Confidential Human Factors
Incident Reporting Programme
The Charity
Aviation
Maritime
FC5102
Initial Report
[Airline] and [Ground Handling Company at Airport] withdrew the role of Turnaround Coordination (TC) in January 2021. This was not communicated to crews. It took place at a time of low levels of flying and low loads. TCs were also banned from boarding ac as a COVID mitigation. No safety control measure is visible. Local crews are using practical drift and local knowledge to overcome operational difficulties but short cuts of a safety nature are also happening. In one example a 1-tonne plus load was loaded in the wrong hold and only spotted by the crew. At the same time [Airline] has introduced further goal-conflict by cutting 5 minutes from its boarding time. Crews are under time pressure and now must be aware that all loading and ramp activities are not co-ordinated by a single person and many are carried out by staff recruited for less safety critical roles. Staff are unable to confirm who security-checks the holds and who is responsible. They are unaware of the LIRF [Loading Instruction Report Form – the loadsheet] or able to produce one despite having signed to say they have loaded the aircraft in accordance with it. Local management have dismissed concerns saying the trial is a success and any operational obstacles shall be overcome with further recruitment of front of house staff who are customer facing to carry out the former TC role. [Airline] are constantly piling more pressure on pilots to be the last and in many cases, only, line of defence whilst being in denial of the goal conflicts it creates with time pressures. The fact that any such changes are made whilst crews struggle with low levels of recency and high anxiety over external pressures shows a total lack of modern safety management.
The BALPA company council (CC) have engaged [Airline] management direct on this matter and quoted ASRs that members have raised, especially the tonne of load in the wrong end of the aircraft. [Airline] have responded by saying they are now conducting an investigation. BALPA are also currently challenging other ramp related programmes in [Airline] that, when brought together with the above, personify the “lining up of the holes in the swiss cheese”. We have constantly fought fatigue battles at [Airline] over the pre-COVID years and now, whilst crews are at their most vulnerable in terms of recency and distraction, [Airline] introduces goal conflict between cabin/flight/ground ops teams by introducing boarding targets that are creating a rush-and-report-early culture as referenced by a recent survey of BALPA members. This latest programme is called “xxxx” and has whisked away another 5 minutes of pre boarding prep time for crews who are largely mitigating this with short cuts on safety checks and reporting early as the culture priorities on-time performance before safety, albeit subtly whilst stating safety is the number one priority (of course we all know stating such a thing does not make it so). This allows for less headcount on the ground which ties into the piece above where we have inadequately trained staff in low numbers under immense time pressure now being responsible for critical safety actions for which they feel under trained (load sheets), the effects of which we have and continue to see.
We have seen no risk assessments for the removal of TC roles and have been told by local ramp staff to not expect to see them returned as local management have quoted how much this has saved.
CAA Comment
It is a regulatory requirement that operators have oversight of their contracted activities and that the assessment of contracted safety-related activities should be included in the operator’s safety management and compliance monitoring programme. Therefore, if there was a change in the condition in relation to these activities that may affect the operations, a management of change process is required to be completed.
The Operator conducted a comprehensive investigation, after receiving several safety reports, to assess the implication of the removal of TC on their operations. This investigation extended to load control, passenger supervision on the ramp, coordination of turnaround activities and communications between ground and flight crew. Subsequently, the operator addressed its identified safety threats through the introduction of several safety recommendations as part of their mitigation strategy. It was also acknowledged that an effective usage of the management of change process would have likely identified the reduction in safety standards and would have also identified safety risks associated with the above-mentioned activities.
CHIRP Comment
Whilst there are obvious cost savings to be made by reducing head-count, some roles are pivotal and their responsibilities must be ensured by other means if the post is deleted. It is not for CHIRP to comment in detail on individual situations such as this because we do not have the full facts, but it is worrying that those affected by the change were seemingly not aware of their extra responsibilities or how the associated threats to safety were otherwise being mitigated. The CAA are unable to share their detailed oversight outcomes with us as an external organisation, but their comment about change management and risk assessment hint that more could have been done in these respects; given the reporter’s comments about loading issues and training, we agree. If anything, as aviation recovers in this post-COVID context of constrained resources and new procedures, more supervision is required, not less, and the TC activity is an important ‘last-chance’ coordinating activity that must surely be safeguarded. Although it may well have been deemed appropriate to persist with the removal of the discrete TC role, we understand that it was subsequently recognised that this can only be sustained in future after the introduction of several unspecified safety recommendations/mitigations, all of which should have been identified beforehand as part of a robust change management review rather than post-implementation.