (Some carriers aim for andachieve 25-minute turnarounds). For theirpart dispatchers, of necessity, have to work
between the ramp, cabin, flight deck andgate. This generates a resident pathogen -the non-supervision of passengersbetween the gate and the aircraft. Thisscenario creates numerous affordances formishap (as in the wayward child-and-engine fan accident). It also gifts a ‘windowof opportunity’ to any passenger withmalicious intent, enabling her/him to eitherruin an airline’s reputation (and make sometabloid money along the way) or sabotagean aircraft. (It is certain that Al-Qaeda isconsidering other modes of attack. Thisyear’s low-intensity civil war in Israel andthe West Bank has magnified tension andloathing and the US/UK campaign in theAfghan mountains has not been assuccessful as we have been led to believe).
Designer error
At one UK airport passengers are funnelledfrom a gate into a roadway. They have tonegotiate the roadway, often withoutsupervision, to get to the aircraft. While theroadway is marked with the usual solid andzig-zag white lines, it is debatable whetherall passengers understand their meaning. Itis also questionable whether road safety isuppermost in passengers’ minds (after all,this is an airport, not a High Street). Atnight and in bad weather being seen andbeing safe on the apron would, in mostpassengers’ ‘hierarchy of needs’, come apoor second to reaching the light andwarmth of the aircraft cabin. Here we havea resident pathogen par excellence — anopportunity for accident rooted in baddesign. It is certain that children will haveno understanding of the dangers inherentin such situations. If it is feasible for a childto run out into a roadway and into the pathof a service vehicle then, one day, this willhappen. It is only a matter of time. Besidesthe immediate tragedy of a child beingkilled or injured the subsequent economicand public relations fallout would bedevastating.
There are other, perhaps more obviousresident pathogens, like service vehiclesparked on the left hand side (or PAX side)
by Dr Simon Bennett FICDDS
Ramping-up Safety
27
of the aircraft. Sometimes these vehicles,whether belonging to engineering orcleaning companies, are left unattendedwith engines running. There is an obviousrisk in asking passengers to negotiatethese vehicles to embark or disembark theaircraft (from either L1 or L2). During myramp work I have witnessed stairsabandoned across bay markings(presenting another obstacle topassengers), bags of waste left on theramp just waiting to be kicked open bypassengers and chocks not returned tothe REP. The obvious solution to poorperformance is for the airline to chooseanother agent. This is not alwaysstraightforward, however.
First, the airport may only have one rampservice provider. If there are two there isalways the possibility that personnel willmigrate from the less favoured to the morefavoured company. While this migration isvital if the more favoured company is tomeet the increased demand for itsservices the down side is that the staff whomigrate may bring with them the badhabits (evidenced in and reproducedthrough a poor safety culture) they pickedup with their previous employer. Thepreferred ramp service provider couldrecruit staff from other airports and/orindustries. But this may be prohibitivelyexpensive. It might also be a logisticalimpossibility, given that many of theregions served by airports are booming,house prices in those regions arerocketing and other, more attractive andbetter-paid jobs are beckoning (ramp workis physically hard, especially in winter). Inconclusion while the co-existence of twocompanies offers a choice in theory, inpractice an over-preference for onecompany will, in time, nullify that choice.The less preferred company will go under.
A manifesto for change
While the ramp safety record of mostairports is good the situation could beimproved. The need for improvement isdriven by the growth in airline traffic. It
stands to reason that the morepassengers the airlines transport thegreater is the potential for mishap —especially when many of thesepassengers will travel by low cost carrierfrom secondary or tertiary airports whereramp loading is the norm. Kueter (2002)observes: ‘The international air transportmarket is characterised by a tendencytoward continuous growth. Estimatespredict growth of 100 to 150 percent inpassenger volume within the next 15years’. Possible measures to improvesafety range from spontaneousorganisational change to regulation:
1. Given that ‘seamlessness’ is one of thekeys to safe operation the ideal wouldbe for the airline to ground handle itsown aircraft. While this would increase
costs (third party operators keep costsdown by servicing more than onecarrier) it would obviate the problemsinherent in divided responsibilities.Safety is indivisible. Through creating adisjuncture in supervision any formaldivision of responsibilities by definitionthreatens safety. A unified, multi-function structure would ensure thatboth air and ground operations weredriven by the same safety culture. Thesame standards would be applied inboth spheres. As everything would bedone in-house error-reporting andproblem-solving would (in theory) beexpedited. (Although there is noguarantee that the resulting inclusive,multi-tasking ‘umbrella’ structure wouldbe more effective than the fragmentedstructure it replaced.)
