Report: Secondary

Manoeuvre Area Safety Team Meeting – Heathrow – 13 April 2011
CE Meeting Summary

Agenda

Review MAST Actions

• Although the AIP now contains work in progress at Heathrow, keeping charts updated with current work in progress still an issue.
• A meeting of chart representatives is being sought by BAA
  • There are 3 chart providers for Heathrow operators :
    • Navtech, Jeppeson and Lido
• Runway markings – these are being used at Heathrow and a Human Factors study carried for NATS will be made available at the next MAST Meeting
• N11 at Heathrow continues to be a hotspot for runway incursions
  • A trial has been proposed by NATS to use a single holding points in all conditions – meaning using Cat 3 hold at all times
  • This has received severe criticism from some airline operators and the trial has been placed on hold whilst other solutions are re-considered
• Runway Incursion Working group to consider the increase in runway incursion events in the past few months is to be held at Heathrow Fri 15 April 11
• Governance of the MAST and the FLOPC committees was discussed. A clearer understanding on the correct decision/making process for changes to address safety issues is needed.
• The recent focus on pushback errors and incidents at Heathrow has resulted in changes which are showing a large decrease in similar incidents
• The recent Laser presentation at Porton discussed in the context of laser attacks at Heathrow – both on aircraft and the tower
  • UKFSC CE to provide meeting briefs to the MAST Sec for info
• Manoeuvre Area Safety Team pages of the website discussed
  • Old info has been removed and changes added
  • A secure area is being established to lodge more detailed WIP information
  • Useful publications list of Heathrow specific info has been added

MAST Action Plan

• Key Safety Performance Indicators.
  • A significant increase in RIs in 2010 which a specially called RIWG meeting is to address(UKFSC CE attended and reported on)
• KPI targets need to be confirmed for 2011 by the MAST at the next meeting
• Runway Incursions so far this year include:
  • Vehicle which crossed the stopbar to change light without ATC permission – technical issue on distance from runway
  • Ac lined up at N11 without clearance
  • Ac landed without clearance –
    • UKFSC CE passed on the MOR and Air France info to MAST
  • Safeguarding – 2 ac exceeded CAT 3 clearance limit
• Van run has identified signage change recommendations for MAST consideration
  • Prioritisation of painting identified by Van Run due to cost constraints
• Wig wags positioning, rationalisation and standardisation being considered
• Another Driver Van run recommended in the near future
• Trial took place over the Winter using vehicle tracking to identify where de-icing trucks had covered and how much de-icing fluids had been used
• New CAA CAP on R/T was issued recently, with driver R/T information included
• New CAA Driver Standards CAP being issued for comment in May 11
• ‘Expect landing clearance’ phrase has been excluded from ATC approach language to help expectation management with pilot community
• Hotspots are being disseminated in the AIP- but are the Chart producers including them?
  • Drivers also need to be aware of hotspots and these need to be added to the maps regularly used by the drivers
  • Hotspots are now posted on the Heathrow MAST webpage
• Any additional Grd markings to be help reduce taxiway errors must be consistent on use of Cat 3 holds

Rich Jones
Chief Exec
UK Flight Safety Committee
20 April 2011

Manoeuvre Area Safety Team – Heathrow – 17 August 11
CE Meeting Summary

Review of Outstanding Actions

• Concern remains about Chart providers for Heathrow unable to keep hotspots and WIP up to date.
  • UKFSC to contact the relevant CAA committee, Navtech and Jeppeson to seek solutions to address the issue
• Control of personal devices such as radios, Ipods and mobile phones in all vehicles operating airside – recommend sterile procedures to avoid distractions as a runway incursion prevention measure – revise the LHR OSI accordingly.
• NATS to open a situational awareness forum for pilots and drivers on the LHR website
• A review of non-standard ICAO issues in light of EAPPRI 2 to be conducted
• Eurocontrol to visit MAST in Oct 11 to discuss EAPPRI 2 issues
• Ground Handlers invited to visit MAST to discuss driver training
• Survey underway on stop bar and red lights switchery for the LHR airfield
  • Stansted have already done it and will be consulted on their findings
  • Manchester have already done work on this issue which may be helpful

