GainJet Aviation Flight Safety Magazine ISSUE 004 Table of Contents Front Cover: GainJet’s Boeing 737, SX-VIP, prior to pushback at Athens International Airport. Editorial . Page 03 Extra Vigilance . .Page 04 Flying On the Ground? . Page 04 Bi-annual Safety Officer’s Review Jan-Jun 2012 . Page 05 Expect the Unexpected . Page 06 Danger Can be On the Ground . .Page 07 The Numbers . Page 09 A Significant Safety Issue – Vortices . Page 09 Extra Care is Extra Important . .Page 10 Ground Accident Prevention . Page 12 Runway Incursions . Page 13 Why Use a Paper Loadsheet? . .Page 17 Case Study – Linate Airport Disaster . .Page 19 Case Study – On Ground Collision Between Two Aircraft . .Page 21 Editorial Welcome to the 4th issue of , GainJet Aviation’s bi-annual flight safety magazine. There are so many factors behind a safe flight operation… almost too many! Flight crew, cabin crew, ground operations, engineers, and so on, all have to fully familiarize themselves with tons of material and procedures in order to know what to do, how to do it, and when. Knowing and following such procedures can make the difference during a flight operation. So I wouldn’t be surprised if it’s a little overwhelming. This is one of the main driving forces behind magazine, which focuses on flight safety issues throughout the industry as an enlightening refresher tool and reminder of such safety issues and precautions. So I urge you to read every article, consider the notions that the writers bring forward and be enlightened. This edition primarily focuses on safety issues present on ground. A non-aviation professional would be taken aback by how many hazards are actually present on ground. However, as aviators, you know different. It is the responsibility of all ground personnel, ATC personnel, flight crew, engineers, cabin crew etc. to ensure that all safety precautions are taken on the ground, as well as in the air. Simply put, one must be constantly alert and follow procedures from the moment he/she signs on for duty till the moment he/she signs off duty. The two case studies in this edition focus on accidents that took place on the ground. Both case studies show how the hectic environment on ground at an airport with high traffic volume increases the chances of an incident or accident. Add the pressure of commercial factors, and things can get very hectic, increasing those chances. Then with adverse weather conditions the situation gets even more complicated. Plus with so many players involved in the flight operation on ground, and during take-off or landing, it is far too easy for one mistake to lead to disastrous results. A lack of following the Standard Operating Procedures (SOPs) was one of the major factors that contributed to both accidents. It is important to recognize that SOPs have been put in place in order to ensure the safest operation and to avoid incidents/accidents. So follow them always. The articles and case studies in this issue have been chosen with great care in order to bring to light safety issues that can lead to incidents or accidents. The case studies included give us the opportunity to learn from the mistakes of others – which is a precious gift. So I urge you to consider all safety issues and precautions brought forward and to apply them to your duties accordingly. A special thanks to all those who participated in this issue: Fly Safe! Capt. Ramsey Shaban, Capt. James McBride, Capt. Vangelis Lykoudis, Andrew Hallak Mr. Kostas Karalis, Mr. Bill Zois, Ms. Olga Beglopoulou, Mr. Imran Saleem, Capt. Dimitris Kehayas, Capt. Konstantinos Molyndris. Editor, 3 Extra Vigilance Corporate aviation, unlike scheduled airlines, often did not help! This was in the days before no-blame entails having to fly at short notice into airports the culture had been invented). crew have not flown into before. These, at times, can produce challenging ground operations, which brings I learnt a valuable lesson from that unfortunate to mind an incident I had many years ago while parked incident. Whenever fuel or service trucks are on the ramp at a remote airport. The water service approaching to service our plane, I made sure one of truck started backing towards the aircraft, however the crew was quickly outside to supervise this service. with no ground marshaller or person to supervise/ direct this movement. Sure enough, the next thing Ground Operations and incidents is the theme of this we felt was an unpleasant jolt! We, the two crew edition. Having a crew member supervise ground ops members, jumped out of the plane, but unfortunately is not a standard procedure, however being extra we were too late. The damage was done and the vigilant to the movement of such vehicles in the plane was grounded for a week. (The truck driver who proximity of their corporate planes would certainly be caused damage to our aircraft was put in jail, but that good practice. By Captain Ramsey Shaban