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Its timely with phase one of SMS implementation on 1 July
this year, to consider all aspects of safety management, and
this includes ground operations. Flight Safety editor, Margo
Marchbank, gives an overview of this often-neglected area of
aviation safety.
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Three accidents which have occurred in the past
four years demonstrate the potential human
and hull cost of ground operations accidents.
The rst took place on 28 December 2005 on
Alaskan Airlines Flight 536, where an MD-80,
20 minutes out of Seattle, bound for California
with 142 people on board, was rocked by a
thunderous blast, and dropped from 26,000ft.
According to the National Transportation Safety
Board (NTSB) senior investigator, baggage
handlers at Seattle had creased the side of the
aircraft with loading equipment. This crease,
20 minutes after takeoff, developed into a one
foot by six inch hole, causing depressurisation
of the aircraft. The aircraft returned to Seattle,
and was landed safely without injury to crew
or passengers.
The second occurred on 18 May 2007 in
Syracuse, New York. The Douglas DC-9-31,
operated by Northwest Airlines, with 99 people
on board, was climbing through approximately
20,000ft, when the ight crew heard a loud
pop and the cabin depressurised. After an
uneventful landing, postight inspection
revealed a 12-inch by ve-inch fuselage
skin tear, approximately six feet forward of
the forward cargo door. After a belt loader
malfunction, the senior ground agent had
attempted to move the belt loader away from
the aircraft by pushing it with a luggage tug,
but the tugs cab hit the fuselage. He had
advised fellow workers not to say anything.
The NTSB determined that the probable cause
of the accident was the the senior ground
agents failure to follow written procedures
and directives.
The third and most recent took place on
1 February 2008, and involved a UK night
cargo ight from Edinburgh to Coventry.
The Fokker F27 was undergoing de-icing at a
wintry Edinburgh Airport, with both engines
started. The commander (captain) signalled
the marshaller to remove the ground power
unit (GPU) from the aircraft, which was facing
nose out from its stand, down a tight slope.
As the marshaller went to assist his colleague
to remove the GPU to a safe distance prior to
the aircraft taxiing off the stand, the aircraft
started to move forward slowly, forcing them
to run to safety. The ight crew, who were
looking into the cockpit, were unaware that
the aircraft was moving. It continued to move
forward until its right propeller struck the GPU,
causing substantial damage to the GPU, the
propeller and the engine. The ground crew
were uninjured.
Accidents and incidents involving ground crew,
who include: cargo/baggage handlers, refuellers,
potable water/ toilet system servicers, catering
support, cleaners, aircraft and equipment
servicers, maintenance and security, have
received little attention historically. However,
as the diagram on the next page of a [B747
on the tarmac surrounded by ground crew
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and vehicles] illustrates, the number
of personnel servicing an aircraft,
and getting it into the air safely, is
signicant, especially in comparison
to ight and cabin crew numbers.
And while the UK accident did not
result in fatality or injury, studies
conrm that the ramp is a dangerous and potentially lethal place a
congested and pressured environment where humans interface with
large aircraft and multiple vehicles and ground support equipment.
According to a 2005 UK Health and Safety Executive (HSE) analysis of
data, the causes of accidents (affecting ground crew) at airports have
remained fairly constant over recent years, with around 50 per cent
related to musculoskeletal disorders (baggage and cargo handling); 25
per cent slips, trips and falls; 15 per cent related to moving vehicles
or ramp equipment; and 12 per cent falls from heights (maintenance,
aircraft access steps, catering high loaders etc). Moreover, the HSE
says, This accident rate is rising compared to numbers of passengers,
numbers of ights and cargo carried. Increasing congestion on the ramp,
and pressure for ever-shorter turnaround times is a cause for concern.
Flight Safety Foundation (FSF) gures conrm the high cost of ground
accidents human and hull to the industry. The FSF has calculated
the annual worldwide nancial cost at $10 billion, that total comprising
a $4.2 billion cost for ground accidents and incidents; and a $5.8 billion
cost for injuries. A comparison between the injury rates in aviation and
other industries is revealing. Scheduled commercial air, with 10.5 total
recordable injuries per 100 employees, is at the top of the list. Other
industry sectors - oil and gas; pulp and paper manufacturing; the chemical
industry; construction - sectors which would be
perceived as being higher risk environments
stereotypically, rate 2.5; 3.2; 3.5 and 6.4 injuries
per 100 employees respectively.
