GainJet Aviation Flight Safety Magazine
ISSUE 004
Table of Contents
Front Cover: GainJet’s Boeing 737, 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
Runway Incursions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Page 13
Why Use a Paper Loadsheet? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Page 17
Case Study – Linate Airport 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
magazine, which focuses on flight safety issues throughout the industry as an enlightening
forces behind
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.
Fly Safe!
Andrew Hallak
Editor,
A special thanks to all those who participated in this issue:
Capt. Ramsey Shaban, Capt. James McBride, Capt. Vangelis Lykoudis,
Mr. Kostas Karalis, Mr. Bill Zois, Ms. Olga Beglopoulou, Mr. Imran Saleem,
Capt. Dimitris Kehayas, Capt. Konstantinos Molyndris.
3
Extra Vigilance
Corporate aviation, unlike scheduled airlines, often
entails having to fly at short notice into airports the
crew have not flown into before. These, at times, can
produce challenging ground operations, which brings
to mind an incident I had many years ago while parked
on the ramp at a remote airport. The water service
truck started backing towards the aircraft, however
with no ground marshaller or person to supervise/
direct this movement. Sure enough, the next thing
we felt was an unpleasant jolt! We, the two crew
members, jumped out of the plane, but unfortunately
we were too late. The damage was done and the
plane was grounded for a week. (The truck driver who
caused damage to our aircraft was put in jail, but that
did not help! This was in the days before no-blame
culture had been invented).
I learnt a valuable lesson from that unfortunate
incident. Whenever fuel or service trucks are
approaching to service our plane, I made sure one of
the crew was quickly outside to supervise this service.
Ground Operations and incidents is the theme of this
edition. Having a crew member supervise ground ops
is not a standard procedure, however being extra
vigilant to the movement of such vehicles in the
proximity of their corporate planes would certainly be
good practice.
By Captain Ramsey Shaban
President
GainJet Aviation S.A
Flying On the Ground?
There is a misconception that the only danger with
flying is in the air - this is not true. If you research
ground accidents and incidents in the aviation
environment, you will see that people are very much
at risk before and after aeroplanes get airborne.
There have been many cases where ground handling
personnel have been injured or killed by getting
too close to operating engines, both propeller and
jet. Falling from aircraft doors onto the concrete
ramp below is an occurrence which happens all too
regularly, while at the same time you must consider
the frequent incidents regarding ground equipment.
Two pilots were struck by a baggage truck at night
on the ramp while not wearing high-visibility jackets.
Note that this occurred at an International Airport to
regular scheduled airline crew.
In our case, as an adhoc charter operator, EVERYTIME
we go to work, is an irregular operation and therefore
ALL THE TIME we should expect the unexpected.
Always look out for yourself and your colleagues
while moving and working on the ground and where
possible always follow Standard Operating Procedures.
It could be as simple as ensuring that you put the
yellow strap across an open door of the B737 or B757
when it is not in use and there are no steps outside.
This could save the life of a fellow crewmember as
these straps are designed to be very strong. When
moving to and from the aircraft in strange locations,
always use High-Vis yellow waistcoats and keep your
eyes and ears open. Never leave your own baggage
unattended and keep thinking about your colleagues’
bags too. If steps are fitted to the aircraft ensure that
the fence/gate across the side of the platform is in
place before you let passengers use them. These might
seem simple things, but we must keep our awareness
level high to keep ourselves, our fellow crewmembers
and our passengers safe.
If you think a dangerous situation is developing,
please stop it before an accident occurs – inform
the Senior Crewmember present and bring it to
their attention. If you break the dangerous chain of
events, quite probably you will prevent an accident.
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
Machines and human factors: Two variables that are
directly connected with aviation.
Over the past decades, major technological
advancements have been made, which has thus
raised flight safety to high levels. Advanced training
models and methods have been established, so flight
crews are able to cope with challenging situations like
adverse weather.
Machines: Are they unpredictable? Yes, in a way they
are. For example, a tiny piece of trash, some dust,
or extra moisture, may all cause some problems. So
we have to constantly monitor, observe and examine
our equipment to ensure nothing has affected
performance.
Humans: Are they unpredictable? No – not when we
deal with professionals, like those expected of GainJet
crew. Sure, there may be moments of stress or bad
mood, but professionals are able to overcome these
when duty calls. Professionals fulfill certain duties and
procedures for which they are well trained. This is the
reason GainJet chooses a certain caliber of crew and
engineers.
GainJet’s accountable personnel, studying past safety
indicators, introducing a safety planning system and
having adopted in its policy highly efficient training
and continuous monitoring, have succeeded in
reducing incidents concerning human deficiencies.
As you can see from the below charts, human
related incidents have decreased, as GainJet focuses
its training on making sure all crew and engineers
know, understand, and follow Standard Operating
Procedures (SOPs).
