ON COMMERCIAL AVIATION SAFETY SUMMER 2002

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ISSN: 1355-1523 SUMMER 2002 ON COMMERCIAL AVIATION SAFETY

FOCUS on Commercial Aviation Safety contents is published quarterly by The UK Flight Safety Committee. Editorial 2

Editorial Office: Chairman’s Column 3 Ed Paintin The Graham Suite Its not the one thing that gets you, 4 Fairoaks Airport, Chobham, Woking, its when they gang up against you Surrey. GU24 8HX Tel: 01276-855193 Fax: 855195 How do you view Ramp Damage? 6 e-mail: [email protected] Web Site: www.ukfsc.co.uk ATC Options 7 Office Hours: 0900-1630 Monday-Friday Aircraft damaged by de-ice rig. Port stabiliser wing tip 8 Advertisement Sales Office: damaged beyond repair Andrew Phillips Dean Godfrey, KLM uk Andrew Phillips Partnership 39 Hale Reeds A Ramp Related Incident 9 Nicole Stewart, bmi regional Farnham, Surrey. GU9 9BN Tel: 01252-642695 Mobile: 07836-677377 Confidential Reporting for Cabin Crew 10 email: [email protected] Stand Discipline - Does your Organisation have it? 11 Printed by Woking Print & Publicity Ltd The Print Works, St.Johns Lye, St.Johns UKFSC List of Members 12 Woking, Surrey GU21 1RS Tel: 01483-884884 Fax: 01483-884880 The JAA’s operations standardisation team visit programme 14 ISDN: 01483-598501 Captain Tim Sindall email: [email protected] Web: www.wokingprint.com CRM training needs measures and remeasures 16 if it is to succeed FOCUS on Commercial Aviation Safety is Keith Bedingham circulated to commercial pilots, flight engineers and air traffic control officers holding current New Human Factors Requirements for JAR145 18 Approved Maintenance Organisations licences. It is also available on subscription to Fiona Merritt, CAA organisations or individuals at a cost of £12 (+p&p) per annum. Frontline Defences? Safety on the Ramp 19 Colin Brown, CHC Scotia FOCUS is produced solely for the purpose of improving flight safety and, unless copyright is The Dangers of Tyre Failure 21 indicated, articles may be reproduced providing that the source of material is acknowledged. Helicopter Ramp Incident & Ground Damage at Zurich 22

Opinions expressed by individual authors or in Implementation of HSE’s Aircraft Turnround 23 advertisements appearing in FOCUS are those Guidance Note HSG209 at Heathrow of the author or advertiser and do not necessarily Ramping-up Safety 26 reflect the views and endorsements of this journal, Dr Simon Bennett FICDDS the editor or the UK Flight Safety Committee. Just Another Ramp Incident 29 The mention of specific companies or products in articles or advertisements does not imply that Thoughts on Ramp Safety 30 they are endorsed or recommended by FOCUS Wg Cdr Dave McCormick, DASC or its publisher in preference to any others.

1 Editorial

Ramp Damage - Time for Action

There are strong indications that the limited to the availability of suitable staff. to work on aircraft. Whilst they do cause business is returning to the pre some damage to aircraft on the ramp it is 11th September 2001 level. I am certain Damage to aircraft on the ramp remains a far less than the damage caused to the that many are breathing a sigh of relief. major concern and the uninsured losses aircraft by the thousands of unqualified This should be good news for all those to air operators continues to grow. Some ramp personnel. who were made redundant. Many have are starting to pay more attention already found jobs and returned to work to the monitoring of these losses as their The cost to the aviation industry due to and I am sure they feel much happier, prevention would lead directly to an injury and damage on the ramp has even if less secure, in their new positions. increase in the profit. Some estimate reached a point where we can no longer Others are still frantically looking for these losses to be in excess of $4 billion ignore it. The current system of suitable employment. annually. employment of ramp personnel will have to change in order to bring the number of For those, unlike the aircrew, who are not The Health and Safety Executive (HSE) is injuries and cost of damage under reliant for employment in the aviation very concerned about the number of control. Should we therefore not “grasp industry, many have found positions in injuries on the ramp and the ever growing the nettle” and introduce some form of other industries, vowing never to return to loss of working time. (Some believe the ground handling certification before the aviation. Some feel there is a total lack of aviation industry injury record is now problem gets even worse? loyalty by management to their staff. The higher than that of the building industry.) loss of experienced aircraft engineers to other industries is certainly not good for Safety on the ramp must be improved, the aviation industry. They should but how? however be a little cautious, as working in another industry does not make them It has become clear that making the air immune to staff cutbacks. operator responsible for the safety of their contractors, as required by JAR-OPS, is One of the byproducts to redundancy not working. Perhaps it would make better action is the effect that it has on the work sense for the airport to be responsible for of the employees. Low moral has a direct safe operation of all contractors on their impact on work practices and employee airport. The airport operator is in a far motivation and can ultimately lead to a better position to monitor how the lowering of safety sandards within an contractors are working, than an airline organisation. It is therefore necessary for based in another city or country. In all managers to be aware of this and to addition they have the ultimate sanction Amendment to ‘Angle of manage accordingly. of withdrawing the right of the contractor Attack’ article in Spring to work on that airfield if they fail to 2002 Issue: On a brighter note the increasing number perform in the correct manner. of air travellers means that the industry “Key Points to emphasise in training” will soon be expanding again and there Has the time come to introduce some bullet point 3, last sentence, 3rd to will be an even greater need for good form of certification for the many workers last word should read ‘inappropriate’ reliable staff at all levels. The rate at which on the ramp? Pilots and engineers are the air operators expand may well be required to be properly qualified in order

UK FLIGHT FLIGHT SAFETY SAFETY COMMITTEE COMMITTEE OBJECTIVES OBJECTIVES ■ To pursue the highest standards of flight safety for public transport operations. ■ To constitute a body of experienced aviationaviaition flight flight safety safety personnel personnel available available for for advice advice and and consultation. 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 aircraftft and passengers. ■ To provide assistanceadvice and toassistance operators to setting operators up a settingflight safety up a flightorganisation. safety organisation.

2 Chairman’s Column

Challenges for the Industry by John Dunne, Airclaims

2001 had all the makings of a good year FOCUS that security measures against the Authorities, Trade Unions, Air Traffic for aviation safety until 11th September. type of attacks of 11th September rest Controllers, Ground Handlers, Engineers, Since then a greater emphasis has been entirely with the state agencies. Lawyers and Insurers meet on a regular placed on new or revised security basis in order to discuss Flight Safety initiatives. Many of these were, arguably, Prior to the 11th September the aviation matters. We do make and will continue to rushed into place. industry was already in a state of a steady make a positive contribution to the but slow decline. Since then passenger improvement of Flight Safety. Historically safety initiatives in our industry numbers have fallen dramatically and have always been carefully thought Company Executives were faced with To date 2002 has seen a number of through to ensure that “improvements” enormous survival challenges. Difficult accidents or incidents whose causal don’t contain any latent problems. Long times call for difficult measures, steady effects have included: CFIT; landing queues of passengers at security nerves and acute business skills. overrun; icing; engine flame-out in rain; screening posts within the terminals have autopilot mode confusion; failure of large become the norm at airports. Recent We have all seen budgets slashed, aircraft diameter fan blades; hostile acts. These press reports have hailed the security parked up and colleagues and friends illustrate that we can never afford to be initiative as a success, quoting the number laid-off. Even the areas of Flight Safety complacent. of Swiss army knives and other and Quality which are considered to be “dangerous” items detected - we trust essential to the safe operation have not We are all responsible for Flight Safety and that they don’t lose sight of the real been immune to the deep cuts. All areas we can all make a difference. objective. of airlines are being forced to make painful cuts, and make rapid changes in policy John Heimlich, Director of Economics at and direction to keep pace with an the US Air Transport Association is quoted uncertain market. Senior Managers need as saying “we’ll never be able to stop the the eyes and ears of their Quality and weapons, so we have to after the Flight Safety departments to ensure that people”. The recent airside robberies at their organisations, now more than ever London Heathrow have illustrated that not will emerge intact, safe and ready for the all the “bad guys” are necessarily going to challenge of the upturn. submit themselves to inspection at the passenger security checkpoints inside the The UK Flight Safety Committee has been terminal building. encouraged to continue its good work. It is the only Aviation Safety body in the I strongly concur with Tom Croke’s world where Operators, Regulators, Pilots, message in the Spring 2002 issue of Air Accident Investigators, Airport

3 It’s not the one thing that gets you, it’s when they gang up against you An account of a windshear event - December 2001, Milan, Jet aircraft

As soon as we contacted Italian ATC we were sent to hold over Bergamo, also being informed that the two Milan airports were snow clearing and closed until further notice. We rechecked our other alternates, Turin and Genoa. Both of these were reporting good weather. A diversion to Genoa was requested, ‘sorry’ came the reply ‘they are unable to accept diversions because of over capacity’ ‘OK, request diversion to Turin’, same reply ‘overcapacity’.

Now we had a problem, nowhere to go. Just as it was looking quite bad ATC asked if we had a fuel problem, well, two minutes ago we hadn’t, now we did, They offered us the just cleared, Malpensa.

While all of this had been unfolding we were burning fuel, precious fuel. Now seemed a good time to change first officers to maximise the experience available.

We anticipated the northerly runway and briefed, it was not to be, the wind had swung round 180 degrees, that was our first clue as to what was in store for us. Then a third rebrief, as the ILS for the south runway was unserviceable.

Down wind the flaps decided to malfunction and stick at zero, I flew a VOR DME approach while the first officer did the relevant calculations and drills, these were all finished as we turned onto final approach, at last a runway ahead. training captain with eight years This is an account of what happens At 1000 feet on final approach all hell experience on type. when several things conspire against you, broke loose, with the wind roaring and to make an ordinary flight into something howling, the aircraft went into an At the pre-flight stage the weather for LIN more dangerous. All the problems that uncontrolled descent, WINDSHEAR GO- and its alternates looked OK, just a are described here are manageable on AROUND was shouted and the aircraft chance of rain and snow on the forecast their own but added together made quite was put into the recovery attitude with full being the worst and further down Italy, an evening. power. ‘Gear up’ was called, but twice two diversions had a quite good stable the reply ‘still descending’ came back. forecasts. Enough fuel to hold for 30 mins The flight was planned to go to Milan How could this be? The aircraft was or divert a long way away was loaded. Linate, it was to be the first line training pitched up and full power was applied. flight for a new first officer, and it is The GPWS joined in, ‘WHOOP WHOOP, The trip down was uneventful; the company policy to carry another first PULL UP, TERRAIN’. officer on the jump seat for safety weathers all remained as forecast. Crossing the Alps that all changed. reasons. The pilot flying was a line- The aircraft data recorder noted that we

4 declared a PAN, as we had to go to Things happen in threes and fours not another airfield. Turin was nominated, and just on their own. ATC, with renewed interest in us, turned us en-route. Weather forecasts are somebody’s best guess, but not a certainty. Fuel and MSA’s where now high on the agenda as the route would take us along Airports close for a variety of reasons not the foot of the Alps, although, as we just weather. approached Turin snow once again The quality of ATC varies with the raised its head. Turin had a long runway workload they have. but the wind was straight across at 20 knots and the runway was covered in The term windshear is often used to snow! Just ideal for a flapless! describe a loss of 10 knots or 100 feet, but don’t forget it can be much worse. The aircraft performed well on the had gone down to 250 feet radio before runway, stopping two thirds down and recovery. taxiing off normally.

