1. Nationaal Lucht- en Ruimtevaartlaboratorium – National Aerospace Laboratory NLR Developed for ECAST by NLR/NLR-ATSI Ramp Resource Management Training Version 1.0 Threat and Error Management

2. Developed for ECAST by NLR/NLR-ATSI Topics Safety regulations Teamwork Team dynamics Leadership Communication Team situational awareness Cultural, ethnic and educational differences Threat and error management Human performance Stress Fatigue Alcohol, medicines and drugs 2

3. Developed for ECAST by NLR/NLR-ATSI Threat and error management 3 How many errors do you make each shift? How many errors are made during a shift? How many accidents occur each shift?

4. Developed for ECAST by NLR/NLR-ATSI CASE: Towing 4 This incident is a fictitious mock-up using de-identified material. Names, dates, and conditions have been altered in order to stimulate thinking in a training environment. No connection to an actual incident should be inferred.

5. Developed for ECAST by NLR/NLR-ATSI Towing Setting the scene: XYZ Airline operates from Terminal at Any Airport Crew consists of two ground support agents from a service provider Crew is towing a fuelled B737-900 from remote parking to gate 71 Weather is clear, sunny, temperature 1 °C, wind is westerly at 29 km/h with gusts to 45 km/h There are several icy patches on the ramp where aircraft have previously been di-iced with water/glycol 5 This incident is a fictitious mock-up using de-identified material. Names, dates, and conditions have been altered in order to stimulate thinking in a training environment. No connection to an actual incident should be inferred.

6. Developed for ECAST by NLR/NLR-ATSI Towing 6 This incident is a fictitious mock-up using de-identified material. Names, dates, and conditions have been altered in order to stimulate thinking in a training environment. No connection to an actual incident should be inferred.

7. Developed for ECAST by NLR/NLR-ATSI Towing Suddenly, without warning, the tractor jackknifes under the aircraft nose, turning approximately 135 degrees 7 This incident is a fictitious mock-up using de-identified material. Names, dates, and conditions have been altered in order to stimulate thinking in a training environment. No connection to an actual incident should be inferred.

8. Developed for ECAST by NLR/NLR-ATSI Towing 8 Buckled frame Light Bracket Sheared off Witness marks Antenna Struck and Torn from Mount This incident is a fictitious mock-up using de-identified material. Names, dates, and conditions have been altered in order to stimulate thinking in a training environment. No connection to an actual incident should be inferred.

9. Developed for ECAST by NLR/NLR-ATSI Towing Driver: More than 7 years experience Trained on the equipment approximately 6 months before Worked 1 hour before the accident Agent 2: 1 to 2 years experience Trained on the equipment approximately 6 months before Worked 1 hour before the accident 9 This incident is a fictitious mock-up using de-identified material. Names, dates, and conditions have been altered in order to stimulate thinking in a training environment. No connection to an actual incident should be inferred.

10. Developed for ECAST by NLR/NLR-ATSI Towing What are your thoughts on this? Errors? Equipment failure? Airport layout? Why do you think so? 10 This incident is a fictitious mock-up using de-identified material. Names, dates, and conditions have been altered in order to stimulate thinking in a training environment. No connection to an actual incident should be inferred.

11. Developed for ECAST by NLR/NLR-ATSI Threat and Error management 11

12. Developed for ECAST by NLR/NLR-ATSI Threat and error management What are expected and unexpected threats? What are internal, external and environmental threats? Did you ever experience threats and how did you deal with those threats? 12

13. Developed for ECAST by NLR/NLR-ATSI Threat and Error management 13  Identify the threat: weather forecast, planning, equipment status  Assess the risk: severity, probability and exposure  Prepare: notify team members, request wing walkers, lock loose equipment  Monitor the threat: recognize distractions, interruptions and preoccupation

14. Developed for ECAST by NLR/NLR-ATSI Situational awareness 14 Look around before you start shit

15. Developed for ECAST by NLR/NLR-ATSI 15 Threat and error management Stupid! vs Consequences of normal human activity

16. Developed for ECAST by NLR/NLR-ATSI 16 Human Error Low Tech Threat and error management

17. Developed for ECAST by NLR/NLR-ATSI 17 Human Error High Tech Threat and error management

18. Developed for ECAST by NLR/NLR-ATSI Threat and error management 18 Different reactions to errors: Ignored : forgetting to place cones or parking of Ground Service Equipment within the aircraft movement zone Exacerbated: the combination of a not fully opened cargo door and an inattentive high loader operator increases the risk of aircraft and equipment damage Trapped: this requires team situation awareness and an active attitude from team members to trap and correct errors – not only their own, but also errors made by fellow workers Report errors to learn and prevent!!!

19. Developed for ECAST by NLR/NLR-ATSI 19 I could have saved a life that day, but I chose to look the other way. It wasn’t that I didn’t care, I had the time, and I was there. But I didn’t want to seem a fool, or argue over a safety rule. I knew he’d done the job before, if I pulled him up, he might get sore. The chances didn’t seem that bad, I’ve done the same, he knew I had. So I shook my head and walked on by, he knew the risks as well as I. He took the chance, I closed an eye, and with that act, I let him die. I could have saved a life that day, but I chose to look the other way. Now every time I see his wife, I’ll know I should have saved his life. That guilt is something I must bear, but it isn’t something you need to share. If you see a risk that others take, that puts their health or life at stake. The question asked, or thing you say, could help them live another day. If you see a risk and walk away, then hope you never have to say, I could have saved a life that day, but I chose to look the other way. Written by Brian McMillan I could have saved a life that day

20. Developed for ECAST by NLR/NLR-ATSI 20 Threats Identify, assess, prepare & monitor Errors Trap & correct Undesired state Emergency action Consequences Threat and Error management