SOAM concept of accident analysis Mirabel Deicing accident
Transcript of SOAM concept of accident analysis Mirabel Deicing accident
-
8/13/2019 SOAM concept of accident analysis Mirabel Deicing accident
1/18
Accident Investigation Report
De-Icing AccidentMirabel Airport
ATM Safety Investigation
& Analysis Course
SAA
-
8/13/2019 SOAM concept of accident analysis Mirabel Deicing accident
2/18
Safety Investigation & Analysis # 2 Ddale Asia Pacific
Organisational
and System Factors
Latent Conditions(adapted fromReason, 1990)
Active
Failures
Contextual
Conditions HumanInvolvement
Limited window/s
of opportunity
Absent or Failed
Barriers
ACCIDENT
People, Task,
Environment
The Reason Model
-
8/13/2019 SOAM concept of accident analysis Mirabel Deicing accident
3/18
Safety Investigation & Analysis # 3 Ddale Asia Pacific
-
8/13/2019 SOAM concept of accident analysis Mirabel Deicing accident
4/18
Safety Investigation & Analysis # 4 Ddale Asia Pacific
-
8/13/2019 SOAM concept of accident analysis Mirabel Deicing accident
5/18
Safety Investigation & Analysis # 5 Ddale Asia Pacific
Summary of the Event
Miscommunication Leads to Three
Fatalities During Ground Deicing of
Aircraft.
-
8/13/2019 SOAM concept of accident analysis Mirabel Deicing accident
6/18
Safety Investigation & Analysis # 6 Ddale Asia Pacific
The Royal Air Maroc Boeing 747-400 was preparing for a
scheduled flight from Mirabel International Airport,
Montreal, Canada, to Casablanca, Morocco, via New York.
The B-747 crew heard the words dgrivage termin
(deicing completed) on the radio frequency assigned to thedeicing crew.
The captain assumed that the operation had been
completed and that the deicing crew had left the area.
Unknown to the B-747 flight crew, two deicing vehicleswere still positioned on opposite sides of the fuselage
forward of the horizontal stabilizers, with five deicing
personnel who were continuing the deicing operation.
-
8/13/2019 SOAM concept of accident analysis Mirabel Deicing accident
7/18Safety Investigation & Analysis # 7 Ddale Asia Pacific
As the aircraft moved forward, its horizontal stabilizersstruck the telescoping booms of the deicing vehicles,
overturning the vehicles.
three occupants of the two buckets (cherry pickers) were
killed when they struck the ground, and the two vehicle
drivers received minor injuries.
-
8/13/2019 SOAM concept of accident analysis Mirabel Deicing accident
8/18Safety Investigation & Analysis # 8 Ddale Asia Pacific
-
8/13/2019 SOAM concept of accident analysis Mirabel Deicing accident
9/18
What happened
Brief summary
of
loss: injuries,
fatalities,
equipment etc
Noise of the engine
prevented snowman to
hear pilots TX properly
De icing area was not
visible from TWR for the
controller
Captain did not confirm
with the de icing crew
about the completion
Transport Canadas laxmentality towards foreign
carriers and private
contractors
No proper Training on
Engines on
configuration.
ADM managementsfailure to prevent deicing
with engines on.
ZZ Zzzzzzz
YY Yyyyyy
Pilot heared the words
De icing completed with
out any station name
CAILs failure to provide a
copy of its de icing
procedure to RAM
ACCIDENTABSENT OR
FAILED
BARRIERS
HUMAN
INVOLVEMEN
T
CONTEXTUAL
CONDITIONS
ORGANISATIONA
L
FACTORS
OTHER
SYSTEM
FACTORS
PIC taxied with
out proper
communication
with theground crew
Pilot did only a
visual check
from th cockpit
Engine on deicing waspervalent with the ADMs
knowledge
No SOPs to do de iceing by
RAM
No checking on wearing
safety harness andprotective gear.
NO ATC
VISUAL
REFERENCE
S TO
DEICING
FACILITY
Snowman
agreed to de
ice with
engines on
Apron controller not
required to confirm withthe crew thRat the
perimeter is clear.
