ground incident review featuring a distinguished panel of ground safety experts transport canada...
TRANSCRIPT
![Page 1: Ground Incident Review Featuring a distinguished panel of ground safety experts Transport Canada Safety Management Systems -SMS Information Session YVR](https://reader035.vdocuments.net/reader035/viewer/2022070305/55152c9a55034685568b4614/html5/thumbnails/1.jpg)
Ground Incident Review
Featuring a distinguished panel of ground safety experts
Transport Canada
Safety Management Systems -SMS
Information Session YVR - Nov. 2009
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• Moderator
• Mr. Gerry Pipe, Mgr. Corporate Safety Air Canada - YYZ
• Mr. Mark Shankland, Mgr. Acrft/Bgge Srvcs Air Canada - YVR
• Mr. Warren Maines, GM Servisair - YVR
• Mr. Steve Sogg Human Factors Consultant Boeing Commercial Aircraft - SEA
• Mr. Brett Patterson Dir Airside Ops YVR
Ground Incident Review
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Location of AC
Jackknife
RF
Path of Travel
Location of main concentration of
glycolPath of travel
Path of travel
In view of camera
Line Key
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Towbarless Tractor Incident - Background• XYZ Airline operates
from Terminal C at Any Airport, CDA.
• The crew consists of two ground support agents from a service provider.
• The agents are towing a fueled B737-900 aircraft from remote parking to their gate for upload.
• The crew is using a “tow barless” tractor.
This incident is a fictitious mock-up using de-identified material. Names, dates, and conditions have been altered in order to stimulate thinking in a training environment. No connection to an actual incident should be inferred.
Location of Incident
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Towbarless Tractor Incident - Background• Date / Time is
December 24th at 14:00
• Weather is clear, sunny, temperature 1c, wind is westerly at 29 gust to 45 Kmph
• The agents are proceeding to gate 71.
• There are several icy patches on the ramp where aircraft have previously de-iced with Water/Glycol
This incident is a fictitious mock-up using de-identified material. Names, dates, and conditions have been altered in order to stimulate thinking in a training environment. No connection to an actual incident should be inferred.
Any Airport, CDA - Terminals
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Towbarless Tractor Incident - Background
• Suddenly, without warning, the tractor jackknifes under the aircraft nose, turning approximately 135 degrees.
• The crew is shocked and stunned. They called maintenance on radio to report. The mechanic relays to ramp control and company operations.
• Within minutes, Airport Ops, Airline Ops, Service Provider and Safety Investigators respond.
This incident is a fictitious mock-up using de-identified material. Names, dates, and conditions have been altered in order to stimulate thinking in a training environment. No connection to an actual incident should be inferred.
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Towbarless Tractor Incident - Investigation
• Mr. Warren Maines,
GM Servisair YVR Vendor to XYZ
Airlines– Freeze Scene
– Disconnect Towbarless Tug 8 to maintenance facility
– Tow damaged aircraft to XYZ Airlines MTC Ops for further inspection
– Arrange for interview of both agents with XYZ and REDA consultant
This incident is a fictitious mock-up using de-identified material. Names, dates, and conditions have been altered in order to stimulate thinking in a training environment. No connection to an actual incident should be inferred.
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Towbarless Tractor Incident – Investigation• Mr. Warren Maines – GM Servisair YVR
• Interviewed driver and second agent at scene of accident– Driver had more than 7 years’ experience and worked 1
hour before the accident (shift change at 13:00 ET)
– Driver statement: “While me and my partner were pulling into Gate 71 with B737 at about 1400, we passed by a patch of glycol on the Taxi -Line. My partner was about to get off the tug, cause we were doing about 5-6 kmph, we loss control of the tug we spun and the side of the AC hitting the cargo door. I did not even apply the brakes the whole time.”
– Agent 2 had 1-2 years experience and worked 1 hour before the accident (shift change at 13:00 ET)
– Agent 2 statement: “to whom it may concern, at about 1415 me and Merv were tow a B737 in tug # 8. As we were come into Gate 71, I was about to get out to wing walk when the tug hit a patch of glycol and the tug lost control. The tug was traveling at about 7-9 kmph.”
