GainJet Aviation Flight Safety Magazine

ISSUE 004

Table of Contents Front Cover: GainJet’s , 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 Incursions ...... Page 13 Why Use a Paper Loadsheet? ...... Page 17 Case Study – 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 , 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 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. This is mainly dueto a combination of varying factors and individuals that the crew are dependent upon to successfully prepare a flight within a relatively short time constraint. However, a number of other unforeseen reasons can and usually do develop, which one must take into consideration. A jet being refuelled. Fuelling delays are prone to happening, so even though everything is done beforehand to ensure no delays, GainJet operate flights globally, so that means our crews must not lose focus if such delays take place. crew often work in unfamiliar environments. Language Catering is another case in point that can be is sometimes a barrier as well as local procedures and problematic. Due to the nature of our business customs that differ from European ones. There are GainJet has very high quality standards in respect some issues which consistently arise irrespective of to the catering we provide to our passengers. So it where GainJet operates. One of the most common could be a case of limited suppliers able to cater to concerns during the ground phase relates to aircraft such standards, which in effect may cause delays; or loading. Airliners have strict guidelines on what, how if these standards fall short of our expectations, it much and where passenger baggage and cargo is requires us to have the order re-supplied, and delays loaded due to aircraft performance. are encountered.

Occasionally local authorities perform SAFA checks that all airlines, including GainJet, must adhere to. While the nature of a SAFA check can differ somewhat depending on location, virtually all proponents of these checks adhere to a pre-defined set of guidelines set out in a checklist. Irrespective of airline schedules these checks must be completed even (and usually) at the expense of the aircraft taking off on time.

Passenger baggage being loaded into an aircraft. Accurate loading information is important to a safe flight operation.

Once loading is complete, accurate information regarding the quantity and location of the load within the cargo compartments must be submitted to the A Safety Assessment of Foreign Aircraft (SAFA) inspection being flight crew. Discrepancies can exist between these conducted. When a SAFA inspection is conducted, it must be and actual figures, sometimes resulting in delays completed even if it leads to a delayed flight. It is important to to the flight and on rare occasions affecting aircraft stay focused. 6 While many of the challenges that GainJet crew are happy with the flight operation, but most face on the ground can be overcome with a little importantly, we should NOT do this at the expense determination and focus, unfortunately the weather of safety. It is imperative to keep calm, focused, and can also adversely affect operations. For example observe all SOPs and flight checks before a flight during inclement weather, ATC usually decide to operation commences. stagger takeoffs and landings depending on visibility and cloud base. Frustratingly this almost inevitably Due to the nature of the types of operations that leads to delays in schedules. GainJet flies, every flight is unlike the previous. Problems during the ground phase of a flight can It is important to always remember, especially in a VIP lead to increased frustrations for everyone jet charter operation where we cater to the world’s involved, but all GainJet flight and cabin crew have elite, that we should not fall to commercial pressures. significant airline experience in dealing with difficult In the event of on ground issues and/or delays, no situations. As the old adage goes an “airplane’s crew matter what circumstances arise, it is important to should leave all their problems behind them once stay focused. Yes, we should do all that we can to they enter the aircraft” - GainJet crew are no ensure the flight is on time and that the passengers’ different.

By Imran Saleem First Officer – Boeing 737 Danger Can be On the Ground

Aircraft accidents are known for their relatively rare, injured each year in these accidents and incidents; but disastrous mid-air occurrences; however these the injury rate is about 9 per 1,000 departures. accidents or incidents can be just as serious on the ground. Such events are far more common than Ramp accidents cost major airlines worldwide at we may believe. The International Civil Aviation least US $10 billion a year, the data indicates. These Organization (ICAO) reports that one-third of all accidents affect airport operations; result in personnel aviation incidents or accidents actually occur on the injuries or fatalities; and damage aircraft, facilities and ground. ground-support equipment.

During takeoff, an aircraft may fail to leave the ground or gain proper altitude, which may lead to an on-ground collision. A failed landing can also lead to a collision, either with a hazard on the runway or by colliding directly with the ground. Improper manoeuvring of planes on the ground can cause the aircraft to collide with each other at slow speeds or put one in the way of an ascending or descending plane, leading to a collision. Also, planes can collide with other vehicles and equipment at the airport.

Imagine that the sheer force of a jet engine is enough to send a light vehicle flying through the air. In several An Airbus A340-300 on a scheduled passenger flight collided cases, weather conditions and strong winds may also with a stationary bus with only the driver on board. Both the be a culprit involved in an accident or incident. aircraft and bus were damaged. No Injuries were reported. Ramp accidents are costly and dangerous. Based on data that was developed by The International Since the operation of aircraft on ground and flying Air Transport Association (IATA), the flight safety above airports requires the coordination of many foundation estimates that 27,000 ramp accidents people, including flight crew, air traffic control and and incidents — one per 1,000 departures — occur ground staff, a single error or miscommunication can worldwide every year. About 243,000 people are result in a devastating accident or incident. 7 The dedicated personnel reached the aircraft just after the incident and took all the necessary measures to secure the aircraft. Additional chocks were placed, two chocks were placed on each main gear as well as two chocks on nose gear and the aircraft was tied down. Later that day, as an extra precaution, the aircraft was towed into a hangar. Probable major contributing factors of the incident were the lack of proper communication between all relevant parties and not following SOPs in this case. Therefore, the precautionary action to secure the aircraft could not be taken in time before the incident took place.

