Narrative:

Upon taxiing to the entrance of the safety zone; there appeared to be a line of luggage carts protruding into the gate area. The taxi director was waving me in but none of the lines outlying the safety zone or engine ingestion zones was visible. The ramp was slick with water though no rain was falling at the time. I stopped the airplane and set the brake. I looked closely to see if I could recognize a line marking the safety zone on the left side (captain's side) where the luggage carts were. I ended up turning my left turnoff lights on. This highlighted what was an infraction of the zone whereas the taxi director crossed his wands and the tug driver of the carts got on the tractor and moved the luggage out of the zone. The lines were not discernible due to color type or to any color contrast to the surface. I recognized the line due to a physical shadowing from the raised surface of the paint compared to the pavement. I must have spent about three minutes staring at the safety zone until it was clear and there were no obstructions before I finally taxied in. While this event highlights a visual hazard; there could be other latent issues related to this as well. If this type of vulnerability has been reported before; how has the risk been classified by a review committee? (An altitude bust at 10;000' in a positive radar environment with a TCAS equipped aircraft might have a lower safety risk than this incident due to the likelihood of outcomes and mitigations in place.) if the risk was classified as needing action; how was this communicated? If it was communicated; what was the safety management/assurance process in place to deal with it? While the hazard of a perception based visual error from the pilot is self evident; the safety assurance process involved in the taxi director and luggage tug driver also needs to be considered. Why did they think it was ok to wave an aircraft in and park a tug when upon closer inspection there was a violation of company policy? We had three sets of eyes and not all of them seemed to have a clear connection between what they saw and what they were supposed to do. The 'layered approach to safety' seems to have broken down. Also; somebody had to identify a hazard from the airport management or airline operator point of view at the airport. Did they look for the hazard and not see it? Did they not look for the hazard to begin with? Did they take a mitigation for the hazard but their safety assurance process was ineffective? I am a little worried that the conditions I witnessed are creating a petri dish ripe for the germination of unforeseen consequences if we all aren't careful and vigilant. I think our safety record at bwi could mask some insidious dangers that won't be apparent until we spend some real money replacing an engine cowl or worse. There are two elements to a successful mitigation. 1. Repaint the lines using the best known materials and practices. If nobody from safety has been to an airport conference lately they should consider going. I won't lecture; the methods and materials are there. 2. There needs to be a safety assurance process. Once the lines are re-painted; how is the likelihood of a perception based error mitigated from the vantage point of a: a) cockpit of a 737 b) taxi director c) tug driver under the conditions on: a) daylight wet/dry b) night time wet/dry. Is the safety assurance process documented? Who knows about it? Is the hazard communicated in such a way as it can be reported if necessary? Are the right people reporting it? Are they rewarded for voluntarily reporting in any manner? To the FAA; how can you show the poi you are ensuring compliance with the sms AC in advance of the rulemaking going on (think promotion to show how smart you are...). To the company; how can you show corporate legal and the firm of X you are engaging in best practices through your process that is both collaborative with the FAA and the union as well as documented? To the union; how can you show you are assessing risk in a manner consistent with the union safety manual that injects relevance and solid human factors schooling? Can you defend your articulation of risk through effective use of both narrative and classification of hazards? North you show you are assessing risk in a manner consistent with the union safety manual that injects relevance and solid human factors schooling? Can you defend your articulation of risk through effective use of both narrative and classification of hazards?

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Original NASA ASRS Text

Title: A B737 Captain commented on ramp safety factor evaluation and potential Corporate; FAA and Union mitigation actions.

Narrative: Upon taxiing to the entrance of the safety zone; there appeared to be a line of luggage carts protruding into the gate area. The taxi director was waving me in but none of the lines outlying the safety zone or engine ingestion zones was visible. The ramp was slick with water though no rain was falling at the time. I stopped the airplane and set the brake. I looked closely to see if I could recognize a line marking the safety zone on the left side (Captain's side) where the luggage carts were. I ended up turning my left turnoff lights on. This highlighted what was an infraction of the zone whereas the taxi director crossed his wands and the tug driver of the carts got on the tractor and moved the luggage out of the zone. The lines were not discernible due to color type or to any color contrast to the surface. I recognized the line due to a physical shadowing from the raised surface of the paint compared to the pavement. I must have spent about three minutes staring at the safety zone until it was clear and there were no obstructions before I finally taxied in. While this event highlights a visual hazard; there could be other latent issues related to this as well. If this type of vulnerability has been reported before; how has the risk been classified by a review committee? (An altitude bust at 10;000' in a positive radar environment with a TCAS equipped aircraft might have a lower safety risk than this incident due to the likelihood of outcomes and mitigations in place.) If the risk was classified as needing action; how was this communicated? If it was communicated; what was the safety management/assurance process in place to deal with it? While the hazard of a perception based visual error from the Pilot is self evident; the safety assurance process involved in the taxi director and luggage tug driver also needs to be considered. Why did they think it was OK to wave an aircraft in and park a tug when upon closer inspection there was a violation of Company policy? We had three sets of eyes and not all of them seemed to have a clear connection between what they saw and what they were supposed to do. The 'layered approach to safety' seems to have broken down. Also; somebody had to identify a hazard from the airport management or airline operator point of view at the airport. Did they look for the hazard and not see it? Did they not look for the hazard to begin with? Did they take a mitigation for the hazard but their safety assurance process was ineffective? I am a little worried that the conditions I witnessed are creating a Petri dish ripe for the germination of unforeseen consequences if we all aren't careful and vigilant. I think our safety record at BWI could mask some insidious dangers that won't be apparent until we spend some real money replacing an engine cowl or worse. There are two elements to a successful mitigation. 1. Repaint the lines using the best known materials and practices. If nobody from Safety has been to an airport conference lately they should consider going. I won't lecture; the methods and materials are there. 2. There needs to be a safety assurance process. Once the lines are re-painted; how is the likelihood of a perception based error mitigated from the vantage point of a: a) Cockpit of a 737 b) Taxi director c) Tug driver under the conditions on: a) Daylight wet/dry b) Night time wet/dry. Is the safety assurance process documented? Who knows about it? Is the hazard communicated in such a way as it can be reported if necessary? Are the right people reporting it? Are they rewarded for voluntarily reporting in any manner? To the FAA; how can you show the POI you are ensuring compliance with the SMS AC in advance of the rulemaking going on (think promotion to show how smart you are...). To the Company; how can you show corporate legal and the firm of X you are engaging in best practices through your process that is both collaborative with the FAA and the Union as well as documented? To the Union; how can you show you are assessing risk in a manner consistent with the Union Safety Manual that injects relevance and solid human factors schooling? Can you defend your articulation of risk through effective use of both narrative and classification of hazards? n you show you are assessing risk in a manner consistent with the Union Safety Manual that injects relevance and solid human factors schooling? Can you defend your articulation of risk through effective use of both narrative and classification of hazards?

Data retrieved from NASA's ASRS site as of April 2012 and automatically converted to unabbreviated mixed upper/lowercase text. This report is for informational purposes with no guarantee of accuracy. See NASA's ASRS site for official report.