This incident is a fictitious mock-up using de-identified material. Names, dates, and conditions have been altered in order to stimulate thinking in a training environment. No connection to an actual incident should be inferred.
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Towbarless Tractor Incident - Investigation Mr. Mark Shankland
Mgr. Acrft/Bgge Srvcs
Air Canada
Photos and Notes
– NLG at max deflection to right
– NLG should be aligned perpendicular to yellow “shoes” in cradle (parallel to tug’s lengthwise axis)
– Pivoting tractor caused NLG to twist out of “cradle”
This incident is a fictitious mock-up using de-identified material. Names, dates, and conditions have been altered in order to stimulate thinking in a training environment. No connection to an actual incident should be inferred.
NLG deflected ~ 45 degrees (red stripe is
max deflection angle)
Cradle
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Towbarless Tractor Incident - Investigation
Mr. Mark Shankland
Mgr. Acrft/Bgge Srvcs
Air Canada
Photos and Notes
– Forward cargo door frame buckled by tractor
– Tractor light separated from bracket
This incident is a fictitious mock-up using de-identified material. Names, dates, and conditions have been altered in order to stimulate thinking in a training environment. No connection to an actual incident should be inferred.
Buckled frame
Light Bracket Sheared
off
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Towbarless Tractor Incident - Investigation Mr. Mark Shankland
Mgr. Acrft/Bgge Srvcs
Air Canada
Photos and Notes
– Aircraft skin punctured by tractor
– Note “continuity of contact surfaces” (witness marks) on skin from tractor light bracket (previous slide)
– Blade antenna struck by tractor
This incident is a fictitious mock-up using de-identified material. Names, dates, and conditions have been altered in order to stimulate thinking in a training environment. No connection to an actual incident should be inferred.
Antenna Struck and Torn from
Mount
Witness marks
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Towbarless Tractor Incident - Investigation
Mr. Mark Shankland
Mgr. Acrft/Bgge Srvcs
Air Canada
Photos and Notes
– High sun angle from southwest (aircraft left)
– Sheen on ramp surface
This incident is a fictitious mock-up using de-identified material. Names, dates, and conditions have been altered in order to stimulate thinking in a training environment. No connection to an actual incident should be inferred.
Sheen
Sheen
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Towbarless Tractor Incident - Investigation Mr. Brett Patterson
Dir. Airside Operations YVR
– Ensure the Safety of the Scene
– Secure Scene Impact on Airport
– Info / Data Gathering
– Contain Spills
– Advise TC of incident
– Restore Operations
– Interview operator
– AVOP enforcement action
– Interview Air Navigation Srvcs
This incident is a fictitious mock-up using de-identified material. Names, dates, and conditions have been altered in order to stimulate thinking in a training environment. No connection to an actual incident should be inferred.
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Towbarless Tractor Incident - Investigation Mr. Steve Sogg
Consultant Human Factors
to XYZ Airlines
– Conduct pre Ramp Error Decision Aid (REDA) interview activities
• Review accident investigation results
• Identify personnel involved
• Review procedures
• Review accident and REDA records for similar events
• Review training records
This incident is a fictitious mock-up using de-identified material. Names, dates, and conditions have been altered in order to stimulate thinking in a training environment. No connection to an actual incident should be inferred.
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Towbarless Tractor IncidentModerator/Audience Interaction
• What’s your initial take on this?
– Operator human factors?
– Environmental conditions?
– Airport physical layout, signage, guidelines?
– Mechanical failure?
– Supervisory human factors?
– Sabotage by little green men from outer space?
• Why do you believe this to be true?
This incident is a fictitious mock-up using de-identified material. Names, dates, and conditions have been altered in order to stimulate thinking in a training environment. No connection to an actual incident should be inferred.
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Towbarless Tractor Incident – Data Analysis• Mr. Warren Maines – GM Servisair YVR Findings
– Both employees received paid suspension pending investigation• Both employees were trained on the equipment
approximately 6 months prior to the accident. • They also had taken a Mishap Training Course.