If heavy winds have been forecasted at an airport, it Inside the tower. Air Traffic Controllers on duty overlooking the is imperative to communicate and take the necessary runway. Many different people are involved in the flight operation action to ensure the safety of personnel, aircraft, and on ground, so clear communication & following procedures is equipment. Tools and loose items need to be packed imperative to avoid accidents or incidents. away, extra securing needs to be used for aircraft, and Heavy winds have been known to cause hardship any vehicles should be cleared away. at airports, where tools, loose objects, vehicles, or even aircraft have been known to blow away with the possibility of causing damage or injury. Such an incident took place earlier this year involving a light jet aircraft, fortunately without causing any injuries or damages.

In the event of heavy winds, it is imperative to secure aircraft, vehicles, tools, equipment, and loose items.

Light Aircraft blown over by heavy winds. It is imperative to secure all aircraft, vehicles, equipment, tools, and loose items in case of heavy winds. Strong winds were prevailing at the airport area and vicinity, with gusts blowing at a speed of about 50 knots or more. Aircraft can also be secured inside hangars during heavy winds. Although a more costly option, it may be the most appropriate The airport authorities issued warnings that were option in some specific cases. distributed to the operators or their representatives Safety is our top priority in GainJet and we must all in order to take necessary action. However, in the pay attention to following the procedures that keeps mean time and before any additional action could our company in the elite league of aviation. be taken, a light jet aircraft was blown and moved from its original position. The aircraft did not hit any other aircraft or vehicles and did not cause any injuries. However, the incident proves to show that communication and immediate response according to the Standard Operating Procedures (SOPs) is By Bill Zois imperative. Flight Dispatcher/Operations Officer 8 The Numbers Almost one-third of airplane accidents that occur landing. Poor runway design and are to worldwide happen on the ground, reports the blame for these incidents. International Civil Aviation Organization (ICAO). The ICAO also cited factors like airport design and The number of accidents did, however, reach an all construction, air traffic control, air traffic management time low in 2010 reports the ICAO. Even though the systems, airline operations, flight crew awareness and number of accidents has decreased, the ICAO has communications as problems. forecast traffic will rise by 70% within a decade, which could change that trend. “The trend is worrisome After the ICAO and IATA released new runway because the rate of accidents is flat, but the (air operation safety guidelines in 2009, the number of traffic) growth is increasing, so when you take those crashes began to drop. two things together, you’re going to get increased accidents,” said ICAO director of air navigation Nancy ICAO news Graham, according to The Age.

In the 13 years between 1995 and 2008, there were 1,429 airline accidents around the world. 431 (or By Captain Konstantinos Molyndris about 30%) of those occurred during takeoff or Training Manager

A Significant Safety Issue - Vortices

Wingtip Vortices are generated by all aircraft asa consequence of producing lift.

The heavier the aircraft and the slower its speed, the stronger is the vortex.

Vortices generally persist at low altitudes for about 80 seconds, but when the wind is light or calm, they can remain in the area up to two minutes.

A Vortex created by the aircraft’s wing is revealed by coloured smoke. Vortices are a dangerous phenomenon and care must be taken during aircraft operation at an airport. The above two pictures are a great real-life example of how an aircraft creates vortices upon lift created by the wingtips. The Once vortices are formed, they continue to descend pictures also show the movement o f these vortices. Vortices can until they decay. Although a vortex encounter at low exist during take-off or landing, and care must be taken when altitude is uncomfortable and alarming, generally operating after another aircraft has taken-off or landed. 9 it is recoverable. Attention should be paid when The vortices are generally invisible, so there are a few extreme conditions are met. In the worst of cases, it techniques to cope with this phenomenon. may be beyond the power of the ailerons to counteract the roll. Even executive jets have been rolled upside Distance can be judged visually by runway length down. so if the recommended spacing is five to six miles, then you need three to six runway lengths between Close to the ground, vortices generally persist yourself and the aircraft ahead of you. for about 80 seconds where their effect is most dangerous. They have a tendency to move apart at about 5 knots in still air, so a crosswind of 5 knots can keep the upwind vortex stationary on or near the runway while the downwind vortex moves away at about 10 knots. In crosswinds of more than 5 knots, the area of hazard is not necessarily aligned with the flight path of the aircraft ahead. Particular care should be taken on airfields where intersecting runways are both in use.

It is important to be aware and take care not to get caught in the vortex created. Calculating distances can help judge the most appropriate action to avoid the vortex danger. If the aircraft on the approach ahead is much heavier than your type, keep it in sight. Generally, vortices drift downwards, so fly above and to the upwind side of the lead aircraft’s flight path. Obviously as you get closer to the runway you should correct lateral and vertical displacement, so plan to land beyond the point where the heavier aircraft touched without risking safety. A Go-Around is always an option.

Vortices are generated as the aircraft rotates on takeoff, so at least 2 minutes interval is required from the heavy Jet rotation in front of you.

When the aircraft’s nose wheel is on the ground, there are no vortices.

You Saved Another Day.