Despite this cost, a focus on ground accident
prevention has been slow to emerge. For too
long, Dr Geoff Dell argues, ight safety and
ground safety have been regarded differently.
He is Dean, College of Fellows, of the Safety
Institute of Australia, and a career safety
systems and accident investigation specialist
with 30 years airline experience in both ight
safety and airport operations safety. Geoff
was awarded the Flight Safety Foundations
inaugural Ramp Safety Award in 1996 for his
research into the causes and prevention of
aircraft pushback accidents. The principles
of Reason, Hudson and Rasmussen transcend
all industries he explains, but aviation has
always regarded itself as being special. He is
passionate about the need to treat ground safety
with the same level of concern as ight safety,
and instances the technological developments
which have been readily adopted in the air.
Aviation has embraced new technology glass
cockpits, ground proximity warning systems/
TCAS quantum leaps in safety technology
Juanita Frantzi: Aero Illustrations
!
in the air, but he argues, theres a resistance to technology on the
ground. The introduction of the A380 he says is a classic example of
high technology aircraft design and was the perfect opportunity, with a
blank sheet of paper, to carry that technology over to ground operations.
But have a look at how they handle it on the ground its circled by how
many vehicles on the tarmac?
The complexity of the ground operations environment is also an
important factor in why ground safety has been slow in gaining
recognition as an aviation safety issue. While safety in the air and on the
runway is the direct jurisdiction of various regulators, safety oversight
of operations in ramp areas of airports is handled primarily by airlines
and airports, and only indirectly by regulators through the airline and
airport operators AOCs. The US Government Accountability Ofce
(GAO) in its November 2007 report to Congress found no federal or
industry-wide standards for ramp operations In the United States,
airlines typically control the ramp areas, and each operates its ramps
with its own specic sets of polices and procedures. The situation is
similar in Australia. Add to that complexity the fact that increasingly,
ground handling services are being contracted out. One ground
handling company, therefore, can service several airlines, each with
their own operating policies and procedures. In the absence of uniform
ramp policies and procedures, these multiple policies and procedures
can cause confusion and increase the likelihood of accidents.
Lack of data has also hampered improvements in ground safety.
The GAO report noted that Efforts to improve airport ramp safety
are hindered by a lack of complete accident data and standards
for ground handling. We found no complete source of data on
ramp accidents (nor) no complete non-fatal injury data. While
individual operators have comprehensive incident databases, this
data is not available to determine industry trends. However, this
shortage of data is gradually being addressed, by agencies such as
the FSF, through their ground accident prevention program (GAP)
and its data collection and analysis service; and the International
Air Transport Associations (IATA) global safety information centre
due for launch in late 2009. This centres aim will be to integrate
safety data from various industry sources to identify issues and
develop prevention strategies.
As the GAP and IATA programs demonstrate, increasingly, work on
ground safety is gaining momentum, but Chris Barber says, Its an
enormous task. When Flight Safety spoke to Chris, he had just returned
from a meeting of the IATA Airside Safety Group, which he chairs.
In his day job as Manager, Ground Safety and Environment with
Qantas Airways Airport Services segment, Chris works on the premise
that critical risk management starts from the ground, and the
Airports segment is embarking on an end-to-end risk identication
process as part of their safety strategy, identifying all the risks from
an airports perspective from the moment a passenger steps out of
their car at the airport, and goes to the terminal, until they reach the
airport at the other end.
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According to Chris, Qantas list of key risks parallels the UK Health and
Safety Executives: manual handling and trips, slips and falls are the
big ones for us; falls from heights; impact by moving equipment, airside
trafc management, and were looking at innovation and best practice
around the world.
Part of the solution, he says, will be increased mechanisation, quoting
the Scandinavians as world leaders in this area. The big bag box
which has streamlined manual handling originated there, as did the
RampSnake (pictured below).
