Aviation Ground Operation Accidents/Incidents (2000-2020) PDF

Transportation Engineering 13 (2023) 100184 Contents lists available at ScienceDirect Transportation Engineering journal home...

Transportation Engineering 13 (2023) 100184 Contents lists available at ScienceDirect Transportation Engineering journal homepage: www.sciencedirect.com/journal/transportation-engineering Full Length Article The role of human factors in aviation ground operation-related accidents/ incidents: A human error analysis approach Nadine Muecklich a, *, Ivan Sikora b, Alexandros Paraskevas b, Anil Padhra b a Fraunhofer Institute for Material Flow and Logistics, Bessie-Coleman-Straße 7, Frankfurt am Main 60549, Germany b London Geller College of Hospitality & Tourism, University of West London, St Mary’s Road Ealing, London W5 5RF, United Kingdom A R T I C L E I N F O A B S T R A C T Keywords: Aviation is a complex socio-technical system with interconnected and interdependent subsystems, such as flight Aviation operations, air traffic control, aircraft maintenance and ground operations. However, safety and risk research has Aircraft accident analysis not paid, thus far, adequate attention to all subsystems, resulting in possibly undetected or underestimated risks. Ground operations This study focuses on Ground Operations (GO) as a subsystem and analyses the role of human factors in ground Human factors analysis and classification operations related accidents and incidents. 87 accident and incident reports (from 2000 to 2020) were analysed scheme Thematic analysis in three stages, using the Human Factors Dirty Dozen (HF DD) Model and the Human Factors Analysis and Content analysis Classification Scheme (HFACS) as a basis for the third stage, a systematic thematic analysis. The findings indicate that lack of situational awareness and failure to follow prescribed procedures are the main causal and contrib­ uting factors in GO-related accidents and incidents. Three operational actions were identified as most critical: aircraft pushback/towing, aircraft arrival and departure, and aircraft weight and balance. An agenda for future research and recommendations for industry corrective action are proposed. 1. Introduction visible ones, such as ground operations (ground crew loading, unload­ ing, and servicing the aircraft), and aircraft maintenance (personnel The aviation system is a complex socio-technical system consisting of conducting the scheduled and unscheduled aircraft maintenance, repair, different subsystems, such as flight operations, ground operations, and overhaul) [19,22]. In this study we focus our analysis on the sec­ aircraft maintenance, or air traffic management. Each of these sub­ ondary subsystem Ground Operations. systems fulfils its part to enable the safe and efficient operation of pas­ The contribution of secondary subsystems to accidents and incidents senger and cargo flights around the world [7,51]. appears to be less studied, even though safety failures in these can lead Technological progress and advances in training, standards, and to overall system disruptions delays, damages to the aircraft or equip­ procedures, have increased flight safety to unprecedented levels [57, ment and injuries of people [13,45,62]. To address this gap, this study 58]. The number of accidents, and especially of fatal accidents, has been aims to explore the role of human factors in aviation Ground staggeringly reduced in the last 60 years, from 40 fatal accidents per 1 Operation-related accidents and incidents in by analysing accident re­ million flights in 1959 to approximately 0.14 fatal accidents per 1 ports between 2000 and 2020 using the Human Factors Dirty Dozen (HF million flights on a five-year average of 2017–2021. [1,25]. Neverthe­ DD) model , the Human Factors Analysis and Classification Scheme less, accidents still happen and new challenges continuously arise. (HFACS) as analytical frameworks, and a systematic thematic When investigating accidents and incidents in aviation, the focus is content analysis. usually placed on the operational subsystems with the most central or visible role, sometimes defined as primary subsystems, such as the cockpit crew flying the aircraft or air traffic control (ATC) managing the 1.1. Human error in aviation airspace [17,30,32]. However, secondary operational subsystems also play a role in ensuring the safety, efficiency, and effectiveness of flights. Human error has been identified as the number one causal and In the context of this study, we define as secondary subsystems the less contributing factor to aviation accidents and incidents. dependant on the source, up to 80% of aviation accidents and incidents identify human * Corresponding author. E-mail address: [email protected] (N. Muecklich). https://doi.org/10.1016/j.treng.2023.100184 Received 3 March 2023; Received in revised form 3 May 2023; Accepted 31 May 2023 Available online 1 June 2023 2666-691X/© 2023 The Authors. Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by- nc-nd/4.0/). N. Muecklich et al. Transportation Engineering 13 (2023) 100184 Fig. 1. Human Factors Dirty Dozen. Fig. 2. The Human Factors Analysis and Classification Scheme – HFACS. error as a causal or at least contributing factor [33,34,41,55]. Therefore, management and training approaches. These approaches aim in pre­ the analysis of potential human error preconditions is a key component venting accidents and incidents within the system caused by errors of in applying the systems view on aviation safety [50,54]. human factors, thus limiting risks, and improving safety in the operation Human error management approaches in aviation address the char­ and its processes [20,49,50,60]. acteristics of the different high-risk subsystems with adapted There are different approaches in analysing human error – the main 2 N. Muecklich et al. Transportation Engineering 13 (2023) 100184 human factor in accidents and incidents - [5,36,48]. TRACEr, for Table 1 example, is a technique for the retrospective and predictive analysis of Operational area related to the probable cause or major contributing factor. cognitive errors in ATC. Other approaches employed in aviation are Working area of # of % Main findings Accident Report the Human Factors Dirty Dozen (HF DD) model [8,35,43,63] and the the probable cause reports Number (Appendix) more advanced Human Factors Analysis and Classification Scheme & contributing factors (HFACS) [18,39,55]. We use the Human Factors Dirty Dozen (HF DD) model - as a Aircraft weight 17 20 - Special cargo AR#: 1, 2, 3, 4, starting point to identify the preconditions for human error in aviation and balance procedures 5, 6, 7, 8, 9, 10, - Load 15 - Misplaced Unit 11, 12, 35, 51, accidents or incidents. The model lists twelve dominant preconditions - Unload 1 Load Device (ULD) 53, 54, 83 for human error in an operation or in a system that can lead to or are - Load and unload 1 - Communication precursors to accidents or incidents (Fig. 1). The HF DD is neither a Aircraft Pushback 28 32 - Commnication AR#: 13, 15, 16, holistic, nor a comprehensive list of precursors. Nevertheless, the model / Towing before and during 17, 19, 22, 26, pushback 28, 32, 36, 39, has been widely used to identify human error factors in accident analysis - Lack of experience 41, 43, 45, 48, in aviation as well as in health care [46,52]. 