Above: examples of the movements of wingtip vortices. At low altitude the area of encountering vortices is not necessarily By Captain Dimitris Kehayas aligned with the flight path of the aircraft ahead. Flight Operations Manager Extra Care is Extra Important

There are many dangers that are present on ground Consider the case when in March 1999 a five year- at an airport, especially when trying to make up for a old child was injured during disembarkation from a delay while preparing an aircraft or upon arrival when at a Canadian airport. The aircraft was passengers are anxious to disembark. Combine this parked on the open ramp away from an aerobridge, with the facts that things are constantly moving at an and steps were used. airport and many different people are involved with flight preparations/operations, and the realization of After the first 10 passengers had left the aircraft a such dangers is looming about. So taking extra care is flight attendant exited the aircraft carrying an infant really important. in a car seat. When the flight attendant stepped onto 10 the passenger stand he noticed it was descending Implementation of safety rules, regulations and slowly away from the aircraft. As he turned to tell the procedures by aircrew while on the ground is very in-charge flight attendant, the infant’s five year-old important. Even at hectic moments like preparing brother, who was following with his mother, stepped an aircraft for departure, it is always imperative to out of the aircraft and fell between it and the stairs stay focused and conduct your duties according to the apron below. The child suffered a broken arm to procedure. Aircrew must be particularly careful and lacerations to the head in the fall and was taken that the air bridge or steps are correctly positioned to hospital for treatment and observation. before opening the door and allowing passengers to disembark. They have to be equally careful, using the safety strap when keeping a door open for service purposes while there are no steps or air bridge at that door. The danger of falling from an airliner (which tends to be at least a 3 meter fall) is real and serious. Extra care is also needed while handling doors equipped with emergency slides. The accidental deployment of a slide will not only be of major cost to the company but, more importantly, can cause serious accidents and injuries. Remember to always check the indicator before opening an aircraft door, and always disarm the door when instructed to do so.

A diagram of the incident where the airstairs retracted during disembarkation, causing a 5 year old child to fall to the tarmac. Caution is required at all times that an aircraft door is open, or passengers are boarding/disembarking. Cabin crews are heavily trained for in-flight safety and emergency situations, and although they are trained to avoid such circumstances, it is still imperative to understand that in cases like the above they have to be equally careful and vigilant.

There are many advantages of being extra vigilant in An accidentally released emergency slide after ground personnel respect to safety. First of all, and most importantly, opened the armed exit door of an American Airlines Boeing 757. it is the responsibility of all crew, engineers, and the After an incident with the B757 in the maintenance entire company to ensure the safety and security of facility, where a mechanic was thrown out of the our passengers, our colleagues, and equipment. So aircraft because of a defective power assist system being extra vigilant ensures the accomplishment of that accidently kicked in, we realized how much more such a mission. Our focus on safety is the first step in careful aircrew have to be in handling doors equipped the success of the entire operation. with slides.

The industry has recently began looking more Our travels sometimes take us to small unknown thoroughly at ground operations, especially since and ill-equipped places that are not quite prepared the advantages and savings of improving safety and or capable to handle the level of services we may reducing damage to aircraft and ground vehicles were require. This is the reason that we, as a company, are estimated at around $4 billion a year for the industry also trained and advised to be very cautious in less as a whole. advanced and equipped airports. I urge you to use that training. My experience has shown that clear Cost has become a major issue in today’s economically communication and any help we can provide the challenged environment. In a world of diminishing ground personnel will be to our benefit since being profit margins, increasing fuel prices and intense proactive is the key to a safe operation. competition with its associated effect on revenue growth, it certainly makes sense to look at every opportunity to reduce costs and boost efficiency without compromising safety and levels of service. So due diligence and extra care are part of such a By Olga Beglopoulou program. Cabin Crew Manager 11 Ground Accident Prevention

The scope of this article is not to analyze in depth systems to determine the common latent failures ground accidents and incident causes, but to give a which contribute to typical ground damage incidents. general picture of how much ground accidents can Problems in identifying causes of recurrent incidents affect the operation of a company. Ground damage are at least partially the result of inadequate methods can be avoided, if maintenance safety procedures, of collecting information about errors. In a typical company rules and safety polices are strictly followed. airline, errors (above a certain threshold of severity) are strictly monitored and recorded. For example, Ground damage incidents (events in which airline airline management may maintain stringent records personnel cause damage to an aircraft on the ground) of on-time flight departures/arrivals, turnaround occur as airline personnel are working on or around time for aircraft requiring maintenance, injuries to an aircraft on the ground, either on the ramp or at personnel, damage to aircraft and other ground a maintenance facility. Ground damage or damage equipment, and other measures that document to an aircraft caused by airline personnel while the the airline’s overall performance. In addition, many aircraft is on the ground, remains a serious problem errors (below the threshold of severity for reporting) for most airlines, with costs in the tens of millions of may be detected and corrected routinely as part of dollars per year. the system with no records kept. For example, if a mechanic drops a wrench on his foot, the incident would be recorded as an OJI (on-the-job injury). If a mechanic drops a wrench on an aircraft, damaging it severely, the incident would be recorded as Technical Operations Ground Damage. If the wrench were dropped on the aircraft, causing no damage, the incident would not be recorded at all! In each of these scenarios, the error was exactly the same, only the final consequences differed, in turn affecting the way in which each of these incidents is recorded.