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
the focus of a number of articles will explain the
challenges faced by GainJet and its crew during the
Ground Phase of our operations.
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 due to
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.
GainJet operate flights globally, so that means our
crew often work in unfamiliar environments. Language
is sometimes a barrier as well as local procedures and
customs that differ from European ones. There are
some issues which consistently arise irrespective of
where GainJet operates. One of the most common
concerns during the ground phase relates to aircraft
loading. Airliners have strict guidelines on what, how
much and where passenger baggage and cargo is
loaded due to aircraft performance.
flight performance. Regrettably other issues can
also arise that lead to flights not taking off on time
such as fuelling delays. In certain locations, fuelling
companies are limited to a few or even one supplier,
who have limited resources and personnel.
A jet being refuelled. Fuelling delays are prone to happening, so
even though everything is done beforehand to ensure no delays,
crews must not lose focus if such delays take place.
Catering is another case in point that can be
problematic. Due to the nature of our business
GainJet has very high quality standards in respect
to the catering we provide to our passengers. So it
could be a case of limited suppliers able to cater to
such standards, which in effect may cause delays; or
if these standards fall short of our expectations, it
requires us to have the order re-supplied, and delays
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
flight crew. Discrepancies can exist between these
and actual figures, sometimes resulting in delays
to the flight and on rare occasions affecting aircraft
6
A Safety Assessment of Foreign Aircraft (SAFA) inspection being
conducted. When a SAFA inspection is conducted, it must be
completed even if it leads to a delayed flight. It is important to
stay focused.
While many of the challenges that GainJet crew
face on the ground can be overcome with a little
determination and focus, unfortunately the weather
can also adversely affect operations. For example
during inclement weather, ATC usually decide to
stagger takeoffs and landings depending on visibility
and cloud base. Frustratingly this almost inevitably
leads to delays in schedules.
It is important to always remember, especially in a VIP
jet charter operation where we cater to the world’s
elite, that we should not fall to commercial pressures.
In the event of on ground issues and/or delays, no
matter what circumstances arise, it is important to
stay focused. Yes, we should do all that we can to
ensure the flight is on time and that the passengers’
are happy with the flight operation, but most
importantly, we should NOT do this at the expense
of safety. It is imperative to keep calm, focused, and
observe all SOPs and flight checks before a flight
operation commences.
Due to the nature of the types of operations that
GainJet flies, every flight is unlike the previous.
Problems during the ground phase of a flight can
lead to increased frustrations for everyone
involved, but all GainJet flight and cabin crew have
significant airline experience in dealing with difficult
situations. As the old adage goes an “airplane’s crew
should leave all their problems behind them once
they enter the aircraft” - GainJet crew are no
different.
By Imran Saleem
First Officer – Boeing 737
Danger Can be On the Ground
Aircraft accidents are known for their relatively rare,
but disastrous mid-air occurrences; however these
accidents or incidents can be just as serious on the
ground. Such events are far more common than
we may believe. The International Civil Aviation
Organization (ICAO) reports that one-third of all
aviation incidents or accidents actually occur on the
ground.
injured each year in these accidents and incidents;
the injury rate is about 9 per 1,000 departures.
Ramp accidents cost major airlines worldwide at
least US $10 billion a year, the data indicates. These
accidents affect airport operations; result in personnel
injuries or fatalities; and damage aircraft, facilities and
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
cases, weather conditions and strong winds may also
be a culprit involved in an accident or incident.
Based on data that was developed by The International
Air Transport Association (IATA), the flight safety
foundation estimates that 27,000 ramp accidents
and incidents — one per 1,000 departures — occur
worldwide every year. About 243,000 people are
An Airbus A340-300 on a scheduled passenger flight collided
with a stationary bus with only the driver on board. Both the
aircraft and bus were damaged. No Injuries were reported. Ramp
accidents are costly and dangerous.
Since the operation of aircraft on ground and flying
above airports requires the coordination of many
people, including flight crew, air traffic control and
ground staff, a single error or miscommunication can
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.
Inside the tower. Air Traffic Controllers on duty overlooking the
runway. Many different people are involved in the flight operation
on ground, so clear communication & following procedures is
imperative to avoid accidents or incidents.
Heavy winds have been known to cause hardship
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.
If heavy winds have been forecasted at an airport, it
is imperative to communicate and take the necessary
action to ensure the safety of personnel, aircraft, and
equipment. Tools and loose items need to be packed
away, extra securing needs to be used for aircraft, and
any vehicles should be cleared away.
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.
The airport authorities issued warnings that were
distributed to the operators or their representatives
in order to take necessary action. However, in the
mean time and before any additional action could
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
imperative.