NATS Update – Safety Enhancments Update
KPI Review

• 17 Runway Incursions this year – all Cat D
  • 35 last year of which 6 were A-C
• Runway Incursions numbers by vehicles were successfully addressed as a priority in 2010 and last year.
  • However RIs by vehicles have increased this year
• Unauthorised push back numbers are improving with 26 in 2010 but 7 this year
• Code F A380 taxi errors have reduced due to changed infrastructure
• Runway Incursions Summary:
  • Several grass cutting vehicle incursions
  • A small number of Stop bar crossings
  • A380 wing over the runway whilst the tail was clear
    • The ground radar A380 return is made smaller due to grass area suppression giving a false impression to controllers – NATS Safety Note out soon
• Ac landing without clearance on wrong freq
• Ac landing without clearance on right freq – 3 times
• Line up without clearance at N11 – twice
• Ac nosewheel stopped beyond Stop bar
• Ac taxied to Cat 1 hold during CAT3 ops

Recent NATS Safety Enhancements

• Runway Entry points withdrawn from taxi clearances
• Trial started to include mention of 2 ac in conditional clearances to improve situational awareness – should reduce the risk of runway incursion
• Runway inspections – hazard analysis shows that with favourable winds, decrease in ac on approach from 15 nms to 12 nms can be allowed
• Use of CAT 1 or CAT 3 in CAT 1 conditions
  • New NATS Electronic Strip System (ESPB) for taxi and take-off management is much better suited to the adoption of a single hold
  • A Paper which explains the ESPB problem to be distributed to MAST

Heathrow FOD Radar System

• FOD radar system is to be enhanced
  • An improved platform for the camera has been introduced
  • Software package upgrade fitted
  • New display with a single integrated screen and FOD position indicator
  • Increased accuracy of camera positioning for FOD detection
• 438 positive radar FOD finds plus 6 manual inspection finds this year so far.
• Birdstrikes – 65 this year plus 33 near misses which is an increase on 2010, possibly due to better reporting?

Heathrow Ground Damage Incidents

• 5 ground damage incidents on ac in July – none bad enough to take an ac out of service
• BA, Virgin and BMI are now reporting all ac damage to BAA
• Tug wheel explosion on the ramp badly damaged a van and debris hit an ac
  • Cause was through previously weakened sidewall damage
  • Similar event occurred recently in Manchester
• Thirty reportable road vehicle incidents on the airport in July
  • 6 serious incidents involving injuries to people which has prompted an awareness campaign to be introduced.
  • Hotspots for vehicle incidents on the airfield to be developed
• AONs – Vehicle Offence Notices – significant increase in speeding and driving without due care
  • Three AON incidents on the manoeuvre area

Rich Jones
Chief Exec
UKFSC
30 Aug 2011

Manoeuvre Area Safety Team (MAST) – Heathrow – 15 February 2012
CE Meeting Summary

Review of Outstanding Actions

• Data consolidation – vehicles endangering ac reports will continue be gathered through other NATS reporting.
• LHR map – HAL will consider adding an insert panel to direct attention to changes from last map issue.
• Sterile cabs for airside vehicles – supplement to LHR OSI being drafted for imminent release.
• NATS situational awareness forum (LHR website) under development.
• Ring of Red – HAL policy aim, engineering survey in progress to define work required and costs for new cabling etc.
  • New NATS policy is that all red stop bar crossings will be considered as a runway incursion even if a conditional clearance has been given – may previously have been treated as a Runway Safety Event.
• VHF/UHF cross-coupling will apply to airside vehicles, not just ac.

Navtech Presentation – Chart Production (Max Harris)

• No current ICAO/EASA/CAA regulations regarding aerodrome charts. Service providers can tailor charts to meet individual customer requirements.
• But 73/2010 (ADQ) requires ANSPs to comply with data quality standards from point of survey to publication.
• EU wants ADQ2 to extend standards from survey through to the cockpit, in place by Jul 2014 – first time charts will be formally regulated.
• Unclear whether regs will refer to data quality or to its presentation.
• Manual process for ground charts will remain – managers need to provide advance info of planned/expected changes to allow lead time for incorporation and publication.
• HAL agreed to assess means for giving chart producers early access to information.