– This is second similar incident at ABC in one year with towbarless tractors at this airport
• Last year’s jackknife incident occurred during wet conditions at a speed of 14 kmph without any abnormal driver control input.
• Glycol, runway deicing fluid, snow rain and ice are common conditions on airports. We already train to reduce speed. Suggest involve manufacturer’s engineering team with this review.
• What steps can taken to reduce loss of vehicle traction? Is there a better tire for conditions specific to this airport, etc?
• Review manufacture recommendationsThis incident is a fictitious mock-up using de-identified material. Names, dates, and conditions have been altered in order to
stimulate thinking in a training environment. No connection to an actual incident should be inferred.
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Towbarless Tractor Incident – Data Analysis Mr. Warren Maines – GM Servisair YVR
– Non-Volatile Memory extracted from Towbarless Tug 8
– Driver used engine braking to decelerate from 28.4 kmph to less than 12.8 kmph just prior to incident (corresponds to his statement)
This incident is a fictitious mock-up using de-identified material. Names, dates, and conditions have been altered in order to stimulate thinking in a training environment. No connection to an actual incident should be inferred.
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Towbarless Tractor Incident – Data Analysis
Mr. Brett Patterson
Dir. Airside Ops - YVR Weather Service
– Temperature 1c
– Wind speed 29 kmph gusts to 45 kmph
– Ground Surface/Sub surface temperature
– No precipitation
This incident is a fictitious mock-up using de-identified material. Names, dates, and conditions have been altered in order to stimulate thinking in a training environment. No connection to an actual incident should be inferred.
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Towbarless Tractor Incident – Follow-up
Mr. Brett Patterson – Dir. Airside Ops YVR During interview with XYZ employee tug driver
before issuing citation
• Employee stated he was tired reporting on shift (up all night with new baby)
• Employee stated supervisor asked him to hurry to get B737 spotted at gate 71 due to maintenance delay
• Employee stated he was distracted by sun angle before initiating turn – did not see Glycol sheen
• Employee stated he had difficulty understanding Agent 2, a new Spanish-speaker who was trying to exit tractor before it had stopped. This was an additional distraction.
This incident is a fictitious mock-up using de-identified material. Names, dates, and conditions have been altered in order to stimulate thinking in a training environment. No connection to an actual incident should be inferred.
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Towbarless Tractor Incident – Data Analysis
Mr. Steve Sogg – XYZ Airlines Consultant – REDA– Conduct separate interview of Driver and Agent
– Contributing factors
Information Equipment/tools/safety equipment
Aircraft Design/Configuration Job/Task
Knowledge/Skills Individual Factors
Environment/Facility/Ramp Organizational Factors
Leadership/Supervision Communications
– Driver • Equipment/tools/safety equipment – Driven too fast in in Glycol
contaminated environment• Technical skills – Didn’t know what to do when jackknife started• Task knowledge – Did not understand how much inertia was involved• Individual factors – Decreased visual perception due to sun• Environment/Facility/Ramp – Glycol on ramp• Organizational Factors – Work process/procedures did not define
careful speed
This incident is a fictitious mock-up using de-identified material. Names, dates, and conditions have been altered in order to stimulate thinking in a training environment. No connection to an actual incident should be inferred.
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Towbarless Tractor Incident – Data Analysis
Mr. Steve Sogg – XYZ Airlines Consultant – REDA
Agent
•Knowledge/Skills – Did not know vendor process requirement to walk when visibility was bad
•Knowledge/Skills – Could not read procedure due to insufficient English language skills
•Organizational Factors – Selection process did not sufficiently assess English language (reading) competency
•Organizational Factor – It is the norm to ride is the tug at that location
This incident is a fictitious mock-up using de-identified material. Names, dates, and conditions have been altered in order to stimulate thinking in a training environment. No connection to an actual incident should be inferred.
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Towbarless Tractor IncidentModerator/Audience Interaction
• How about the facts brought forward now?
– Operator human factors?
– Environmental conditions?
