Thousands of ramp accidents and incidents occur each year worldwide. Ground support vehicles like pushbacks or baggage tugs crashing into aircraft are among the worst case scenarios. But unless people take time to understand the root cause of why they occur in the first place, they will continue to happen regardless.
My story is of an incident involving a forklift that rolled away down a slope and collided with a baggage dolly at an airport in Australia. There was not a lot of damage but, in different circumstances, the consequences could have been far more severe. The investigation was completed when I visited the site.
The operator had dismounted to help a colleague; but he had forgotten to lower the tyres; the front wheels were positioned at the top of a small slope, and the handbrake failed allowing the forklift to roll forward. This seemed a classic “Swiss cheese” effect where all the gaps lined up. They had their answers but the one question the investigators did not ask was “how did these gaps all line up?”
The mechanic told me that he had tested the handbrake and it was working properly. He had tried it on a much larger slope, and it worked perfectly.
During our site walk, we saw a second operator dismount the forklift before the vehicle had fully stopped – no handbrake and the tyres still raised. Right there we had our answer to how the gaps all lined up. These behaviours had become endemic in the operation. This was the real cause of the incident but why? Was it a lack of training, a lack of understanding, shortcutting….?
The learnings from this incident and every other that has potentially severe consequences is to:
- Dig deep to understand the underlying (or root) causes and why these occurred. These are rarely immediately obvious because remedying these provide no safety improvements.
- Review the training, the support, and the procedures to ensure they capture all the necessary steps and controls. If the training and procedures are not correct, then we have not done our job so our staff can do theirs.
- Regularly inspect the operation to see that the expected procedures are in place and working as expected. Without reviews, small incremental changes will become large ones increasing the risk of incidents. Where a procedure needs to be revised because of equipment changes or better work methods, then change the procedure and training rather than accepting non-compliances.
- Communicate safety expectations clearly and regularly in unambiguous language making sure that everyone who needs to understand it, does. Not just those on duty at the time of the discussion. Those off-shift or on leave are just as important.
- When writing incident learnings do not focus on the actual asset because those who don’t use it will tune out. It applies to every piece of mobile equipment and those you use them – not just forklift drivers but to baggage or pushback tractors and all apron equipment.
Inspecting the workplace is a fundamental need for every supervisor and manager. Understanding the risks of the activity and the controls – both physical and behavioural – that need to be in place is key to controlling the risks.
In our forklift incident, staff had decided that certain shortcuts could be taken. These had been in place for some time because they had been adopted by several forklift drivers. There had been no incidents, so this practice had become self-reinforcing. But most worrying is the fact that the risks had not been seen or challenged by those who should have seen them and corrected them. This was the real failure, and it could have been avoided by recognising that prioritising inspections, discussions and proactive corrections would have saved us from this and other incidents, costs, and reputational damage.
Who gives a damn?
Recently, there was a You Tube video of baggage handlers from Swissport throwing bags from containers to baggage belts and slamming them down onto the belts with no regard for the passengers’ personal belongings. The fact that someone videoed the incident indicates that this is not the first time this had happened. The video shows us the visible behavioural factors of the incident but not the underlying causes. The incident will occur again unless these underlying causes of the incident are identified, assessed, and addressed. Simply terminating the people shown on the video is not enough!
Swissport confirmed an urgent investigation was undertaken into the recent behaviour of two team members at Melbourne Airport who handled customer luggage in an unacceptable manner. As a result of that investigation, Swissport terminated the employment of these individuals.
In a statement released at the time of the incident. Swissport said: “Swissport trains and manages all staff to handle customer possessions with care and diligence. Our 3,000 strong team across the network (in Australia) works hard to ensure these standards are upheld, and it is important that when those standards are breached by a small group of individuals that we take action.”
In addition, they conducted a briefing of all operations teams to remind them of the high standards they expect, and enforce, saying: “The unacceptable behavior of a few individuals will not be allowed to tarnish the quality work of our whole team.”
Inspections of the workplace at various times, in different conditions and with different people provides us an opportunity to understand what is happening, the issues they experience, and provide early intervention where this is required to prevent these sort of incidents. There really is no excuse for not reviewing operations.