52, 55, 57, 58, The Human Factors Analysis and Classification Scheme (HFACS) 60, 64, 65, 67, provides a more systematic approach to identifying precursors for 70, 72, 73, 80, human error leading to aviation accidents or incidents. 82 Ramp Driving 11 13 - Lack of awareness AR#: 14, 18, 23, The HFACS framework was developed by Shappell and Wiegmann 25, 31, 34, 42, and is based on the groundwork of James Reason on safety and risk 66, 74, 75, 85 management. HFACS provides four levels of analysis: Organisation, De-icing 3 3 - Lack of or AR#: 24, 29, 33 Supervision, Preconditions for Unsafe Acts, and Unsafe Acts (Fig. 2). insufficient communication Thus, it does not only focus only on human error alone, but also on the Aircraft arrival/ 21 24 - Lack of awareness AR#: 20, 37, 38, underlying preconditions that exist in the environment the human is departure 40, 44, 46, 49, working in. -set-up/arrival 11 50, 56, 61, 62, HFACS has been used by aviation researchers and accident in­ -wrap-up/ 10 63, 68, 69, 76, vestigators, but also in the maritime, rail and the chemical sectors to departure 77, 78, 79, 81, 84, 86 identify potential active and latent system failures [6,59]. Aircraft 4 5 - Lack of awareness AR#: 27, 59, 71, marshalling/ - Lack of 87 2. Methodology positioning at experience/ the gate training - Miscommunication A three-stage systematic content analysis of aviation accident and Other 3 3 - Lack of awareness AR#: 21, 30, 47 incident reports was undertaken, using the HF DD (Stage 1), HFACS TOTAL 87 100 (Stage 2) as guiding frameworks. This was akin to a template analysis (Stage 3) which is a special form of thematic analysis that emphasises the use of hierarchical coding but achieves a balance between a rela­ identify the contribution areas of ground operations. This analysis aids tively high level of structure in the analysis of textual data with the to organise, structure, and quantify data and information with identifi­ potential of also allowing the identification of emerging themes that able ground operations/ground services components. In addition, were not included in the original template. reliability measures for the applied methods and conducted analysis All three stages were based on the analysis of official accident and were applied. Intercoder reliability tests were applied to reduce incident reports retrieved from official governmental national aviation subjectivity bias. [14,47] The researchers read, sorted, and re-read the accident investigation (please see Table 6 in the Appendix). The reports incidents until they reached agreement on the coding strategy (themes – in those databases were evaluated against the following criteria: The codes). The tests for homogeneity of the codes did not show significant search was limited to accidents and incidents between the years 2000 differences between the coders at the 0.05 level. To further ensure and 2020, thus limiting the reports to accidents and incidents that reliability with a test-retest check the researchers undertook the same happened in the latest evolutionary stage in aviation safety, the system task for a second time, three weeks later, resulting in an 84.2% agree­ stage. Only commercial air transport accidents were examined, ment which is higher than the 80% prescribed level of acceptance including turboprop and jet aircraft involved. Reports that have been included contained identifiable ground operations’ causal or contrib­ 3. Results & discussion uting factors. The initial search resulted in 105 accident and incident reports, while after the detailed screening 87 reports remained. 3.1. Analysis of accidents and incidents in ground operational working Excluded reports could not provide sufficient information to be included areas in the analysis, for example caused by a superficial description of the occurrences. A list of the selected reports can be found in the Appendix – The first level of analysis sought the operational areas of actions in Table 6. which Ground Operations’ failures or mismanagement contributed to The strategy used in the current study employed three steps: First, it accidents and incidents reported in the sample (Table 1). Those actions systematically analysed the selected reports and identified what include aircraft weight and balance issues such as misplaced containers happened, where, how, and what contributed to it. Main ground oper­ or loose load or error during weight planning; aircraft pushback and ational areas in which those accidents or incident occurred were defined towing operations; ramp operations such as driving of ground support and a template was developed for the classification and quantification of equipment or service cars on the apron; aircraft de-icing; aircraft arrival data and information. Second, it identified the main human error pre­ and departure, i.e., the preparation processes for aircraft arrival and conditions for accidents and incidents using the human factors ‘dirty departure (e.g., placing pylons or wheel chocks,1 check of the parking dozen’ model and a more systemic analysis with the Human Factors position); and aircraft marshalling and positioning procedures. Analysis and Classification Scheme (HFACS). Third, a thematic analysis is offered to unveil main areas in which either organisational, opera­ tional, procedural, or training improvements might be necessary. The 1 When the aircraft arrives, pylons are placed to mark the aircraft perimeter, data and information were coded into themes and categories relevant to while the wheel chocks are placed to prevent the aircraft from moving. 