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2. If option 1 is rejected there is afallback: a member of the airline’s staffmust be on the ramp exercising theairline’s authority during embarkationand disembarkation. This ensures thatthe airline’s safety culture permeatesboth air and ground operations.Continuity of oversight is the key tosafe ground handling.
3. If option 2 is considered too ambitiousthere is a final fallback: airlines shouldprovide feedback to and be preparedto deploy sanctions against waywardground handling companies. Thehandling company should be madeaware of what is not acceptable (likeparking vehicles on the left hand sideor leaving stairs on the ramp). Airlinesmight consider punitive financialsanctions against transgressors. (Thismanagement technique will only work ifemployed sparingly. If over-used theramp service provider may go under,creating a short-term operationalproblem and longer-term diminution ofcompetition and choice.)
At the end of the day no solution isperfect. The problem with using cabin staffto supervise the ramp is that it leaves justtwo cabin crewmembers to completeturnaround duties. Given this logisticalhurdle it is likely that some — perhaps amajority — of airlines would carry on asbefore. This raises the question of whetherregulators should require airlines tomanage the ramp. A statutory duty onairlines would (theoretically) raisestandards and ensure a level playing fieldbetween carriers. My inclination would beto choose persuasion over compulsion.Operators should be appraised of thelikely consequences — in terms of death,injury, financial loss and bad press — of amishap on the ramp.
Having said this I am under no illusion asto the magnitude of the problem. Rampindiscipline is a major topic of conversationamongst cabin and flight crew. One pilotremarked that amongst some groundhandlers ‘competence’ seemed to be
measured not in terms of how safely (i.e.slowly and carefully) workers drove servicevehicles, but how fast they could drivethem without skidding and/or colliding withparked aircraft or ramp furniture. This pilothad observed a truck driven so fast thatwhen the brakes were applied ten yardsfrom a parked aircraft the vehicle skiddedfor three yards! I have observed a handlingagent reverse a car at speed acrossseveral ramps. There is no way that thedriver could have seen exactly where hewas going. The car was packed with hiscolleagues. The fact that they saw me(dressed in regulation clothing with airlinelogos on display) making a note of theirnumber plate made no differencewhatsoever to their conduct. But it didchange their demeanour. They smiled.
Having said this I am aware that rampservice providers perform their dutieswithin a context fashioned in part by theairlines. The airlines, in turn, respond tomarket demands. As Chong (2001) hasput it: ‘[T]he ever-increasing number ofpassengers boarding our airplanes areexpecting ... better performance, value andservice ...’. If low cost carriers demandquick turnarounds ramp service providersrespond. No company would risk losing itscontract to the opposition by ignoring itsclient’s requirements. So the drive toimprove ramp safety has two elements.First, carriers must re-emphasise theprimacy of safe operation. This should bean ongoing activity, secured throughperiodic safety audits and debriefings withramp service providers. Without feedbackto subjects audits are useless. As Jones(2002) puts it: ‘[L]ike all reports, carryingout an inspection can be the easy part ofthe process; the question remains as towhat to do with the information gleaned’.All carriers should commit one cabincrewmember to the ramp. Allcrewmembers should be trained in rampmanagement (it is much more commonsense than rocket science) and should begiven the requisite assertiveness training(the ramp can be a pretty macho workingenvironment!). They should also beprovided with appropriate warm and
waterproof clothing. Secondly, rampservice providers must respond to carriers’feedback (as well as feedback from theairport authority). If this ‘softly softly’approach fails to produce results theresponsible authorities should considertighter regulation of the interface betweenthe airlines and their handling agents. I amsure we can all agree that public safety isour number one priority.
Sources
Chong, D.R. (2001) ‘Dealing withPsychological Stress’, Air Line Pilot,October, p. 28.
Jones, T. (2002) ‘Audits, Inspections andSurveys’, Aviation Security International,April, pp. 32-34.