8
Aircraft can also be secured inside hangars during heavy winds.
Although a more costly option, it may be the most appropriate
option in some specific cases.
Safety is our top priority in GainJet and we must all
pay attention to following the procedures that keeps
our company in the elite league of aviation.
By Bill Zois
Flight Dispatcher/Operations Officer
The Numbers
Almost one-third of airplane accidents that occur
worldwide happen on the ground, reports the
International Civil Aviation Organization (ICAO).
The number of accidents did, however, reach an all
time low in 2010 reports the ICAO. Even though the
number of accidents has decreased, the ICAO has
forecast traffic will rise by 70% within a decade, which
could change that trend. “The trend is worrisome
because the rate of accidents is flat, but the (air
traffic) growth is increasing, so when you take those
two things together, you’re going to get increased
accidents,” said ICAO director of air navigation Nancy
Graham, according to The Age.
In the 13 years between 1995 and 2008, there were
1,429 airline accidents around the world. 431 (or
about 30%) of those occurred during takeoff or
landing. Poor runway design and pilot error are to
blame for these incidents.
The ICAO also cited factors like airport design and
construction, air traffic control, air traffic management
systems, airline operations, flight crew awareness and
communications as problems.
After the ICAO and IATA released new runway
operation safety guidelines in 2009, the number of
crashes began to drop.
ICAO news
By Captain Konstantinos Molyndris
Training Manager
A Significant Safety Issue - Vortices
Wingtip Vortices are generated by all aircraft as a
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.
Once vortices are formed, they continue to descend
until they decay. Although a vortex encounter at low
altitude is uncomfortable and alarming, generally
The above two pictures are a great real-life example of how an
aircraft creates vortices upon lift created by the wingtips. The
pictures also show the movement o f these vortices. Vortices can
exist during take-off or landing, and care must be taken when
operating after another aircraft has taken-off or landed.
9
it is recoverable. Attention should be paid when
extreme conditions are met. In the worst of cases, it
may be beyond the power of the ailerons to counteract
the roll. Even executive jets have been rolled upside
down.
Close to the ground, vortices generally persist
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.
The vortices are generally invisible, so there are a few
techniques to cope with this phenomenon.
Distance can be judged visually by runway length
so if the recommended spacing is five to six miles,
then you need three to six runway lengths between
yourself and the aircraft ahead of you.
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
aligned with the flight path of the aircraft ahead.
By Captain Dimitris Kehayas
Flight Operations Manager
Extra Care is Extra Important
There are many dangers that are present on ground
at an airport, especially when trying to make up for a
delay while preparing an aircraft or upon arrival when
passengers are anxious to disembark. Combine this
with the facts that things are constantly moving at an
airport and many different people are involved with
flight preparations/operations, and the realization of
such dangers is looming about. So taking extra care is
really important.
10
Consider the case when in March 1999 a five yearold child was injured during disembarkation from a
Boeing 767 at a Canadian airport. The aircraft was
parked on the open ramp away from an aerobridge,
and steps were used.
After the first 10 passengers had left the aircraft a
flight attendant exited the aircraft carrying an infant
in a car seat. When the flight attendant stepped onto
the passenger stand he noticed it was descending
slowly away from the aircraft. As he turned to tell the
in-charge flight attendant, the infant’s five year-old
brother, who was following with his mother, stepped
out of the aircraft and fell between it and the stairs
to the apron below. The child suffered a broken arm
and lacerations to the head in the fall and was taken
to hospital for treatment and observation.
Implementation of safety rules, regulations and
procedures by aircrew while on the ground is very
important. Even at hectic moments like preparing
an aircraft for departure, it is always imperative to
stay focused and conduct your duties according
to procedure. Aircrew must be particularly careful
that the air bridge or steps are correctly positioned
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
respect to safety. First of all, and most importantly,
it is the responsibility of all crew, engineers, and the
entire company to ensure the safety and security of
our passengers, our colleagues, and equipment. So
being extra vigilant ensures the accomplishment of
such a mission. Our focus on safety is the first step in
the success of the entire operation.
The industry has recently began looking more
thoroughly at ground operations, especially since
the advantages and savings of improving safety and
reducing damage to aircraft and ground vehicles were
estimated at around $4 billion a year for the industry
as a whole.
Cost has become a major issue in today’s economically
challenged environment. In a world of diminishing
profit margins, increasing fuel prices and intense
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
program.
An accidentally released emergency slide after ground personnel
opened the armed exit door of an American Airlines Boeing 757.
After an incident with the B757 in the maintenance
facility, where a mechanic was thrown out of the
aircraft because of a defective power assist system
that accidently kicked in, we realized how much more
careful aircrew have to be in handling doors equipped
with slides.
