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
• 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
Location of AC
Jackknife
Path of Travel
Line Key
Path of travel
Path of travel
In view of
camera
Location of main
concentration of
glycol
RF
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.
Location of
Incident
• 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.
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
Any Airport, CDA - Terminals
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 - 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
•
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 – 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.
Towbarless Tractor Incident - Investigation
Mr. Mark Shankland
Mgr. Acrft/Bgge Srvcs
NLG deflected ~ 45
degrees (red stripe is
max deflection
angle)
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)
Cradle
– 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 - Investigation
Mr. Mark Shankland
Mgr. Acrft/Bgge Srvcs
Air Canada
Buckled frame
Photos and Notes
– Forward cargo door frame
buckled by tractor
Light
Bracket
Sheared
off
– 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 - Investigation
Mr. Mark Shankland
Mgr. Acrft/Bgge Srvcs
Witness
marks
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)
Antenna
Struck and
Torn from
Mount
– 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 - Investigation
Mr. Mark Shankland
Mgr. Acrft/Bgge Srvcs
Air Canada
Photos and Notes
Sheen
– 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 - 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.
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.
Towbarless Tractor Incident
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.
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 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 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.
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.
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.
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.
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.
Towbarless Tractor Incident
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
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.
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.
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.
Towbarless Tractor Incident – Mitigation
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.
Towbarless Tractor Incident
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.