3 N. Muecklich et al. Transportation Engineering 13 (2023) 100184 Table 2 Damage and injuries of selected reports.21 Damage to aircraft and equipment Injury Severity Negligible Minor Major Hazardous/ Negligible Minor Major Hazardous/ catastrophic catastrophic Severity No damage to Minor damage to Significant Serious damage or No Small injury Injury to people Serious injuries or definition aircraft or aircraft or damage and total hull loss of injuries without without long-term death to people (e.g. equipment equipment, smaller operation aircraft or consequences consequences personnel, crew, operation disruptions equipment passengers) limitations Number of 21 20 18 28 70 9 2 6 accidents and incidents TOTAL in% 24% 23% 21% 32% 80% 10% 2% 7% (rounded numbers) Table 3 Table 4 The Human Factors Dirty Dozen - relevance to the identified accidents and Results of the Human Factors Analysis and Classification Scheme. incidents. HFACS Causal Categories # of % Human Factors Dirty Dozen # of accidents & incidents reported % reports 1. Lack of communication 36 41.38 Organisational Influences Resource Management 23 26.44 2. Distraction 10 11.49 Organisational Climate 9 10.34 3. Lack of resources 30 34.48 Organisational Process 62 71.26 4. Stress 13 14.94 Unsafe Supervision Inadequate supervision 7 8.05 5. Complacency 11 12.64 Planned inappropriate 7 8.05 6. Lack of teamwork 0 0.00 operations 7. Pressure 9 10.34 Failed to correct problem 9 10.34 8. Lack of awareness 54 62.07 Supervisory violations 0 0 9. Lack of knowledge 8 9.19 Preconditions for Unsafe Environmental Factors 10. Fatigue 4 4.59 Acts - Physical Environment 17 19.54 11. Lack of assertiveness 2 2.29 - Technological Environment 19 21.84 12. Norms 15 17.24 Condition of Operators - Adverse Mental State 33 37.93 - Adverse Physiological State 0 0 The majority of the accidents and incidents occur during Aircraft - Physical/Mental 13 14.94 Limitations Pushback/Towing (32%), during aircraft arrival and departure opera­ Personnel Factors tions (24%), and in relation to the weight and balance of the aircraft - Crew Resource 44 50.57 (20%) (see Table 1). Management Thereafter we analysed the impact severity these GO failures. This - Personal Readiness 1 1.15 Unsafe Acts Errors impact was evaluated in terms of damage to the aircraft or equipment, - Decision Errors 33 37.93 and harm to persons such as the ground personnel, flight crew, or pas­ - Skill-based Errors 20 22.98 sengers (Table 2). - Perceptual Errors 46 52.87 Severe damage to an aircraft or equipment ranges from damages Violations requiring major repairs (AR# 32) to a total hull loss of the aircraft (AR# - Routine 3 3.45 - Exceptional 5 5.75 1). In more than 30% of the reports (n = 28), serious damage- to the aircraft or other ramp equipment was identified. (AR# 9 & 10), or during the pushback operation, the pushback driver and wingwalker3 may not be aware of the improper clearance to ob­ 3.2. Human factors analysis stacles or another aircraft (AR# 28 & 32). This lack of awareness is often compounded by other human error preconditions, such as lack of In exploring the Human Factors contribution to the reported acci­ communication or miscommunication (AR# 15, 40), lack of resources dents and incidents, the reports were first screened through the lens of (AR# 42) or time pressure (AR# 6, 7). Miscommunication resulting in HF DD as an accident or an incident can be attributed to several human lack of awareness can involve unclear information on the payload for the error preconditions from the ‘dirty dozen’ framework. Then, the HFACS aircraft (AR# 11, 12, 35), on the clearance of the aircraft to obstacles framework was used to further analyse the contributing factors. (AR# 15), and miscommunication between the GO and other sub­ In the HF DD analysis (Table 3), the three most prominent human systems (AR# 24, 29) error preconditions that can be considered as accident/incident causal Lack of resources typically involves insufficient GO personnel or contributing factors are lack of awareness, lack of communication, numbers (e.g., loading team, missing a load planner or wingwalker - and lack of resources. AR# 3, 6, 19), missing the necessary equipment (e.g. a radio, a de-icing Lack of awareness appeared in all operational areas of GO. During vehicle or a missing belt loader -AR# 24, 84), or even not having the the turnaround, personnel may not be aware of errors on load sheets 3 Wingwalker: „A member of the ground crew whose primary job function is to walk alongside the aircraft’s wing tip during aircraft ground movement (e.g. pushback, towing) to ensure the aircraft does not collide with any objects“ ([23-2, p.255) 4 N. Muecklich et al. Transportation Engineering 13 (2023) 100184 Table 5 implementation (AR# 2, 3, 7 19). Compounding factors include the lack Thematic Analysis with HF Dirty Dozen Codes Included. of proper communication procedures (AR# 40), lack of reporting pro­ Themes and sub-themes # of % of accidents cedures (AR# 44), and insufficient training provision (AR# 44, 63). reports or incidents Other prominent factors were ‘Perceptual Error’ (n = 46, in 52.87% of Training and - Insufficient training 11 12.64 the analysed accidents), and ‘Crew Resource Management’ related ac­ Education - Insufficient personnel 4 4.60 tivities or omissions (n = 44, in 50.57% of the analysed accidents). The qualification ‘Perceptual Error’ factor refers to an error caused by decreased sensory - Lack of knowledge 10 11.49 perception or a decision based on false information [53,54]. Perceptual - Lack of experience 4 4.60 Communication - Lack of communication 18 20.69 errors would be directly associated with ‘Lack of awareness’ in the HF - Wrong/insufficient 16 18.39 DD analysis (AR# 78, 79, 83, 86). ‘Crew Resource Management’ (AR# 1, communication 5, 17) normally refers to communication, coordination, planning, and Culture - Lack of organisational 11 12.64 teamwork or the lack of these elements. An inadequate decision culture taken in and for a specific situation, not leading to the intended outcome - Lack of safety culture 9 10.34 Rulemaking/ - Lack of regulatory 5 5.75 are so called ‘Decision Errors’ (AR# 2, 12, 67): Adverse mental state Policymaking framework includes mental conditions, such as stress, fatigue or even the personal - Lack of guidance material 16 18.39 motivation to complete a task, that limit the performance of the human Procedures - Lack of (proper) procedures 21 