NATS Update

KPI Review

• 24 runway incursions (5 per 100,000 movements) in 2011, all Cat D, vice 41 Cat A-D in 2010.
• 5 in Jan 2012, including 2 ac lining up out of sequence.
• Unauthorised push-back rate halved (to 15).
• 2 x A380 Code F infrastructure taxy errors – future stats will record infrastructure breaches for all types.
• No unauthorised vehicle movements on manoeuvring area.
• 3 ground collisions.

Safety Improvements

• NATS would prefer LHR Runway Holding Points to be Cat III only.
  • If Cat I holds still required, proposal is to rename all to the same as the associated Cat III hold (ie NB3 becomes N3). SB1 and SB7 would be renamed separately.
  • For normal ops, RGAs would be at the Cat I hold, plus red stop bar.
  • During Safeguarding, RGAs and stop bars would revert to Cat III, allowing immediate move to LVPs when required.
• Excessive requests for runway crossings since Tug road closed for repairs – HAL monitoring.

HAL Update

• 626 FOD radar hits – 619 ‘not found’, 7 found (incl 2 bird remains), 2 x manual detects.
• High no of ‘not found’ generated by passing vehicles, wildlife etc.
• 40% of FOD wildlife-related, 10% litter.
• 27 birdstrikes = 0.82 per 10,000 movements.
• AONs in 3 main areas – driving without due care, speeding, and driving while using a handset.
• 33 vehicle incidents, incl 4 x personal injury and one outsize vehicle striking a pier.
• HAL and NATS working on promoting open reporting as being best means of identifying safety events.
• Internal HAL restructure, Katie Norton appointed as new Head of Safety and Compliance, will chair MAST.

Dai Whittingham
Chief Executive
UKFSC
20 February 2012

Heathrow Manoeuvre Area Safety Team Meeting – 3 May 2012
CE Meeting Summary

• MAST under new management (Katie Norton, Hd Airfield Safety & Compliance, HAL).
• Draft TORs discussed. MAST is subordinate to Runway Safety SG but will undertake preliminary review of safety data.
• 13 Cat D incursions to date (24 in 2011), many related to Cat I vs Cat III holds in safeguarding.
• 3 of 6 Cat D in Feb/Mar occurred at S7, all with ac taxying to SB7 in safeguarding.
  • Safeguarding needs to be completed before LVPs declared.
• Physical design of N11 hold responsible for some incursions? To be reviewed.
• One incursion involved conditional line up clearance for BAW8D being read back by DAL4, error not detected by ATC. BA has since removed ‘D’ suffix from callsigns.
• 104 FOD objects found via radar Feb/Mar.
• 10 wildlife strikes YTD, 2 high risk, 4 medium.
• AONs – main offences are driving without due care and attention, not wearing a seatbelt, using a hand-held mobile while driving.
  • 6 vehs failed to give way to aircraft.
• Sterile cockpit – HAL requiring no use of commercial radio or PEDs by airside drivers.

Dai Whittingham
Chief Exec
1 June 2012

Heathrow MAST – 17 December 2012
CE MEETING REPORT

Matters Arising

• Issue with ‘Delta’ suffix callsigns had been raised with Eurocontrol for consideration by Callsign Similarity WG. Eurocontrol did not want to include ‘Delta’ on list of suffixes to avoid. Item closed.
• Jeppeson plates include airport hotspots but it is an individual airline decision on whether these are displayed on the purchased version. CE recommended that master plates are routinely checked by airport operators for consistency with AIP entry. (CE note: this is part of a wider issue on charting that will be the subject of work with the CAA.)
• Jet blast incident at T4 (A380) had shown requirement for a jet blast survey for all stands.

HAL Update

• 27 x runway incursions in 2012 (26 Cat D, 1 Cat C)
  • 3 Cat D reports Oct, 2 were ac moving to ‘wrong’ hold during safeguarding. ATC had omitted “hold at the Cat 3 holding point” on both occasions.
  • 13 incursions on line-up for 27L, 13 at S7.
• FOD radar activations reduced but still high false alarm rate (approx 90%).
  • Stats need filtering to remove out-of-hours events generated by WIP, contractor and other vehicle movements.
• Wildlife strikes: no significant change for Oct/Nov. 22 kestrel strikes this year.
• Failure to give way to aircraft: improving situation, fewer AONs issued. All infringing drivers have face-to-face debrief. Clear message being passed to all drivers and trainers: aircraft moving or anti-colls on = stop! One contractor was banned from the airport for 6 weeks for repeated driver failures to observe airside rules.