Our travels sometimes take us to small unknown
and ill-equipped places that are not quite prepared
or capable to handle the level of services we may
require. This is the reason that we, as a company, are
also trained and advised to be very cautious in less
advanced and equipped airports. I urge you to use
that training. My experience has shown that clear
communication and any help we can provide the
ground personnel will be to our benefit since being
proactive is the key to a safe operation.
By Olga Beglopoulou
Cabin Crew Manager
11
Ground Accident Prevention
The scope of this article is not to analyze in depth
ground accidents and incident causes, but to give a
general picture of how much ground accidents can
affect the operation of a company. Ground damage
can be avoided, if maintenance safety procedures,
company rules and safety polices are strictly followed.
Ground damage incidents (events in which airline
personnel cause damage to an aircraft on the ground)
occur as airline personnel are working on or around
an aircraft on the ground, either on the ramp or at
a maintenance facility. Ground damage or damage
to an aircraft caused by airline personnel while the
aircraft is on the ground, remains a serious problem
for most airlines, with costs in the tens of millions of
dollars per year.
A Sabena Airbus A330-301 was being towed to a maintenance
facility at Brussels Airport when the driver of the TUG lost
directional control on the slippery ground surface. The aircraft slid
out of control and impacted a Sobelair Boeing 737-329.
Based on activity data developed by the International
Air Transport Association (IATA), it is estimated
that 27,000 ramp accidents and incidents - one per
1,000 departures - occur worldwide every year.
About 243,000 people are injured each year in these
accidents and incidents; the injury rate is 9 per 1,000
departures. The economic toll is significant: The
current estimate is that ramp accidents are costing
major airlines worldwide at least US$10 billion a year.
A conservative estimation is that ramp accidents cost
corporate aircraft operators $1 billion a year. Damage
caused by hail, bird strikes, mechanical failure is not
considered to be ground damage, and have their own
separate prevention programs.
Each incident can be very expensive to a company,
with costs both tangible (repair costs and lost
revenue) and intangible (passenger inconvenience,
increased maintenance workload). One of the
companies’ most difficult tasks has been to utilize the
information collected in their existing error reporting
12
systems to determine the common latent failures
which contribute to typical ground damage incidents.
Problems in identifying causes of recurrent incidents
are at least partially the result of inadequate methods
of collecting information about errors. In a typical
airline, errors (above a certain threshold of severity)
are strictly monitored and recorded. For example,
airline management may maintain stringent records
of on-time flight departures/arrivals, turnaround
time for aircraft requiring maintenance, injuries to
personnel, damage to aircraft and other ground
equipment, and other measures that document
the airline’s overall performance. In addition, many
errors (below the threshold of severity for reporting)
may be detected and corrected routinely as part of
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,
active failures are errors or violations that have a
direct and immediate effect on the system.
Latent failures are those failures that derive from
decisions made by supervisors and managers who are
separated in both time and space from the physical
system. For example, technical writers may write
procedures for a task with which they are not totally
familiar; if the procedure has even one mistake in it,
the mechanic using the procedure will be encouraged
to commit an error.
For an incident to occur, latent failures must combine
with active failures and local triggering events,
such as unusual system states, local environmental
conditions, or adverse weather. There must be
a precise alignment of all of the ‘holes’ in all the
defensive layers in a system. For example, rain may
cause a mechanic’s foot to be wet, allowing his foot to
easily slip off the worn brake pedal in a pushback tug
when the mechanic becomes distracted. The tug may
then lunge forward contacting a parked aircraft.
The latent failure in the system is that the brake pedal
has no anti-slip surface in place, but the problem
does not become an issue until the rainy conditions
(a local trigger) cause an incident. If any one of these
failures had not occurred (mechanic did not become
distracted, the tarmac was not wet, or the brake pedal
was in better condition), the incident would have
been avoided.
A pushback tug strikes the engine of a Continental B737.
There is growing realization in the aviation industry
that encouraging prompt reporting of safety issues
actually reduces the number of accidents and
incidents. An environment of a “just culture” is
a key element in fostering “open reporting” - for
the systematic reporting, collection, analysis and
dissemination of safety information that will be used
solely to prevent accidents.
An important concept in an effective Ground
Accident Prevention System is that it is not the sole
responsibility of the company’s Safety Officer; it is the
responsibility of everyone within the company.
Senior managers are responsible for establishing and
maintaining this System. Their roles and
responsibilities include:
• Establishing levels of acceptable risk;
• Establishing safety policy;
• 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,
• Conducting incident investigations.
Employee acceptance of this System and Safety
Programs is essential for success and can be achieved
by having employees:
• Help develop and establish safety programs;
• Participate on safety committees;
• Follow established procedures and not take short
cuts;
• Assist in investigations;
• Report hazards and incidents; and,
• Provide feedback to managers.
