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February 7 th , 2017 TWIGA AERO LTD | www.twigaaero.com 1 Solutions to the High Costs of Aircraft Ground Damage: White Paper Maurizio Anichini | Author’s Twitter Handle February 7 th , 2017 EXECUTIVE SUMMARY From Operational Risks to Accidents, From Aircraft Damages to Root Cause Analysis. This White Paper addresses the $12B pain point the aviation industry incurs annually in terms of aircraft ground damage and injuries combined. We will explore how industry efforts fail to address the key problems and what mechanisms, techniques and solutions are available to reverse this alarming trend, thereby generating significant savings.

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February 7th, 2017 TWIGA AERO LTD | www.twigaaero.com

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Solutions to the High Costs of Aircraft Ground Damage: White Paper Maurizio Anichini | Author’s Twitter Handle February 7th, 2017 EXECUTIVE SUMMARY From Operational Risks to Accidents, From Aircraft Damages to Root Cause Analysis. This White Paper addresses the $12B pain point the aviation industry incurs annually in terms of aircraft ground damage and injuries combined. We will explore how industry efforts fail to address the key problems and what mechanisms, techniques and solutions are available to reverse this alarming trend, thereby generating significant savings.

February 7th, 2017 TWIGA AERO LTD | www.twigaaero.com

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TABLE OF CONTENTS INTRODUCTION ................................................................................................... 6 BACKGROUND/PROBLEM STATEMENT .......................................................... 7 SOLUTION ............................................................................................................ 8 CONCLUSION .................................................................................................... 11 ADDITIONAL RESOURCES ............................................................................... 12

February 7th, 2017 TWIGA AERO LTD | www.twigaaero.com

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INTRODUCTION Reportedly, occupational hazards, injuries and absences from the work place result in multi-billion dollar costs to the aviation industry and more specifically in the ground operations sector. In terms of aircraft ground damages, the $4B figure is elevated to about $12B when the ancillary costs related to injuries, lost time away from work, insurance-related costs to both employers and employees and other factors are considered. These numbers were derived during from the time I worked as Project Manager for the IATA Ground Damage Prevention Programme (GDPP). The Flight Safety Foundation did some great work to identify injury-related costs and a decade ago everyone was pushing hard for a centralised data base of all near-miss ground events, injuries, incidents and accidents. It is only in the last couple of years that such a database has been developed. (See: https://flightsafety.org/wp-content/uploads/2016/09/asw_may07_p20-24.pdf for information on the FSF GAP program).

Source IATA Safety Report

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The IATA Ground Damage Database (GDBB) collects information as relates only to events that impact the aircraft. This presents a shortfall in that any other near-miss, injury, incident during ground operations is not registered nor considered. What does this mean? The industry is in the dark about why major events take place, given that 90% of the events are rooted in other areas. prior to causing serious injury or causing aircraft damage.

Operational phase Source IATA Safety Report

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BACKGROUND/PROBLEM STATEMENT Certainly, a $12B annual pain point is something the industry should address, you might ask. Many are working on various initiatives from the very top of the industry, such as the ISAGO (IATA Safety Audit for Ground Operations) program. Other means to address the problems linked to this are by way of standard setting for operational practices and procedures, such as IGOM (IATA Ground Operations Manual) and some great, daily work done in a variety of ways by the many individuals across the globe.

But how many individuals and companies work preventively, in line with ICAO Doc 9859 Safety Management Manual (SMM) and implement SMS?

And as part of those systems being implemented how many are addressing the problems from the early stages of hazard identification and conducting risk assessments in the operations?

Rhetorical though the questions may seem, they shed light on the fact that, as an industry, we satisfy ourselves with knowing the documentation is in place and aligns with industry best practice to achieve an acceptable means of compliance. Let's take a closer look at the main areas of intervention:

• Risk-based approach to reduce aircraft ground damage, • Training • Organisational culture.

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Risk-based Approach to Reduce Aircraft Ground Damage With this backdrop, we go to work on developing a systematic approach to not only identify the problems and how they occur, we seek to identify the operational hazards and risk that lead to near-misses, injuries, incidents and accidents. In so doing the investigation process comes into play. Conducting investigations is interesting, but only for so long. Many accidents present repetitive, common problems linked to oversight, or the virtual absence thereof and a seeming unwillingness of people working in the dangerous airport ramp environment to do the right thing to save themselves and others in the process.