The failures caused by those in direct contact with the system, i.e. the mechanics that are working on the aircraft, are considered to be active failures. Thus, A Airbus A330-301 was being towed to a maintenance active failures are errors or violations that have a facility at Airport when the driver of the TUG lost direct and immediate effect on the system. directional control on the slippery ground surface. The aircraft slid out of control and impacted a Sobelair Boeing 737-329. Latent failures are those failures that derive from Based on activity data developed by the International decisions made by supervisors and managers who are Air Transport Association (IATA), it is estimated separated in both time and space from the physical that 27,000 ramp accidents and incidents - one per system. For example, technical writers may write 1,000 departures - occur worldwide every year. procedures for a task with which they are not totally About 243,000 people are injured each year in these familiar; if the procedure has even one mistake in it, accidents and incidents; the injury rate is 9 per 1,000 the mechanic using the procedure will be encouraged departures. The economic toll is significant: The to commit an error. current estimate is that ramp accidents are costing major airlines worldwide at least US$10 billion a year. For an incident to occur, latent failures must combine A conservative estimation is that ramp accidents cost with active failures and local triggering events, corporate aircraft operators $1 billion a year. Damage such as unusual system states, local environmental caused by hail, bird strikes, mechanical failure is not conditions, or adverse weather. There must be considered to be ground damage, and have their own a precise alignment of all of the ‘holes’ in all the separate prevention programs. defensive layers in a system. For example, rain may cause a mechanic’s foot to be wet, allowing his foot to Each incident can be very expensive to a company, easily slip off the worn brake pedal in a pushback tug with costs both tangible (repair costs and lost when the mechanic becomes distracted. The tug may revenue) and intangible (passenger inconvenience, then lunge forward contacting a parked aircraft. increased maintenance workload). One of the companies’ most difficult tasks has been to utilize the The latent failure in the system is that the brake pedal information collected in their existing error reporting has no anti-slip surface in place, but the problem 12 does not become an issue until the rainy conditions Senior managers are responsible for establishing and (a local trigger) cause an incident. If any one of these maintaining this System. Their roles and failures had not occurred (mechanic did not become responsibilities include: distracted, the tarmac was not wet, or the brake pedal • Establishing levels of acceptable risk; was in better condition), the incident would have • Establishing safety policy; been avoided. • Establishing safety performance goals that are in line with other company goals and help set a direction for improvement; • Allocating sufficient resources; • Overseeing system performance; and, • Modifying policies and goals, as necessary.

Line managers carry out the instructions of senior management by: • Implementing safety programs; • Ensuring that staff receives safety training; • Ensuring that staff has and uses, safety equipment; • Enforcing safety rules; • Including safety in performance reviews; • Providing safety coaching to staff; • Monitoring staff safety performance; and, A pushback tug strikes the engine of a Continental B737. • Conducting incident investigations.

Employee acceptance of this System and Safety There is growing realization in the aviation industry Programs is essential for success and can be achieved that encouraging prompt reporting of safety issues by having employees: actually reduces the number of accidents and • Help develop and establish safety programs; incidents. An environment of a “just culture” is • Participate on safety committees; a key element in fostering “open reporting” - for • Follow established procedures and not take short the systematic reporting, collection, analysis and cuts; dissemination of safety information that will be used • Assist in investigations; solely to prevent accidents. • Report hazards and incidents; and, • Provide feedback to managers. An important concept in an effective Ground Accident Prevention System is that it is not the sole GainJet Accident Prevention and Flight Safety Program responsibility of the company’s Safety Officer; it is the provides guidelines for accidents prevention and is a responsibility of everyone within the company. “must read” manual for all GainJet employees.

By Kostas Karalis Chief of Engineering Department Runway Incursions

From time to time aviation tragedies convulse the universe. Aviation accidents, with many fatalities, which occur due to mechanical malfunction, human error or extreme weather conditions, cause great distress and bereavement to thousands more. Statistically it is said that every fatality has a direct effect on 300 other people.

The rare occurrence of air accidents is accepted as CGI render of 2 B747s, KLM 4805 and Pan Am 1736, collision due a part of the nature of flying; however events like to a runway incursion at Los Rodeos Airport in Tenerife in March ground collisions are much harder to understand. 1977. It’s one of the deadliest accidents in aviation history. 13 A Runway Incursion is defined as “Any occurrence at first aircraft, which has entered the active runway an aerodrome involving the incorrect presence of an contrary to clearance and at an intermediate aircraft vehicle or person on the protected area of point, the controller clears a second aircraft for a a surface designated for the landing and takeoff of full-length take-off. aircraft.” • Flight Crew-induced situation. An aircraft lands at an unfamiliar airport and the flight crew becomes Contemporary aerodrome security procedures ensure disorientated as they exit the runway. Despite this, that it is a well supervised environment within which they acknowledge taxi instructions and without to operate aircraft. Modern ATC and Ground radar being confident of their position or the taxi route support minimize abnormalities or risks that may rise. given, continue taxing and inadvertently enter an active runway. The personnel involved, controllers and pilots, are specially educated and trained professionals able Contributory Factors to cope with any situation, but accidents involving • Weather: Low visibility may increase the chance aircraft on the ground still happen. Analysis ofall of flight crew becoming disorientated and unsure runway incursions clearly indicates human error of their position whilst taxiing. Low visibility is also or negligence. Fatigued or distracted air traffic likely to restrict a controller’s ability to identify controllers and/or flight crew, air traffic congestion or and follow aircraft visually so that cross-checking bad communications are some of the factors which a reported aircraft position with its actual location can contribute to runway incursions. may become impossible.

