Aviation safety issues and actions

Coordination of activities related to pushback

Issue number: AO-2016-028-SI-01
Who it affects: Air transport ground handling
Issue owner: Malaysia Airlines Berhad and Menzies Aviation
Operation affected: Aviation: Air transport
Background: Investigation Report AO-2016-028
Date: 13 September 2016

Safety issue description

The procedures provided to ground and flight crews by Malaysia Airlines Berhad and the towbarless tractor operator did not provide clear guidance or instruction on coordinating activities related to pushback and, in the case of the tractor operator, were informally replaced by local procedures

Proactive Action

Action organisation: Malaysia Airlines Berhad
Action number: AO-2016-028-NSA-002
Date: 27 May 2016
Action status: Closed

On 27 May 2016, Malaysia Airlines Berhad reported that it was planning to amend its procedures so that flight crews advise ground crews whenever the park brake is about to be released. As an interim measure before the amendment could be approved, the operator sent A330 flight crews a reminder to communicate with ground crews before releasing the park brake to verify that chocks are in place.

Proactive Action

Action organisation: Menzies Aviation
Action number: AO-2016-028-NSA-003
Date: 05 August 2016
Action status: Closed

On 5 August 2016, Menzies Aviation (the tractor operator) developed a written local operating procedure to incorporate local differences in work practices and improve coordination between work crews.

Safety Advisory Notice

Action organisation: Organisations that work airside
Action number: AO-2016-028-SAN-006
Date: 13 September 2016
Action status: Closed

Effective coordination and communication between airside crews can prevent or detect mistakes that could otherwise lead to damage or injury. The ATSB advises organisations that work airside and aircraft operators to ensure that ground and flight crew activities are harmonised, and to foster active communication and coordination between working crews.

Safety Advisory Notice: Coordination is key to airside safety

Current issue status: Adequately addressed
Status justification:

The proactive safety actions taken and planned by Malaysia Airlines Berhad and Menzies Aviation, in conjunction with the additional safety action taken by Aircraft Maintenance Services Australia (the engineering organisation), will improve crew coordination during ground operations and adequately address the safety issue.

Last update 27 July 2017