Source ICAO Doc 9859 Safety Management Manual (SMM) Often investigators concern themselves with understanding how the event happened, as compared to understanding the variation between how it should have taken place and how it took place, the well-described “practical drift” or

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deviation, which leads to the ‘Swiss cheese’ model we all know about. The real answers lie elsewhere, in a much deeper place. Only after conducting deep root cause analysis, do we understand that some of the problems may lie in the least expected places; organisational culture, processes linked to specifying and procuring equipment or even the common task of hiring the ‘right’ manpower. Let us look at this last point in a bit more detail. Often, we assume that because the person being interviewed for a position has a level of basic education commensurate with the job he/she has applied for and is fit-for-duty. Once accepted, this trail of assumptions continues and takes on a new perspective. Training Through initial/induction training, common place items in most, if not all companies in ground operations, the individual is expected to pass tests, gain scores and build up a level of knowledge that should be the support mechanism put in place as the foundation for his/her career in ground operations. We are all different beings, come from many cultures, levels of society and have differing educational backgrounds, aspirations and achievements. Once we pass the test though, we are presumed to be all on the same level. As an industry, this is where we go wrong. Our assumptions about someone’s capability to understand the training materials, is compounded by the fact that even if the individual sat through the course, took the exam and past, he/she may have done so just to pass the test. In fact, upon closer investigation, we establish that the individual has retained a minimal amount from the training sessions. Designed to ace tests, many training sessions look for scores, rather than what people retain from them. We fall short of matching individuals’ competence levels with the training program requirements to build the desired level of skill But let us not only focus on training the individual, let us now move the conversation to that of culture.

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Organisational culture is inextricably linked to the culture of the individuals in that region and the region where others from other regions inject and blend into the company’s own culture. The complexities are often categorised into one, as they are as intricate to manage as they are difficult to understand. Simplifying it to the lowest common denominator, let us talk about the internal company culture. Take a moment to reflect on your own organisational culture; is it one of collaboration or authoritarian rule, one of fear or positive, just culture? Though prescribed by ICAO in Doc 9859 SMM, it appears just culture is a little bit more complicated to put in place than simply writing it in the policy statement, that ‘..the company operates in a just culture environment..’ Let us take an introspective look.

• As a CEO or MD of your company, what keeps you awake at night in terms of safety risks and exposures? And are you comfortable with the level of risk mitigation in place?

• Is the lack of robust processes resulting in the purchase and use of unusable or incompatible equipment?

• Is your lack of retention policy resulting in a high employee turnover rate, which further drives costs up?

• How is the balance between cost and operational safety established and maintained?

• How is analysis and understanding the human factors that drive incident and accident statistics currently being done when the single central database does not capture ground events?

• What do your indicators tell you in terms of the amount of time spent and funding committed to the problems discussed?

Most importantly perhaps is how your company can benefit in terms of operational performance, reputation and cost savings. Drive (r)evolutionary

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changes by implementing systems, establishing simple, robust processes and procedures. Also ensure control mechanisms are in place to facilitate monitoring, compliance and operational performance. With the ICAO Asia Pacific regional targets set to increase ISAGO registrations by 50% by the end of 2017, ask yourself if your company is ready for the next steps; implementing systems, compliance and monitoring and proactively managing safety risks. Solutions highlighted in the information below have proven to achieve these points in a variety of culturally diverse environments and in companies ranging from GSPs to airlines and from airport to civil aviation authorities responsible for oversight.

February 7th, 2017 TWIGA AERO LTD | www.twigaaero.com

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SOLUTIONS Masterclasses IGOM Gap Analysis & Implementation To address the problem of weak processes and procedures, as opposed to robust ones, we assist companies in the implementation of the core, industry process and procedures manual; the IATA Ground Operations Manual (IGOM) Gap Analysis & Implementation. Preparation & Implementation, New Model ISAGO To achieve a higher level of control that enables the senior executives to ensure consistently robust and reliable operations, we work with companies to implement the IATA Safety Audit for Ground Operations (ISAGO). This further aligns the Ground Service Providers with their airline clients, a majority of which undergo the IATA Operational Safety Audit (IOSA) program as a part of their IATA membership. In the Asia Pacific region alone, the ICAO APAC targets call for a 50% increase in ISAGO registrations by the end of 2017. Are you ready? Risk-Based Approach to Reduce Aircraft Ground Damage The classic iceberg shows that numerous near-miss events result in aircraft ground damage. A combined approach of proper hazard identification, risk assessment and mitigation as well as root cause analysis is required to gain intelligence and drive change. This will reduce costs and improve your bottom line.

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FOD patrol in Bangkok GSE Operational Risk Assessment & Letter of Expertise & Endorsement (ORA LEE) Having an expert assessment on the GSE interfaces with the human, in the operational environment to check for operational efficacy and efficiency will save the company from a higher rate of injuries, aircraft damages and operational inefficiencies. Prior to introducing GSE in the operational environment, consideration to specifying and then deploying/commissioning the equipment for its intended use is typically done. In between lies the fabrication of the equipment to cross check what ‘..goes into making it..’. Finally the human interface in the operational environment comes into play.