Chris Barber is also chairman of the Australasian Aviation Ground Safety
Council (AAGSC), founded over 25 years ago. The AAGSC was one of
the driving forces behind the introduction, years ago, of the 32kg bag
weight, adopted by IATA some ve years later. The IATA Airside Safety
Group recently recommended in their Airport Handling Manual, that
this be further reduced to a 23kg individual checked maximum bag
weight. This limit already applies in the United Kingdom, driven by the
Health and Safety Executive.
European industry estimates the workload per man per shift for a
baggage loader to be an average ve and a half tons, rising to nine
tons in the peak summer season. There is little public understanding
of the difculties of working in a conned space, especially in the
narrow bodies, as shown in a Brisbane Times Your say blog which
ran from April to December 2008. The responses to the question: Is it
fair for baggage handlers to expect travellers to keep their luggage in
bags weighing less than 20kg? displayed ignorance at best, and vitriol
at worst. Cols post was typical: In all seriousness, there is lifting
equipment, all these turkeys have to do is lift something, what is it
32kg, from a trolley to a conveyor? The hold of an aeroplane has been
described by Norman Hogwood, (the grandfather of ground safety,
according to Chris Barber) as like a mine pit dark, sweaty, hot and
conned. Conditions are more difcult in the loose-loaded, narrow
bodies, such as the 737, where space is conned, and lifting while
kneeling and crouching can lead to musculoskeletal injury.
Consequently, an afliated group in Scandanavia (Copenhagen Airport
Company, airlines, group handling companies and unions) is embarking
on an awareness campaign to educate travellers about taking extra
luggage on board, in an effort to reduce bag weights. Obviously, manual
handling is the key driver, but other cost-saving, both in fuel and handling
is a secondary driver. If successful, the campaign will have an impact on
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Baggage handling 5.
Aircraft handling & loading 6.
Aircraft ground movement 7.
Cargo & mail handling. 8.
Its a massive task, Chris Barber acknowledges,
getting airlines to see the benets, such as
reducing the number of third-party audits; and
changing the culture, but he remains hopeful of
the success of the program. Qantas undertakes
its own Compliance Audit Program and have
also initiated their own Human Factor type
Threat and Error Safety Audit process called
Ground Operations Safety Audit (GOSA) and
in the US, Continental Airlines is working with
the University of Texas on a ramp operations
safety audit, or ROSA.
Arguably, to improve the safety of ground
operations effectively requires several
concurrent strategies. Perhaps the most
challenging of these is changing the culture;
through the implementation of robust and
integrated safety management systems to
establish a just culture, so that increased
reporting of incidents, for example, would
create data to drive improvement. As the FSFs
Bob Vandel said in a presentation given on the
Gold Coast in 2004, It is a time-proven adage
that the workers do well what the boss checks.
If the CEO puts safety high on his corporate
agenda, and checks the results, then his
managers who set safety policy will conform
to the CEOs lead.
Geoff Dell is passionate about the need to
apply the same safety management standards
to ground safety as those which apply to ight
manual handling injuries. However, any adoption of further reductions in
bag weight has to be standardised, because stringency in applying such
restrictions can place compliant airlines at a commercial disadvantage, as
can be seen in the comments on the Brisbane Times blog.
Modication to aircraft design is another area where advances can be
made in improving safety for manual handlers Chris Barber explains.
For example, in our 737 aircraft we have sliding carpets (a poly-coated
Kevlar conveyor belt which moves baggage within the compartment)
tted in the hold, like a roller system, which in conjunction with our
RTTs, (a mechanised belt-loader extension), assist us greatly in reducing
manual handling when loading our aeroplanes. Qantas may be
demonstrating best practice in adopting such technology, but according
to a 2005 study on manual handling at Dublin Airport, while such
systems are available, they are not yet the industry norm. And although
made four years ago, it seems that statement still applies. Geoff Dell
would agree, arguing there are still many changes necessary to bring
aviation manual handling standards in line with other industries. If you
compare baggage handling standards with every other industry, he
says, the difference is very apparent. Theyre now all automated, even
cement handlers. If youre making decisions based on risk, he claims,
you wouldnt be lifting bags.
Last year IATA launched an initiative which promises to assist in bringing
some standardisation to ground operations. Based on the successful
ight lATA operational safety audit IOSA principle, the IATA Safety
Audit for Ground Operations, or ISAGO, aims to audit all industry ground
service providers, establishing a worldwide ground operational safety
benchmark and standard. The program was launched in February 2008,
and during the year, trained 200 auditors from 60 different airlines,
and conducted 45 audits. The 2009 target is 80 audits, examining eight
ground safety areas:
Organisation & management system 1.
