Safety Investigation Report

Ground Incident
AP – BMC External Power Access Door Damage
Karachi Station (23rd January, 2017)

DEPARTMENT Safety Management System

CATEGORY Safety Accident / Incident Investigation
DATED 25th January, 2017
PREPARED BY Abdul Rehman Shaikh Manager SMS
Malik Ali Hassan Safety System Officer
ASSISTED BY
Jawwad Ahmed Safety Management Officer

Housing & Facilities SEAMS

Shaheen Hangar Terminal-1 Road, JIAP, KARACHI
Office: +92-21-34604624
Mobile : +92-334-1324096
UAN: 111-656-565
Email: abdul.shaikh@seams.com.pk
safety@seams.com.pk
 SAFETY MANAGEMENT SYSTEM I

Investigation Report
Ground Incident
AP – BMC External Power Access Door Damage
Karachi Station (23rd January, 2017)

This investigation is based on WHY and HOW, not WHEN and WHO. Intention of investigation
is not to apportion blame rather implement safe and efficient working environment.

1. PRELIMINARY INFORMATION

Aircraft Registration Nomenclature Position Station

AP – BMC (A320) External Power Access Door 121AL Zone 120 Karachi

2. SYNOPSIS
AP – BMC was parked at night parking Bay # 68 for scheduled maintenance work. GPU
(IDE # GE/GPU-002) was connected to power the aircraft (AP – BMC APU is on MEL).

At 0425, maintenance work was completed by Alpha shift, aircraft was de-energized by
line personnel and before leaving, they informed GPU operator Mr. Afzaal (SEAMS #
20664) to shut down and remove GPU from the aircraft.

On the way back to line office (Bay 73), one of the maintenance team member Mr. Mujtaba
(SEAMS # 21032) noticed GPU being towed by vehicle operator with cable unsecured
rolling on ground. Line personnel intercepted GPU operator to secure the cable. Shift
engineer Mr. Ahsan Ali Chauhan (SEAMS # 20206) suspected that operator may have
towed the GPU inadvertently without disconnecting the power cable from receptacle panel
(108VU). Maintenance team on returning to AP – BMC found 121AL power receptacle
access door and bonding jumper damaged (as suspected).

GPU-002 was called again on AP - BMC and ground power was once again connected to
verify and confirm if there was any damage to receptacle pins and related electrical system.
Aircraft was powered ON by shift engineer and luckily related electrical system were found
working satisfactory. Access Door 121AL replacement was available in aero store and was
replaced by line maintenance staff.

SEAMS Safety Management System Department

SEAMS Hangar, JIAP, Karachi
Email: safety@seams.com.pk

25th JAN, 2017 SEAMS/SMS/IIR/10/005 SMS DEPARTMENT Page 1 of 5

 SAFETY MANAGEMENT SYSTEM I

Initially AP – BMC was scheduled to operate on NL 161 (KHI – MUX) at 1200 hours but
departed on NL 144 (KHI – LHE) at 1900.

3. HAZARD IDENTIFICATION (FINDINGS)

i) GPU operator drove away vehicle without proper detachment of power cables from
aircraft panel and cable was not stowed adequately which caused damage to
external power receptacle access door (Refer Figure below) subsequently reflecting
negligence, unsafe attitude and complacency on part of AGES operator.

SEAMS Safety Management System Department

SEAMS Hangar, JIAP, Karachi
Email: safety@seams.com.pk

25th JAN, 2017 SEAMS/SMS/IIR/10/005 SMS DEPARTMENT Page 2 of 5

 SAFETY MANAGEMENT SYSTEM I

ii) In spite of this incident, apparently no damage to receptacle pins or nearby

CBs/buttons were observed.

iii) A320 AMM Chapter 24 (Electrical Power) Subtask 24-41-00-480-050 A (Appendix

A) refers to installation of cable holding strap with aircraft structure. However, TLD
GPU 002 doesn’t have holding strap which is contrary to AMM requirements. Should
the strap have been available and installed, chances of incident would have been
minimized.

SEAMS Safety Management System Department

SEAMS Hangar, JIAP, Karachi
Email: safety@seams.com.pk

25th JAN, 2017 SEAMS/SMS/IIR/10/005 SMS DEPARTMENT Page 3 of 5

 SAFETY MANAGEMENT SYSTEM I

iv) During investigation it was also noted that AGES operator may have been fatigued
(12 Hours shift) and possibly his diminished cognitive abilities contributed towards
loss of situational awareness. It is pertinent to mention that incident occurred at 0425
in the morning during which humans are prone to lowest circadian rhythm resulting
in human error.
v) During audit of AGES department conducted jointly by SEAMS SMS and QA, safety
work permit system was recommended to be issued to the operators after training and
competence assessment of AGES staff by respective manager. However, it still is not
in practice yet.
vi) AGES manager position is vacant since Sep 2015. AGES department and staff due
to lack of managerial supervision is unable to function at its required standard level.
vii) Mr. Afzaal joined SEAMS on AUG 2014 and since then, except human factor, no
other training or competence assessment has been carried out. Apart from GPU, he
drives sky jack, fork lifter, bed lifter and even carries out towing of Shaheen fleet.

4. MAINTENANCE COST OF INCIDENT

Component Cost

EXTERNAL POWER RECEPTACLE ACCESS DOOR $3,000**

DAMAGED ACCESS DOOR REPAIR N/A

LOGISTIC COST FOR REPAIR N/A $3,000

Man Hours Utilized

2 PERSONNEL (LM) (4 Man-Hours x $37*) $148 $148

TOTAL MAINTENANCE COST (DIRECT COST ONLY) = $3,148

*Rates are calculated on arm length basis
** As per 2014 P&L record

SEAMS Safety Management System Department

SEAMS Hangar, JIAP, Karachi
Email: safety@seams.com.pk

25th JAN, 2017 SEAMS/SMS/IIR/10/005 SMS DEPARTMENT Page 4 of 5

 SAFETY MANAGEMENT SYSTEM I

5. RISK MITIGATION

Corrective and Preventive Recommendations

i. Vacant position of Manager AGES should be fulfilled by HR.

ii. Safety work permit to be issued by AGES department after necessary competence
assessment of AGES staff.

iii. It is highly recommended that HR ensures AGES staff trainings are conducted on
war footing basis. During last 6 months, AGES staff is found to be involved in 3
significant incidents.

iv. Power cable holding straps shall be made available on GPUs since it is required by
Airbus AMM subtask 24-41-00-480-050A (Appendix A)

v. Since GPU power cable installation/removal and open/close of panels are

mentioned in AMM, it warrants that tasks to be conducted by AME or under AME’s
supervision. Therefore it is recommended to certifying staff to monitor activities of
other support staff working near the aircraft.

6. CONCLUSION
This ground incident and resultant damage of External Power Receptacle Access
Door was AVOIDABLE. Culpable negligence on part of AGES operator resulted in
aircraft damage and subsequent loss to the organization.

_______________________
ABDUL REHMAN SHAIKH
Manager SMS
Safety Management System,
SEAMS
To:
a. Accountable Manager (CEO) - SEAMS
CC:
a. C.E (QA) – SEAMS
b. Director of Maintenance – SEAMS
c. C.E (L/M), SEAMS
d. GMCS – SAI
SEAMS Safety Management System Department
SEAMS Hangar, JIAP, Karachi
Email: safety@seams.com.pk

25th JAN, 2017 SEAMS/SMS/IIR/10/005 SMS DEPARTMENT Page 5 of 5

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
 
 
 

 
 

 

 