As we climbed away the TCAS went red I always thought beer tasted best in in the whole of the climb segment; we Holland, but it tastes much better in Turin! levelled off, guessing that we may impinge on the holding traffic above and What did we learn?

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5 How do you view Ramp Damage? An account of a windshear event -December 2001, Milan, Jet aircraft

Who was held to be at fault? Yes you guessed it, THE CAPTAIN. Although he stopped in a position ordered by the marshaller, it was his responsibility to ensure the aircraft was suitably parked. Who paid for the damage? You can imagine the sloping shoulders on this one. The handling agent and airport authority claimed that they were blameless in spite of the obvious failings in their performance but ultimately a bargain was struck.

What are the lessons learnt following such an incident? The Captain is the Captain and is likely to be blamed for anything. Be aware of ramp markings even if you have followed external instructions correctly. Do not expect external agencies to put up their hands to accept blame, at least not without a fight.

How do you view Ramp Damage? Is it structure to separate from the aircraft. The Ramp Damage remains one of the most because poorly trained, poorly paid, APU continued to run but was shut down significant areas of airline loss. workers are employed to carry out their immediately the Captain returned to the Isn’t it about time we got our act work with heavy vehicles close to Flight Deck. together? expensive aircraft? Is it because training standards are low and quality assurance An investigation was initiated and several poor? Is it the fault of the airlines who interesting points emerged. The steps want everything for almost nothing? Is it were being towed in an unauthorised due to unrealistic time pressures during configuration i.e. sideways rather than turn-rounds? lengthways and although the Captain had stopped the aircraft following instructions This is a tale of a short turn-round at a from the marshaller, the tail of the aircraft Spanish airfield on a Charter Airline extended by a few inches beyond the Boeing 757. The aircraft has been de- ‘yellow line’. identified in the photographs to protect the innocent.

The Captain had followed the signals from a marshaller and stopped the aircraft in accordance with his orders. The parking brake had been applied, shut down checks carried out and the passengers had deplaned. The APU was running in accordance with normal SOPs. A tremendous jolt was felt throughout the airframe and some of the crew left the aircraft to check for the cause. A set of passenger steps, that were being towed by a vehicle, had impacted the APU exhaust and caused part of the exhaust

6 7 Aircraft damaged by de-ice rig. Port stabiliser wing tip damaged beyond repair by Dean Godfrey KLM uk

Weather at the time of the incident: Freezing, dry.

Lighting: Dark, stand lights.

Surface conditions: Dry, no contamination.

Aircraft damaged by de-ice rig. Port stabiliser wing tip damaged beyond repair. This occurred whilst repositioning the de-ice rig from the port to the starboard side of the aircraft; the rig boom came into contact with the rear port tail plane wing tip.

Due to congestion between the driver and bucket operator, that the best taken by the rig to pull away from the passenger air-bridge and the port wing, it approach would be to de-ice the wing aircraft and to manoeuvre to the other was discussed and agreed between and the rear tail plane, from the side of the aircraft. It was discussed and one position between wing agreed between the driver and bucket Airstaff Associates and tail plane. The driver operator, what the best means to in association with approached the aircraft at 90 manoeuvre clear of the aircraft and Nigel Bauer & Associates degrees to the main fuselage reposition on the other side were. The and de-icing commenced, manoeuvre would involve a reverse QUALITY MANAGEMENT FOR OPERATORS * by spraying the root of the straight back as far as possible, before JAR-OPS Quality Systems, documentation & auditing wing and working back coming into contact with the bowser and 5 days - LGW - 17 Jun, 23 Sep, 25 Nov towards the wing tip. This the use of a hard right lock to turn away SAFETY MANAGEMENT SYSTEMS was completed by reversing from the aircraft. SMS course for air & ground operators the rig to allow the bucket 2 days - LGW - 29 Oct operator the best angle of The bucket operator guided the rig AUDITING IN AN OPERATIONAL ENVIRONMENT * attack possible. On straight back as far as possible and then Air & ground operations auditing 3 days - on request or ‘in-company’ completing the wing, the rig the driver turned full right lock and moved was driven forward again at forward. As the de-ice rig moved forward AUDIT IMPROVEMENT WORKSHOP Experience sharing & improvement of audit process 90 degrees to the fuselage and right, the boom came into contact 2 days - LGW - 31 Oct and the rear tail plane was with the port rear tail plane wing tip, QUALITY FOR SENIOR MANAGEMENT de-iced using the same causing a crumple and tear to the wing New Course - JAR Quality Management Accountability method. tip approximately twelve inches in length. 2 days - ‘in-company’ only As a result of the investigation the * Incorporating Nigel Bauer & Associates While the de-icing operation procedures for moving from one side to IRCA certificated Internal Auditor Training course of the port side was the other for this aircraft were changed: For further details including In-Company courses and consultancy underway, a fuelling bowser Whilst manoeuvring, the boom should be or auditing services please contact: had parked on the adjacent positioned below the level of the tail plane Airstaff Associates: Tel +44 (0) 1780 721223 e-mail: [email protected] stand, to refuel another to avoid any possible contact with the Fax +44 (0) 1780 720032 www.airstaff.co.uk aircraft. The position that the aircraft. Nigel Bauer & Associates: fuel truck had taken blocked Tel +44 (0) 1243 778121 e-mail: [email protected] the normal reversing route Fax +44 (0) 1243 789121 www.nb-a.demon.co.uk

8 A Ramp Related Incident by Nicole Stewart, Embraer Fleet Safety Officer, bmi regional

The Captain, 2. Captains to brief cabin attendants to conscious of not check prior to pushback that the inviting bogus theft viewer is clear. claims, told the now- boarded passengers 3. Crews to file ASR’s in all instances to that he had received assess the scale of the problem. information that their bags may not have 4. Cabin Services to issue crew directive been 100% screened to be aware of this problem. during the check-in procedure. The 5. That a label be produced in English, passengers were then German and French to state that this disembarked whilst area must be kept clear of luggage at During turnaround at a UK International their bags were removed and rescreened. all times. The lens itself to be at the airport, the number 1 cabin attendant centre of the label and attached to the noticed that the viewfinder in the rear Whilst the aircraft was empty, the police bulkhead. toilet, that allowed sight into the hold, was boarded and inspected the cargo hold obscured. viewfinder from inside the toilet and inside the hold. They found a new, still sticky She informed the Captain who asked the ‘FRAGILE’ label on the floor of the hold. loaders to have the blockage removed. It matched the marks still He then, during his walk-round, checked evident on the lens and to make sure this had been done. It was adjacent bulkhead. obvious to him that something sticky had Scarman Centre been put there due to adhesive still The police agreed with remaining on the lens. the crew that it was a deliberate attempt to Postgraduate The Captain then asked the loader who prevent the loading staff was walking away from the aircraft, what being observed from Courses exactly had caused the blockage. The within the aircraft. Distance Learning - next intake loader said that a sticker had come off Contact September 2002 one of the bags and had stuck to the lens. The following day the Master of Science/PgD in: same Captain had a Course Administrator Scarman Centre ● Risk, Crisis & Disaster Management University of Leicester Knowing the height to which the bags were similar incident at a ● The Friars Security & Risk Management stacked in the hold and likewise the height European International 154 Upper New Walk (Each module on the Security course earns 3 Leicester LE1 7QA, UK of the lens itself, the Captain surmised that airport. Again a label CPP credits towards recertification and are Tel: accredited by ASIS) the sticker would have needed to grow its appeared to have been +44 (0) 116 252 3946 New Foundation Degree in: own wings to get up there! stuck over the lens to Fax: +44 (0) 116 252 5788 ● Security & Risk Management prevent the crew inside Email: The incident was discussed amongst the the aircraft seeing into [email protected] Website: The Scarman is holding whole crew and it was decided to contact the hold. www.le.ac.uk/scarman/ an Open Afternoon on the police and the duty ground manager. Please quote ref FOC/06 in all Friday 5 July 2002. Certain communication The police agreed that there was a strong recommendations were possibility that the bags had been made:- tampered with. Whilst unlikely that anything had been placed in the bags, it 1. Advise all crews to Delivering excellence in University could not be eliminated without further inspect the viewer on teaching and research screening. walk-rounds.