NATS

• Increasing incidence of pushback errors, frequently associated with conditional clearances. WG to be re-convened Jan 13.
• Use caution with combination of hand-signals and conditional clearances! (CE note)
• Heavy wake vortex monitoring exercise under way.

AOB

• N11 is still an incursion hotspot but there is no budget for pavement realignment. Divergence of opinion on requirement, HAL does not believe alignment is the issue but the operators do! WG to be convened.
• OSI to be issued on ‘sterile cockpit’ for airside drivers.
• CAA will be undertaking an audit of ground handling agents to ensure that MOR scheme is being used.
• ‘Ring of red’ should be in place 24/7 by Spring but lighting software changes required.

DONM: 20 Feb 2013
Dai Whittingham
Chief Exec
18 January 2013

CE Meeting Summary

HAL Update

• FOD:
  • 45% of debris traced to contractors
  • Radar detections: 134 in Apr, 251 in May (but 1145 ‘false positives’)
  • 2 x manual detects Apr/May
  • Wildlife – 54 incidents YTD (5 high risk, 7 medium)
• Birdstrikes @ 0.85 per 10,000 movements.
• Driving without due care still main concern airside.
• 100 AONs issued in May, approx half related to speeding.
• Ac damage incident (Cat C) Apr. Hand-held scanner left on intake, ingested on engine start during pushback and ejected forwards by fan. Debris struck tug and driver.
• One other Cat C, fuselage damage from belt loader.
• 13 veh safety incidents, incl URD lowered onto ramp-worker’s foot causing serious injury.
  • NB: safety shoes probably prevented loss of foot.

NATS Update

• 17 RIs (2012), 16 x Cat D, 1 x Cat C (reduced separation).
• Pushbacks: only 4 unauthorised, of which 1 ac under tow
• 1 x use of inappropriate infrastructure: temp restriction on taxyway, B777, under invest.
• Holding points S7, SB7 and N11 are RI hotspots, especially under safeguarding.
• 4 x RIs in Jun: 2 x S7 (safeguarding) and 2 x N11 (ac lined up without clearance)
  • Ac lined up with landing traffic inbound, but with time for incursion ac to clear RW. Dual cause ATC/crew – ATC did not notify of landing traffic when issuing ‘hold’ instruction.
• N11 to be realigned to 90 degrees from RW within 18 months.

Dai Whittingham
Chief Executive
9 July 2012

Heathrow MAST – 17 December 2012
CE MEETING REPORT

Matters Arising

• Issue with ‘Delta’ suffix callsigns had been raised with Eurocontrol for consideration by Callsign Similarity WG. Eurocontrol did not want to include ‘Delta’ on list of suffixes to avoid. Item closed.
• Jeppeson plates include airport hotspots but it is an individual airline decision on whether these are displayed on the purchased version. CE recommended that master plates are routinely checked by airport operators for consistency with AIP entry. (CE note: this is part of a wider issue on charting that will be the subject of work with the CAA.)
• Jet blast incident at T4 (A380) had shown requirement for a jet blast survey for all stands.

HAL Update

• 27 x runway incursions in 2012 (26 Cat D, 1 Cat C)
  • 3 Cat D reports Oct, 2 were ac moving to ‘wrong’ hold during safeguarding. ATC had omitted “hold at the Cat 3 holding point” on both occasions.
  • 13 incursions on line-up for 27L, 13 at S7.
• FOD radar activations reduced but still high false alarm rate (approx 90%).
  • Stats need filtering to remove out-of-hours events generated by WIP, contractor and other vehicle movements.
• Wildlife strikes: no significant change for Oct/Nov. 22 kestrel strikes this year.
• Failure to give way to aircraft: improving situation, fewer AONs issued. All infringing drivers have face-to-face debrief. Clear message being passed to all drivers and trainers: aircraft moving or anti-colls on = stop! One contractor was banned from the airport for 6 weeks for repeated driver failures to observe airside rules.