President GainJet Aviation S.A Flying On the Ground? There is a misconception that the only danger with possible always follow Standard Operating Procedures. flying is in the air - this is not true. If you research It could be as simple as ensuring that you put the ground accidents and incidents in the aviation yellow strap across an open door of the B737 or B757 environment, you will see that people are very much when it is not in use and there are no steps outside. at risk before and after aeroplanes get airborne. This could save the life of a fellow crewmember as these straps are designed to be very strong. When There have been many cases where ground handling moving to and from the aircraft in strange locations, personnel have been injured or killed by getting always use High-Vis yellow waistcoats and keep your too close to operating engines, both propeller and eyes and ears open. Never leave your own baggage jet. Falling from aircraft doors onto the concrete unattended and keep thinking about your colleagues’ ramp below is an occurrence which happens all too bags too. If steps are fitted to the aircraft ensure that regularly, while at the same time you must consider the fence/gate across the side of the platform is in the frequent incidents regarding ground equipment. place before you let passengers use them. These might Two pilots were struck by a baggage truck at night seem simple things, but we must keep our awareness on the ramp while not wearing high-visibility jackets. level high to keep ourselves, our fellow crewmembers Note that this occurred at an International Airport to and our passengers safe. regular scheduled airline crew. If you think a dangerous situation is developing, In our case, as an adhoc charter operator, EVERYTIME please stop it before an accident occurs – inform we go to work, is an irregular operation and therefore the Senior Crewmember present and bring it to ALL THE TIME we should expect the unexpected. their attention. If you break the dangerous chain of Always look out for yourself and your colleagues events, quite probably you will prevent an accident. while moving and working on the ground and where Work Safe! By Captain James McBride CEO and Accountable Manager GainJet Aviation S.A 4 Bi-annual Safety Officer’s Review Jan-Jun 2012 Achieving The Target crew. Sure, there may be moments of stress or bad Machines and human factors: Two variables that are mood, but professionals are able to overcome these directly connected with aviation. when duty calls. Professionals fulfill certain duties and procedures for which they are well trained. This is the Over the past decades, major technological reason GainJet chooses a certain caliber of crew and advancements have been made, which has thus engineers. raised flight safety to high levels. Advanced training models and methods have been established, so flight GainJet’s accountable personnel, studying past safety crews are able to cope with challenging situations like indicators, introducing a safety planning system and adverse weather. having adopted in its policy highly efficient training and continuous monitoring, have succeeded in Machines: Are they unpredictable? Yes, in a way they reducing incidents concerning human deficiencies. are. For example, a tiny piece of trash, some dust, or extra moisture, may all cause some problems. So As you can see from the below charts, human we have to constantly monitor, observe and examine related incidents have decreased, as GainJet focuses our equipment to ensure nothing has affected its training on making sure all crew and engineers performance. know, understand, and follow Standard Operating Procedures (SOPs). Humans: Are they unpredictable? No – not when we deal with professionals, like those expected of GainJet Please always remember that safety is our top priority. 2012 2011 MONTH TYPE OF INCIDENT MONTH TYPE OF INCIDENT Jan HUMAN MAY TECHNICAL Jan WEATHER MAY HUMAN Jan HUMAN MAY HUMAN Jan TECHNICAL November HUMAN May TECHNICAL December HUMAN December HUMAN December TECHNICAL 6 5 4 HUMAN TECHNICAL 3 OTHER 2 1 0 2011 2012 By Captain Vangelis Lykoudis Flight Safety Officer 5 Expect the Unexpected In this issue of Blue Skies flight safety magazine flight performance. Regrettably other issues can the focus of a number of articles will explain the also arise that lead to flights not taking off on time challenges faced by GainJet and its crew during the such as fuelling delays. In certain locations, fuelling Ground Phase of our operations. companies are limited to a few or even one supplier, who have limited resources and personnel. It is common knowledge among pilots, particularly in the world of VIP charter, that the few hours leading up to the point where Air Traffic Control clear the flight crew to start engines and begin taxiing in preparation for the take off roll, is perhaps one of the most difficult portions of any flight.