9 Confidential Reporting for Cabin Crew An account of a windshear event -December 2001, Milan, Jet aircraft

2001 to include Cabin Crew, for a trial ‘discretion time’, lack of time/opportunity period of one year. Recently, with the to take rest/meal breaks (short-haul multi- agreement of CAA (SRG) the trial has sector and charter operators). Some been extended to March 2003. It has reports allege pressure/coercion by either been emphasised that CHIRP should not flight crew or Company. be seen as a replacement for Company Confidential Reporting Schemes and that Faulty Equipment/Health & Safety - it is important that safety-related matters Reports of unserviceable/faulty cabin be reported to the Company in the first equipment interfering with normal duties instance, whenever possible. A separate and/or giving rise to safety concerns. newsletter, Cabin Crew FEEDBACK, Examples are; galley/catering equipment containing disidentified reports is in a potentially dangerous condition, distributed to companies participating in fumes in cabin, crew rest area unusable the Trial; these are pigeon-holed or sent due to excessive temperature on an ultra direct to bases/crew rooms. long-haul sector, insect infestation in The UK Confidential Human Factors In the period 1 July 2001 - 1 May 2002, cabin crew rest area. Incident Reporting Programme (CHIRP), 78 reports were received. Of these, 23 has been operating since 1982 and were represented to the relevant operator Security Procedures - Reports of receives confidential incident reports from and 25 were made available to the Cabin breaches/lapses in airport/airline security professionally licensed pilots, air traffic Safety Office of CAA (SRG). Issues procedures, such as a potentially controllers, licensed engineers and raised have been in the following dangerous passenger permitted to board approved maintenance organisations categories; Standard Operating at foreign stopover, segregation/screening employed within the UK Air Transport Procedures/Safety Emergency of crew baggage, procedures for carry-on industry along with individuals involved Procedures (21); Rosters/duty baggage during transit stops, screening with General Aviation. CHIRP was time/breaks (21); Faulty Equipment/Health of airport personnel. established in its present form, as an & Safety (9); Security (9); Abusive independent charitable company limited Passengers (7); Potential Health Risks (4); For further information on the CHIRP by guarantee in 1996. The Programme Experience/Training (3); Programme please contact: receives a Grant of Funding from the Civil Dismissal/Discipline Due Sickness (3); Aviation Authority. Company Discipline (1). The CHIRP Charitable Trust Building Y20E, Room G15 Reports are validated as far as is possible Typical issues raised have been: Cody Technology Park through a callback process. If Ively Road, Farnborough appropriate, report information is brought Standard Operating Procedures Hampshire GU14 0LX to the attention of the relevant operational (SOPs)/Safety Emergency Procedures management or CAA (SRG). Only (SEPs) - Incidents reported in which Tel: 01252 395013 or Freefone 0800- disidentified information is used in any SOPs/SEPs have not been followed, 214645 (UK only) discussions with third party organisations. leading to potentially unsafe operations. Fax: 01252 394290 The confidentiality of the reporter is Examples are; take-off/landing without e-mail: [email protected] assured and the reporter’s permission is receiving ‘Cabin Secure’ report and Website: www.chirp.co.uk always sought before any action is taken. without notifying Cabin Crew; emergency No personal details are retained from exits blocked during ground operations reports received and on closing a report by drinks trolleys, equipment not used in all personal details are returned to the accordance with correct procedures reporter with a letter notifying them of the (portable oxygen bottles/crash axe), cabin action that has been taken. Each report crew seating allocations not in is allocated a unique reference accordance with SEPs. identification. The reporter may, if they wish, contact the CHIRP office for Rosters/Duty Time/Breaks - Reports additional information by using the report include misinterpretation of Company FTL reference identification. schemes by either Company or Aircraft Commander leading to onerous duty The Programme was extended in July periods and/or requirement to work into

10 Book Review

The Field Guide to Human Error Investigations by Sidney Dekker, Linköping Institute of Technology, Sweden

Human error may be the dominant understand human error in complex, Hardback 0 7546 1917 6 £40.00 contributor to incidents and accidents dynamic domains and offers concrete Paperback 0 7546 1924 9 £19.95 today, it is probably also the most guidance for reconstructing or misunderstood. How do you reconstruct investigating human error – not to find out the human contribution to system failure? where people went wrong, but why their Human error investigations must often performance made sense to them at the follow a path of intuition or common time. sense, but can fall into the biases and traps inherent in understanding past, Contents: puzzling performance. Human Errors as a Cause of Mishaps: The bad apple theory; Reacting to failure; Many domains, including aviation, What is the cause?; Human error - in the medicine, shipping, road and rail head or in the world?; Put data into transportation, process control and context. Human Error as a Symptom of military applications can benefit from The Trouble Deeper Inside the System: Field Guide to Human Error Investigation Human error - the new view; Human – using its methods, reminders, pointers, factors data; Reconstruct the unfolding hints and tips to ultimately produce mindset; Patterns of failure; Writing credible, well documented findings. recommendations; Learning from failure; It is intended for those who want to Rules for in the rubble; Index

Stand Discipline - Does Your Organisation Have It ? by Sidney Dekker, Linköping Institute of Technology, Sweden Apparently it is lacking on the stand equipment in the marked areas and left instead of waiting for the other equipment illustrated in the picture and has caused them overhanging, thus blocking the to be moved. problems and danger for the catering correct approach path. operators. Positioning the vehicle like this increases Note the errors: the risk of injury to staff and damage to The correct approach line for the catering the aircraft. vehicle should have been from the The mobile conveyor belt wheels just photographer’s position following inside the line but the boom is sticking Only the day before this picture was taken approximately the black line at the middle well out. a similar angled approach had resulted in of the bottom edge. However, other the catering vehicle striking the opened operating staff have failed to park ground The container/pallet loader with most of forward hold door. its main platform over the white line. What instructions are given to ground staff on your station when they find their Behind that, an AKH container route blocked? lying on the ground on the A. "Do not approach until the wrong side of the line. obstructions are cleared" B. "Get in there somehow and In this situation, the catering don't delay the service" operator, trying to help the airline to achieve an on time Which is the correct answer in keeping departure has elected to break with one of your goals to be a safe and the operating procedure rules secure airline? and come in at an angle

11 Members of

Full members bmi regional EVA Airways Capt. Steve Saint Alex Reid Chairman Airclaims CitiExpress Ltd Excel Airways John Dunne Capt. Ed Pooley Peter Williams

Vice-Chairman British International British European Capt. Terry Green Capt. Derek Murphy Stuart McKie-Smith British Mediterranean Airways GAB Robins Aviation Treasurer Robin Berry Rob Burge Air 2000 Capt. Martin Pitt CAA GAPAN Dave Lewis - MRPS Capt. Chris Hodgkinson External Affairs Officer Chrys Hadjiantonis - Safety Data Dept. RAeS Brian Synnott - Flight Operations GATCO Peter Richards Alison Thomas - Intl. Services Richard Dawson

Aer Lingus Cardiff International Airport GO FLY Ltd Capt. Tom Croke Alan Whiteside Capt. Simon Searle

Aerostructures Hamble CargoLux HeavyLift Cargo Dr. Marvin Curtiss Capt. David Martin Capt. Mike Jenvey

Air Contractors Cathay Pacific Independent Pilots Association Capt. Tony Barrett-Jolley Capt. Richard Howell Capt. Mike Nash

Air Mauritius Irish Aviation Authority Roy Lomas Rob Trayhurn Capt. Bob Tweedy

Air Scandic CityJet JMC Airlines Paul Ridgard Capt. Mick O’Connor Capt. Graham Clarke

Air Seychelles Cougar Leasing LAD (Aviation) Ltd Capt. Curtis Allcorn Shaun Harborne Steve Flowers

Air Transport Avionics DHL Air Colin Buck Peter Naz Doug Akhurst

ALAE Dragonair London- Dave Morrison Alex Dawson Wally Walker

BAA plc UK Ltd Maersk Air Francis Richards Capt. Jacqueline Mills Capt. Robin Evans

BAC Express EasyJet plc Capt. Steve Thursfield Capt. John Broomfield Peter Hampson

BAE SYSTEMS Reg. A/C Emerald Airways Middle East Airlines Dan Gurney Capt. Roley Bevan Capt. Mohammed Aziz

BALPA European Aviation Air Charter Monarch Airlines Carolyn Evans David Wilkinson Capt. Gavin Rowden

12 MyTravel Britannia Airways Lufthansa Cargo AG Capt. Tom Mackle Jez Last Capt. Nigel Ironside

NATS Britannia Airways Eng. Condor/Lufthansa & CityLine Paul Jones Adrian Vaughan F/O Paul Stevens

PrivatAir British Airways MOD Capt. Boris Beuc Steve Hull DASC Col. Arthur Gibson DASC Eng. - Wg Cdr Dave McCormick Ryanair British Airways Eng. HQ STC MOD - Sqn Ldr Jeff Collier Capt. Gerry Conway Penny Barltrop RAeS SBAC British European Peter Richards John McCulloch - Secretariat Stuart McKie-Smith Bryan Cowin - BAE SYSTEMS RAeS Eng. Vic Lockwood -FR Aviation British European Eng. Jack Carter Chris Clark Schriener Airways Arnoud Schriener CHC Scotia Co-opted Advisers Capt. David Bailey Servisair AAIB Eric Nobbs CHC Scotia Eng. Phil Gilmartin Colin Brown Shell Aircraft CHIRP Cliff Edwards Eurocypria Peter Tait Capt. Constantinos Pitsillides The Boeing Co. GASCo Edward Berthiaume Cyprus Airways John Campbell Capt. Spyros Papouis TRW Aeronautical Systems Royal Met. Society Keith Joyner FLS Aerospace (IRL) Dr John Stewart Frank Buggie Airways Capt. Jason Holt FLS Aerospace (UK) Andrew Hoad Willis Aerospace Ian Crowe Ford Air F/O Paul Stevens

Group members Ford Motor Co. Eng F/O Paul Stevens bmi british midland Capt. Ian Mattimoe GB Airways Capt. Aaron Cambridge bmi british midland Eng. Peter Horner GB Airways Eng. Terry Scott Capt. Derek Whatling KLM uk Dean Godfrey Bristow Helicopters Eng. Richard Tudge KLM uk Eng. Andy Beale