24.14 factor (AR# 4, 19, 32). [53,54] - Insufficient procedures 22 25.29 - Failure to follow procedures 57 65.52 (2) 3.3. Emerging factors Oversight - Inadequate regulatory 7 8.05 oversight During the analysis of accident and incident causes, several of the - Insufficient internal 12 13.79 identified factors could not adequately be classified under the HF DD or oversight (e.g. audits, control, observation) HFACS frameworks. The most prevalent of these were Training and - Wrong norms established & 6 6.90 Education (only partly covered in HF DD and HFACS) (AR # 1, 19, 53), not detected Oversight (AR# 12, 40, 46) and Rulemaking/Policymaking (AR# 33, Resources - Lack of resources 16 18.39 53, 87) - Incorrect planning of 7 8.05 resources* Integrating the factors identified in this study as the ones causing Management - Insufficient change 4 4.60 aviation accidents and incidents, Table 5 provides an overview of rea­ management sons for which human factor theme in GO have caused an accident or an - Insufficient supervision 17 19.54 incident over the last two decades. Environmental - Technical problems/ 14 16.09 One accident or incident often has various influencing factors across Influences deficiencies - Physical environment (e.g. 12 13.79 the themes and categories. For example, the failure to follow prescribed severe weather) procedures can be related to wrong norms, an insufficient safety culture, Front-line - Human - Distraction 8 9.19 the lack of resources, high time pressure, and even personal stress Factors - Stress 9 10.34 (AR#17, 29). Two sub-themes can be highlighted: (1) lack of awareness - Complacency 8 9.19 - Lack of teamwork 0 0.00 and (2) failure to follow prescribed procedures, which both can be found - Pressure 6 6.90 in nearly two-thirds of the analysed reports (Table 5). - Lack of situational 58 66.67 Although the analyses do not provide a complete picture, due to the awareness (1) varying degree of detail in the accident reports, they show unique - Fatigue 3 3.45 human error preconditions for the subsystem ground operations in all - Lack of assertiveness 0 0.00 - Incorrect interpretation of 15 17.24 three stages of the analysis. While there are many similarities to other information subsystems in the influencing factors of accidents and incidents (human error categories, such as situational awareness), there are also major differences, such as the failure to follow prescribed procedures. For an appropriate manuals (AR# 38, 46, 67, 83). adapted human error management approach, one must consider these In the HFACS analysis that followed, the framework was to look at differences and similarities, as well as available human error manage­ causes of these accidents and incidents from a more organisational ment approaches in other subsystems and other industries. perspective. Even though the categories of human error preconditions show Table 4 shows that the main organisational factors causing or similarities across subsystems, how these preconditions for accidents contributing to the accidents and incidents were ‘Organisational Pro­ and incidents are managed and mitigated must be adapted to the distinct cesses’, ‘Perceptual Error’ and ‘Crew Resource Management’. In addi­ characteristics of the subsystem. To date, ground operations safety tion, ‘Decision Errors’ and ‘Adverse Mental State’ could also be observed research and academic literature are very limited in addressing these as contributing human error factor in approx. one third of the accident and other safety issues [10,40,44]. While industry-related guidance reports respectively. exists, such as IATA IGOM or ICAO Manuel on Ground Handling The main causal factor was related with ‘Organisational Processes’ , these are potentially not or limited research-based and are not (n = 62, in 71.26% of the analysed accidents), in other words decisions focused on the safety issues that emerged from this study. and rules made within the organisation to govern the daily activities, The idea of a Ramp Resource Management (RRM) concept already such as operational processes, procedures, control, and oversight [53, exists, and similarly to Crew Resource Management (CRM), focuses on 60]. This factor is mainly linked with a lack of necessary operational and the non-technical and human factors issues in the subsystem. Never­ safety processes (AR# 1, 36, 40) or with major failures in their theless, the RRM is neither embedded in any ground operations regu­ latory framework nor otherwise widely present within the ground operations industry – while the latest information is dated to 2013 and 2 The classification of incidents is based on the ICAO Risk Severity earlier [9,44]. Thus, research-based existing knowledge and application Table (, p.37), but has been simplified so that four categories are used of safety methods are limited, while it must be noted that more industry instead of five. In the ICAO Risk Severity Table, the reports are classified in guidance is available. The main results of this study, with human error ‘Hazardous’ and ‘Catastrophic’ separately. preconditions in different areas, are similar to those identified and 5 N. Muecklich et al. Transportation Engineering 13 (2023) 100184 Table 6 Overview of selected reports. Accident Name of Report Year of Accident, Reference/Link Report # Incident, or Occurrence AR#1 Steep Climb and Uncontrolled Descent During 2013 https://www.ntsb.gov/investigations/AccidentReports/Reports/AAR1501.pdf Takeoff National Air Cargo, Inc., dba National Airlines AR#2 Aircraft loading-related occurrence involving 2017 http://www.atsb.gov.au/publications/investigation_reports/2018/aair/ao-2018–003/ Airbus A330–303, VH-QPD, Sydney Airport, New South Wales, on 17 December 2017 AR#3 Aircraft loading event involving Fokker F28, 2017 http://www.atsb.gov.au/publications/investigation_reports/2017/aair/ao-2017–019/ VH–NHV, Perth Airport, Western Australia, on 3 February 2017 AR#4 Aircraft loading involving Boeing 737, ZK-TLK, 2016 http://www.atsb.gov.au/media/5772697/ao-2017–002_final.pdf Sydney Airport, NSW, on 17 December 2016 AR#5 Loading related event involving Airbus A320, 2016 http://www.atsb.gov.au/publications/investigation_reports/2016/aair/ao-2016–177/ VH-VGI, Melbourne Airport, Victoria, on 21 December 2016 AR#6 Loading related event involving Airbus A320, 2016 http://www.atsb.gov.au/publications/investigation_reports/2016/aair/ao-2016–145/ VH-VQC, Gold Coast Airport, Queensland, on 29 October 2016 