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PANUS Assembly BLISS-FOX F180 ORA LEE This is when the ‘rubber-hits-the-road’ and often proves to be the hardest test of all. How will the machine perform in the actual operational environment? How will the operators interface with the machine? How different in terms of standard configuration related to anthropometrics is the machine? Many questions still remain even if and when the machine is built to specifications. This approach addresses many of the potential and actual pitfalls before they cause costly damages and injuries. Internal Audit & Monitoring Compliance How come the internal audit department failed to identify this problem? The question itself clearly suggests that an organization's last line of defence failed to do its job. Is it realistic for internal audit programs to identify all the shortcomings? The need to provide assurance is not only constant, but critical. We will explore the ways in which the audit program can safeguard against risks by:

• Create strong risk assessment processes • Develop robust audit programs

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Team is awarded for their safety improvements after intensive monitoring masterclass in Bangkok Interpreting the IATA SGHA & SLA Widely used since decades in our industry the many grey areas, pitfalls and legal language in the SGHA Articles and Sub-Articles makes the SGHA both a valuable tool and a maze to go through for the expert and novice user. Using practical examples linking contracts and SLAs to operations, discover what practical benefits can be brought to light through a better understanding of this long-standing industry document the SGHA. Management Systems for Ground Operations - SMS, QMS, RMS 2017 will bring notable changes to ISAGO and ISO 9001:2015 standards. Risk management will be a requirement in due course. This is in addition to Safety and Quality Management Systems. Implementation is the key work when it

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comes to systems. Practical information and tools to drive the implementation processes have proven their ease of use and effectiveness in demonstrable on-the-shop-floor implementation. Understanding & Managing Through Human Factors in Ground Ops Everyone in aviation knows and talks about human factors. When discussed around the ground operations environment, the discussion is often limited to maintenance HF studies. Exploring and understanding HF in ground operations in practical terms, using real data from studies conducted provides insights as to how HF can positively influence management decisions that will drive costs, injuries, incidents and accidents down.

HF Course in Kuala Lumpur

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Aviation Ground Operations Management Essential in laying down the foundational elements to understand ground operations viewed from a 360º perspective, this course provides the framework from regulations to operational standards, from commercial agreements and sales to operations and from systems to monitoring. Accelerating competence and building capacity, it provides a competitive advantage through a thorough understanding of the complexities of the ‘unregulated’ world of ground operations management.

AGOM course in Johannesburg

February 7th, 2017 TWIGA AERO LTD | www.twigaaero.com

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CONCLUSION With the $12B cost of aircraft ground damage, injuries and accidents, the time is right to apply concrete solutions that deliver results to change the trend. Although many initiatives are underway to address the problems, little or no work has been done to collect the required data that concerns all of ground operations. This includes collecting human factors data in ground operations. In this regard, much work needs to be done. Understanding the human factors driving the accidents, will empower management decisions that are good for the GSP companies, the airlines and equally so for the employees. Implementing systems, SMS, QMS, RMS, remains a largely misunderstood dilemma, with many still considering the systems fully implemented once the documentation is completed and shelved. A radically different approach, taken through practical implementation is required. Convinced that the solve-it-all is an audit program, we must consider the implementation of standard processes and procedures to simplify and streamline operations and verify the same through standard audit programs, specifically developed for ground operations. Lastly, ensuring the best equipment for the task is selected is key to a successful operation. Consideration for the human to machine interface in the operational environment will drive the difference between a safe or unsafe operation taking place or one that is accident-prone, versus an accident-free operation. All things considered, though perfection may be unrealistic to reach, without aiming for a high place, the industry will continue footing the increasing costs of $12B + annual bill linked to aircraft ground damage and ancillary injuries and accidents.

February 7th, 2017 TWIGA AERO LTD | www.twigaaero.com

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ADDITIONAL RESOURCES If you would like to know more on our approach to reducing aircraft ground damage, injuries and accidents, implementing systems, understanding human factors in ground operations and much more, please contact us:

www.twigaaero.com , [email protected] +66 80-808-4836

• Flight Safety Foundation GAP Program: https://flightsafety.org/wp-

content/uploads/2016/09/asw_may07_p20-24.pdf • FAA:

https://www.faa.gov/about/initiatives/maintenance_hf/library/documents/media/support_documentation/opsman_ramp_final.pdf

• Dutch NLR (CAA): https://www.ilent.nl/Images/rapport%20HF%20in%20grondafhandeling_tcm334-319100.pdf

FOR MORE INFORMATION

www.twigaaero.com , [email protected] +66 80-808-4836

ã Copyright Information 2017, TWIGA AERO Ltd. All Rights Reserved For more information, please contact [email protected]