13 The JAA’s operations standardisation team visit programme by Captain Tim Sindall

Romania, Switzerland, Finland, the field’ will not be realised. Whilst a Questionnaires are sent also to three United Kingdom, the Republic of Ireland, common compliance level is, perhaps, operators who have been issued with an and Austria – these are the first six the most sought-after ‘prize’ expected by AOC based upon JAR-OPS, typically one European States whose national aviation those who have had to invest heavily to large aeroplane operator and one small, safety authorities have been listed to meet the standards required for the issue and one helicopter operator. receive audits from the Joint Aviation of a JAR-OPS Air Operator Certificate Authorities’ (JAA) Operations (AOC), the true beneficiaries will be the In the week prior to the visit, the three Standardisation Team (OPST). customers, those who pay for the team members travel to Hoofddorp, services on offer. It is they who should where Central JAA is based, to meet the JAA audits are not new: maintenance and hereafter be assured of a common, high national co-ordinator of the ‘host’ State licensing already have well-established level of safety whenever they travel or and to be briefed by the Operations visit programmes, but operations – the send cargo in an aircraft operated by any Division visit programme manager on the ‘sharp end’, some might say – has AOC holder regulated by a JAA Member objectives and procedures concerning hitherto been spared. One reason for the State, wherever in the world their flight the audit. The audit programme is delay has been the relative immaturity of may take place. However, the levels of discussed and agreed, and any queries JAR-OPS 1 and 3, which contain safety established in JAR-OPS 1 and 3 arising from information provided in requirements and guidance material will be effective only when the operators answers to the questionnaires are addressing commercial air transport concerned have implemented fully the answered or noted for later investigation. operations by aeroplanes and helicopters, requirements they prescribe. Team members collect copies of the respectively. However, recent checklists they will use and the amendments to both documents, It is thus appropriate that Central JAA associated forms on which they can note correcting omissions, creating alleviations should now begin the process of their observations. One checklist where the early rules were unnecessarily satisfying itself that States that have contains questions targeted directly at the onerous, and accommodating recent issued AOCs based upon JAR-OPS 1 requirements to be observed by States as ICAO Standards and Recommended and 3 have ensured full compliance, that have been published in Joint Practices, have done much to improve there are no National Variants from the Implementation Procedures - Operations the acceptability and reasonableness of requirements, and that no long-term (JIPs). Others have been designed to both sets of JARs. In turn, this has Exemptions or Exceptions have been indicate the level of compliance with JAR- removed many objections to granted. The means by which the JAA OPS, and do this through queries implementation from States that had does this is by the formation of OPSTs, targeted at selected requirements that undertaken to do so for all requirements each of which comprises three inspectors have been prescribed in all the relevant adopted by the JAA Committee. The few seconded temporarily from three different Subparts. years that have passed since adoption of States – the team composition being JAR-OPS 1 and 3 has also given many different for each audit – working to a In the week following the briefing, on the States the time they needed to develop or common set of procedures. This is to morning after their arrival, team members to elaborate their national legislation to ensure that all audits are conducted in are usually first given a welcome by the accommodate their provisions, and to like fashion and that a fundamental set of authority of the State they have come to complete text translation into national questions of critical importance is put to audit. The OPST leader, or languages. all States. One State will be visited every spokesperson, then explains the process month until all full members of the JAA that the team will follow before they begin Implementation in national legislation or have been audited. to work their way through the ‘National equivalent arrangements that result in all Aviation Authority’ checklist. By the end commercial air transport operators The OPST audit process begins in the of the day, the team will probably have complying fully with JAR-OPS is the aim month before the visit is due to take made a few observations that might later of Central JAA’s Operations Division, place, with the ‘host’ State being invited be confirmed as non-compliances, and which is masterminding the OPST visit to complete a questionnaire, the contents many others that will have indicated full programme. Unless either solution is of which will assist team members to compliance. On the second and third achieved, the much-desired ‘level playing understand the organisation within its days, the OPST visits each of the three flight operations authority/inspectorate. operators in turn, not to carry out any

14 audits (that activity is the function of the OPS in national legislation, the absence Committee/Sectorial Team responsible for State), but to ascertain whether any of National Variants or long-term developing JAR-OPS 1 and 3. He helped applicable requirements of JAR-OPS have Exemptions/Exceptions, and full the Operations Division to establish not been implemented. So-called implementation by operators of procedures for use by the OPST, and ‘Operator’ checklists are used for this commercially sensitive items such as participated as a member of the first three purpose. performance degradations associated audit teams. with operations on contaminated It then remains for the team to discuss runways, and the existence of a flight time their observations with the national co- limitations scheme that satisfies the ordinator, who has accompanied them requirements of Subpart P. Many readers throughout their visit, to obtain will know that the JAA Committee never clarification, to correct any adopted Subpart Q, which had been misunderstandings, and to obtain designed to accommodate requirements acceptance or agreement by the authority for a JAA FTL scheme. However, Subpart of any apparent non-compliances that P requires operators to have a scheme have been observed. All relevant based upon that prescribed by their State observations are transposed onto an authority and to specify how crews should electronic report form, and any that manage exceedences of flight duty and appear to require remedial action may reductions of rest. The OPST checks then become ‘findings’. Before members these points. of the team depart on the third or fourth day, they debrief the ‘host’ State on the Although still in its infancy, contents of the report. Finally, the report the OPST visit programme is first printed and then signed by each has got off to a very good member of the OPST. start thanks largely to the enthusiasm shown by all Global benchmarking and audit specialists Once completed, the report is handed who have been involved. All Meeting the needs of Dynamic Industries over to the JAA Operations Division, who parties seem to share in the will first review it and then formally send it belief that time and ■ measures of excellence to the State that has been audited. The resources allotted to this latter is then required to construct an exercise are well spent if they ■ independence Action Plan that will include proposals for ensure that operational addressing all items listed in the report safety standards have been ■ standards of quality and show time scales within which raised to the levels contained corrective action will be completed. in JAR-OPS 1 and 3, and ■ unsurpassed in experience When the Plan has been accepted by that compliance levels Central JAA, staff there will monitor applied by JAA Member Development of Audit Systems & Procedures progress until they are satisfied that all States to their operators are remedial action has been fulfilled. not below the required level. Operation and Management of Audit Systems Now, what has been found so far from the Professional guidance on regulatory requirements first States to have been made subject to The author, Tim Sindall, was OPST visits? Well, this is for the formerly Head of the Flight Operational cost reduction Operations Division to declare at their Operations Inspectorate discretion and to share with all the other (Aeroplanes) in the UK CAA’s For information contact JAA Member States in a manner of their Flight Operations MiSu International Limited choosing. As may be expected, the Department, and the UK Tel: +44 (0) 01638 780154 Fax: +44 (0) 01638 781218 OPST has concentrated on ‘high profile’ member of the JAA’s E-mail: [email protected] issues such as implementation of JAR- Operations www.misuinternational.com

15 CRM training needs measures and remeasures if it is to succeed by Keith Bedingham

CRM can help prevent accidents caused much higher. So, things have moved measurement tool (Personal Effectiveness by human error, but it must be measured substantially in the right direction, but Profile, or PEP) - which is used for or it could continue to fail, writes Keith there is a problem - and it is diagnosing and analysing individuals’ Bedingham, Chairman, Verax. encapsulated in human nature, which preferred communication and influencing hasn’t changed as rapidly in the same style -is that around half the population Crew Resource Management (CRM) is time frame. systematically has difficulty understanding sometimes touted as a quick fix for their own style, compared to how it is situations where people are not working What is the solution? experienced by others. well together, or where an improvement in communication is required. Training is If we believe that flight deck crew, air This research has covered about 7,500 the deliverer of CRM, but is the training traffic controllers and all others involved in individuals and there is no reason to effective? If CRM training achieved its the communications process intend to do believe that flight crew are any different objectives, we wouldn’t continue to hear a good job -and intend to impart the right from the rest of the population. Indeed, stories of communication lapses between kind of information in the right way and at work that Verax carried out five years ago members of the flight crew and/or air the right time - we can only assume that with the RAF indicated exactly the same traffic control. Nor would we continue to the reason things don’t happen properly trend. hear apocryphal stories of grumpy, is because individuals are unaware of taciturn or arrogant pilots creating their communication failings, or don’t How do we break through this impasse of potentially dangerous situations. know how to communicate. poor self-knowledge in key areas such as communication? The solution lies in each It’s common knowledge that all No training, however good, is of any use individual who attends CRM training commercial flight crew are obliged to unless the trainees see a personal benefit agreeing to submit to analysis of his/her attend CRM training, although it is largely to them. CRM or communications communication and behaviour styles. left to individual airlines as to the form it training has little impact because most The analysis is of their own view of takes. Yet there is very little evidence to people think they are already good at it - themselves and the views of the show that increases in the frequency of just like everyone is a good driver (except colleagues who fly with them i.e. of self CRM training - where it is practised - the others on the road). Only by and peer views of an individual’s results in a reduction of accidents. demonstrating real and personally communication and behaviour styles. specific need, will individuals take CRM or Such a holistic, or ‘helicopter’, view is However, there is evidence from the communications training seriously. This also known as a 360 degree view. military that with the current level of can only be done through feedback, not technical reliability and sophistication, from the classroom - because we can all A tool such as PEP provides information over 90 per cent of current aircraft fake it for a short while - but from the from - and analysis of - the various accidents are due to human error. Fifty flight deck or workplace. ‘views’. It allows individuals (users) to years ago the percentage of accidents identify their own communication attributable to mechanical failure was very One of the findings of a feedback and strengths and identify their own weaknesses and work to improve them. It also allows users to understand the kinds of people they are likely to ‘turn off’ by their communication style and to learn techniques for communicating more effectively with this latter group.

Re-measures (i.e. post training measures) provide a means of monitoring the extent to which air crew are actually applying these new acquired capabilities in the cockpit. Training alone may be counter-productive, whereas continuous assessment improves communication performance.

16 Why may training be on the negative When the RAF adopted a 360 degree individuals’ view of how they see scale of things? Someone may sail measure approach (with re-measures) in themselves, those views can be through training on ‘how to be a good the 1990s, the number of aircraft compared to how others see them. listener’, or ‘how to be a good team accidents attributed to human error member’, because he is ‘listening’ well in reduced to zero for more than two years. Many airlines don’t use any measurement order to show a good result. However, if When the programme ended, having or re-measures after training, while those his attitude to the world is ‘everybody’s an succeeded in its aim of reducing the that do tend to use rather antiquated and idiot’, he will revert to type when he gets number of accidents, human error-led less effective measurement tools. I do not back to the flight deck. He can thus fool accidents re-occurred. It does seem that argue that all aircraft accidents are everybody with short term behaviour while archetypal human behaviour will re-assert caused by human error, but I do know on CRM training, but his underlying itself unless we are regularly reminded of that human error is often blamed when attitude to people is unchanged. how things should be! fatal incidents occur: e.g. a number of Measures and re-measures should give a Airbus incidents and the crash in South truer picture, certainly where his peers’ A tool like PEP could be included in the Korea in April. views of his behaviour are concerned. training and performance review of flight Direct objective feedback is likely to be crew members. But let’s not point the I cannot be sure that human error-led the start point for real behaviour change. finger of bad behaviour solely at flight incidents would cease totally if all airlines crews. Similar CRM-led issues are found carried out measures and re-measures on board warships and in civvy street - after CRM training, but I do know about for example, in the control units of the RAF’s experience, as I was involved in Table of communication nuclear power stations, where the the measurement programme. skills seen as important dangers of ‘I know what I’m doing because I’m always right’ could translate Old methods of measurement do need to to CRM, and measured into disaster. be phased out and replaced by modern by PEP. 360 degree measures. These show why 360 degree measures are simple people hold particular attitudes...and can 1: Communication style (open and honest or otherwise) objectively phrased questionnaires about help in changing those attitudes. Until this behaviour and communications that happens and until re-measures are more 2: Advocacy (willing to state a guarantee anonymity and can therefore widely taken up, CRM training will position or point of view) not lead to ‘comebacks’. The exception continue to disappoint. might be where an individual learns that a 3: Enquiry (happy to question in majority of the people he/she works with order to understand) are critical of him/her. But in that case the individual should then realise pretty 4: Critique (i.e., analyse one’s own - and the team’s - performance) quickly that positive change is paramount. Analysis of questionnaire 5: Assertiveness (willing to speak feedback can be carried out by an up, so that your point of view is airline’s own HR people who have been heard) trained to do this job, or by an authorised third party, or a combination of the two. 6: Synergy (able to ensure that the crew’s performance is better than that of any individual in it) Summary