Station management 2.
Load control 3.
Passenger handling 4.
MAC lifting score for one operator outside the aircraft
Bag weight One lift every
5 secs 9 secs 14 secs 30 secs
Less than 10kg
10kg
15kg
20kg
25kg
32kg (IATA max)
MAC lifting score for one operator inside the aircraft
Bag weight One lift every
5 secs 9 secs 14 secs 30 secs
Less than 10kg
10kg
15kg
20kg
25kg
32kg (IATA max)
Manual handling assessment chart (MAC)
Colour code:
Low level risk

Medium level of risk, task should be examined closely.

High level of risk, prompt action needed

Very high level of risk
HSE 2005 Bagagge handling report page 11
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safety. He instances the case of the fuelling of
a hypothetical B-747 ying from Sydney to Los
Angeles, arguing that the integrity of the fuel for
the ight is checked between six to eight times
between the distillation towers at the renery,
to when passengers buckle themselves into
their seats for takeoff. There are six to eight
levels of administrative redundancy in that
process, but we dont do that anywhere else.
Then, he argues, improved training is needed.
At the minimum end, theres basic training, in
lifting techniques for example, but thats about
it. At the enlightened end, there are behavioural
observation/intervention programs, such as
the one introduced at Frankfurt Airport in the
mid-nineties by Dr Walter Gaber. He treated
baggage handling as a human performance
issue, asking the question Geoff Dell says,
How do we get administrative reliability into
baggage handling? His solution was to treat
baggage handlers like athletes, if necessary
intervening early at the rst sign of discomfort,
before damage such as muscle tears occurred.
In Geoffs recollection, the ground handling
company involved had a workforce of about
4,500 baggage handlers, and was spending
$60 million a year in workers compensation.
Outlaying $2.5 million, Gaber engaged human
performance specialists, who coached the
handlers individually in tness and technique
on a weekly basis. This program reduced
compensation claims over three years by 90
per cent.
Automation of some features of ground
operations has already been discussed, but
Geoff Dell says more is needed. We need to move from a vehicle-
based industry to a technology-based one. The vehicle-free ramp is not
a futuristic concept, but was instituted at two airports in the 1990s:
Terminal 2 at Stockholms Arlanda International Airport (with eight
gates), and the purpose-built Zhuhai Airport in southern China (with
four). Again, the concept resulted from Scandinavian technology, the
product of Swedish company, Fabriksmontering i Trelleborg (FMT).
Rather than being serviced by a eet of vehicles and accident-prone
human drivers, a set of modules pop-up from the tarmac and supply
fuel, water, air, ground power, toilet waste disposal, and cabin heating
or air conditioning to the parked aircraft. Combined with an automatic
push-back pilot, eliminating the need for manned tractors, FMT claims
the technology can dispense with 80 per cent of current ramp vehicles.
However, take-up of the technology has been slow: it is expensive, with
the cost of retrotting the units in existing infrastructure deterring many
European airports; and Zhuhai Airport has faced economic difculties
since its opening. The technology therefore does not seem to have been
promoted widely. Then there is the considerable pressure to maintain
the status quo: with signicant money and resources committed to
existing infrastructure by airports and airlines; and in some countries,
pressure from unskilled and semi-skilled airport ground workers, who
are highly-unionised, politically-strong and resistant to change.
So where to from here?
Geoff Dell contends that ground safety would be advanced by the
widespread application of real safety management systems, with
appropriate validation, rather than systems which just tick the boxes.
Future ground safety efforts, he says, need to address the two high risk
areas: the congestion around ramp operation, and baggage handling.
The Dublin manual handling practices study concluded that solutions
to reducing manual handling-related injuries among airport workers
are, in the short term, to be found in the introduction of mechanical
aids, but in the long term, through the implementation of higher levels
of automation. As the Scandinavian experience shows, higher levels of
automation, reecting standards in other high-risk industries, are likely
to gain wider acceptance.