– Airport physical layout, signage, guidelines?
– Mechanical failure?
– Supervisory human factors?
– Sabotage by little green men from outer space?
• Do we stop here?This incident is a fictitious mock-up using de-identified material. Names, dates, and conditions have been altered in order to
stimulate thinking in a training environment. No connection to an actual incident should be inferred.
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Towbarless Tractor Incident – Mitigation Mr. Warren Maines – GM Servisair YVR
– Company accepted Aviation Safety Action Program (ASAP) report from both employees
– Board of Inquiry (BOI) corrective action:• Company Safety Bulletin and shift relief awareness
campaign using de-identified incident photos to emphasize – never egress from a moving vehicle, even at slow speed!
• Employees are encouraged to report to Shift Supervisor any unusual personal circumstances affecting fitness to work; this could permit temporary re-assignment to non-technical tasks
• Supervisor training to emphasize adverse effect of suggesting subordinates hasten to accomplish complex tasks
• Company will investigate the standardization of training materials perhaps with pictorial support for English as Second Language employees.
This incident is a fictitious mock-up using de-identified material. Names, dates, and conditions have been altered in order to stimulate thinking in a training environment. No connection to an actual incident should be inferred.
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Towbarless Tractor Incident – Mitigation
Mr. Mark Shankland - Mgr. Acrft & Bgge Srvcs Air Canada– Company restricted the practice of de-icing aircraft in the Romeo
Fox Alley within 2 weeks of incident
– Field conditions and speed operations are briefed daily.
– Further speed restrictions are being considered during contaminated conditions.
– The safety department has approached XYZ Aprt Authority with concerns about the paving/sealing conditions around the Terminal B gate and ramp areas.
– GSE is investigating tire replacement on Supertugs to achieve greater friction in snow, ice, sleet, freezing rain and rain conditions
– Change to Ground Support Manual: “While driving in near-freezing conditions, especially in strong or gusting winds, be mindful of forces on the airplane which, combined with towing speed and inertia, may generate a skid…particularly on sloped and/or contaminated surfaces.”This incident is a fictitious mock-up using de-identified material. Names, dates, and conditions have been altered in order to
stimulate thinking in a training environment. No connection to an actual incident should be inferred.
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Towbarless Tractor Incident – Mitigation Mr. Brett Patterson – Dir. Airside Ops YVR
Brief incident at monthly Airport ASOC Meeting
• Review Ramp Ops Committee
– Liaison with Airport Maintenance and Planning Departments
• Post airport taxiway lights and signage around contaminated areas to warn ground handlers
• Post contaminated taxiway/ramp info on tower Voice Advsry to alert pilots
• Bulletins to Ramp Offices
This incident is a fictitious mock-up using de-identified material. Names, dates, and conditions have been altered in order to stimulate thinking in a training environment. No connection to an actual incident should be inferred.
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Towbarless Tractor Incident – Mitigation Mr. Steve Sogg – XYZ Human Factors
ConsultantRecommendations:• Expand towing training to include emergency conditions.
• Emphasize in training and crew meetings the effects of heavy aircraft on towing.
• Provide and require the use of sunglasses in bright sunlight conditions.
• Address the issue of Glycol on the ramp.
• Revise selection policy and process to assess reading competency.
• Emphasize to first level management the requirement for agents to walk, not ride on tractors in poor visibility conditions.
• Revise towing procedure to specifically define maximum speed in poor visibility conditions.
This incident is a fictitious mock-up using de-identified material. Names, dates, and conditions have been altered in order to stimulate thinking in a training environment. No connection to an actual incident should be inferred.
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Towbarless Tractor IncidentModerator/Audience Wrap-up
• Does it make sense?
– Hazard identification
– Risk assessment
– Development of mitigation strategies
– Measurement of effectiveness
• Is the mere absence of an event a confirmation of mitigation effectiveness?
– Why or why not?
– Questions?
This incident is a fictitious mock-up using de-identified material. Names, dates, and conditions have been altered in order to stimulate thinking in a training environment. No connection to an actual incident should be inferred.