Different communication
procedures follwed by the
deicing crew
No TX on the CAIL
frequency after beginning
of the deicing
Flight attendant not
required to prevent taxi
Non availability of aircraft
marshaller at ground
during de icing
RAM deicing with engines
ON
ADMs failure to issue
deicing licence
Animosity between CAIL
de icing crew and private
contractors
competition on deicing
operations between
Airliners and contractors
Snowmans heavy work
load
XX Xxxx
Iceman notpreventing
snowman to
deice with
engines on
Apron
controller
assumed that
ACFT started
after deicing
LACK OF SOP
REGARDING
DE-ICING
FLIGHT ATT. NOT
REQUIERED TO
INFORM THE
CREW ABOUT
A/C PERIMETER
Not having enough crew to
handle B747 de icing
CONTRADICTI
NG TC AND
ICAO
CIRCULARS
TC LIMITATIONSTO CHECK
FOREIGN
CARRIERS AND
CONTRACTOR
NO AGREED
UPON VISUAL
SIGNAL TO
INDICATE THE
COMPLETIONOF WORK
inadequate
communications
equipment
-
8/13/2019 SOAM concept of accident analysis Mirabel Deicing accident
10/18
-
8/13/2019 SOAM concept of accident analysis Mirabel Deicing accident
11/18Safety Investigation & Analysis # 11 Ddale Asia Pacific
The errors and/or violations (actions or omissions) by people at the
scene which triggered the accident.
Human involvement 1
Human involvement 2
Human involvement 3 Human involvement 1
..
Human Involvement
-
8/13/2019 SOAM concept of accident analysis Mirabel Deicing accident
12/18Safety Investigation & Analysis # 12 Ddale Asia Pacific
The task, situation, environment, or people conditions existingimmediately prior to, or at the time of the accident.
Contextual Conditions
Contextual condition 1
Contextual condition 2
Contextual condition 3 Contextual condition 4
..
-
8/13/2019 SOAM concept of accident analysis Mirabel Deicing accident
13/18Safety Investigation & Analysis # 13 Ddale Asia Pacific
The organisational and system factors (failures) that created the
prevailing Contextual Conditions or allowed them to exist (~ task,
environmental, people conditions).
Organisational Factors
Organisational factor 1
Organisational factor 2
Organisational factor 3 Organisational factor 4
..
-
8/13/2019 SOAM concept of accident analysis Mirabel Deicing accident
14/18Safety Investigation & Analysis # 14 Ddale Asia Pacific
Recommendations:
Absent or Failed Barriers
IMPLEMENTATION OF PROPER SOP
REGARDING DE-ICING
OPERATION INSTALATION OF A PROPER
CCTV SURVEILLANCE SYSTEM IN
TWR Recommendation A4
..Corrective actions to address deficiencies in the barriers which shouldor could have prevented the occurrence
-
8/13/2019 SOAM concept of accident analysis Mirabel Deicing accident
15/18Safety Investigation & Analysis # 15 Ddale Asia Pacific
Recommendations:
Organisational Factors
Provide adequate manpower to
carry out de-icing with engines
running RAM should assure that proper
procedure are in place for the
cabin crew to inform the flightcrew about any safety issue..
Corrective actions to address organisational deficiencies which
contributed to the occurrence
-
8/13/2019 SOAM concept of accident analysis Mirabel Deicing accident
16/18Safety Investigation & Analysis # 16 Ddale Asia Pacific
Key Learnings
(for Our Organisation)
Compliance with the R/T
phraseology procedure
Intervene immediately in theinterest of safety even though you
are not required to do so by the
procedure Key Learning 3
Key Learning 4
..
Lessons from this occurrence which can
be applied across our organisation
-
8/13/2019 SOAM concept of accident analysis Mirabel Deicing accident
17/18Safety Investigation & Analysis # 17 Ddale Asia Pacific
Questions
or
Comments?
-
8/13/2019 SOAM concept of accident analysis Mirabel Deicing accident
18/18Safety Investigation & Analysis # 18 Ddale Asia Pacific