7: Acknowledgement (able to What everybody on CRM training really confirm commands, questions needs is 360 degree measurement and and observations) re-measurement. This gives anonymous feedback from everybody the crew works 8: Crew co-ordination/observation with, from among themselves on the (i.e. ability to clarify tasks, roles and responsibilities) flight deck to ground support/ATC. Because the measurement includes

17 New Human Factors Requirements for JAR145 Approved Maintenance Organisations by Fiona Merritt, CAA Human Factors Specialist, Operating Standards Division

Many of you will be aware of accidents from both industry and regulators, The UK CAA has published a document, and incidents where ‘human factors’, from specifically formed for the express entitled “CAP 716: Aviation Maintenance a maintenance standpoint, have been purpose of looking at human factors in Human Factors (JAR145)” containing identified as having contributed to the maintenance. The group has published, more comprehensive guidance material in event. Some issues, such as poor on the JAA website (www.jaa.nl), a report support of human factors requirements, procedures or maintenance data, explaining the background to NPA12 and both existing and proposed, in JAR145. It engineers signing off tasks without having providing additional guidance material. is available from the CAA website seen or checked the work, information (www.caa.co.uk), in the publications misinterpreted at handover, etc. can be page. Also recently published is CAP715 described as ‘human factors’ since it is “An introduction to aircraft maintenance people who write the procedures, engineering human factors for JAR66” engineers who sign off work not seen, which is study material in support of human beings who become complacent, JAR66 module 9. or make assumptions, etc. In order to inform industry about NPA12, The UK CAA has invested time and and the rationale behind it, the UK CAA resources encouraging industry to adopt have recently run a ‘roadshow’ across the methods of minimising the risks UK, at 7 different venues and with over associated with human factors during the 400 attendees from UK JAR145 last few years. Whilst this has been companies, JAR147 training schools and successful in some areas the CAA The scope of issues addressed by NPA12 other organisations which expressed an consider that a change to requirements, include: interest. underpinned by organisations adopting ■ human factors best practice and publication of a safety and quality The aim of NPA12 is to create a level principles, will raise standards resulting in policy, signed by the Accountable playing field by requiring all JAR145 a reduction of maintenance errors. In any Manager organisations to adopt the good safety case recent amendments to ICAO Annex practices already implemented by more ■ 6 standard states that “the design and an internal occurrence reporting, conscientious companies. The application of the operator’s maintenance investigation and analysis system requirement proposals allow enough programme shall observe human factors flexibility to enable organisations to apply ■ principles” and “the training programme reporting of inaccurate and the changes as appropriate to the size established by the maintenance ambiguous maintenance data and nature of the company, and not to organisation shall include training in impose an excessive financial burden ■ knowledge and skills related to human reporting of poorly designed upon industry. performance”. Therefore in order to procedures and work instructions comply with ICAO Annex 6, there was a The CAA remains committed to the ■ need to have an appropriate national or shift and task handovers success of this requirement change and JAA requirement. considers the implementation of NPA12, ■ implications of fatigue on human can minimise the likelihood of Consequently there has been an initiative, performance maintenance error being cited as a factor driven by the JAA, to mandate good in aircraft incidents and accidents. ■ safety practice, with the emphasis upon planning of work to take account of human factors. human factors

■ Some of you will already be aware that error capturing mechanisms and there are new human factors duplicate inspections requirements round the corner, for ■ JAR145 organisations, in the form of signing off tasks not seen NPA12 to JAR145. These proposed ■ changes were drafted by the JAA human factors initial and continuation Maintenance Human Factors Working training Group (MHFWG), with representation

18 Frontline Defences? Safety on the Ramp by Colin Brown, CHC Scotia

However, as Ramp personnel related accidents have increased over the last 5 years the UK’s Health and Safety Executive (HSE) have advised their grave concerns to the industry. They have identified that Airport Ramp workers are more exposed to serious injuries than agricultural workers and equal to the mining industry for minor incidents.

Such concern has prompted their guidance document titled;

■ Aircraft Turnaround (Publication ID# - HSG209)

This guide is suitable for airport and aerodrome operators, airlines and service providers. It offers advice on control, co- operation and co-ordination of turnaround activities performed by through our obvious responsibilities, Formula-One motor racing pit stops are companies and contractors to reduce utilising our individual internal SMS and planned, rehearsed and monitored to staff risks. extract the best from a team performance hardware. However, the airport Ramp is a jigsaw of systems trying to function under for safety, accuracy and speed. The race As with many failings that can culminate extreme pressures for a common goal. can be won or lost purely on what into an accident, communication errors Mike Seller’s article “How safe is your transposes in a very brief period as are a key failing. Lack of, mistaken or destination airport” (FOCUS, Spring multiple operations take place in a failure to communicate in partnership with 2002), touched on a few of the issues that severely limited time frame. Is this other cross boundary services is a cause can affect ramp operations worldwide analogy comparable to that of frontline of concern if safety could be and pointed out the valuable direction of flight receipt and dispatch – Ramp compromised. operations? auditing. The problem with Ramp incidents is the diversity of possible error Through CRM & MRM teachings the situations/events resulting from overlap In a way yes, but the systems being benefits of education on the Human activities. Thus it is harder to ensure linked are more diverse and multiple. Factors affecting communication and realistic and practical controlling barriers Similar determined objectives can be other important tenets are recognised. are in place. observed by aircraft/airport operators as This level of knowledge though is not well as handling agents as they are widely available to other labour skills This is not a new awareness problem. forced to meet commercial/contractual found with access to the ramp area. Safe The UKFSC voiced concern about Airport and ATC deadlines. With a touch of driver working practices require specific staff Ramp operations early in 1994 and will do error thrown in for good measure on training, procedures and terms of so again this year, basing its 2002 Annual occasion. reference. However, considerable conflict Safety Seminar in September on Ramp and dissonance could result if an Safety issues. An industry axiom echoes that the Airport individual in charge of ramp function Ramp is the last area still to be procedures also had overriding Two relevant CAPs are available; addressed by many operatives with the constraints to perform goals on-time. same enthusiastic safety protocols ■ CAP 642 - Airside Safety utilised for core business Safety Since the horrific events of September Management Management System (SMS) activities. 11th 2001 higher pressures have been placed on all aspects of flight operations ■ CAP 700 - Aerodrome Safety In the UK civil aviation industry we have to ensure their operations maintain quality Management Operational Safety enviable safety and quality initiatives while being efficient, secure and Competencies

19 unintentionally by whether or not the braking School of educating company mechanism had failed, or if the wind Engineering staff in each others just proved too strong even with roles with active proven adequate, serviceable brakes. participation where As a result of that incident, Air Safety Management - possible. This approximately £6000 worth of aircraft an exciting new career included aircrew staging is now in several pieces and experiencing ground consequently scrapped. By chance development opportunity staff duties willingly only the staging came to rest before Introducing a brand new course designed for those rising in and allowed damaging anything else; it had the their careers in airlines, air traffic control, airports, aircraft and awareness and potential to hit at least two fixed wing systems manufacturing and related industries. appreciation to all. aircraft, which were parked nearby at MSc Air Safety Management is for those who have an interest the time. in or a significant level of responsibility for defining and The aim was to implementing the management of air safety in all areas of the ■ industry - not just operations, but also aircraft and equipment produce faster turn- Recently a ramp worker got lost in fog design and manufacture. This course has been initiated in arounds but did on an airfield. Finally suppressing response to the needs of both the industry and the regulatory produce beneficial embarrassment to use the vehicle authorities. The course is: side results and a radio and requesting assistance he • Businesslike - modules are taught by leaders in the industry teamwork respect. returned safely. Fortunately, nothing • Flexible - modules last three mid-week days • Practical - study at your own pace to fit your own schedule else was moving around at the time • Outward looking - with interest coming from many Personnel, and his manoeuvrings were extremely companies, there are excellent opportunities for networking Vehicular/Equipment, cautious. • Modules run in London and Dubai FOD, Manoeuvring and Jet Blast hazards ■ A helicopter crew mistakenly became For further information, please contact: The Courses Officer, are prolific and misled by the attending ground staff School of Engineering, City University, Northampton Square, London EC1V 0HB. Tel: +44 (0)20 7040 8112; amongst the most hand signals and lifted into the air. fax: +44 (0)20 7040 8101; e-mail: [email protected] common incidents (Physical miscommunication is a www.city.ac.uk/atm globally. They may be common error). Unfortunately the The University for business and the professions in danger of being cargo boot was still in the process of just accepted being loaded and a handler economically effective. The ramp now has exposures if experienced a very brief 2m lift into greater challenges to deal with because awareness is not constantly enforced and the air. of possible shortfalls in staffing numbers, failure to adopt safe practices controlled. ■ heightened security awareness, etc. Incident diversity is restricted only to the Rodents have stowed away in fresh imagination as the Ramp has a unsecured freight and chewed their Everyone including the general public is personality culture of its own. Careful way through navigation computer aware of the hazards of overcrowding the planning of appropriate ground hazard wiring, crippling two independent skies but are we not in danger of analysis and risk assessment methods is systems. In sunnier climes large overcrowding the aprons? required and these must be periodically lizards have strayed aboard and, re-evaluated. exploring new found territories, Do we or our contractors take it for discovered the cockpit, “and so the ■ granted that someone else has In November last year a large piece of tails go on.” responsibility for overseeing basic safety aircraft staging (used for tail work on concerns that are not actually even flight SAAB 340s) “took-off” with an Ramp incidents will continue to take place related? assisting 35knot wind gust along the without concerted efforts by all in the main taxi-way of a northern airport in industry. An adage circulates amongst us Embarrassingly other industries externally . The taxi-way was closed that states, “If it is on the ground it costs remote to aviation have tackled until the staging was cut up and had money”. This is now truer than ever but, it overlapping error management, though been removed from the area by the is not necessarily the safest anymore sometimes through experiencing a severe Airport Fire Service. The staging had either! cost first. One US airline did overcome been stored outside in the lea of a some ramp exposures perhaps large Hangar, following cessation of maintenance. It is still unclear

20 The Dangers of Tyre Failure

In our manuals, staff are warned against approaching hot aircraft wheels from the sides, in case they explode. Although they are fitted with fusible plugs which melt if they become too hot and allow the tyres to deflate, there is a risk that they could fail.

If a wheel did fail what could be the result?