NATS

• Increasing incidence of pushback errors, frequently associated with conditional clearances. WG to be re-convened Jan 13.
• Use caution with combination of hand-signals and conditional clearances! (CE note)
• Heavy wake vortex monitoring exercise under way.

AOB

• N11 is still an incursion hotspot but there is no budget for pavement realignment. Divergence of opinion on requirement, HAL does not believe alignment is the issue but the operators do! WG to be convened.
• OSI to be issued on ‘sterile cockpit’ for airside drivers.
• CAA will be undertaking an audit of ground handling agents to ensure that MOR scheme is being used.
• ‘Ring of red’ should be in place 24/7 by Spring but lighting software changes required.

DONM: 20 Feb 2013

Dai Whittingham
Chief Exec
18 January 2013

Aviation Ground Safety Council – 72nd Meeting – Staines Rugby Club, Hanworth – 23 September 2009

Agenda

Drugs/Alcohol Update

• Concateno plc Rep briefed on the background and elements involved in provision of a drugs testing service to the aviation industry. The elements required and available from the company were:
  • Implementing Policy
    • Policy Content advice and training
    • Implementation of policy
    • Managerial training package
  • DrugTesting Options
    • Urine is the test of choice. Well-proven medically and legally and has a 3-4 hour window for sample taking
    • Oral fluid. 12-24 detection window. Not as reliable or proven as urine
    • Hair. Long detection window (years). Longer turn round time for test results
  • Testing Process
    • All testing facilities, techniques and outcomes are formally accredited
    • All tests have robust QC and QA schemes
    • A Medical Review Officer is available to independently review test results in light of the medication declaration on the consent form.
      • Each individual tested must consent in writing beforehand
    • Testing can be done as a no notice regular checks or as a one-off in response to an incident

HSE Update

• The UK HSE is keen to introduce the maximum 23Kg weight limit for hold baggage as soon as possible. If this is not achieved through co-operation with airlines and handlers then enforcement will be used.

Infections and Bio Agent Risks

• The presentation identified training given to Border Agency personnel since the risks of infection from numerous sources on and around airports was significant.
• The majority of micro organisms can be killed by frequent and effective hand washing
• Protection of the skin through good hygiene was essential
• Bio agents are widespread and common and act in a variety of ways.
  • Serious bio agents and diseases such as anthrax and ebola can be a threat
  • Zoonoses are also high threats to airport cargo and baggage handling staff
• Risk to Airport Staff
• Numerous threats – baggage, clothes, people, bushmeat
• Skin Protection is staff responsible
  • Good hygiene is key
  • Wash hands regularly
  • Protect cuts and abrasions
  • Use disposable gloves
  • Use overalls which stay in the work place
• Training and Awareness
  • Training programmes in place
  • Monitoring performance of staff
  • Accident and incident reporting
  • Talk with staff about the issue regularly

Audits OHSAS18001 (2007)

Audit Characteristics

• Pre-planning
• Examine evidence not opinion
• Qualitative and quantative evidence
• Seek a positive outcome
  • Strengths and weaknesses
• Subjectivity – to match the standard
• Do not confuse audits with inspections
  • Do you comply with your own rules(inspection)
  • Do you do what you say you do(audit)

Audit Success Tips for those being audited

• Need to know their company systems and procedures well
• Be able to answer questions precisely
• Be able to sell and defend your systems’ completeness and adequacy
• Have evidence readily available

In response to an audit, culturally – you and the organisation should:

• Be willing to consider worst case scenarios
• Be able to accept criticism and deal with it in a positive manner
• Seek to improve continuously

Senior Management should be interested and ideally involved with the findings.