Air Traffic Controllers have a very important duty. However, Operation during low visibility at and around an airport is there may be times they are distracted, overworked, tired, or challenging and requires extra attention. overstressed. So confirm all communications and be alert. While most events do not result in accidents, there • Late Issue of Departure Clearances: This may lead have been some noteworthy tragedies. The accidents to a temporary lapse in flight crew situational at Tenerife North and Linate cannot be deleted awareness as the aircraft must be set up for the from the mind. departure whilst taxiing. • Multiple Line-ups: Use of Multiple Line-ups for Most Common Types of incursions aircraft departures from the same runway at • Departing aircraft runway entry contrary to ATC different entry positions increases the potential clearance for error. • Aircraft runway crossing after landing contrary to • Simultaneous Use of Intersecting Runways: ATC clearance Unless ATC SOPs are carefully formulated and • ATC runway occupancy clearance in error or rigorously applied, use of intersecting runways misjudged can significantly raise the risk of both runway • Towed aircraft runway crossing contrary to ATC incursions and loss of Separation between aircraft clearance near the ground and aircraft on the ground. At some airports where intersecting runways Typical Scenarios are used, especially in the USA, Land and Hold • ATCO-induced situation: With Low Visibility Short Operations are part of normal procedures. Procedures in force because of fog, a controller These are considered by some non-US aircraft gives a clearance to an aircraft without operators to introduce an unacceptable level subsequently checking for a correct read-back of additional risk; consequently, their flight from the flight crew who have misunderstood the crews are instructed to decline offers of such instructions. Without checking the location of the clearances. 14 of taxiways and airport layout. After clearing the landing runway, they also have to reconfigure aircraft systems in accordance with the After Landing Checks and may receive detailed taxi instructions from ATC. Similar levels of workload may occur prior to departure while the flight crew are concurrently carrying out tasks including configuring the aircraft systems ready for take- off, briefing crew and passengers, receiving amended departure clearance instructions from ATC, checking unfamiliar departure procedures, etc. Under these circumstances of high workload, Intersecting runways propose a risk if precise coordination is not used. In cases where airports utilize intersecting runways a temporary loss of situational awareness or simultaneously, there is great risk for runway incursions to take communications confusion are more likely to place. It is important to be alert & aware of surroundings. occur. ➣➣ Controller Workload. Controllers handling • Aerodrome design: If, as a consequence of multiple aircraft movements and handovers aerodrome design, aircraft are obliged to taxi have relatively little time available for monitoring across active runways in order to get to parking, individual aircraft to confirm that they are taxiing or to reach another active runway, the likelihood in accordance with their clearances. of runway incursions is increased. (See Barcelona LEBL runway chart reproduced on page 16). This Communication breakdown risk may be reduced if Runway Hotspots have been Examples of communication breakdown on the identified and the flight crew applies effective maneuvering area include, but may not be limited to: risk mitigation. Operation with intersecting -- Complex instructions to different aircraft; active runways is also likely to require careful -- Controller high speech rate; consideration to ensure that risk of conflict is not -- Two different languages; thereby increased. -- R/T Frequency congestion / blocked frequency; • Conditional Clearances: If conditional clearances -- Use of non standard ICAO phraseology by air traffic are used, the risk consequent upon any error control; in their issue or actioning may be increased -- Call sign confusion; especially because of aircraft identification errors. -- Poor read-back procedure; The chances of such errors are increased if aircraft -- Inadequate aviation English; livery does not readily correspond to the RTF -- Different frequencies associated with runway call sign being used; this is sometimes the result operations. of airline alliance livery policies or the ad hoc

operational substitution of leased-in aircraft. Loss of communication and runway incursions. • Phraseology: Use of Non-Standard Phraseology Entering a runway (to line up or cross) or landing or non-adherence to Standard Phraseology can without a valid clearance will lead to the incorrect lead to clearance confusion and misunderstanding presence of traffic on a runway and requires a runway between flight crew and controllers. incursion to be reported. Pilots should squawk 7600 • Simultaneous Use of More than One Language in VMC or IMC to advise loss of communication on the for ATC communications: At some international maneuvering area. airports, domestic flights may communicate in the local language whereas international flights should Defences do so in English. Depending on the nature of the The best defence in order to minimize/avoid such local language and the language skills of the visiting occurrences is to keep a continuous listening watch flight crew, this may have the effect of significantly to the frequencies in use. Be prepared to clarify any reducing their awareness of the relative position differences or omissions between communications. of other traffic. Do not be in doubt. Do not hesitate to confirm the instructions given and re-advise your intentions. Distraction. This is the immediate cause of many incursions, although the context in which it occurs FLY SAFE. is often of more direct relevance to effective risk mitigation

Workload Factors such as: ➣➣ Pilot Workload. Shortly after landing, flight crew By Captain Vangelis Lykoudis have to orientate themselves quickly in respect Flight Safety Officer 15 A Jeppesen airport runway layout chart of Barcelona Airport (LEBL/BCN) in Spain. Notice how many Runway Incursion Hotspots are present! Runway incursions are a major hazard that could lead to disastrous consequences. It is imperative to be alert for such hazards, especially at airports with runway incursion hotspots. 16 Why Use a Paper Loadsheet? As pilots, we are all computer literate these days and On balance; the way we use our paper loadsheet much of our working life is spent operating our aircraft is simply safer and that is the reason why it is our via keypads, touchpads, alphanumeric keys and other Standard Operating Procedure. The following article remote control devices. On the Boeing fleet at GainJet regarding the potentially catastrophic results of however, we still make our weight calculations the automatic (computerised) loadsheet calculations “old fashioned” way with a paper loadsheet and confirms that we have made the right decision. a calculator. This may seem strange to some of our pilots – especially those who are new to the company. United Overweight Takeoff on Computer We can imagine that they are thinking it would be Mistake Prompts Changes much easier and quicker to use an electronic means - Aimee Turner, Correspondent with Flight International – of loadsheet (and trim) calculation – after all we use an electronic flightbag don’t we? We must always A computer breakdown caused a United Continental remember the first rule of computers however – they Holdings Inc. (UAL) flight to take off earlier this year are only going to be ever as good as the programmer: about 20,000 pounds (9,071 kilograms) heavier than “Garbage in = Garbage out”. pilots believed, prompting the carrier to add extra checks to ensure accurate weight calculations.

