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Ground Incident Review. Transport Canada Safety Management Systems -SMS Information Session YVR - Nov. 2009. Featuring a distinguished panel of ground safety experts. Ground Incident Review. Moderator Mr. Gerry Pipe, Mgr. Corporate Safety Air Canada - YYZ

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Slide1 l.jpg

Ground Incident Review

Transport Canada

Safety Management Systems -SMS

Information Session YVR - Nov. 2009

Featuring a distinguished panel of ground safety experts


Slide2 l.jpg

Ground Incident Review

  • 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


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Location of AC

Jackknife

Path of Travel

Location of main concentration of glycol

Line Key

Path of travel

RF

Path of travel

In view of camera


Towbarless tractor incident background l.jpg

Location of Incident

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.


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Any Airport, CDA - Terminals

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.


Towbarless tractor incident background6 l.jpg
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.


Towbarless tractor incident investigation l.jpg
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.


Towbarless tractor incident investigation8 l.jpg
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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NLG deflected ~ 45 degrees (red stripe is max deflection angle)

Cradle

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.


Towbarless tractor incident investigation10 l.jpg

Light Bracket Sheared off angle)

Buckled frame

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.


Towbarless tractor incident investigation11 l.jpg

Antenna Struck and Torn from Mount angle)

Witness marks

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.


Towbarless tractor incident investigation12 l.jpg

Sheen angle)

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

Sheen

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.


Towbarless tractor incident investigation13 l.jpg
Towbarless Tractor Incident - Investigation angle)

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.


Towbarless tractor incident investigation14 l.jpg
Towbarless Tractor Incident - Investigation angle)

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 Incident angle)Moderator/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 angle)

  • 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 recommendations

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.


Towbarless tractor incident data analysis17 l.jpg
Towbarless Tractor Incident – Data Analysis angle)

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.


Towbarless tractor incident data analysis18 l.jpg
Towbarless Tractor Incident – Data Analysis angle)

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.


Towbarless tractor incident follow up l.jpg
Towbarless Tractor Incident – Follow-up angle)

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 angle)

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 carefulspeed

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 angle)

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 Incident angle)Moderator/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.


Towbarless tractor incident mitigation l.jpg
Towbarless Tractor Incident – Mitigation angle)

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 angle)

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.


Towbarless tractor incident mitigation25 l.jpg
Towbarless Tractor Incident – Mitigation angle)

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 angle)

Mr. Steve Sogg – XYZ Human Factors Consultant

Recommendations:

  • 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 Incident angle)Moderator/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.


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