NLR-CR-2010-125 Executive summary AIRCRAFT GROUND HANDLING AND HUMAN FACTORS A comparative study of the perceptions by ramp staff and management Problem area were sent to the target groups Human factors have been Management and Operational Report no. identified by the European personnel and interviews were NLR-CR-2010-125 Commercial Aviation Safety conducted afterwards to verify Team as a ground safety issue the results and to place them in Author(s) for which safety enhancement the right context. A.D. Balk J.W. Bossenbroek action plans have to be developed. Results and conclusions Report classification The results identified UNCLASSIFIED The objective of this study is to opportunities for improvement investigate the causal factors in the propagation of the safety Date which lead to human errors policy and principles, April 2010 during the ground handling substantiation of the principles process and create unsafe of a just culture, communication Knowledge area(s) situations, personal accidents or of safety related issues, the Vliegveiligheid (safety & incidents. ‘visibility’ of management to security) operational personnel, This document describes the standardisation of phraseology Descriptor(s) Human factors results of the study, performed on the ramp and awareness of Safety culture the potential risks of human by the Air Transport Safety Ground handling Institute of the National factors like time pressure, Aerospace Laboratory NLR in stress, fatigue and cooperation with the Civil communication. Aviation Authority of the Netherlands. Applicability The results of this study are Description of work considered applicable to all The study has been performed European ground service by investigating safety culture providers. and human factors in seven ground service providers in the Netherlands. Questionnaires UNCLASSIFIED NLR-CR-2010-125 NLR Air Transport Safety Institute Anthony Fokkerweg 2, 1059 CM Amsterdam, UNCLASSIFIED P.O. Box 90502, 1006 BM Amsterdam, The Netherlands Telephone +31 20 511 35 00, Fax +31 20 511 32 10, Web site: http://www.nlr-atsi.nl NLR-CR-2010-125 AIRCRAFT GROUND HANDLING AND HUMAN FACTORS A comparative study of the perceptions by ramp staff and management A.D. Balk 1 J.W. Bossenbroek 1 IVW No part of this report may be reproduced and/or disclosed, in any form or by any means without the prior written permission of the owner. Customer Directorate General of Civil Aviation of the Netherlands/ European Commercial Aviation Safety Team Contract number ---- Owner NLR Division Air Transport Distribution Limited Classification of title Unclassified April 2010 Approved by: Author Reviewer Managing department SUMMARY The Ground Safety Working Group of the European Commercial Aviation Safety Team has the overall objective to encourage implementation of action plans developed by existing ground safety initiatives when addressing European ground safety issues and to develop new safety enhancement action plans otherwise. The topic of human factors has been addressed as one of the ground safety issues for which safety enhancement plans have to be developed. This document describes research on human factors in ground handling, performed under the authority of the European Commercial Aviation Safety Team by the Air Transport Safety Institute of the National Aerospace Laboratory NLR, in cooperation with the Civil Aviation Authority of the Netherlands. The objective of this study is to investigate the causal factors which lead to human errors during the ground handling process, creating unsafe situations, personal accidents or incidents. The results provide a basis for recommendations to the participating ground service providers and the European aviation industry. Seven ground service providers within the Netherlands participated in the study. Questionnaires were distributed to two target groups: Management and Operational personnel, with an average response rate of 33%. The first section of the questionnaire aimed to assess the organisations’ safety culture; the second section focused on human factors. The overall level of safety culture of the participating ground service providers ranges from 3.4 to 3.8 on a five point scale. With regard to safety culture, attention should be paid to: • The propagation of the safety policy and principles by Management to Operational personnel; • Substantiate and elaborate the principles of a just culture; • Communication of safety related issues, a.o. by developing and maintaining a safety reporting system; • The ‘visibility’ of Management to Operational personnel. NLR-CR-2010-125 April 2010 5 With regard to human factors, points of particular attention are: • Emphasize awareness of the potential risks of human factors like time pressure, stress, fatigue and communication, and