GainJet Accident Prevention and Flight Safety Program
provides guidelines for accidents prevention and is a
“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
a part of the nature of flying; however events like
ground collisions are much harder to understand.
CGI render of 2 B747s, KLM 4805 and Pan Am 1736, collision due
to a runway incursion at Los Rodeos Airport in Tenerife in March
1977. It’s one of the deadliest accidents in aviation history.
13
A Runway Incursion is defined as “Any occurrence at
an aerodrome involving the incorrect presence of an
aircraft vehicle or person on the protected area of
a surface designated for the landing and takeoff of
aircraft.”
Contemporary aerodrome security procedures ensure
that it is a well supervised environment within which
to operate aircraft. Modern ATC and Ground radar
support minimize abnormalities or risks that may rise.
The personnel involved, controllers and pilots, are
specially educated and trained professionals able
to cope with any situation, but accidents involving
aircraft on the ground still happen. Analysis of all
runway incursions clearly indicates human error
or negligence. Fatigued or distracted air traffic
controllers and/or flight crew, air traffic congestion or
bad communications are some of the factors which
can contribute to runway incursions.
first aircraft, which has entered the active runway
contrary to clearance and at an intermediate
point, the controller clears a second aircraft for a
full-length take-off.
• Flight Crew-induced situation. An aircraft lands at
an unfamiliar airport and the flight crew becomes
disorientated as they exit the runway. Despite this,
they acknowledge taxi instructions and without
being confident of their position or the taxi route
given, continue taxing and inadvertently enter an
active runway.
Contributory Factors
• Weather: Low visibility may increase the chance
of flight crew becoming disorientated and unsure
of their position whilst taxiing. Low visibility is also
likely to restrict a controller’s ability to identify
and follow aircraft visually so that cross-checking
a reported aircraft position with its actual location
may become impossible.
Air Traffic Controllers have a very important duty. However,
there may be times they are distracted, overworked, tired, or
overstressed. So confirm all communications and be alert.
Operation during low visibility at and around an airport is
challenging and requires extra attention.
While most events do not result in accidents, there
have been some noteworthy tragedies. The accidents
at Tenerife North and Milan Linate cannot be deleted
from the mind.
• Late Issue of Departure Clearances: This may lead
to a temporary lapse in flight crew situational
awareness as the aircraft must be set up for the
departure whilst taxiing.
• Multiple Line-ups: Use of Multiple Line-ups for
aircraft departures from the same runway at
different entry positions increases the potential
for error.
• Simultaneous Use of Intersecting Runways:
Unless ATC SOPs are carefully formulated and
rigorously applied, use of intersecting runways
can significantly raise the risk of both runway
incursions and loss of Separation between aircraft
near the ground and aircraft on the ground.
At some airports where intersecting runways
are used, especially in the USA, Land and Hold
Short Operations are part of normal procedures.
These are considered by some non-US aircraft
operators to introduce an unacceptable level
of additional risk; consequently, their flight
crews are instructed to decline offers of such
clearances.
Most Common Types of incursions
• Departing aircraft runway entry contrary to ATC
clearance
• Aircraft runway crossing after landing contrary to
ATC clearance
• ATC runway occupancy clearance in error or
misjudged
• Towed aircraft runway crossing contrary to ATC
clearance
Typical Scenarios
• ATCO-induced situation: With Low Visibility
Procedures in force because of fog, a controller
gives a clearance to an aircraft without
subsequently checking for a correct read-back
from the flight crew who have misunderstood the
instructions. Without checking the location of the
14
Intersecting runways propose a risk if precise coordination is
not used. In cases where airports utilize intersecting runways
simultaneously, there is great risk for runway incursions to take
place. It is important to be alert & aware of surroundings.
• Aerodrome design: If, as a consequence of
aerodrome design, aircraft are obliged to taxi
across active runways in order to get to parking,
or to reach another active runway, the likelihood
of runway incursions is increased. (See Barcelona
LEBL runway chart reproduced on page 16). This
risk may be reduced if Runway Hotspots have been
identified and the flight crew applies effective
risk mitigation. Operation with intersecting
active runways is also likely to require careful
consideration to ensure that risk of conflict is not
thereby increased.
• Conditional Clearances: If conditional clearances
are used, the risk consequent upon any error
in their issue or actioning may be increased
especially because of aircraft identification errors.
The chances of such errors are increased if aircraft
livery does not readily correspond to the RTF
call sign being used; this is sometimes the result
of airline alliance livery policies or the ad hoc
operational substitution of leased-in aircraft.
• Phraseology: Use of Non-Standard Phraseology
or non-adherence to Standard Phraseology can
lead to clearance confusion and misunderstanding
between flight crew and controllers.
