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crew members as an underlying cause
of incidents.
These and other sources of distraction
also caused a marked reduction of
cockpit coordination and CRM skills.
A plane’s rear airstairs received damage
when the crew became distracted
by multiple demands, and failed to act
as a team:
✍ “[This incident was caused by] distractions
in the cockpit, plus a desire to
operate on schedule. There were several
conversations going on from inside and
outside the aircraft. Raising the airstairs
is a checklist item…backup is another
checklist item which requires the Second
Officer to check a warning light. No one
noticed the light. The pushback crew consisted
of 2 wing observers plus the individual
in the tug…all failed to observe
the rear stairs.” (#264692)
Procedures Roulette
Reporters identified two types of air
carrier operations management issues:
some cited instances of a crew’s failure
to follow an established policy or procedure;
others referred to a lack of established
procedure. In the following
report, the crew followed one company
procedure—requesting a tow-in
on an icy ramp; however, misunderstandings
about a new towing procedure
paved the way for a ramp
incident:
✍ “Tow crew did not follow their checklist
(unknown to us that they even had
one for that situation), and did not challenge
us to switch off hydraulic pressure
to nosewheel. We overlooked it—new
situation, no checklist or SOP for it. They
hooked up, and called for brake release a
little sooner than I expected. Result was a
broken tow bar connection on the nosewheel.
I should have retained command
of the aircraft until I was satisfied we
were all ready for tow in.” (#264610)
Reporters offered suggestions for alleviating
some of these procedural errors—
for example, that simulator
training in ramp operations and pushback
procedures be instituted for pilots,
and that both flight crews and
ground crews receive parallel training
(that is, each group receive the same
information and training that is provided
the other). Parallel training
would promote a clearer understanding
of flight/ground crew responsibilities
and expectations during ramp and
gate operations.
Issue Number 8 19
Recommendations for Reducing
Ramp Operation Incidents
There are a number of actions that
air carrier managers can take to reduce
ramp incidents. The following recommendations
are based on the findings
presented above and on suggestions
from a panel of highly-experienced
ASRS analysts.
• Require certification for the
marshaler and wingwalker positions.
• Provide scenario-based training
for ground crews, using ramp incident
reports available from the
ASRS database.
• Increase the use of radio communications
between flight and ground
crews.
• Maintain paint lines, taxiway
markings, and light guidance systems
in highly visible condition.
• Establish and enforce speed restrictions
and communications procedures
for vehicles drivers.
Ultimately, however, the responsibility
for safe operation of the aircraft
rests with the flight crew. Therefore,
regardless of any actual or assumed inadequacy
on the part of management
or the ground crew, it is up to the
flight crew to take action to prevent
incidents. The discussion presented
above suggests the following preventive
actions for flight crews:
• Perform a flight crew briefing of the
gate entry or exit procedure. Follow
the established procedure for operation
at that gate. Reaffirm cockpit
coordination and CRM
techniques.
• All flight crew members should
maintain an outside scan during
aircraft movement. Be self-aware
when judging ground equipment
clearance. Any portion of the operation
that doesn’t “feel right”
probably isn’t right!
• Be particularly wary of faded or
painted-over foul lines, the use of
orange cones to mark foul lines or
taxi lanes, or reflections on guidance
light systems.
• If no taxi guidance is provided, a
“no taxi” situation exists. Wait for
an “all-clear” salute or other specific
guidance (which may include
the “all-clear” salute), from the person
identified as having the authority
and responsibility for
marshaling the aircraft. If the
　
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