Kueter, J. (2002) ‘Optimising AirportBusiness’, Airport Safety and SecurityManagement, Volume 3, February, pp. 14-15.
Reason, J. (1990) Human Error,Cambridge: Cambridge University Press,pp. 197-199.
About the AuthorDr Bennett directs the MSc in Risk, Crisisand Disaster Management at the ScarmanCentre, University of Leicester, England. Hislatest book Human Error — by Design? isavailable from Perpetuity Press [email protected]
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Some of the most costly types ofincidents that still affect airlines today arethose on the Ramp. Although, usually, ofa relatively low order in terms of individualcost, they occur frequently enough thatthe annual bill can still be very significant.What do I mean? Lets look at a recentincident that affected one major UKscheduled carrier in the last couple ofyears.
Imagine a major UK airport on a pleasantday with a 737 crew manoeuvring onto arecently vacated stand. The standconcerned is wide enough for one 747 ortwo 737s, but the jetty is only usable forthe left-hand stand when two 737s areparked. The correctly parked groundpower supply, painted yellow, is fixed andmounted on an extending cradle onwheels to the front right of theapproaching 737. The crew are trained toensure that the stand is clear ofobstructions before entering the stand.The crew have been allocated the righthand of the two parking slots and thestandard STOP line is in use and markedon the concrete to the left of the standcentreline. Unfortunately, the standgeometry dictates that the AGNIS display
is mounted very high, and to the right ofthe crew, on the terminal structure whichcreates a significant split of the Captain’sattention, especially as the aircraft nearsthe final parking position.
The crew concerned both ensured, to thebest of their ability, that the stand wasclear and that the guidance system wasswitched on. Accordingly, theyproceeded slowly onto stand. Just beforethe aircraft reached the correct STOPposition, the crew were signalled to stopby an agitated member of the loadingcrew who were awaiting the aircraft’sarrival. The Captain stopped the aircraftand shutdown the engines on theinstructions of the ground personnel.
Upon initial investigation, it transpired thatthe right-hand engine intake hadcontacted a small pair of engineeringaccess steps. Needless to say, a fullinvestigation was launched and,inevitably, there was more to the incidentthan met the eye. I don’t wish to boreyou, the reader, with the full details so Iwill confine myself to the important bits.
The error chain began before the creweven approached the stand. The aircraft
that had previously been on stand hadundergone minor corrective maintenanceusing the steps for access. The removedpart had been bagged up and placed onthe top of the steps – no doubt intendingto return the offending article to storesonce the aircraft had been dispatched(Error 1). The steps had been movedforward away from the aircraft, but wereleft on the active stand area (Error 2) infront of the extending arms of the groundpower with the brakes off (Error 3). Theaircraft was then instructed to carry out along push to allow our aircraft onto thestand. Our dispatcher arrived at thestand in a hurry having had a long way totravel, saw the offending steps parked infront of the extending arms of the groundpower unit but infringing the protectedzone. The dispatcher decided that thesteps were parked too far away to be ahazard and left the stand guidanceilluminated (Error 4). The crew did notnotice the steps parked on stand (Error 5)as they were roughly the same height asthe ground power system and paintedalmost exactly the same colour!
As the aircraft approached the correctparking position, the airflow through theright engine was sufficient to suck theunbraked steps towards the intake.Unfortunately, suction was also strongenough to cause the engine to ingest thesmall packaged aircraft part that hadbeen left on top of the steps with theinevitable damage to the engine.
The moral of the story?Adherence to correct procedures andmeticulous attention to removing standobstructions - even if you are in a rush.
Just Another Ramp Incident
by Wing Commander Dave McCormickSO1 Engineering PolicyDefence Aviation Safety Centre
Thoughts on Ramp Safety
Aircraft operating ramps are home tomany aviation safety hazards. Themixture of aircraft, refuellers, hot engineexhausts, ground equipment, vans,people and a variety of noises ispotentially lethal. But, are ramps safe? Ican hear the ramp managers nowexplaining that, considering the number ofaircraft movements on our ramps, thereare few reported accidents. Unfortunately,that is not convincing for 2 reasons.
