Effective coordination and communication between airside crews could help prevent or detect mistakes that led to a collision between an Airbus A330 and aerobridge during boarding.
On 31 March 2016, an Airbus A330 was being boarded at Melbourne Airport, Victoria. Seeing that the parking brake was on, a maintenance engineer removed the main chocks early. The crews removed the nose gear chocks to dock the towbarless tractor without checking the main gear chocks. The captain, unaware that no chocks were in place, released the park brake and the aircraft rolled back, striking the aerobridge. There were no injuries and the aircraft door and aerobridge were damaged.
Why did it happen
The ATSB found that the ground and flight crew procedures were not harmonised, reducing cohesion between the crews. In the absence of clear guidance or instruction on coordinating activities during pushback, and based on incorrect assumptions, key steps involving the chocks and parking brake were performed out of sequence and without being communicated between tractor, engineering and flight crews.
Safety advisory notice
AO-2016-028-SAN-001: 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 to ensure that ground and flight crew activities are harmonised, and to foster active communication and coordination between working crews.
Communicate and coordinate airside activities
An aircraft is attended at a terminal bay by people carrying out a wide range of concurrent tasks. Typically, they and their respective organisations work alongside many others, each operating with different processes and to varying contractual arrangements. Defining a set of processes that can apply across such varied situations and aligning them well with the other activities can be difficult. In practice, mechanical malfunctions and honest mistakes can rarely be completely eliminated. An effective procedure will include steps to ensure that activities are appropriately aligned with other procedures. One way to achieve this is to pause and check if the situation is as it should be, and to inform others of activities that could affect them.
|Type:||Safety Advisory Notice|
|Publication date:||13 September 2016|