I, for one, did not appreciate the potential danger until a recent incident occurred to one of our aircraft. Strangely enough, it was not an aircraft wheel which failed but one fitted to an apron drive jetty. Position of air jetty to aircraft when jetty wheel failed

The design of the jetty wheel was similar jetty to be driven to its parking position. At fuselage some 1.3m (4ft) above the to that of many aircraft wheels with the this point a loud bang was heard. The ground. tyre held between two halves of the wheel outer half of the split hub flew across the hub. The two halves of the split hub were ramp and struck the B737 aircraft just Only the ground engineer was near the bolted together with 12 bolts and the behind the nose undercarriage causing a aircraft at the time. He was checking the wheel hub was attached to the axle with a large hole in the fuselage. removal of the nose wheel steering pin. further 12 bolts. Fortunately he was located on the Why the wheel failed is still under opposite side of the aircraft. Had he been The pressure of the air in the tyre was investigation. The jetty had been in on the left hand side of the aircraft it is nominally 16 bar (235 psi) which is service less than three months. The probable that the hub would have hit him slightly higher than the pressure of most potential risk, particularly to staff, of such causing serious injury or even aircraft tyres. a failure is more fully appreciated when death. one realises that the split half of the hub, The jetty had been retracted from the which weighed 52kg (115lb), travelled Aircraft and air jetty wheels are not the aircraft following completion of boarding 17m (55ft) through the air without only ones utilising high pressure tyres. Be and the wheels were turned to allow the touching the ramp and struck the aware of the risks of any equipment fitted with them.

Split hub lying below the hole in the fuselage

21 Helicopter Ramp Incident

A helicopter was taxied from the At this stage the aircraft was taxied The aircraft was shut down, the maintenance area to a position outside forward and commenced a gentle right passengers disembarked and the terminal building where it was due to turn towards the taxiway. engineering support requested. embark its passengers. When the tower controller saw the On arrival in the hangar the crew were The crew were aware that whilst the helicopter for the first time he noticed that advised that the aircraft had collided with passengers were being loaded, a the baggage door seemed to be open the baggage truck and the baggage baggage vehicle approached the aircraft and advised the Commander of the loader. and later departed from the aircraft. The aircraft. The aircraft came to a halt and First Officer was given the manifest and the First Officer was dispatched to secure It transpired that the baggage loader was whilst he was checking it the passengers the door. On his return the aircraft still busy loading the aircraft and the were given the normal briefing. continued to taxi. The Tower controller baggage compartment door was open. received a telephone call from the The crew had missed the illuminated door With all the preparations completed the operator regarding the baggage that he light during their checks. When the Commander called for pre-taxi checks. At did not understand and so advised the Captain taxied forward and started his the time no ground personnel were in aircraft to return to the stand for turn he crushed the baggage loader sight. The checks were completed clarification. against the baggage truck, causing injury without either pilot noticing an illuminated to the baggage loader and damage to baggage bay warning light. Once on stand , another helicopter the frangible fairing on the aircraft. advised the Commander that there seemed to be some damage to the frangible fairing below the tail.

Ground Damage at Zurich

and the front steps the steps became imbedded in the wing remained in place and was stopped by the leading edge until the ‘head count’ spar. was completed and the paperwork The aircraft was grounded for two weeks handed off. while the repairs were carried out with the handling agents accepting full The front steps were responsibility for the ‘downtime’ and for then removed, first by the cost of a replacement aircraft during reversing from the this time. aircraft and then by driving away from the In the final report there were no real aircraft to drive extenuating circumstances given either by around the port wing. the driver or by the airport authorities as The parking area is to what caused the incident other than The aircraft was parked on one of the quite tight. There is a manoeuvring area perhaps inattention by the driver. There remote stands and was being prepared for vehicles which forms the boundary of was a lot of rebuilding going on at the for a night departure to Turin. The crew the parking area for aircraft and time. The stands had aircraft positioning had operated an earlier flight and designates the parking area for vehicles. past them on both sides, but were fairly remained on board during the turnaround. The stairs had not been fully retracted well lit and had been in use for some when they were pulled from the aircraft considerable time. A local curfew was in The passengers were bussed out to the and the driver turned too early when place but was not a factor in this incident. stand and were boarded from the front turning onto the parking area and drove and rear steps. When boarding was the steps into the port wing, about two completed the rear steps were removed feet in from the wing tip. The vehicle was not being driven quickly but the left rail of

22 Implementation of HSE’s Aircraft Turnround Guidance Note HSG209 at Heathrow

The Health and Safety Executive’s Aircraft involvement of the whole airport or Interestingly it can be argued that the Turnround Guidance Note HSG209 first aerodrome community. A simple but very introduction of the EU Directive for published in 2000 came straight to the important message inherent to the new Ground Handling at Heathrow created the point in its introduction by stating document is that success can only be need for a changed environment where ‘currently, accident rates in the industry delivered by all parties working together. airport users took on responsibility are well above the national average for all through collaborative decision making for industries, and for ground handling and Control of contractors has become more of shaping how the market would be airport workers, accident rates exceed an issue over the years. Services at one structured and managed. Initially HAL even those of the construction industry time provided in house by airlines have saw the introduction of an open market and the agricultural sector’. been divested and are now carried out by as contrary to maintaining a safe and separate companies. The HSE document efficient airside working environment. For These are strong words for an industry states that legal safety responsibilities an airport that already had 8 ground that can rightly pride itself on an aviation cannot be delegated and that it is not handlers it was difficult to see that there safety culture which has delivered possible to merely rely on standard would be any benefits from having more, unparalleled safety performance in the clauses requiring contractors to comply as more handlers almost inevitably meant skies but why has this not been translated with relevant health and safety legislation. more equipment and congestion. onto the ramp? To outsiders it may seem While companies are responsible for a strange anomaly but those within the checking their prospective contractors’ Further to HAL’s request for a restriction, a industry will be able to recognise that in arrangements for health and safety, they ruling by the CAA in December 1998 in the past a task culture was nurtured that should also co-ordinate and control the favour of an open market thrust all the focused on getting the job done rather work they carry out on the company’s parties involved into forming the Airport than how it was done. behalf and monitor their performance. Users Committee (the body described in One of the key recommendations is that the legislation) and putting in place all the The HSE document raises many companies should appoint a supervisor to measures necessary to support the important issues. It focuses on the control the turnround, who could be a implementation of the new legislation from responsibilities of the airport operator, the member of the airline or handling agent April 1999. The work was undertaken by airline or aircraft operator and the service staff. This supervisor should have the AUC Licensing Sub Group which has providers as individuals and also acting sufficient authority to control the activities since become a model for developing collectively. Under existing Health and around the aircraft and should work to an proposals that have wider community Safety Legislation, all companies have agreed turnround plan. benefits. It was this sub group that was responsibility to protect the health and safety of their employees and to protect them from risks created by the activities of other airport users. If others are likely to be affected by a company’s activities, the HSE define three guidelines that companies should follow:-

1. Co-operate and co-ordinate with other employers

2. Control your contractors

3. Assess and control the risks to other people from your activities and inform them of any risks still left

Under the first point the HSE recognises that the airport or aerodrome operator is best placed to develop co-operation and co-ordination on an airport wide basis, but can only do so with the active

23 reconvened in October 2001 at the should be considered at each stage sub processes: off load, core request of the AUC to examine the HSE together with checklists. The plan can be servicing, on load and departure. document and identify if a Heathrow represented as four key sub processes as framework could be developed. shown at Figure 1. d) Make Ready for Next Turnround Membership of the AUC Licensing Sub Process Group was comprised of 5 nominated a) Resource Planning Process This final sub process importantly airlines, 5 airlines who were also handlers This sub process requires companies describes the activities which should and 5 independent handlers. A series of to have all necessary risk be undertaken after the aircraft has weekly meetings was established to move assessments, trained staff, equipment left the stand to ensure everything is the task forward rapidly with HSE invited and resources in place together with a in place for the next turnround. to attend. Their presence proved very co-ordinated turnround plan for any beneficial and maintained a focus on particular aircraft movement. It also The second part of the Aircraft Turnround avoiding the risk of injury to people which identifies the need for a Turnround Co- Plan () contains is now a consistent theme in the Heathrow ordinator (TCO), and the need to appendices which have been collated as document. It is probably significant that analyse performance against the examples of current good practice, to before this work, safety data on aircraft turnround plan and review if assist airlines and service providers in the damage incidents and vehicle incidents necessary, communicating any development of their own more was widely monitored and while significant changes to all parties. comprehensive Turnround Plans. improvements have been achieved over the last year (a reduction of 16% and 20% b) Preparation and Arrival Process The AUC has now approved the final draft respectively), there was not the same The preparation sub process contains of the document and the licensing sub focus on personal injuries. That is not to all the checks that are necessary prior group has been stood down. The say that companies were not monitoring to the arrival of the aircraft, while the document will now be issued under a and reporting personal injuries as required arrival sub process describes the General Notice and will effectively by legislation, but as a community we ground procedures for the safe arrival embody relevant safety requirements into found it difficult to share the data and use of the aircraft onto stand. the licence documentation. it to target improvement. c) Turnround Servicing Process The success of the new document has The document developed was titled ‘The The turnround servicing sub process yet to be proved although it should result Aircraft Turnround Plan (Heathrow Airport)’ involves all the core activities in decreasing personal injuries and and describes the activities involved in the undertaken while the aircraft is on aircraft and vehicle incidents. The generic aircraft turnround process which stand and is further divided into four document is an important starting point but will be reviewed and improved as felt necessary. What is clear is that through the airside community involvement a wide range of expertise from various companies has been brought together to create a simple document that will provide a common framework for companies working airside at Heathrow.