• Simultaneous Use of More than One Language
for ATC communications: At some international
airports, domestic flights may communicate in the
local language whereas international flights should
do so in English. Depending on the nature of the
local language and the language skills of the visiting
flight crew, this may have the effect of significantly
reducing their awareness of the relative position
of other traffic.
Distraction. This is the immediate cause of many
incursions, although the context in which it occurs
is often of more direct relevance to effective risk
mitigation
Workload Factors such as:
➣➣ Pilot Workload. Shortly after landing, flight crew
have to orientate themselves quickly in respect
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 takeoff, briefing crew and passengers, receiving
amended departure clearance instructions from
ATC, checking unfamiliar departure procedures,
etc. Under these circumstances of high workload,
a temporary loss of situational awareness or
communications confusion are more likely to
occur.
➣➣ Controller Workload. Controllers handling
multiple aircraft movements and handovers
have relatively little time available for monitoring
individual aircraft to confirm that they are taxiing
in accordance with their clearances.
Communication breakdown
Examples of communication breakdown on the
maneuvering area include, but may not be limited to:
-- Complex instructions to different aircraft;
-- Controller high speech rate;
-- Two different languages;
-- R/T Frequency congestion / blocked frequency;
-- Use of non standard ICAO phraseology by air traffic
control;
-- Call sign confusion;
-- Poor read-back procedure;
-- Inadequate aviation English;
-- Different frequencies associated with runway
operations.
Loss of communication and runway incursions.
Entering a runway (to line up or cross) or landing
without a valid clearance will lead to the incorrect
presence of traffic on a runway and requires a runway
incursion to be reported. Pilots should squawk 7600
in VMC or IMC to advise loss of communication on the
maneuvering area.
Defences
The best defence in order to minimize/avoid such
occurrences is to keep a continuous listening watch
to the frequencies in use. Be prepared to clarify any
differences or omissions between communications.
Do not be in doubt. Do not hesitate to confirm the
instructions given and re-advise your intentions.
FLY SAFE.
By Captain Vangelis Lykoudis
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
much of our working life is spent operating our aircraft
via keypads, touchpads, alphanumeric keys and other
remote control devices. On the Boeing fleet at GainJet
however, we still make our weight calculations the
“old fashioned” way with a paper loadsheet and
a calculator. This may seem strange to some of our
pilots – especially those who are new to the company.
We can imagine that they are thinking it would be
much easier and quicker to use an electronic means
of loadsheet (and trim) calculation – after all we use
an electronic flightbag don’t we? We must always
remember the first rule of computers however – they
are only going to be ever as good as the programmer:
“Garbage in = Garbage out”.
A baggage handler loading luggage into an aircraft. It is important
to ensure correct load calculations, which is assisted by using the
old fashioned, but safe, paper loadsheet and calculator. Vigilant
coordination with loading personnel will also help ensure correct
loading calculations.
The subject has been debated many times in GainJet
Aviation Management meetings at head office and
all the pros and cons have been carefully considered.
There is no doubt that there are some automated
systems which would be potentially much quicker
than manual calculation of the aircraft weights,
however our real risk is that ours is not a scheduled
airline operation. We believe it is important for our
pilots to always be actively ‘engaged’ in the loading
and load calculations for departure. The principle
that we follow as an SOP is that one pilot makes the
calculations for Weights, CofG, Stab Trim setting,
Takeoff Speeds/Power Settings and the second pilot
makes an independent crosscheck of all the figures.
This method ensures that both pilots are critically
aware of what weight is being loaded in which
compartment – especially the aircraft holds.
Using a process which involves the flight crew actually
thinking about all the performance parameters,
means that it is more likely they will see errors before
they are lost in an automatic system of load control.
On balance; the way we use our paper loadsheet
is simply safer and that is the reason why it is our
Standard Operating Procedure. The following article
regarding the potentially catastrophic results of
automatic (computerised) loadsheet calculations
confirms that we have made the right decision.
United Overweight Takeoff on Computer
Mistake Prompts Changes
- Aimee Turner, Correspondent with Flight International –
A computer breakdown caused a United Continental
Holdings Inc. (UAL) flight to take off earlier this year
about 20,000 pounds (9,071 kilograms) heavier than
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
issues, according to another person.
“Earlier this year, we experienced technology issues in
capturing correct passenger counts on a small number
of our flights,” Megan McCarthy, a spokeswoman for
the airline, said in an e-mail yesterday. The incident
was recounted in a July 9 bulletin from United
management to its pilots, said one person, who
couldn’t say when the incident occurred.
United and the U.S. Federal Aviation Administration
(FAA), which said the airline reported the breakdowns
to it, said they’ve taken steps to prevent such incidents
in the future. United is requiring its pilots to perform
two additional, manual checks on weight and balance
calculations before each flight, the FAA said in an
e-mailed statement.