United sent pilots a weight estimate that assumed the coach section of the Boeing Co. 737-900 was empty when it was full, according to three people familiar with the incident who asked not to be named because they weren’t authorized to speak about it. While the pilots, who didn’t catch the mistake, had difficulty getting the jetliner airborne, “the plane wasn’t damaged and the flight was completed without incident”, one of the people familiar with the event said. The pilots reported the trouble to a United program that encourages employees to identify safety A baggage handler loading luggage into an aircraft. It is important issues, according to another person. to ensure correct load calculations, which is assisted by using the old fashioned, but safe, paper loadsheet and calculator. Vigilant “Earlier this year, we experienced technology issues in coordination with loading personnel will also help ensure correct capturing correct passenger counts on a small number loading calculations. of our flights,” Megan McCarthy, a spokeswoman for The subject has been debated many times in GainJet the airline, said in an e-mail yesterday. The incident Aviation Management meetings at head office and was recounted in a July 9 bulletin from United all the pros and cons have been carefully considered. management to its pilots, said one person, who There is no doubt that there are some automated couldn’t say when the incident occurred. systems which would be potentially much quicker than manual calculation of the aircraft weights, United and the U.S. Federal Aviation Administration however our real risk is that ours is not a scheduled (FAA), which said the airline reported the breakdowns airline operation. We believe it is important for our to it, said they’ve taken steps to prevent such incidents pilots to always be actively ‘engaged’ in the loading in the future. United is requiring its pilots to perform and load calculations for departure. The principle two additional, manual checks on weight and balance that we follow as an SOP is that one pilot makes the calculations before each flight, the FAA said inan calculations for Weights, CofG, Stab Trim setting, e-mailed statement. Takeoff Speeds/Power Settings and the second pilot makes an independent crosscheck of all the figures. Difficult Liftoff This method ensures that both pilots are critically “The FAA has been monitoring the situation and is aware of what weight is being loaded in which satisfied with this interim measure while the airline compartment – especially the aircraft holds. develops a permanent solution,” the agency said. United has had computer and operational problems Using a process which involves the flight crew actually in recent months as it transitioned to new passenger- thinking about all the performance parameters, service and aircraft preventive-maintenance systems. means that it is more likely they will see errors before Both were used at Inc. before it they are lost in an automatic system of load control. merged with United parent UAL Corp. in 2010. 17 All airlines estimate a plane’s weight before each airport structure before climbing. “There were no flight. The weight information, along with data on injuries, but this accident was considered to be a close air temperature and other factors, allows pilots to escape from catastrophe,” a NASA report on the issue calculate the precise speed at which they should lift published in June said. the nose during takeoff. If pilots try to take off with too much weight, it can cause a plane to scrape its Seven people aboard an MK Airlines Ltd. Boeing tail on the ground or to skid off the runway without 747 freighter died on Oct. 14, 2004, after making a getting airborne, according to accident reports. 249,000-pound (113,000 kilograms) error before attempting to take off in Halifax, Canada, according to Boeing’s 737-900 models can take off weighing the NASA report. as much as 187,700 pounds (85,141 kilograms), according to Boeing’s website. Even fully-loaded jets frequently take off at lower weights.

Accident History The incident exposed a safety risk that has caused several accidents, including a 2004 crash in Canada that killed seven people, according to accident reports and a recent NASA study. On March 20, 2009, an Emirates Airlines Airbus A340 carrying 275 people nearly crashed in Melbourne after pilots made a 100,000-kilogram (220,460-pounds) error in pre-takeoff calculations, according to an Australian Transport Safety Bureau report.

The MK Airlines B747 freighter was completely destroyed after a 249,000 pound load error led the aircraft to overrun the runway. The aircraft was destroyed by impact forces and a severe post- crash fire. All seven crew members suffered fatal injuries.

Typos, Miscalculations The researchers also found that U.S. pilots had anonymously told of similar incidents to the Aviation Safety Reporting System, a NASA-run program that gathers safety reports from pilots and others. In one such case, pilots at an unspecified carrier reported taking off 19,000 pounds (8,618 kilograms) heavier than estimated because an airline employee had listed 33 passengers instead of 133, according to the report.

“Although relatively few major accidents have yet been caused by performance data errors, our study suggests that more accidents are likely to occur unless existing measures to prevent and catch these errors are improved and new measures developed,” the report said. The report recommended technology improvements and additional cross-checks by pilots to ensure math errors, typos and other miscalculations don’t become fatal. The Emirates A340 underside of the rear fuselage was significantly damaged, after erroneous load inputs resulted in a tailstrike at the end of the runway. One of the pilots accidentally entered a weight of 262,000 kilograms into a laptop used for takeoff calculations instead of the actual 362,000 kilograms, investigators found. The jet’s tail skidded on the By Captain James McBride pavement as it failed to get airborne and clipped an CEO & Accountable Manager 18 Case Study Linate Airport Disaster Cessna Citation 525-A, D-IEVX – flight 686 – MD87 October 8, 2001.

