SAA

ATM Safety Investigation & Analysis Course

Accident Investigation Report

De-Icing Accident Mirabel Airport

The Reason Model

Contextual Conditions Organisational and System Factors

Human Involvement
Absent or Failed Barriers

People, Task, Environment

ACCIDENT
Latent Conditions Active Failures Limited window/s of opportunity

(adapted from Reason, 1990)

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Summary of the Event

Miscommunication Leads to Three Fatalities During Ground Deicing of Aircraft.

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 The Royal Air Maroc Boeing 747-400 was preparing for a scheduled flight from Mirabel International Airport, Montreal, Canada, to Casablanca, Morocco, via New York. The B-747 crew heard the words dgrivage termin (deicing completed) on the radio frequency assigned to the deicing crew. The captain assumed that the operation had been completed and that the deicing crew had left the area. Unknown to the B-747 flight crew, two deicing vehicles were still positioned on opposite sides of the fuselage forward of the horizontal stabilizers, with five deicing personnel who were continuing the deicing operation.
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 As the aircraft moved forward, its horizontal stabilizers struck the telescoping booms of the deicing vehicles, overturning the vehicles. three occupants of the two buckets (cherry pickers) were killed when they struck the ground, and the two vehicle drivers received minor injuries.

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OTHER SYSTEM FACTORS

ORGANISATIONA L FACTORS No proper Training on Engines on configuration. No checking on wearing safety harness and protective gear.

CONTEXTUAL CONDITIONS

HUMAN INVOLVEMEN T

ABSENT OR FAILED BARRIERS

ACCIDENT

Noise of the engine prevented snowman to hear pilots TX properly

De icing area was not visible from TWR for the controller

inadequate communications equipment

XX Xxxx

Non availability of aircraft marshaller at ground during de icing

YY Yyyyyy No SOPs to do de iceing by RAM Not having enough crew to handle B747 de icing CAILs failure to provide a copy of its de icing procedure to RAM competition on deicing operations between Airliners and contractors Transport Canadas lax mentality towards foreign carriers and private contractors Snowmans heavy work load ADMs failure to issue deicing licence ADM managements failure to prevent deicing with engines on.

Snowman agreed to de ice with engines on

LACK OF SOP REGARDING DE-ICING

Different communication procedures follwed by the deicing crew Engine on deicing was pervalent with the ADMs knowledge Animosity between CAIL de icing crew and private contractors Pilot heared the words De icing completed with out any station name Apron controller not required to confirm with the crew thRat the perimeter is clear. RAM deicing with engines ON Captain did not confirm with the de icing crew about the completion No TX on the CAIL frequency after beginning of the deicing Flight attendant not required to prevent taxi Iceman not preventing snowman to deice with engines on

NO ATC VISUAL REFERENCE S TO DEICING FACILITY

CONTRADICTI NG TC AND ICAO CIRCULARS

PIC taxied with out proper communication with the ground crew Apron controller assumed that ACFT started after deicing Pilot did only a visual check from th cockpit

FLIGHT ATT. NOT REQUIERED TO INFORM THE CREW ABOUT A/C PERIMETER

What happened Brief summary of loss: injuries, fatalities, equipment etc

ZZ Zzzzzzz

TC LIMITATIONS TO CHECK FOREIGN CARRIERS AND CONTRACTOR NO AGREED UPON VISUAL SIGNAL TO INDICATE THE COMPLETION OF WORK

Absent or Failed Barriers

Absent or failed barrier 1

Absent or failed barrier 2 Absent or failed barrier 3 ..

The last minute defences or barriers which failed or were missing, and therefore did not prevent the accident.
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Human Involvement

Human involvement 1

Human involvement 2
Human involvement 3 Human involvement 1 ..

The errors and/or violations (actions or omissions) by people at the scene which triggered the accident.
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Contextual Conditions

Contextual condition 1

Contextual condition 2
Contextual condition 3 Contextual condition 4 ..

The task, situation, environment, or people conditions existing immediately prior to, or at the time of the accident.
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Organisational Factors

Organisational factor 1

Organisational factor 2
Organisational factor 3 Organisational factor 4 ..

The organisational and system factors (failures) that created the prevailing Contextual Conditions or allowed them to exist (~ task, environmental, people conditions).
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Recommendations:

Absent or Failed Barriers

IMPLEMENTATION OF PROPER SOP REGARDING DE-ICING OPERATION INSTALATION OF A PROPER CCTV SURVEILLANCE SYSTEM IN TWR Recommendation A4 ..

Corrective actions to address deficiencies in the barriers which should or could have prevented the occurrence
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Recommendations:

Organisational Factors

Provide adequate manpower to carry out de-icing with engines running RAM should assure that proper procedure are in place for the cabin crew to inform the flight crew about any safety issue..

Corrective actions to address organisational deficiencies which contributed to the occurrence

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Key Learnings (for Our Organisation)

Compliance with the R/T phraseology procedure Intervene immediately in the interest of safety even though you are not required to do so by the procedure Key Learning 3
from this occurrence which can Key Lessons Learning 4 be applied across our organisation

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Questions or Comments?

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