AR#7 Loading event involving Airbus A320, VH-VFN, 2016 http://www.atsb.gov.au/publications/investigation_reports/2016/aair/ao-2016–119/ Sydney Airport, NSW, on 8 September 2016 AR#8 Loading event involving an Airbus A330, VH- 2015 http://www.atsb.gov.au/publications/investigation_reports/2015/aair/ao-2015–088/ QPJ, at Bangkok, Thailand on 23 July 2015 AR#9 Loading event involving a Bombardier DHC-8, 2014 http://www.atsb.gov.au/publications/investigation_reports/2014/aair/ao-2014–145/ VH-LQK, at Brisbane Airport, Qld on 25 August 2014 AR#10 Loading related events involving a Boeing 737, 2014 http://www.atsb.gov.au/publications/investigation_reports/2014/aair/ao–2014–110/ VH-YIR, Bali, Indonesia on 26 May and an Airbus A330, VH-XFE, at Perth, WA on 16 June 2014 AR#11 Aircraft loading event - Airbus A330–202, VH- 2009 http://www.atsb.gov.au/publications/investigation_reports/2009/aair/ao–2009–034/ EBB, Sydney Airport NSW, 4 July 2009 AR#12 Weight and balance event - Airbus A330–303, 2009 http://www.atsb.gov.au/publications/investigation_reports/2009/aair/ao–2009–011/ VH-QPJ, Sydney Aerodrome, New South Wales, 6 March 2009 AR#13 Collision involving a Boeing B737, VH-VZZ and a 2017 http://www.atsb.gov.au/media/5775312/ao–2017–099_final.pdf catering vehicle at Sydney Airport, NSW, on 14 October 2017 AR#14 Occurrence #1: ON GROUND/WATER 2007 https://app.ntsb.gov/pdfgenerator/ReportGeneratorFile.ashx?EventID=20071231 × 02 COLLISION; Phase of Operation: TAXI - FROM 012&AKey=1&RType=Summary&IType=LA LANDING AR#15 N725PS: Bombardier, Inc. / CL-600–2C10, 2008 https://data.ntsb.gov/carol-main-public/basic-search N228PS: Bombardier, Inc. / CL-600–2B19 NTSB No: NYC08LA234 AR#16 N122UX: Beech / 1900D 2008 https://data.ntsb.gov/carol-main-public/basic-search NTSB No: DEN08LA151 AR#17 N254WN: Boeing / 737–700 2008 https://data.ntsb.gov/carol-main-public/basic-search NTSB No: WPR09IA033 AR#18 N8698A: BOMBARDIER INC / CL-600–2B19 2008 https://data.ntsb.gov/carol-main-public/basic-search NTSB No: DCA09FA011 AR#19 Date & Time: December 26, 2012, 02:15 Local 2012 https://data.ntsb.gov/carol-main-public/basic-search Registration: N612FE NTSB No: DCA13CA035 Aircraft: McDonnell Douglas MD-11F AR#20 Date & Time: February 2, 2012, 17:05 Local 2012 https://data.ntsb.gov/carol-main-public/basic-search Registration: N912SW, Aircraft: Bombardier NTSB No: DCA12CA035 CL600 2B19 AR#21 Date & Time: December 23, 2008, 01:02 Local 2008 https://data.ntsb.gov/carol-main-public/basic-search Registration: N486EV NTSB No: CEN09LA114 Aircraft: Boeing 747–212B AR#22 Date & Time: June 10, 2011, 17:58 Local 2011 https://data.ntsb.gov/carol-main-public/basic-search Registration: N571UA NTSB No: DCA11CA073 Aircraft: Boeing 757–222 AR#23 Date & Time: October 3, 2012, 20:10 Local 2012 https://data.ntsb.gov/carol-main-public/basic-search Registration: N894AT NTSB No: CEN13LA004 Aircraft: Boeing 717–200 AR#24 Date & Time: January 16, 2012, 07:00 Local 2012 https://data.ntsb.gov/carol-main-public/basic-search Registration: N839EX NTSB No: ERA12LA147 Aircraft: Boeing DHC-8–102 AR#25 Date & Time: December 22, 2011, 14:37 Local 2011 https://data.ntsb.gov/carol-main-public/basic-search Registration: N469WN NTSB No: CEN12IA123 Aircraft: Boeing 737–7H4 AR#26 Date & Time: May 31, 2011, 12:15 Local 2011 https://data.ntsb.gov/carol-main-public/basic-search Registration: N526UA NTSB No: WPR11LA300 Aircraft: Boeing 757–222 (continued on next page) 6 N. Muecklich et al. Transportation Engineering 13 (2023) 100184 Table 6 (continued ) Accident Name of Report Year of Accident, Reference/Link Report # Incident, or Occurrence AR#27 Date & Time: February 16, 2010, 06:35 Local 2010 https://data.ntsb.gov/carol-main-public/basic-search Registration: N226SW NTSB No: WPR10IA135 Aircraft: Embraer EMB-120ER AR#28 Date & Time: December 28, 2008, 07:00 Local 2008 https://data.ntsb.gov/carol-main-public/basic-search Registration: N585NW NTSB No: WPR09FA068 Aircraft: Boeing 757–351 AR#29 Date & Time: December 24, 2008, 07:00 Local 2008 https://data.ntsb.gov/carol-main-public/basic-search Registration: N516AS NTSB No: WPR09IA065 Aircraft: Boeing 737–890 AR#30 Date & Time: December 20, 2008, 07:47 Local 2008 https://data.ntsb.gov/carol-main-public/basic-search Registration: N771AS NTSB No: ANC09IA015 Aircraft: Boeing 737–4Q8 AR#31 Date & Time: December 18, 2009, 11:15 Local 2009 https://data.ntsb.gov/carol-main-public/basic-search Registration: N515AE NTSB No: DCA10CA018 Aircraft: Bombardier CL600 2C10 AR#32 Date & Time: January 12, 2008, 19:29 Local 2008 https://data.ntsb.gov/carol-main-public/basic-search Registration: N705SK NTSB No: SEA08LA061 Aircraft: Bombardier, Inc. CL-600–2C10 AR#33 Type of Occurrence: Accident 2015 https://www.bfu-web.de/EN/Publications/Investigation%20Report/2015/Report_15–00 Date: 20 January 2015 59-AX_Fokker100_Nurnberg.pdf?__blob=publicationFile Location: Nuremberg Airport Aircraft: Transport aircraft Manufacturer / Model: Fokker Aircraft B.V. / F28 Mark 0100 Injuries to Persons: None Damage: Aircraft severely damaged Other Damage: None AR#34 Type of Occurrence: Accident 2011 https://www.bfu-web.de/EN/Publications/Investigation%20Report/2011/Report_11 Date: 14 December 2011 _AX001_DHC8_Berlin-Tegel.pdf?__blob=publicationFile Location: Berlin-Tegel Airport Aircraft: aeroplane Manufacturer / Model: Bombardier / DHC8–300 Injuries to Persons: One person severely injured AR#35 Kind of occurrence: Serious incident 2002 https://www.bfu-web.de/EN/Publications/Investigation%20Report/2002/Report_02 Date: 29 November 2002 _EX007-0_Dortmund_B737.pdf?