training on how to manage these factors; • Standardisation of phraseology on the ramp. Further research may be focused on the potential effects (damage, injury) of the current focus on on-time-departures. Simultaneously, further development of the communication chain on the ramp should be explored. NLR-CR-2010-125 6 April 2010 CONTENTS 1 INTRODUCTION 10 1.1 Background 10 1.2 Objective 11 1.3 Scope 12 1.4 Document setup 12 2 APPROACH 13 2.1 Introduction 13 2.2 Safety culture framework 15 2.2.1 Introduction 15 2.2.2 Characteristics 15 2.2.3 Indicators 16 2.2.4 Processing of results 16 2.2.5 Presentation of results 17 2.3 Ramp Error Decision Aid 18 2.4 Investigation process 19 3 RESULTS 21 3.1 Participation 21 3.2 Safety culture 22 3.2.1 Commitment 24 3.2.2 Justness 24 3.2.3 Information 25 3.2.4 Awareness 25 3.2.5 Adaptability 26 3.2.6 Behaviour 26 3.3 Human factors analysis 27 3.3.1 Incidents 27 3.3.2 Direct causes 34 3.3.3 Contributing factors 35 3.4 Interviews 46 4 CONCLUSIONS AND RECOMMENDATIONS 48 5 REFERENCES 51 NLR-CR-2010-125 April 2010 7 APPENDIX A SAFETY CULTURE INDICATORS 52 A.1 Indicators relating to Commitment 52 A.2 Indicators relating to Justness 53 A.3 Indicators relating to Information 53 A.4 Indicators relating to Awareness 55 A.5 Indicators relating to Adaptability 56 A.6 Indicators relating to Behaviour 57 APPENDIX B LEVELS OF SAFETY CULTURE 58 APPENDIX C QUESTIONNAIRE 60 C.1 Safety culture – Management 61 C.2 Safety culture – Operational personnel 63 C.3 Human factors 66 NLR-CR-2010-125 8 April 2010 ABBREVIATIONS ADAMS Aircraft Dispatch and Maintenance Safety ASC-IT Aviation Safety Culture Inquiry Tool CAA NL Civil Aviation Authority of the Netherlands CAA UK Civil Aviation Authority of the United Kingdom CAST Commercial Aviation Safety Team COSCAP Cooperative Development of Operational Safety and Continuing Airworthiness Programme EASA European Aviation Safety Agency ECAST European Commercial Aviation Safety Team ESSI European Strategic Safety Initiative FAA Federal Aviation Administration GHOST Ground Handling Operations Safety Team GSP Ground Service Provider(s) GSWG Ground Safety Working Group HFACS Human Factors Analysis and Classification System HSE Health and Safety Executive IATA International Air Transport Association ISAGO IATA Safety Audit for Ground Operations MEDA Maintenance Error Decision Aid NLR National Aerospace Laboratory NLR NLR-ATSI NLR Air Transport Safety Institute OTD On Time Departure REDA Ramp Error Decision Aid SAT Safety Analysis Team SCARF Safety Course for Airport Ramp Functions SMS Safety Management System STAMINA Safety Training for the Aircraft Maintenance Industry NLR-CR-2010-125 April 2010 9 1 INTRODUCTION 1.1 BACKGROUND The European Commercial Aviation Safety Team (ECAST) has been established in 2006 as a component of the European Strategic Safety Initiative (ESSI). ESSI is based on the principle that the industry can complement regulatory action by voluntary committing to cost effective safety enhancements. ECAST is a partnership between the European Aviation Safety Agency (EASA), other European regulators and the aviation industry. ECAST addresses large fixed wing aircraft operations and aims to further enhance commercial aviation safety in Europe and for European citizens worldwide. ECAST cooperates with the United States’ Commercial Aviation Safety Team (CAST) and other major safety initiatives worldwide, in particular under the Cooperative Development of Operational Safety and Continuing Airworthiness Programme (COSCAP). ECAST has developed a safety approach using a three phase process: Phase 1 - Identification and selection of safety issues; Phase 2 - Safety issues analysis; Phase 3 - Development, implementation and monitoring of actions plans. Phase 1 has been conducted from April 2006 to December 2007, in which eighteen safety subjects have been identified as topics for further analysis in Phase 2. Using a prioritising process, combining safety importance, coverage (the extent to which subjects are already covered in other safety works) and high level cost benefit considerations, ECAST decided in 2008 to launch activities on Safety Management Systems (SMS) and Ground Safety, as part of Phase 2. In phase 2, the ECAST Ground Safety Working Group (GSWG) has been established in February 2009 and coordinates with major ground safety initiatives including the IATA Safety Audit for Ground Operations (ISAGO) established by the International Air Transport Association (IATA) and Ground Handling Operations Safety Team (GHOST) established by the Civil Aviation Authority of the United Kingdom (CAA UK). The GSWG has the overall objective to encourage implementation of action plans developed by existing ground safety NLR-CR-2010-125 10 April 2010 initiatives