Changing Safety Culture

While the Aircraft Turnround Plan (Heathrow Airport) has been produced to provide a generic template for specific aircraft turnround plans, another important initiative has been running alongside, based initially on work undertaken by Dupont Safety Specialists. Previous experience has shown that it has proved difficult to sustain safety Figure 1

24 which sought to identify how we as an injuries. While everyone accepts there is airport community could lead a change much to do, there is a community programme. Dupont found that 95% of approach being developed with common injuries and incidents were caused by strategies for sharing data and ‘unsafe acts’ as opposed to ‘unsafe improvement. It clearly will take time to conditions’ which focused attention change a task culture particularly one that strongly onto behaviour and developing a has been built over many years but there safety culture where people identify and is a growing commitment to wanting to eliminate ‘unsafe acts’. Their studies also act as part of an airport community to found that there was a strong make a sustainable safety culture change Figure 2 commitment towards aircraft and that will be for everyone’s benefit. improvement and while various passenger safety, while staff, vehicle and campaigns have had some impact, the infrastructure came significantly lower as Copies of the Aircraft Turnround Plan benefits tended to dissipate fairly quickly. shown in the Safety Curve at Figure 2. (Heathrow Airport) are available from It was recognised that to make a George Cook, General Manager Airside, significant change in safety performance Behavioural auditing training has Heathrow Airport Ltd it would require a step change in the commenced so that line managers can safety culture which affected everyone’s interact with the front line teams to Tel: 020-8745 5252 behaviour. As a result Dupont Safety support good safety performance but [email protected] Specialists were commissioned to carry also to address areas where further out a ‘peg in the ground’ safety study with improvement must be made. eight significant ramp operators. A Safety Leadership Group has been Separate individual company reports were formed and membership expanded, produced but also a communal report sharing a vision of zero incidents and Air Transport Avionics Ltd AVIONIC REPAIR OVERHAUL SUPPLY AND EXCHANGE TCAS EQUIPMENT SUPPLIED AND INSTALLED, F.D.R. AND C.V.R. REPLAYS 8.33 KHz AND FM IMMUNITY MODIFICATIONS FOR ARINC AND GA AIRCRAFT FROM COMPS TO CALIBRATION, OUR LARGE CAPABILITY LIST IS AVAILABLE ON LINE WWW.AIRTRANSPORT.CO.UK

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25 Ramping-up Safety by Dr Simon Bennett FICDDS

Ramp safety is of importance to all those obvious problem is a passenger, possibly a between the ramp, cabin, flight deck and involved in commercial air operations — if poorly or non-supervised infant, running gate. This generates a resident pathogen - only because the economic and public across the ramp and sticking her arm into the non-supervision of passengers relations fallout of a mishap involving a revolving compressor blade (the 737’s between the gate and the aircraft. This passengers transiting the ramp could CFM-56 is a low-slung engine that almost scenario creates numerous affordances for easily cripple the airline involved, its ramp invites the curious and naive to crawl mishap (as in the wayward child-and- service provider and the airport authority. inside). As we all know children are engine fan accident). It also gifts a ‘window This article will look at safety issues unpredictable, supervising adults are not of opportunity’ to any passenger with pertaining to passenger embarkation and always attentive (especially when tired, wet, malicious intent, enabling her/him to either disembarkation using stairs (either carried cold, disorientated and/or intoxicated) and ruin an airline’s reputation (and make some or provided by ground handlers). compressor fans freewheel in the wind. tabloid money along the way) or sabotage an aircraft. (It is certain that Al-Qaeda is The rise of the ‘low cost’ carrier has meant Having worked as a safety consultant to an considering other modes of attack. This a greater focus on turnaround time. The airline for two years I can attest to both the year’s low-intensity civil war in Israel and low cost business model requires that unpredictability of children and their the West Bank has magnified tension and aircraft spend as little time as possible on (nominal) guardians. I have witnessed loathing and the US/UK campaign in the terra firma. An airframe’s profitability is numerous near misses. On occasion, when Afghan mountains has not been as partly a function of its utilisation level managing the ramp on turnaround, I have successful as we have been led to believe). (although numerous other factors act on found myself monitoring then the bottom line). The embarkation of apprehending wayward children. Finding passengers across the ramp to, say, a 737 the supervising adult is not always easy. Designer error has a number of advantages. First, it obviates the use of a (potentially) more Of course, airport designers use such At one UK airport passengers are funnelled costly air bridge. Secondly, passengers devices as barriers and markings to impose from a gate into a roadway. They have to can be embarked via L1 and L2 a measure of discipline on the ramp. At negotiate the roadway, often without simultaneously. Thirdly, carriers practised in Stansted, for example, all ramps are marked supervision, to get to the aircraft. While the this method are free to choose secondary to mandated standards, with the usual roadway is marked with the usual solid and or tertiary airports where air bridges are not green and white lines indicating passenger zig-zag white lines, it is debatable whether provided. Fourthly, because of their ways, the red and white lines indicating the all passengers understand their meaning. It technical complexity air bridges are prone ramp equipment park (REP) and the double is also questionable whether road safety is to failure. In this context a carrier that whites indicating the aircraft manoeuvring uppermost in passengers’ minds (after all, becomes reliant on air bridging may area (prohibited to all except those workers this is an airport, not a High Street). At encounter operational problems. (Of directly involved in push-back, start-up and night and in bad weather being seen and course a 737’s integral air stairs can also release). Of course the obvious problem is being safe on the apron would, in most jam, although redeploying the ground that while such markings mean – or should passengers’ ‘hierarchy of needs’, come a stairs from L2 to L1 is always an option). mean – something to ramp workers, they poor second to reaching the light and As a consequence of such factors ramp carry no meaning for passengers. Hence warmth of the aircraft cabin. Here we have loading is attractive to low cost operators. the need for the supervision of passengers a resident pathogen par excellence — an on the ramp. opportunity for accident rooted in bad design. It is certain that children will have Resident pathogens This creates potential problems: no understanding of the dangers inherent The low cost business model requires that in such situations. If it is feasible for a child The ramp is an example of what overheads be minimised. To pare down to run out into a roadway and into the path technologists call an ‘open system’. In an costs aircraft are usually operated with the of a service vehicle then, one day, this will open system people, technologies and the legal minimum number of cabin crew. In happen. It is only a matter of time. Besides natural environment may interact in the case of a 148-seat 737 this means the immediate tragedy of a child being unpredictable and potentially unsafe ways. three. Ideally, one cabin crewmember killed or injured the subsequent economic These potentially dangerous interactions should, in concert with the dispatcher, and public relations fallout would be constitute ‘resident pathogens’ or supervise the ramp. In practice, due to on- devastating. ‘problems waiting to happen’ (see board duties at turnaround, this is not Reason’s book Human Error for a fuller always done. (Some carriers aim for and There are other, perhaps more obvious explanation. Details below). The most achieve 25-minute turnarounds). For their resident pathogens, like service vehicles part dispatchers, of necessity, have to work parked on the left hand side (or PAX side)

26 of the aircraft. Sometimes these vehicles, stands to reason that the more costs (third party operators keep costs whether belonging to engineering or passengers the airlines transport the down by servicing more than one cleaning companies, are left unattended greater is the potential for mishap — carrier) it would obviate the problems with engines running. There is an obvious especially when many of these inherent in divided responsibilities. risk in asking passengers to negotiate passengers will travel by low cost carrier Safety is indivisible. Through creating a these vehicles to embark or disembark the from secondary or tertiary airports where disjuncture in supervision any formal aircraft (from either L1 or L2). During my ramp loading is the norm. Kueter (2002) division of responsibilities by definition ramp work I have witnessed stairs observes: ‘The international air transport threatens safety. A unified, multi- abandoned across bay markings market is characterised by a tendency function structure would ensure that (presenting another obstacle to toward continuous growth. Estimates both air and ground operations were passengers), bags of waste left on the predict growth of 100 to 150 percent in driven by the same safety culture. The ramp just waiting to be kicked open by passenger volume within the next 15 same standards would be applied in passengers and chocks not returned to years’. Possible measures to improve both spheres. As everything would be the REP. The obvious solution to poor safety range from spontaneous done in-house error-reporting and performance is for the airline to choose organisational change to regulation: problem-solving would (in theory) be another agent. This is not always expedited. (Although there is no straightforward, however. 1. Given that ‘seamlessness’ is one of the guarantee that the resulting inclusive, keys to safe operation the ideal would multi-tasking ‘umbrella’ structure would First, the airport may only have one ramp be for the airline to ground handle its be more effective than the fragmented service provider. If there are two there is own aircraft. While this would increase structure it replaced.) always the possibility that personnel will migrate from the less favoured to the more favoured company. While this migration is vital if the more favoured company is to meet the increased demand for its services the down side is that the staff who migrate may bring with them the bad habits (evidenced in and reproduced through a poor safety culture) they picked up with their previous employer. The preferred ramp service provider could recruit staff from other airports and/or industries. But this may be prohibitively expensive. It might also be a logistical impossibility, given that many of the regions served by airports are booming, house prices in those regions are Experience rocketing and other, more attractive and With nearly thirty years experience, we can easily better-paid jobs are beckoning (ramp work claim to be one of Europe’s leading providers of is physically hard, especially in winter). In aircraft services. conclusion while the co-existence of two companies offers a choice in theory, in practice an over-preference for one company will, in time, nullify that choice. Air Contractors The less preferred company will go under. The Plaza, New Street Swords, Co. Ireland A manifesto for change Tel +353 1 812 1900 Fax +353 1 812 1919 While the ramp safety record of most [email protected] airports is good the situation could be improved. The need for improvement is www.aircontractors.com driven by the growth in airline traffic. It

27 2. If option 1 is rejected there is a measured not in terms of how safely (i.e. waterproof clothing. Secondly, ramp fallback: a member of the airline’s staff slowly and carefully) workers drove service service providers must respond to carriers’ must be on the ramp exercising the vehicles, but how fast they could drive feedback (as well as feedback from the airline’s authority during embarkation them without skidding and/or colliding with airport authority). If this ‘softly softly’ and disembarkation. This ensures that parked aircraft or ramp furniture. This pilot approach fails to produce results the the airline’s safety culture permeates had observed a truck driven so fast that responsible authorities should consider both air and ground operations. when the brakes were applied ten yards tighter regulation of the interface between Continuity of oversight is the key to from a parked aircraft the vehicle skidded the airlines and their handling agents. I am safe ground handling. for three yards! I have observed a handling sure we can all agree that public safety is agent reverse a car at speed across our number one priority. 3. If option 2 is considered too ambitious several ramps. There is no way that the there is a final fallback: airlines should driver could have seen exactly where he provide feedback to and be prepared was going. The car was packed with his Sources to deploy sanctions against wayward colleagues. The fact that they saw me ground handling companies. The (dressed in regulation clothing with airline Chong, D.R. (2001) ‘Dealing with handling company should be made logos on display) making a note of their Psychological Stress’, Air Line Pilot, aware of what is not acceptable (like number plate made no difference October, p. 28. parking vehicles on the left hand side whatsoever to their conduct. But it did or leaving stairs on the ramp). Airlines change their demeanour. They smiled. Jones, T. (2002) ‘Audits, Inspections and might consider punitive financial Surveys’, Aviation Security International, sanctions against transgressors. (This Having said this I am aware that ramp April, pp. 32-34. management technique will only work if service providers perform their duties employed sparingly. If over-used the within a context fashioned in part by the Kueter, J. (2002) ‘Optimising Airport ramp service provider may go under, airlines. The airlines, in turn, respond to Business’, Airport Safety and Security creating a short-term operational market demands. As Chong (2001) has Management, Volume 3, February, pp. 14- problem and longer-term diminution of put it: ‘[T]he ever-increasing number of 15. competition and choice.) passengers boarding our airplanes are expecting ... better performance, value and Reason, J. (1990) Human Error, At the end of the day no solution is service ...’. If low cost carriers demand Cambridge: Cambridge University Press, perfect. The problem with using cabin staff quick turnarounds ramp service providers pp. 197-199. to supervise the ramp is that it leaves just respond. No company would risk losing its two cabin crewmembers to complete contract to the opposition by ignoring its About the Author turnaround duties. Given this logistical client’s requirements. So the drive to Dr Bennett directs the MSc in Risk, Crisis hurdle it is likely that some — perhaps a improve ramp safety has two elements. and Disaster Management at the Scarman majority — of airlines would carry on as First, carriers must re-emphasise the Centre, University of Leicester, England. His before. This raises the question of whether primacy of safe operation. This should be latest book Human Error — by Design? is regulators should require airlines to an ongoing activity, secured through available from Perpetuity Press at manage the ramp. A statutory duty on periodic safety audits and debriefings with [email protected] airlines would (theoretically) raise ramp service providers. Without feedback standards and ensure a level playing field to subjects audits are useless. As Jones between carriers. My inclination would be (2002) puts it: ‘[L]ike all reports, carrying to choose persuasion over compulsion. out an inspection can be the easy part of Operators should be appraised of the the process; the question remains as to likely consequences — in terms of death, what to do with the information gleaned’. injury, financial loss and bad press — of a All carriers should commit one cabin mishap on the ramp. crewmember to the ramp. All crewmembers should be trained in ramp Having said this I am under no illusion as management (it is much more common to the magnitude of the problem. Ramp sense than rocket science) and should be indiscipline is a major topic of conversation given the requisite assertiveness training amongst cabin and flight crew. One pilot (the ramp can be a pretty macho working remarked that amongst some ground environment!). They should also be handlers ‘competence’ seemed to be provided with appropriate warm and