__blob=publicationFile Location: Dortmund Airport Aircraft: transport category aeroplane Manufacturer/type: Boeing Company / Boeing 737–800 Injuries to persons: no injuries Damage to aircraft: aeroplane slightly damaged AR#36 Date and hour: 24 November 2013 at 09:46 UTC 2013 https://mobilit.belgium.be/sites/default/files/downloads/2013–25%20Final%20report. Aircraft type: Boeing 757–200 pdf?language=fr Year of manufacture: 2000 Total flight time: 43,125:13 FH Type of engine: 2 Rolls-Royce RB211–535E4, high-bypass turbofan engines Operator: US Airways1 Accident location: EBBR - Brussels Airport, Belgium Type of flight: Commercial Air Transport - Passengers Phase: Pushback/towing AR#37 Cargo door opening on take-off 2001 https://www.tsb.gc.ca/eng/rapports-reports/aviation/2001/a01f0094/a01f0094. Bradley Air Services Ltd. (First Air) html#3.0 Boeing 727–225 C-FIFA Corcaigh International Airport, Ireland 20 July 2001 AR#38 Cargo Door Opening on Take-Off 2006 https://www.tsb.gc.ca/eng/rapports-reports/aviation/2006/a06c0204/a06c0204. Kelowna Flightcraft Air Charter Ltd. html#3.0 Boeing 727–227 C-GJKF Regina, Saskatchewan 13 December 2006 AR#39 Ground collision, fire, and evacuation 2018 https://www.tsb.gc.ca/eng/rapports-reports/aviation/2018/a18o0002/a18o0002.html WestJet Airlines Ltd., Boeing 737–800, C-FDMB and Sunwing Airlines Inc., Boeing 737–800, C-FPRP Toronto/Lester B. Pearson International Airport, Ontario 05 January 2018 AR#40 Investigation of causes of an incident 2013 https://uzpln.cz/pdf/incident_nke8P5BP.pdf at Airport Karlovy Vary - fall of a person from the aircraft A320, registration VQ-BRE, on 6 August 2013 (continued on next page) 7 N. Muecklich et al. Transportation Engineering 13 (2023) 100184 Table 6 (continued ) Accident Name of Report Year of Accident, Reference/Link Report # Incident, or Occurrence AR#41 Investigation of the ACCIDENT 2005 https://uzpln.cz/pdf/incident_MzAxFWNK.pdf Allitalia airlines, MD 80 At LKPR on 26th May 2005 AR#42 Accident 2016 https://en.havarikommissionen.dk/media/9449/l_2016_havari_510–2016–321_oykff_ 16–12–2016 motorfly_koebenhavn-ekch.pdf involving BOMBARDIER CL600 2D24 900 OY-KFF AR#43 Accident 2016 https://en.havarikommissionen.dk/media/10573/l_2016_havari_510–2016–322_sedst- 26–12–2016 oykbc_motorfly_koebenhavn-ekch.pdf involving BAE AVRO RJ100 SE-DST and AIRBUS A340 OY-KBC AR#44 C6/2008 L A serious incident on the apron of 2008 https://turvallisuustutkinta.fi/en/index/tutkintaselostukset/ilmailuonnettomuuksientut Helsinki-Vantaa airport on 23 September 2008 kinta/tutkintaselostuksetvuosittain/ilmailu2008/c62008lvaaratilannehelsinki -vantaanasema.html AR#45 Accident to the Boeing B777–333 ER 2019 https://www.bea.aero/fileadmin/user_upload/BEA2019-0413.en.pdf registered C-FNNQ on 24 July 2019 at Paris-Charles de Gaulle (Val-d’Oise) AR#46 C10/2003 L Taxiing incident at Helsinki-Vantaa 2003 https://turvallisuustutkinta.fi/en/index/tutkintaselostukset/ilmailuonnettomuuksientut Airport on 6 December 2003 kinta/tutkintaselostuksetvuosittain/ilmailu2003/c102003lrullausvauriohelsinki-vantaa lla6.html AR#47 C7/2005 L Falling of passenger stairs at 2005 https://turvallisuustutkinta.fi/en/index/tutkintaselostukset/ilmailuonnettomuuksientut Rovaniemi airport on 14 December 2005 kinta/tutkintaselostuksetvuosittain/ilmailu2005/c72005lmatkustajaportaidenkaatu minenrova.html AR#48 Accident to the Embraer 190 registered F-HBLF 2014 https://www.bea.aero/en/investigation-reports/notified-events/detail/accident-to-the occured on 19/04/2014 at Paris Charles-de- -embraer-190-registered-f-hblf-occured-on–19–04–2014-at-paris-charles-de-gaulle-airport Gaulle Airport (95) -95/ AR#49 Accident to the Airbus A320 2016 https://www.bea.aero/fileadmin/uploads/tx_elydbrapports/BEA2016-0582.en.pdf registered F-HBNK on 11 September 2016 at Bastia Poretta (2B) AR#50 Aircraft Embraer 190 registered G-LCYJ 2012 https://www.bea.aero/fileadmin/documents/docspa/2012/g-yj120121.en/pdf/g-yj12 Date and time 21 January 2012 à 08 h 20 UTC(1) 0121.en_06.pdf Operator BA CityFlyer Place Chambéry Aix-les-bains Airport (73) Type of flight Scheduled public transport of passengers AR#51 Erroneous takeoff performance calculation, 2017 https://www.onderzoeksraad.nl/en/page/4808/erroneous-takeoff-performance-calcul Boeing 777 ation-boeing-777. On21 April 2017 AR#52 Collision with tug, Boeing 737–400, Amsterdam 2006 https://www.onderzoeksraad.nl/en/page/1104/collision-with-tug-boeing–737 Airport Schiphol –400-amsterdam-airport-schiphol AR#53 Tail strike during take-off, Boeing 737–800, 2003 https://www.onderzoeksraad.nl/en/page/910/tail-strike-during-take-off-boeing–73 Rotterdam Airport 7–800-rotterdam-airport AR#54 Final Report: Serious Incident ATR 72–212A, (EI- 2015 http://www.aaiu.ie/node/1153 FAV) Dublin Airport Ireland, 23 July 2015 Report - 2018–002 AR#55 Final Report: Serious Incident Airbus A320, (EC- 2017 http://www.aaiu.ie/sites/default/files/report-attachments/REPORT%202018–009.pdf LVQ) Dublin Airport Ireland, 27 September 2017 Report - 2018–009 AR#56 Serious Incident: A330–300, EI-ORD, Dublin 2005 http://www.aaiu.ie/sites/default/files/report-attachments/REPORT%202007_007.pdf Airport, 28 December 2005, Report No: 2007–007 AR#57 Accident: Bombardier BD-700–1A10, N20EG and 2007 http://www.aaiu.ie/sites/default/files/upload/general/10715–2008010_N20EG_AND_N Bombardier BD-700–1A10, N6VB, Dublin 6VB-0.PDF Airport, 4 July 2007: Report No 2008–010 AR#58 Incident: Airbus A321 G-MIDH, Dublin Airport, 2000 http://www.aaiu.ie/sites/default/files/report-attachments/3558-REPORT_2000_006–0. 15 Jan 2000: Report No 2000–006 PDF AR#59 Aircraft accident to YK-AHB at Stockholm/ 2006 https://www.havkom.se/assets/reports/rl2007_23e.pdf Arlanda airport, AB county. AR#60 AIRBUS A380–800, REGISTRATION 9V-SKA 2008 https://www.mot.gov.sg/docs/default-source/about-mot/investigation-report/10-jan PUSHBACK INCIDENT IN SINGAPORE CHANGI -2008.pdf AIRPORT 10 JANUARY 2008 AR#61 AIRBUS A320, REGISTRATION 9M-AHA 2010 https://www.mot.gov.sg/docs/default-source/about-mot/investigation-report/final- FOREIGN OBJECT INGESTION INCIDENT 2010-feb-28.pdf AT SINGAPORE CHANGI AIRPORT ON 28 FEBRUARY 2010 (continued on next page) 8 N. Muecklich et al. Transportation Engineering 13 (2023) 100184 Table 6 (continued ) Accident Name of Report Year of Accident, Reference/Link Report # Incident, or Occurrence AR#62 CONTACT BETWEEN AIRBUS A320 2012 https://www.mot.gov.sg/docs/default-source/about-mot/investigation-report/contact-be AND AEROBRIDGE tween-airbus-a320-and-aerobridge—final-report.pdf 5 OCTOBER 2012 AR#63 BOEING B777–200, REGISTRATION 9V-SRP 2013 https://www.mot.gov.sg/docs/default-source/about-mot/investigation-report/container CARGO CONTAINER INGESTION -ingestion-19‑dec-13—fr.pdf 19 DECEMBER 2013 AR#64 B737–800, REGISTRATION 9V-MGM 2015 https://www.mot.gov.sg/docs/default-source/about-mot/investigation-report PUSHBACK INCIDENT /b738-(9v-mgm)-pushback-incident-6‑dec-2015-final-report.pdf 6 December 2015 AR#65 GROUND INCIDENT INVOLING M/S ETHIOPIAN 2017 http://164.100.60.133/accident/reports/incident/VT-EXD.pdf AIRLINES AIRCRAFT ET-AMG AND M/S AIR INDIA AIRCRFT VT-EXD AT DELHI ON 08.08.2017 AR#66 Final investigation report on ground incident to 2015 http://164.100.60.133/accident/reports/incident/VT-ABO.pdf m/s alliance air ATR42–320 aircraft vt-abo with jet airways passenger coach on 22.12.2015 at kolkata airport