The SAS MD87 was destroyed in the accident after a runway incursion led it to smash into a baggage handling facility, which was also damaged. On 8th October 2001, a Cessna Citation 525-A via Romeo 5, QNH 1013, call me back at the stop business jet, with registration D-IEVX, was scheduled bar…” The pilot acknowledged by saying: “Roger to depart Linate Airport in Milan, bound for , via Romeo 5 and ... 1013, and call you back before France for a demo flight for a prospective buyer who reaching main runway.” Shortly after beginning taxi, was onboard. The aircraft had arrived in Milan earlier the aircraft reached a position where the yellow taxi that day from Germany during foggy conditions and line splits into two diverging directions, and the pilot low visibility, and the landing run took the aircraft erroneously took the taxi line to the right and entered beyond Taxiway (TWY) R6 (intersecting with the taxiway R6 (southern taxiway). At 8:08 lt, the Cessna runway) and the crew then requested and obtained crew confirmed their position as “approaching the permission to backtrack and to taxi on that TWY in runway…Sierra 4,” and at 08:09, even though he was order to proceed towards the West apron (General not familiar with the position, the ground controller Aviation apron). No other incidents were reported cleared the Cessna to continue its taxi on the North before departure. apron, clearly not aware where the aircraft was actually located. At the same time, the MD87 was At about the same time of the Cessna’s departure, given clearance to take off from runway 36R. About Scandinavian Airlines (SAS) Flight 686, flown by a minute later, the MD87, traveling at about 270 km/ a McDonnell Douglas MD87 with registration SE- hour, collided with the Cessna, which accidentally DMA, was also scheduled to depart Linate Airport entered the active runway 36R. The MD87 lost its right to , Denmark. The two aircraft collided engine and the starboard landing gear in the collision, during the takeoff run of the MD87 when the Cessna but the flight crew still attempted to take off, reaching accidentally entered the active runway, creating a an altitude of approximately 12 meters. However, runway obstruction. After the collision, the MD87 the remaining engine lost some thrust due to debris continued down the runway until it crashed into a ingestion, and the aircraft descended. The pilot baggage handling facility, which was also destroyed. applied thrust reverser and brakes, and tried to guide All 110 people onboard of the MD87 as well as four the plane through its control surfaces (a maneuver ground personnel were killed and several more that was judged so skillful that it is now incorporated ground personnel injured. The Cessna remained on into SAS technical manuals). Alas, his efforts were, the runway and was destroyed by post-impact fire; all however, insufficient to stop the aircraft. It skidded its four occupants also being killed. past the grass overrun area, across a service road, and crashed into a baggage hangar facility located near On the day of the accident, at 7:41 local time (lt) the the end of the runway, at a speed of about 251 km/ ground controller cleared the MD87 to start engines hour. and advised that the slot time for takeoff of the flight was at 08:16. At 08:05, the pilots of the Cessna then In its final report, the Agenzia Nazionale per la received taxi clearance: “Delta Victor Xray taxi north Sicurezza del Volo (ANSV) states that the immediate 19 • The Cessna crew was not qualified to operate in such conditions. • The failure to check the Cessna crew’s qualifications.

Procedural and Technical Factors: • At the time of the accident, Linate Airport was operating without a functioning ground radar system at the time, despite having had a system delivered some years beforehand, which had not been fully installed. • A lack of visual aids. • Operational procedures allowed high traffic volume in the given weather conditions and in the absence of technical aids. So despite these circumstances, the traffic volume was high. • The Cessna crew was not aided properly with correct publications, lights, markings, and signs to enhance their situational awareness. The Cessna remained on the runway after the collision, where it • The lack of official documentation to report the was completely destroyed by post-impact fire. presence of unpublished marking, which were therefore unknown to the ATC controllers. cause of the accident was the runway incursion in • Lack of adequate training of ATC personnel. the active runway by the Cessna. However, the ANSV determined that there were other factors beyond the obvious human factors relating to the Cessna crew that had been major contributing factors, specifically the system in place at Linate airport was not set up to trap misunderstandings and the airport had a faulty layout and inadequate airport markings. The weather was another major contributing factor because visibility was low at about 50-100 meters, so the Cessna crew couldn’t properly see where they were going, and the crew of the MD87 didn’t see the runway incursion by the Cessna until it was too late. Other major contributing factors included:

Human Factors • The Cessna crew used the wrong taxiway and A diagram showing the Cessna’s mistaken route which led it to produce the runway incursion that resulted in the accident. entered the runway without specific clearance. • The ground controller was not familiar with the The “Linate Airport Disaster” is a clear indication identifier S4 when the Cessna crew correctly that following Standard Operating Procedures reported its position, which was on the wrong (SOPs) is a MUST. Obviously the lack of certain aids taxiway, and disregarded this identification. and markings, accompanied by the adverse weather • ATC personnel did not realize that the Cessna was conditions were major contributing factors in this on taxiway R6 (southern taxiway). case, but miscommunication and misunderstanding • The ground controller issued a taxi clearance were also crucial factors here. Clear communication, towards “Main Apron” even though he didn’t know confirmation of instructions, and following the where the Cessna was since he didn’t recognize Standard Operating Procedures are key always, the correctly reported position S4. especially when there are other adverse factors • Radio Procedures were not performed using surrounding the operation like weather and high traffic standard phraseology (read back) and resulted in volume. This case demonstrates that commercial misunderstandings and miscommunication. pressures should be secondary to safety. The crew • Radio communications were performed in both was not qualified to operate in such weather and Italian and English and not in one consistent should have made the decision to “wait it out”. Safety language. is the first priority. • The nature of the flight, as a test flight for a buyer, might have applied commercial pressures on the This case study uses excerpts from the ANSV accident Cessna crew to commence the flight despite the report N.A/1/04. For more information please visit: http:// prevailing weather conditions. www.ansv.it/cgi-bin/eng/ FINAL%20REPORT%20A-1-04.pdf 20 Case Study On Ground Collision Between Two Aircraft United Airlines Boeing 747-433 – N127UA Australian Airlines (Qantas) Boeing 767-338ER – VH-OGH February 2, 2006