28 Just Another Ramp Incident

that had previously been on stand had undergone minor corrective maintenance using the steps for access. The removed part had been bagged up and placed on the top of the steps – no doubt intending to return the offending article to stores once the aircraft had been dispatched (Error 1). The steps had been moved forward away from the aircraft, but were left on the active stand area (Error 2) in front of the extending arms of the ground power with the brakes off (Error 3). The aircraft was then instructed to carry out a long push to allow our aircraft onto the stand. Our dispatcher arrived at the stand in a hurry having had a long way to travel, saw the offending steps parked in front of the extending arms of the ground power unit but infringing the protected zone. The dispatcher decided that the steps were parked too far away to be a hazard and left the stand guidance illuminated (Error 4). The crew did not Some of the most costly types of is mounted very high, and to the right of notice the steps parked on stand (Error 5) incidents that still affect airlines today are the crew, on the terminal structure which as they were roughly the same height as those on the Ramp. Although, usually, of creates a significant split of the Captain’s the ground power system and painted a relatively low order in terms of individual attention, especially as the aircraft nears almost exactly the same colour! cost, they occur frequently enough that the final parking position. the annual bill can still be very significant. As the aircraft approached the correct What do I mean? Lets look at a recent The crew concerned both ensured, to the parking position, the airflow through the incident that affected one major UK best of their ability, that the stand was right engine was sufficient to suck the scheduled carrier in the last couple of clear and that the guidance system was unbraked steps towards the intake. years. switched on. Accordingly, they proceeded slowly onto stand. Just before Unfortunately, suction was also strong enough to cause the engine to ingest the Imagine a major UK airport on a pleasant the aircraft reached the correct STOP small packaged aircraft part that had day with a 737 crew manoeuvring onto a position, the crew were signalled to stop been left on top of the steps with the recently vacated stand. The stand by an agitated member of the loading inevitable damage to the engine. concerned is wide enough for one 747 or crew who were awaiting the aircraft’s two 737s, but the jetty is only usable for arrival. The Captain stopped the aircraft The moral of the story? the left-hand stand when two 737s are and shutdown the engines on the Adherence to correct procedures and parked. The correctly parked ground instructions of the ground personnel. meticulous attention to removing stand power supply, painted yellow, is fixed and obstructions - even if you are in a rush. mounted on an extending cradle on Upon initial investigation, it transpired that wheels to the front right of the the right-hand engine intake had approaching 737. The crew are trained to contacted a small pair of engineering ensure that the stand is clear of access steps. Needless to say, a full obstructions before entering the stand. investigation was launched and, The crew have been allocated the right inevitably, there was more to the incident hand of the two parking slots and the than met the eye. I don’t wish to bore standard STOP line is in use and marked you, the reader, with the full details so I on the concrete to the left of the stand will confine myself to the important bits. centreline. Unfortunately, the stand geometry dictates that the AGNIS display The error chain began before the crew even approached the stand. The aircraft

29 Thoughts on Ramp Safety by Wing Commander Dave McCormick SO1 Engineering Policy Defence Aviation Safety Centre

Aircraft operating ramps are home to How safe are your people? many aviation safety hazards. The Do you have a system in place to mixture of aircraft, refuellers, hot engine ensure that your people are competent exhausts, ground equipment, vans, for the processes you expect them to people and a variety of noises is complete? Do your people have a potentially lethal. But, are ramps safe? I positive attitude to safety? Do you can hear the ramp managers now have enough people for the tasks explaining that, considering the number of you intend to complete? Are all the aircraft movements on our ramps, there people on the ramp really necessary? are few reported accidents. Unfortunately, that is not convincing for 2 reasons. How safe are your processes? Are all your processes Saying “we have few accidents” is not the validated and documented? same as saying “we are safe”. For For complex processes, example, flying hour for flying hour, would do you have quick an organisation that had 3 different reference checklists aircraft accidents be less safe than one that are suitable that had 2 identical and preventable for use on the accidents? I think not! Current safety ramp? Do your experts agree that being safe implies safety critical looking at all the hazards, carrying out processes rely risk assessments and mitigating all the on perfect risks until they are as low as reasonably performance by practical and tolerable. Also, reported individual staff accidents are a function of 2 variables: members? Do your how many accidents occurred and the safety critical processes proportion of accidents reported. define required levels of If there is a poor reporting culture, the supervision and independent number of reported accidents may be checks? Do you have a quick irrelevant to the safety level. and simple system for validating process change If the number of reported accidents does proposals and altering your not tell you how safe your ramp is, what documents and training where does? To measure safety you need to appropriate? look at the following 4 things: Does your organisation use risk How safe is your equipment? management principles in your Has a competent individual decided that work on the ramp? your equipment is designed to meet the Are you continually looking for task for which it is used? Do you have an hazards, particularly during adequate and responsive equipment unusual events? When you maintenance regime? Do you have identify a hazard, do you assess enough equipment for the tasks you intend the likelihood and consequences to complete? Is there a management of realising those hazards? Do system in place to maintain adequate you mitigate the risks to achieve availability of the equipment? Is all the a tolerable level that is as low as equipment on the ramp really necessary? reasonably practicable? Every

30 time something goes wrong, do you investigate why it went wrong and implement a solution intended to prevent recurrence?

These are basic elements of a safety management system. How often do you carry out an independent audit of your systems to ensure that they are working as intended?

How does all this theory apply on the avoid ramp? Well, consider aircraft refuelling. “shooting the Are the only personnel aware of the messenger”; that will hazards the recent arrivals? The routine ensure that they do not find nature of aircraft refuelling inevitably out about future near misses! increases the likelihood of complacency. I am not an advocate of the Might there be an element of “blame free” working complacency amongst some of your environment. Where an employee more experienced refuelling staff? When does something was the last time they were reminded of the hazards? How often do supervisors or safety staffs watch aircraft refuelling to malicious or knowingly takes an ensure that procedures are being unjustifiable risk, discipline is appropriate I will finish with some questions for you to followed? What about aircraft loading? and most employees would agree. contemplate! What about cabin cleaning? What about However, I commend management aircraft de-icing? What about aircraft encouraging an open reporting culture ■ Is your ramp a safe one? despatch teams? All these areas deserve and being seen to produce practical and regular scrutiny. After scrutiny do you effective recurrence prevention strategies. ■ How do you know? have a team debrief where your findings and observations are openly discussed? A particularly difficult issue to deal with is ■ Is safety the fortunate result of professional effort? People will always make errors; it is an the “can do” attitude amongst ramp staff. inevitable consequence of being human! Despite any problems, ramp staff will ■ Or is it the planned result of active If you can understand why people make always attempt to get the aircraft away on management? those simple mistakes, you can design time. your systems to be more tolerant of error. ■ Can you justify everything that Safety is all about how error tolerant your Unfortunately, in these circumstances, happens on your ramp? systems are! they will often focus only on meeting the time slot. This focus can lead to ■ Is an ounce of effort worth a ton of The problem for any organisation is unintentional risk taking. When things are theory? preventing the next accident, rather than not going well or are rushed, that is the the simpler task of dealing with the last time for a supervisor to be standing back one! Until everyone reports all the near and taking the overview. He must try not misses and these are dealt with actively, to get involved in the detail but only to they will continue to occur. Eventually step in when safety is compromised. You they may cause an accident rather than might say he is your goalkeeper and he is another near miss. Thus, if managers trying to prevent an own goal! want to make the ramp safer, they must

31 UK FLIGHT SAFETY COMMITTEE

Annual Seminar 2002

3rd/4th September 2002 The Radisson Edwardian Hotel Heathrow Seminar Objective The 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. Programme 3rd 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 1155-1215 Health & Safety on the Ramp Christine Barringer - HSE Session Chairman - Capt.Steve Solomon, MyTravel 1215-1245 Discussion

0900-0910 Opening Remarks 1245-1400 Lunch John Dunne - Chairman UKFSC

1400-1430 Where is Best Practice 0910-0940 Keynote Speech - UK or Abroad? Ken Smart - AAIB Richard Heard - Intl. Airport Ltd 0940-1010 Regulators View Mike Overall - Aviation Consultant 1430-1500 Damage Assessment & Stan Brown - CAA Claim Recovery from an Airline’s Perspective 1010-1040 How We Do It Ivar Busk - SAS Charlie Clifton - Ryanair 1500-1530 Airport Design Influence 1040-1100 Refreshment Break on the Problem Mark Oliver - Jacob Gibb Ltd 1100-1130 Case Studies in Damage Paul Clark/Peter Cooper - Airclaims 1530-1550 Discussion

1130-1155 Ground Handlers’ Dilemma 1550-1600 Closing Remarks Bob Newman - Menzies Aviation Group 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 Form Please 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 INFORMATION Seminar 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 not include 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 (please note 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. WHATSWHATS YOURYOUR DAMAGEDAMAGE THISTHIS MONTH?MONTH?

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