Difficult Liftoff
“The FAA has been monitoring the situation and is
satisfied with this interim measure while the airline
develops a permanent solution,” the agency said.
United has had computer and operational problems
in recent months as it transitioned to new passengerservice and aircraft preventive-maintenance systems.
Both were used at Continental Airlines Inc. before it
merged with United parent UAL Corp. in 2010.
17
All airlines estimate a plane’s weight before each
flight. The weight information, along with data on
air temperature and other factors, allows pilots to
calculate the precise speed at which they should lift
the nose during takeoff. If pilots try to take off with
too much weight, it can cause a plane to scrape its
tail on the ground or to skid off the runway without
getting airborne, according to accident reports.
Boeing’s 737-900 models can take off weighing
as much as 187,700 pounds (85,141 kilograms),
according to Boeing’s website. Even fully-loaded jets
frequently take off at lower weights.
airport structure before climbing. “There were no
injuries, but this accident was considered to be a close
escape from catastrophe,” a NASA report on the issue
published in June said.
Seven people aboard an MK Airlines Ltd. Boeing
747 freighter died on Oct. 14, 2004, after making a
249,000-pound (113,000 kilograms) error before
attempting to take off in Halifax, Canada, according to
the NASA report.
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 postcrash 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
pavement as it failed to get airborne and clipped an
18
By Captain James McBride
CEO & Accountable Manager
Case Study
Linate Airport Disaster
Cessna Citation 525-A, D-IEVX
Scandinavian Airlines – 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
business jet, with registration D-IEVX, was scheduled
to depart Linate Airport in Milan, Italy bound for Paris,
France for a demo flight for a prospective buyer who
was onboard. The aircraft had arrived in Milan earlier
that day from Germany during foggy conditions and
low visibility, and the landing run took the aircraft
beyond Taxiway (TWY) R6 (intersecting with the
runway) and the crew then requested and obtained
permission to backtrack and to taxi on that TWY in
order to proceed towards the West apron (General
Aviation apron). No other incidents were reported
before departure.
At about the same time of the Cessna’s departure,
Scandinavian Airlines (SAS) Flight 686, flown by
a McDonnell Douglas MD87 with registration SEDMA, was also scheduled to depart Linate Airport
to Copenhagen, Denmark. The two aircraft collided
during the takeoff run of the MD87 when the Cessna
accidentally entered the active runway, creating a
runway obstruction. After the collision, the MD87
continued down the runway until it crashed into a
baggage handling facility, which was also destroyed.
All 110 people onboard of the MD87 as well as four
ground personnel were killed and several more
ground personnel injured. The Cessna remained on
the runway and was destroyed by post-impact fire; all
its four occupants also being killed.
On the day of the accident, at 7:41 local time (lt) the
ground controller cleared the MD87 to start engines
and advised that the slot time for takeoff of the flight
was at 08:16. At 08:05, the pilots of the Cessna then
received taxi clearance: “Delta Victor Xray taxi north
via Romeo 5, QNH 1013, call me back at the stop
bar…” The pilot acknowledged by saying: “Roger
via Romeo 5 and ... 1013, and call you back before
reaching main runway.” Shortly after beginning taxi,
the aircraft reached a position where the yellow taxi
line splits into two diverging directions, and the pilot
erroneously took the taxi line to the right and entered
taxiway R6 (southern taxiway). At 8:08 lt, the Cessna
crew confirmed their position as “approaching the
runway…Sierra 4,” and at 08:09, even though he was
not familiar with the position, the ground controller
cleared the Cessna to continue its taxi on the North
apron, clearly not aware where the aircraft was
actually located. At the same time, the MD87 was
given clearance to take off from runway 36R. About
a minute later, the MD87, traveling at about 270 km/
hour, collided with the Cessna, which accidentally
entered the active runway 36R. The MD87 lost its right
engine and the starboard landing gear in the collision,
but the flight crew still attempted to take off, reaching
an altitude of approximately 12 meters. However,
the remaining engine lost some thrust due to debris
ingestion, and the aircraft descended. The pilot
applied thrust reverser and brakes, and tried to guide
the plane through its control surfaces (a maneuver
that was judged so skillful that it is now incorporated
into SAS technical manuals). Alas, his efforts were,
however, insufficient to stop the aircraft. It skidded
past the grass overrun area, across a service road, and
crashed into a baggage hangar facility located near
the end of the runway, at a speed of about 251 km/
hour.
In its final report, the Agenzia Nazionale per la
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.
The Cessna remained on the runway after the collision, where it
was completely destroyed by post-impact fire.
cause of the accident was the runway incursion in
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
entered the runway without specific clearance.