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For more information
Best manual handling practices at Dublin Airport
Duignan, CA & Fallon, EF National University of Ireland for the
Health & Safety Authority 2005 y y y y
Aircraft Turnaround Inspection Sector Information
Minute
British Health & Safety Executive (accessed at www.hse.gov.uk
April 2009, due for cancellation May 2009) p y p y
Ground Crew Injuries in US Commercial Aviation
Grabowski, T; Baker, S & Guohua, Li in Aviation, Space &
Environmental Medicine, November 2005
IATA Safety Audit for Ground Operations - ISAGO y p y p www.iata.org/isago
Aviation Runway & Ramp Safety sustained efforts to
address leadership, technology and other challenges need
to reduce accidents & incidents
US Government Accountability Ofce (GAO) Congressional Report
November 2007
Equipment damage and human injury on the apron. Is it
a cost of doing business? gg
Flight Safety Foundation presentation Bob Vandel. International
Society of Air Safety Investigators 2004 conference. y y g y y g
Safety management systems for regular public transport
operators pp
Civil Aviation Advisory Publication (CAAP-SMS-1(0), downloadable
fromwww.casa.gov.au
Ground accident prevention (GAP)
Flight Safety Foundation: e-tools to eliminate accidents & incidents
which occur on airport ramps & adjacent taxiways,
www.ightsafety.org/gap
Ground accident prevention: the Foundations answer
Earl Weener, PhD. May 2007. Presentation given to 52nd Annual
Corporate Aviation Safety Seminar. p y p y
European Ramp Checks Find Increase p p p p Aviation Safety World August 2006 y g y g
Ramp accidents & incidents constitute a signicant safety
issue
Robert Matthews Federal Aviation Administration in the ICAO
Journal , No. 3 2004 JJ
Communicating from the pushback-tractor seat helps
prevent serious injuries p j p j
Flight Safety Foundation Airport Operations, May-June 2004
Airline baggage handler back injuries: a survey of baggage
handler opinion on causes & prevention p p p p
Geoff Dell in Safety Science Monitor Issue 2 1998
Baggage handling in narrow-bodied aircraft: identication
& assessment of musculoskeletal injury risk factors j y j y
Sarah Tapley & David Riley, January 2005. Health and Safety
Executive
Safe access to aircraft for catering operations Sector
Information Minute 05/2008/02
Health and Safety Executive, May 2008
Flying towards SMS
The introduction of safety management
systems (SMS) is considered by many to be the
most signicant development in the history
of aviation safety. Consequently, CASA has
developed two new tools to assist operators
in meeting the new SMS and human factors
(HF) requirements.
The rst is a manual builder to assist in
developing CASA-required manuals. The
Manual Authoring and Assessment Tool (MAAT)
proposes text which meets CASA requirements,
but importantly, can also be modied to suit your
individual organisation. The tool also provides
guidance material, so organisations know what
needs to be addressed within each element.
This means that not only will you know what is
required, but you can ensure that your manual
reects your operations. MAAT is free and will
be available on the CASA website. MAAT will
assist in, and provide guidance on, building an
SMS manual. The tool will be expanded to meet
other requirements in the future.
Theres also a regular electronic newsletter so that industry will know
what assistance is available, and to keep operators up-to-date with SMS
and HF information. To subscribe to the e-newsletter please contact
SMS@casa.gov.au.
These are part of the planned three-phase SMS implementation process,
following legislation coming into effect from 31 January 2009.
The rst phase requires regular public transport (RPT) operators to
submit an implementation plan (low capacity RPT); and draft manual
and SMS infrastructure (high capacity RPT) to CASA by 1 July 2009. The
SMS infrastructure requires establishment of a safety management
organisation, policies, procedures and accountabilities.
The second phase includes establishment of a pro-active risk
management system, and SMS training for safety-critical personnel.
The nal phase is full implementation of all elements of the SMS, and
the continuous improvement of the system. Under the new CASR 119
regulations (currently under development) these requirements will
extend to all passenger-carrying operations.
CASA recognises that some of these requirements may prove challenging,
particularly for low capacity airlines. CASA has held a series of workshops
for RPT-operator safety managers throughout April to assist them in
meeting the new requirements, with more planned in the future.
For more information on SMS, HF or MAAT, please contact SMS@casa.gov.au.