Saying “we have few accidents” is not thesame as saying “we are safe”. Forexample, flying hour for flying hour, wouldan organisation that had 3 differentaircraft accidents be less safe than onethat had 2 identical and preventableaccidents? I think not! Current safetyexperts agree that being safe implieslooking at all the hazards, carrying outrisk assessments and mitigating all therisks until they are as low as reasonablypractical and tolerable. Also, reportedaccidents are a function of 2 variables:how many accidents occurred and theproportion of accidents reported. If there is a poor reporting culture, thenumber of reported accidents may beirrelevant to the safety level.
If the number of reported accidents doesnot tell you how safe your ramp is, whatdoes? To measure safety you need tolook at the following 4 things:
How safe is your equipment? Has a competent individual decided thatyour equipment is designed to meet thetask for which it is used? Do you have anadequate and responsive equipmentmaintenance regime? Do you haveenough equipment for the tasks you intendto complete? Is there a managementsystem in place to maintain adequateavailability of the equipment? Is all theequipment on the ramp really necessary?
How safe are your people? Do you have a system in place toensure that your people are competentfor the processes you expect them tocomplete? Do your people have apositive attitude to safety? Do youhave enough people for the tasksyou intend to complete? Are all thepeople on the ramp really necessary?
How safe are your processes? Are all your processesvalidated and documented?For complex processes,do you have quickreference checkliststhat are suitablefor use on theramp? Do yoursafety criticalprocesses relyon perfectperformance byindividual staffmembers? Do yoursafety critical processesdefine required levels ofsupervision and independentchecks? Do you have a quickand simple system forvalidating process changeproposals and altering yourdocuments and training whereappropriate?
Does your organisation use riskmanagement principles in yourwork on the ramp?Are you continually looking forhazards, particularly duringunusual events? When youidentify a hazard, do you assessthe likelihood and consequencesof realising those hazards? Doyou mitigate the risks to achievea tolerable level that is as low asreasonably practicable? Every
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time something goes wrong, do youinvestigate why it went wrong andimplement a solution intended to preventrecurrence?
These are basic elements of a safetymanagement system. How often do youcarry out an independent audit of yoursystems to ensure that they are workingas intended?
How does all this theory apply on theramp? Well, consider aircraft refuelling.Are the only personnel aware of thehazards the recent arrivals? The routinenature of aircraft refuelling inevitablyincreases the likelihood of complacency.Might there be an element ofcomplacency amongst some of yourmore experienced refuelling staff? Whenwas the last time they were reminded ofthe hazards? How often do supervisorsor safety staffs watch aircraft refuelling toensure that procedures are beingfollowed? What about aircraft loading?What about cabin cleaning? What aboutaircraft de-icing? What about aircraftdespatch teams? All these areas deserveregular scrutiny. After scrutiny do youhave a team debrief where your findingsand observations are openly discussed?
People will always make errors; it is aninevitable consequence of being human!If you can understand why people makethose simple mistakes, you can designyour systems to be more tolerant of error.Safety is all about how error tolerant yoursystems are!
The problem for any organisation ispreventing the next accident, rather thanthe simpler task of dealing with the lastone! Until everyone reports all the nearmisses and these are dealt with actively,they will continue to occur. Eventuallythey may cause an accident rather thananother near miss. Thus, if managerswant to make the ramp safer, they must
avoid“shooting themessenger”; that willensure that they do not findout about future near misses!I am not an advocate of the“blame free” workingenvironment. Where an employeedoes something
malicious or knowingly takes anunjustifiable risk, discipline is appropriateand most employees would agree.However, I commend managementencouraging an open reporting cultureand being seen to produce practical andeffective recurrence prevention strategies.
A particularly difficult issue to deal with isthe “can do” attitude amongst ramp staff.Despite any problems, ramp staff willalways attempt to get the aircraft away ontime.
Unfortunately, in these circumstances,they will often focus only on meeting thetime slot. This focus can lead tounintentional risk taking. When things arenot going well or are rushed, that is thetime for a supervisor to be standing backand taking the overview. He must try notto get involved in the detail but only tostep in when safety is compromised. Youmight say he is your goalkeeper and he istrying to prevent an own goal!
I will finish with some questions for you tocontemplate!
■ Is your ramp a safe one?
■ How do you know?
■ Is safety the fortunate result ofprofessional effort?
■ Or is it the planned result of activemanagement?