AR#67 General Civil Aviation Authority 2010 https://www.gcaa.gov.ae/en/departments/airaccidentinvestigation/Pages/ Air Accident Investigation Department InvestigatorMagazinesView.aspx?min=mxkazpYdJ0&type=ir Abu Dhabi, UAE 02/2010 FINAL REPORT On AIRCRAFT INCIDENT INVESTIGATION Ground Collision During Parking of the National Air Services Gulfstream GIV-X (G450), Registration N452NS Dubai International Airport, United Arab Emirates Feb. 28th, 2010 AR#68 INCIDENT 2005 https://www.gov.uk/aaib-reports/airbus-a320-lz-bha-19-june-2005 Aircraft Type and Registration: Airbus A320, LZ- BHA No & Type of Engines: 2 CFM56–5A turbofan engines Year of Manufacture: 1989 Date & Time (UTC): 19 June 2005 at 0755 hrs Location: Stand 27, Belfast International Airport, Northern Ireland AR#69 INCIDENT 2005 https://www.gov.uk/aaib-reports/boeing-767–200-ei-dbw-12-april-2005 Aircraft Type and Registration: Boeing 767–200, EI-DBW No & Type of Engines: 2 General Electric CF6–80C2 turbofan engines Year of Manufacture: 1987 Date & Time (UTC): 12 April 2005 at 1015 hrs Location: London Gatwick Airport, West Sussex AR#70 INCIDENT 2010 https://www.gov.uk/aaib-reports/fokker-100-D-afkc-18-november-2010 Aircraft Type and Registration: Fokker 100, D- AFKC No & Type of Engines: 2 Rolls Royce Tay 650–15 turbofan engines Year of Manufacture: 1996 Date & Time (UTC): 18 November 2010 at 1445 hrs Location: London Heathrow Airport AR#71 SERIOUS INCIDENT 2018 https://www.gov.uk/aaib-reports/aaib-investigation-to-boeing-737–9h-bbj-and-embraer- Aircraft Type and Registration: 1) Boeing 737, 145lr-g-cisk 9H-BBJ 2) Embraer 145LR, G-CISK Date & Time (UTC): 10 January 2018 at 1238 hrs Location: Bristol Airport AR#72 ACCIDENT 2014 https://www.gov.uk/aaib-reports/aaib-investigation-to-boeing-737–8as-ei-enl-and- Aircraft Type and Registration: 1) Boeing boeing-737–8as-ei-dlj 737–8AS, EI-ENL 2) Boeing 737–8AS, EI-DLJ Date & Time (UTC): 28 June 2014 at 0546 hrs Location: London Stansted Airport AR#73 ACCIDENT 2017 https://www.gov.uk/aaib-reports/aaib-investigation-to-airbus-a320–214-g-eztv Aircraft Type and Registration: Airbus A320–214, G-EZTV (continued on next page) 9 N. Muecklich et al. Transportation Engineering 13 (2023) 100184 Table 6 (continued ) Accident Name of Report Year of Accident, Reference/Link Report # Incident, or Occurrence Date & Time (UTC): 3 March 2017 at 1825 hrs Location: Stand 1, Manchester Airport AR#74 ACCIDENT 2014 https://www.gov.uk/aaib-reports/aaib-investigation-to-boeing-737–8jp-wl-ln-dys Aircraft Type and Registration: Boeing 737–8JP (WL), LN-DYS Date & Time (UTC): 23 December 2014 at 0602 hrs Location: London Gatwick Airport AR#75 ACCIDENT 2014 https://www.gov.uk/aaib-reports/aaib-investigation-to-boeing-737–8as-ei-exf Aircraft Type and Registration: Boeing 737–8AS, EI-EXF Date & Time (UTC): 3 December 2014 at 0815 hrs Location: London Stansted Airport AR#76 ACCIDENT 2006 https://www.gov.uk/aaib-reports/boeing-737–45d-sp-llb-20-february-2006 Aircraft Type and Registration: Boeing 737–45D, SP-LLB Date & Time (UTC): 20 February 2006 at 1140 hrs Location: Stand 114, London Heathrow Airport AR#77 INCIDENT 2006 https://www.gov.uk/aaib-reports/britten-norman-bn2a-mk-iii-1-trislander-g-lcoc-7-june- Aircraft Type and Registration: Britten-Norman 2006 BN2A Mk III-1 Trislander, G-LCOC Date & Time (UTC): 7 June 2006 at 0530 hrs Location: Saint Brieuc, Brittany, France AR#78 ACCIDENT 2020 https://www.gov.uk/aaib-reports/aaib-investigation-to-dhc-8–402-g-jeck-and-emb- Aircraft Type and Registration: 1) DHC-8–402, G- 145ep-g-sajs JECK 2) EMB-145EP, G-SAJS Date & Time (UTC): 16 June 2020 at 1646 hrs Location: Aberdeen International Airport AR#79 SERIOUS INCIDENT 2019 https://www.gov.uk/aaib-reports/aaib-investigation-to-boeing-747–436-g-civu Aircraft Type and Registration: Boeing 747–436, G-CIVU Date & Time (UTC): 20 December 2019 at 1543 hrs Location: London Heathrow Airport AR#80 ACCIDENT 2011 https://www.gov.uk/aaib-reports/boeing-737–800-ei-dym-12-may-2011 Aircraft Type and Registration: Boeing 737–800, EI-DYM Date & Time (UTC): 12 May 2011 at 0815 hrs Location: Liverpool John Lennon Airport AR#81 ACCIDENT 2005 https://www.gov.uk/aaib-reports/boeing-b737–800-ei-dai-21-july-2005 Aircraft Type and Registration: Boeing B737–800, EI-DAI Date & Time (UTC): 21 July 2005 at 1655 hrs Location: London Stansted Airport, Essex AR#82 ACCIDENT 2009 https://www.gov.uk/aaib-reports/airbus-a320–233-ha-lpj-correction-12-march-2009 Aircraft Type and Registration: Airbus A320 − 233, HA-LPJ Date & Time (UTC): 12 March 2009 at 0902 hrs Location: Stand 40, London Luton Airport AR#83 INCIDENT 2005 https://www.gov.uk/aaib-reports/saab-scania-ab-sf340b-g-lgnh-2-january-2005 Aircraft Type and Registration: Saab-Scania AB SF340B, G-LGNH No & Type of Engines: 2 General Electric CT7–9B turboprop engines Year of Manufacture: 1993 Date & Time (UTC): 2 January 2005 at 1405 hrs Location: Sumburgh Airport, Shetland Isles, Scotland AR#84 ACCIDENT 2014 https://www.gov.uk/aaib-reports/aaib-investigation-to-boeing-737–8as-ei-ebr Aircraft Type and Registration: Boeing 737–8AS, EI-EBR Date & Time (UTC): 17 December 2014 at 0605 hrs Location: London Luton Airport AR#85 ACCIDENT 2012 https://www.gov.uk/aaib-reports/airbus-a380-vh-oqd-14-january-2012 Aircraft Type and Registration: Airbus A380, VH–OQD Date & Time (UTC): 14 January 2012 at 1045 hrs Location: London Heathrow Airport AR#86 Aircraft Type and Registration: Boeing 747–4Q8, 2004 https://www.gov.uk/aaib-reports/boeing-747–4q8-g-vtop-16-november-2004 G-VTOP Date & Time (UTC): 16 November 2004 at 0915 (continued on next page) 10 N. Muecklich et al. Transportation Engineering 13 (2023) 100184 Table 6 (continued ) Accident Name of Report Year of Accident, Reference/Link Report # Incident, or Occurrence hrs Location: Stand 327, London Heathrow Airport AR#87 Aircraft Accident Report No: 2018/01 2018 https://www.mot.gov.my/en/AAIB%20Statistic%20%20Accident%20Report% 20Document/2018/07%20July%202,018.pdf discussed in other subsystems, such as flight operations [15,16,21] or air 29]. Australia, for example, publishes occurrences with smaller payload traffic control [2,11,61]. In those primary subsystems, these issues are discrepancies (e.g. AR# 8, AR#11 and AR# 12), and other countries do included in their safety management concepts, specifically in CRM and not publish these occurrences, but only more severe incidents and ac­ Team Resource Management (TRM) training frameworks. As an cidents. Not all