After a B747 collided on ground with the aircraft, this Australian Airlines B767 sustained substantial damage to the right horizontal stabilizer and a significant portion outboard of the elevator was also destroyed. On February 2, 2006 a United Airlines Boeing 747- In the accident, the 747 sustained considerable 422, registered N127UA, was scheduled to depart damage to the leading edge of the left wing tip. The left Melbourne Airport in Australia travelling to Sydney. wing tip fairing sustained chord-wise damage except The B747 was cleared to taxi along a route from the for a small section near the trailing edge of the wing, international apron to the holding point Bravo (B), and the left navigation and strobe light coverings were for departure on runway 16. This route took the 747 destroyed. The 767 sustained substantial damage through taxiways Uniform (U) and Alpha (A). During to the right horizontal stabilizer. A significant part the 747’s taxi for departure, an Australian Airlines outboard of the elevator was also destroyed. (Qantas) Boeing 767-338ER, registered VH-OGH, was stationary on taxiway Echo (E) and waiting in line to depart also to Sydney from runway 16, awaiting clearance to enter the runway. In its waiting position, the tail of the B767 was sticking out into taxiway Alpha (A), partially blocking the designated taxi route of the B747. The pilot in command of the B747 deviated from the taxi clearance issued, and turned the aircraft right, into taxiway Echo, to pass behind the B767. During this maneuver, the left wing tip of the 747 collided with the right horizontal stabilizer of the 767. No injuries were reported. The United Airlines B747 sustained substantial damage to the leading edge of the left wing tip when it collided with a B767 after trying to maneuver round the obstruction on the taxiway, against the ground controllers instructions. In its report, the Australian Transport Safety Bureau (ATSB) determined that the major causal factor of the collision was the B747 pilots’ decision to deviate off the center line of taxiway Alpha and taxi behind the 767, which did not comply with the taxi clearance issued by the Surface Movement Control (SMC). They should have either waited for the obstruction to clear or contacted SMC to coordinate with them for the A diagram of the intersection where the accident occurred. next move. 21 The United Airlines B747 seen here before (left) and after (right) the accident where it sustained significant damage to its left wingtip after colliding with a stationary B767 in Melbourne, Australia. The immediate preliminary/temporary fix was to remove the left winglet, as you can see in the “after” photograph (right). Contributing factors of the accident are: remember that it is the Ground Controllers’ duty to • The pilot in command of the B747 made the guide all movements on ground. Maneuvering off any decision to make the maneuver to taxi behind the clearances or instructions given by them could lead to B767 based on his assessment that it was safe to do collisions or even runway incursions. so. However, he misjudged the distance between the two aircraft. • Even though there was a large area at that point for the B747 to maneuver to the south and east of the 767, the north-eastern side of that area narrowed, which reduced the space the 747 had to maneuver round the 767. So, as he was maneuvering, the pilot thought the left wingtip of the 747 was clear of the tail section of the 767, he decided it was safe to proceed, not realizing the north-eastern side of the maneuvering space narrowed considerably. Keep in mind, however, that the taxiway dimensions and markings at Melbourne Airport complied with international standards and were suitable for use by the aircraft types involved in the occurrence. • Even though the B747 was on schedule, and the pilots were not under any pressure, the commercial A view from the control tower at Melbourne airport. As you can demands may have played a role in the pilots’ see, the intersection where the accident occurred was partially decision to make the maneuver rather than wait. blocked by structural obstructions. So when the B747 deviated from its cleared taxi route, the controllers had no way of assisting. • Views from the tower to the intersection were partially obstructed by structural materials, in However, also keep in mind that human error is addition to the fact that distances and major natural and mistakes will happen, especially when the details were hard to judge from that vantage point. controllers are understaffed or are simply tired, and So once the B747 deviated, the ground controllers especially considering that we sometimes operate to could not help. airports with limited resources and where language • Once the 747 deviated, they also lost the could also be an additional obstacle. It is imperative assistance of markings on site. So the 747 crew to confirm all instructions and pay attention to your was maneuvering on its own, with no guidance. situation, in order to avoid accidental consequences of incorrect/unconfirmed ATC clearances or It is important to remember that procedures have instructions. Flight crew should be alert while taxiing. been put in place in order to avoid instances like If in doubt, stop the aircraft and request progressive this. Yes, it is part of our duty to make sure our taxi instructions from ATC, or marshaller assistance. passengers’ flights are satisfactory, which includes on- time departures, but we should not make sacrifices to This case study uses excerpts from the ATSB accident report safety in order to accomplish this. Following Standard 200600524. For more information please visit: Operating Procedures (SOPs) is a must. Please also http://www.skybrary.aero/bookshelf/books/1210.pdf 22 Can You Spot the Safety Hazard?

For any questions or safety/security concerns please contact: GainJet Aviation S.A Phone: +30 210 9636101 Address: A. Papandreou 108, Glyfada 16561. Athens – Greece

Answer: Capt. Vangelis Lykoudis Mr. Vassilis Apostolou The guard rail at the top of the stairs does Flight Safety Officer (FSO) Company Security Officer not cover the entire area, leaving a gap large Email: [email protected] Email: [email protected] enough for someone to fall through and down to the tarmac. Or visit www.gainjet.com