• The ground controller was not familiar with the
identifier S4 when the Cessna crew correctly
reported its position, which was on the wrong
taxiway, and disregarded this identification.
• ATC personnel did not realize that the Cessna was
on taxiway R6 (southern taxiway).
• The ground controller issued a taxi clearance
towards “Main Apron” even though he didn’t know
where the Cessna was since he didn’t recognize
the correctly reported position S4.
• Radio Procedures were not performed using
standard phraseology (read back) and resulted in
misunderstandings and miscommunication.
• Radio communications were performed in both
Italian and English and not in one consistent
language.
• The nature of the flight, as a test flight for a buyer,
might have applied commercial pressures on the
Cessna crew to commence the flight despite the
prevailing weather conditions.
20
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 lack of official documentation to report the
presence of unpublished marking, which were
therefore unknown to the ATC controllers.
• Lack of adequate training of ATC personnel.
A diagram showing the Cessna’s mistaken route which led it to
produce the runway incursion that resulted in the accident.
The “Linate Airport Disaster” is a clear indication
that following Standard Operating Procedures
(SOPs) is a MUST. Obviously the lack of certain aids
and markings, accompanied by the adverse weather
conditions were major contributing factors in this
case, but miscommunication and misunderstanding
were also crucial factors here. Clear communication,
confirmation of instructions, and following the
Standard Operating Procedures are key always,
especially when there are other adverse factors
surrounding the operation like weather and high traffic
volume. This case demonstrates that commercial
pressures should be secondary to safety. The crew
was not qualified to operate in such weather and
should have made the decision to “wait it out”. Safety
is the first priority.
This case study uses excerpts from the ANSV accident
report N.A/1/04. For more information please visit: http://
www.ansv.it/cgi-bin/eng/ FINAL%20REPORT%20A-1-04.pdf
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 747422, registered N127UA, was scheduled to depart
Melbourne Airport in Australia travelling to Sydney.
The B747 was cleared to taxi along a route from the
international apron to the holding point Bravo (B),
for departure on runway 16. This route took the 747
through taxiways Uniform (U) and Alpha (A). During
the 747’s taxi for departure, an Australian Airlines
(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.
In the accident, the 747 sustained considerable
damage to the leading edge of the left wing tip. The left
wing tip fairing sustained chord-wise damage except
for a small section near the trailing edge of the wing,
and the left navigation and strobe light coverings were
destroyed. The 767 sustained substantial damage
to the right horizontal stabilizer. A significant part
outboard of the elevator was also destroyed.
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.
A diagram of the intersection where the accident occurred.
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
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:
• The pilot in command of the B747 made the
decision to make the maneuver to taxi behind the
B767 based on his assessment that it was safe to do
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
demands may have played a role in the pilots’
decision to make the maneuver rather than wait.
• Views from the tower to the intersection were
partially obstructed by structural materials, in
addition to the fact that distances and major
details were hard to judge from that vantage point.
So once the B747 deviated, the ground controllers
could not help.
• Once the 747 deviated, they also lost the
assistance of markings on site. So the 747 crew
was maneuvering on its own, with no guidance.
It is important to remember that procedures have
been put in place in order to avoid instances like
this. Yes, it is part of our duty to make sure our
passengers’ flights are satisfactory, which includes ontime departures, but we should not make sacrifices to
safety in order to accomplish this. Following Standard
Operating Procedures (SOPs) is a must. Please also
22
remember that it is the Ground Controllers’ duty to
guide all movements on ground. Maneuvering off any
clearances or instructions given by them could lead to
collisions or even runway incursions.
A view from the control tower at Melbourne airport. As you can
see, the intersection where the accident occurred was partially
blocked by structural obstructions. So when the B747 deviated
from its cleared taxi route, the controllers had no way of assisting.
However, also keep in mind that human error is
natural and mistakes will happen, especially when the
controllers are understaffed or are simply tired, and
especially considering that we sometimes operate to
airports with limited resources and where language
could also be an additional obstacle. It is imperative
to confirm all instructions and pay attention to your
situation, in order to avoid accidental consequences
of incorrect/unconfirmed ATC clearances or
instructions. Flight crew should be alert while taxiing.
If in doubt, stop the aircraft and request progressive
taxi instructions from ATC, or marshaller assistance.
This case study uses excerpts from the ATSB accident report
200600524. For more information please visit:
http://www.skybrary.aero/bookshelf/books/1210.pdf
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:
The guard rail at the top of the stairs does
not cover the entire area, leaving a gap large
enough for someone to fall through and down
to the tarmac.
Capt. Vangelis Lykoudis
Mr. Vassilis Apostolou
Flight Safety Officer (FSO)
Company Security Officer
Email: [email protected]
Email: [email protected]
Or visit www.gainjet.com