■ Can you justify everything thathappens on your ramp?
■ Is an ounce of effort worth a ton oftheory?
UK FLIGHT SAFETY COMMITTEE
Annual Seminar 2002
3rd/4th September 2002
The Radisson Edwardian Hotel Heathrow
Seminar ObjectiveThe UKFSC visited this topic in 1994 - what has changed? Statistics show an increasing incident/accident trend;areas still require major improvement - why? If you are involved in any way with Ramp activities, you should attend.
Programme3rd September 2002
1600-1700 Registration 2000hrs Seminar Dinner
This will take place in the Hotel Foyer After Dinner Speaker -
Air Cdre. Chris Moran OBE MVO MA BSc
4th September 2002
0800-0900 Registration
Session Chairman -
Capt.Steve Solomon, MyTravel
0900-0910 Opening Remarks
John Dunne - Chairman UKFSC
0910-0940 Keynote Speech
Ken Smart - AAIB
0940-1010 Regulators View
Mike Overall - Aviation Consultant
Stan Brown - CAA
1010-1040 How We Do It
Charlie Clifton - Ryanair
1040-1100 Refreshment Break
1100-1130 Case Studies in Damage
Paul Clark/Peter Cooper - Airclaims
1130-1155 Ground Handlers’ Dilemma
Bob Newman - Menzies Aviation Group
1155-1215 Health & Safety on the Ramp
Christine Barringer - HSE
1215-1245 Discussion
1245-1400 Lunch
1400-1430 Where is Best Practice
- UK or Abroad?
Richard Heard - Birmingham
Intl. Airport Ltd
1430-1500 Damage Assessment &
Claim Recovery from an
Airline’s Perspective
Ivar Busk - SAS
1500-1530 Airport Design Influence
on the Problem
Mark Oliver - Jacob Gibb Ltd
1530-1550 Discussion
1550-1600 Closing Remarks
John Dunne - Chairman UKFSC
Seminar Information• Hotel Accommodation
Hotel Accommodation is not included in the Seminar Registration Fee. A rate of £137 (including breakfast & VAT) has been negotiated with the Radisson Edwardian Hotel (valid only until 16th August). If you require accommodation please contact the hotel directly on Tel: +44 (0) 20 8759 6311 and quote Block Booking Code 0309 UKF when making your reservation.
• Seminar Dinner Dress for Dinner - Black Tie
• Cancellations/Refunds Cancellations received prior to 2nd August 2002 will be refunded 50% of registration fee. Refunds after this date will not be given.
If you are unable to attend why not nominate a colleague to take your place. If so, please advise the UKFSC Fairoaks office of any changes prior to the Seminar.
Seminar Registration FormPlease complete in full one registration form per person. (Photocopies accepted)
REGISTRATION INFORMATION(Please print clearly)
First Name: Surname:
Company: Job Title:
Address:
Tel No: Fax No: e-mail:
PAYMENT INFORMATIONSeminar Fee: £125 UKFSC Member £175 Non-UKFSC Member
This includes the Seminar Dinner on the evening 3rd September, lunch, refreshments and car parking. This does notinclude hotel accommodation - please see 'Seminar Information' above.
Payment is by Sterling cheque only. No credit cards are accepted. Bank transfer is available, details on request (pleasenote an additional cost of £6 will be added to cover handling charges). The UKFSC is not VAT Registered.
Sterling cheques should be made payable to UK Flight Safety Committee.
• Do you plan to attend the Seminar Dinner on Tuesday 3rd September? Yes No• Do you require a Vegetarian alternative? Yes No
PLEASE SEND YOUR COMPLETED REGISTRATION FORM WITH YOUR CHEQUE TO:
UK Flight Safety Committee, Graham Suite, Fairoaks Airport, Chobham, Woking, Surrey, GU24 8HX.Tel No: +44 (0)1276 855193 Fax No: +44 (0)1276 855195 email: [email protected]
Confirmation will be faxed to you on receipt of your Registration Form and payment.
✂
WHATS YOUR DAMAGETHIS MONTH?
DAILYPROBLEM
IMMEDIATESOLUTION
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Safety
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WHATS YOUR DAMAGETHIS MONTH?
DAILYPROBLEM
IMMEDIATESOLUTION