reports that have been identified and used in this study example, communication and lack of awareness are integral parts of the provide a thick description of the accidents (e.g. AR# 1, x 42), with some CRM concept. Both concepts adapt the training on the identified providing only a short synopsis over the situation (e.g. AR# 13, 16). As a safety issues on the distinct characteristics of the specific subsystem [11, result, some accident and incident causes may have not been detected in 15]. the analysis and the findings cannot be considered as fully We identified human error preconditions for accidents in the sub­ comprehensive. system ground operations, as the first step for a better comprehension of ground operations characteristics and influences. This subsystem- 4. Conclusion specific analysis is considered critical as ground operations have a unique working environment and task design, as well as different All stages of this study showed that human factors in Ground Oper­ characteristics of the people working in this subsystem compared to the ations can and do influence the safety of the aircraft and the people other subsystems in aviation. In addressing the human error pre­ acting around it. Consequences can reach from no or only minor dam­ conditions, these characteristics must be understood and considered in ages or injuries (Example: AR# 3, 19, 21) to serious or even fatal designing adapted human error management approaches, such as a RRM damages or injuries (Examples: AR# 44, 45, 90) (Table 2). The results concept. revealed that the main causal and contribution human error factors in The human error analysis models focus on analysing a specific ac­ ground operations related accidents and incidents based on the three cident or incident report, or specific subsystems, but none yet in a wider stage analysis process are: 1) lack of awareness, 2) lack of communica­ system context displaying interdependencies between subsystems, this is tion, and 3) lack of resources (HF DD – Table 3), 1) organisational also limited by the current reporting frameworks - how accidents and processes, 2) perceptual error and 3) crew resource management incidents in ground operations are reported. There exists no standard (HFACS – Table 4), and 1) lack of awareness and (2) failure to follow except for ICAO Annex 13 on severe accidents. prescribed procedures (Thematic Analysis – Table 5). As a result, a The results suggest that current human error analysis models may reduction of ground operations-related accidents and incidents cannot need to be extended to a more systemic approach – aligning the de­ only reduce harm to people or damage to equipment, but also increases velopments of the evolution of safety on the system level [26,37,38]. efficiency, effectiveness, and the financial health and sustainability of an HFACS is already on the organisational level, but aviation is more organisation and the system. The identified human error pre­ complex and interactions and dependencies between subsystems must conditions for accidents and incidents are recommended to be addressed also be considered. Thus, as a result of all analyses, it is recommended to in an adapted ground operations-related context. Additionally, the in­ consider the broader organisation and aviation system also from a terdependencies and correlations between human error preconditions in quantitative perspective to identify additional causal and contributing aviation accidents shall be explored. Based on the results of this study, it factors and ultimately address the problem (i.e. overrepresentation of is recommended to evaluate if the development of a comprehensive particular human error factors per working area and severity level, or RRM framework, including training, education, communication, etc., as correlation and interdependencies of human error factors). detected in the themes, can be beneficial for the individual organisation For a more complete picture of the current ground operations and the aviation system safety. An adapted RRM concept would provide framework and the role of human factors in ground operations, current a standard framework for ground operations that focuses on rules, regulations, standards, and guidance material shall be reviewed non-technical skills and tasks, similar to the CRM concept for flight for detecting potential gaps. Both, this accident analysis and the analysis operations, but adapted to the needs and characteristics of ground op­ of regulations and standards could provide the basis for a comprehensive erations. The ten emerging themes (Table 5) may serve as a first human error management framework. framework for enhancing specific topics in an RRM concept and to guide Finally, a potential outcome could be a comprehensive RRM frame­ further research on human error in the critical GO working areas, work to address the safety issues as identified in this study, but in an namely aircraft pushback/towing, aircraft arrival/departure, and adapted and thus effective concept for ground operations and the peo­ aircraft weight and balance. All themes shall be viewed in the system ple, equipment, and information in the specific subsystem, while not context and considering interactions with other operational sub-systems disregarding the wider systematic context. (flight operations, maintenance operations, air traffic control). In addi­ tion, it must be examined which methods and tools are already applied in the industry, by either industry associations or ground handling ser­ 3.4. Limitations vice providers themselves. The research on ground operations is limited, but not necessarily the industry guidance, therefore safety measures Although every effort was made to identify the reports most relevant applied within ground handling service providers should be assessed, to this study, the research team was faced with a few challenges to that including ICAO and IATA guidance material [24,28]. end. First, the accident and incident reporting standards differ from country to country and are only guided by a few international/supra­ national frameworks or laws, such as ICAO Annex 13 ‘Aircraft Accident Declaration of Competing Interest and Incident Investigation’ or ‘Regulation (EU) No 376/2014 ‘on the reporting, analysis and follow-up of occurrences in civil aviation’ [12, The authors declare that they have no known competing financial 11 N. Muecklich et al. 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