Rich Jones
Chief Executive
UKFSC
23 September 2009

75th Meeting of The Aviation Ground Safety Council – Staines – 22nd September 2010
CE Meeting Summary

Agenda

New Advanced Hearing Protection – Paul Ness

• Sensear Hearing Protection consists of
• Voice filtering, noise suppression headsets for use on noisy ramps
• Bluetooth capable option – with dongle fit for Boeing ac
  • No Airbus capability as yet.
• Initial design aimed at the commercial mining market but numerous options have been developed since, but not ideal for aviation yet
  • Some form of ramp team networking communication capability is required to meet the ramp requirement
• Best way to develop these headsets is as a tool to provide ramp control in order to offer a more reliable and  efficient turn round

HAL Heathrow Update on safety Issues – Steve Buckridge

• Heathrow airside website is publicly available at heathrowairport.co./airside
• The pages include:
  • OSIs, Byelaws, airfield maps for the airport community
  • Recent safety alerts: eg personal music devices
  • Text messaging: used to communicate on work in progress on the airport
  • Future developments

• Driving ACNs and penalty points
  • Numbers – 300 drivers per year get penalty points
  • 50 drivers lose their airport driving licences annually
  • In future, a new points penalty system is being introduced which will result in the loss of an individual’s airside pass

• Third party safety audit programme is to be introduced to review all ground handling companies and a selection of the other Heathrow-based companies
• Including Met police driver training!

• New OSIs to be issued covering:
  • Fuelling
  • Doors Open With Ground Equipment In Place

• On average, 2 people get killed at HTW each year
  • HSE is undertaking an audit of Heathrow companies shortly

• Space Allocation
  • Menzies are taking over Aviance ground handling tasks at Heathrow over next few weeks
  • Major T2 changes coming up in the next few months
  • T4 change development ongoing

• Winter Ops Readiness and Cleansweep programmes will be commencing soon.

• Other HAL Initiatives and Activity
  • Vehicle and personnel injury reduction programme
  • Driver material and CAP 790 input to the CAA
  • Latest IOSH DVD – recommendations to be applied
  • FOD conference to be held
  • Heathrow.Safe – specifically D&A

• Questions:
  • The establishment of a LHR Ramp safety committee would be useful
  • Waste Slides for servicing and cleaning bags at ac were recommended rather than personnel carrying the bags down stairs – with the increased risk of falling.  HAL will consider the idea.

GPU Connection with Engines Running

• Background and current situation briefed by CE UKFSC
• Steps problems and accidents reports also raised
• CAP 790 Industry Day at the CAA to consult with industry to be held on 24 Sep 10 at SRG/CAA Gatwick

AOB

• Airside Induction Training DVD from IOSH to be issued next week. Copies to be made available free of charge

• High Risk/Dodgy Chemical Goods Traffic is passing through fast track at Heathrow – report from HMC at the airport. Most of these consignments are inaccurately recorded and are often dangerous to health.
  • There are few detectors available to identify these chemicals. Burst packages need to be carefully handled but neither does the airport want to be closed regularly by mistake or over reaction.

Rich Jones
UKFSC
30 September 2010

Aviation Ground Safety Council – 25 April 2012
CE Meeting Summary

Heathrow Update

• Recent incident with ground power cable – sheathing had eroded. Emphasised the need for regular visual checks.
• One vehicle vs wingtip collision in March.
• No Cat C events in Feb, but still having ULD handrails hit with cargo doors.
• Terminal 2a will go live in 2014. Old Tower coming down imminently!
• A-380/ULD collision last year involved a diesel tug. Possibility that high/rapid available torque may have been a factor.
• Need to involve ground handling agents in emergency exercises, not just local staff.

GHOST – Dangerous Goods

• 2008 fire at MCR – electric wheelchair activated in flight causing overheat, caught fire after landing.
• CAA worked with manufacturers to identify generic make-safe procedures.
• Problems generated by multiple models, providers and processes.
• Database now published, training video available via CAA.
• EU law: airport is responsible for PRMs and also for making mobility devices safe for carriage.
• Airlines need to engage early with PRM customers to get the right make-safe info.

Misc

• FOD – scanner left on intake, ingested on start, parts hit tug and driver.
• Hazard went well beyond normal FOD/ECU damage – serious kinetic impact potential.
• Driver major injury prevented by first impact with toughened windscreen – direct impact on unprotected personnel could have been very significant. Eye protection for start crews?
• HSE Update

Dai Whittingham
UKFSC
11 May 2012