JIG ‘Learning From Incidents’ Toolbox
Meeting Pack
Pack 9 – August 2013
This document is made available for information only and on the condition that (i) it may not be relied upon by anyone, in the conduct of their own operations or otherwise; (ii) neither JIG
nor any other person or company concerned with furnishing information or data used herein (A) is liable for its accuracy or completeness, or for any advice given in or any omission from
this document, or for any consequences whatsoever resulting directly or indirectly from any use made of this document by any person, even if there was a failure to exercise reasonable
care on the part of the issuing company or any other person or company as aforesaid; or (B) make any claim, representation or warranty, express or implied, that acting in accordance with
this document will produce any particular results with regard to the subject matter contained herein or satisfy the requirements of any applicable federal, state or local laws and regulations;
and (iii) nothing in this document constitutes technical advice, if such advice is required it should be sought from a qualified professional adviser.
Joint Inspection Group Limited
Shared HSSE Incidents
1
Learning From Incidents
How to use the JIG ‘Learning From Incidents’
Toolbox Meeting Pack
• The intention is that these slides promote a healthy, informal
dialogue on safety between operators and management.
• Slides should be shared with all operators (fuelling operators, depot
operators and maintenance technicians) during regular, informal
safety meetings.
• No need to review every incident in one Toolbox meeting, select 1
or 2 incidents per meeting.
• The supervisor or manager should host the meeting to aid the
discussion, but should not dominate the discussion.
• All published packs can be found in the publications section of the
JIG website (www.jigonline.com)
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Shared HSSE Incidents
2
Learning From Incidents
For every incident in this pack, ask yourselves the
following questions:
• What is the potential for a similar type of incident at our site?
• How do our risk assessments identify and adequately reflect these
incidents?
• What prevention measures are in place and how effective are
they (procedures and practices)?
• what mitigation measures are in place and how effective are they (safety
equipment, emergency procedures)?
• What can I do personally to prevent this type of incident?
Joint Inspection Group Limited
Shared HSSE Incidents
3
Lifting platform hit aircraft wing
(LFI 2012-04)
Incident Summary - A pilot approached an
operator and asked to use the lifting platform
to inspect the wing area. The operator agreed
to assist when fuelling was ended and raised
the platform with the pilot inside. Operator
raised the platform a bit more as the pilot
could not see the whole wing area, causing a
blanking screw on the platform to strike the
landing flap.
Causes –
•
•
•
Blanking screw of the pipe
Operator used fuelling equipment for a non standard operation
The operator was not authorised and therefore not trained for this
specific task
The safety devices (proximity sensors) on the platform were not
designed for this task and therefore did not provide any protection
Discussion Points –
•
•
•
How would you handle any requests to perform activities beyond
standard fuelling ? (e.g. staff empowered to refuse such requests
and instructed to inform supervisors)
Would there be any situations where it would be appropriate to
use fuelling equipment for non fuelling tasks ?
What supervision/observation is undertaken to ensure that staff
are performing tasks in accordance with company procedures ?
Damage to aircraft flap
Can you think of any similar situations that YOU have experienced or witnessed? Did you report it?
Joint Inspection Group Limited
Shared HSSE Incidents
4
Ankle Sprain from fall on fuelling steps
(LFI 2013-02)
Incident Summary – The operator had connected an underwing refuelling hose to an Airbus A320 and was
descending the steps of a mobile refuelling platform when he received a call on his portable two-way radio. As
he reached up to the lapel microphone to answer the call, he became distracted and missed the last step of the
stairs, losing his balance and falling to the ground, injuring his right ankle. The original steps design had been
modified and available tread was limited so that only half the foot could be placed on the step when descending
Causes –
•
•
•
Operator was using radio communications equipment while
descending the steps.
Operator did not maintain 3 points of contact whilst descending
steps
The refuelling stairs did not comply with a recognised design
standard.
Discussion Points –
•
•
•
•
When should you be able to use radio equipment and other two way
communication equipment ? What controls should be in place ?
What other distractions could lead to an incident of this nature. How
could these distractions impact other tasks ?
How do you determine whether your steps and ladders are fit for
purpose
What is the safest way of ascending and descending ladders, steps,
stairs etc.?
Can you think of any similar situations that YOU have experienced or witnessed? Did you report it?
Joint Inspection Group Limited
Shared HSSE Incidents
5
Electrical burn from working on live equipment
(LFI 2013-03)
Incident Summary – A contract electrician opened an electrical panel to confirm the position of the circuit
breaker leading to a faulty motor. He accessed the panel without informing the shift supervisor and worked
on a live system without having a valid work permit or verifying the isolation. While doing this, he was
exposed to an electric spark resulting in minor skin burns to his right hand, face and neck.
Underlying Causes –
•
The access to the electric panel room was not controlled (no door or locks).
•
The annual electrical inspection of this site did not highlight the existence of the
non-insulated wires.
•
Site staff failed to control the work and implement and apply the Permit to Work &
Isolation procedure, despite having undertaken training a few weeks before
Discussion Points –
•
How do you ensure there is controlled access to the electric panel rooms i.e. a lock & key arrangement,
warning signs of “Entry by Authorized Persons ONLY” ?
•
What is your site procedure to ensure faulty equipment is reported and that action is taken in a timely
manner ? Do you withdraw equipment from service and tag equipment when critical issues are identified ?
•
How effective is the work permitting and / or job safety analysis process at your Site? How do you ensure
staff and contractors follow these?
•
How effective are your arrangements for managing contractors i.e. Planning the work, choosing a
contractor, controlling their work on site, keeping a check and reviewing the work?
Can you think of any similar situations that YOU have experienced or witnessed? Did you report it?
Joint Inspection Group Limited
Shared HSSE Incidents
6
Ladder blown over by jet blast hitting operator in face
(LFI 2013-04)
Incident Summary – During an aircraft fuelling an Operator received bruises and swelling when a ladder
he was using was blown over as a result of jet blast from another plane leaving the terminal area. The
fuelling operation was in progress with the hose connected and the Operator was at ground level next to the
fuelling ladder. The aircraft responsible for the jet blast was approximately 80m away. The fuelling operator
turned away from the blast to afford some protection however was struck in the face by the aluminium
fuelling ladder.
Underlying Causes –
•
•
Excessive jetblast was a result of a combination of the following: airport
layout, aircraft pushed back beyond pushback lines, excessive thrust by
the pilot.
Some airport configurations increase the exposure to jet blast. Jet blast
has been responsible for serious injuries including one at this particular
airport 2 years earlier.
Discussion Points –
•
•
•
•
Are you and your team aware of potential Jet Blast and where this can happen at your site?
Are your fuelling ladders fit for purpose ? Do you know of any incidents where they have moved in high
wind conditions or due to jet blast ?
Ask yourself and your team “what is occurring in my environment that can impact the task I am involved
with and the safety of me and those around me?”
Which stakeholders could you work with to improve safety at your airport? The positive outcomes
achieved from the incident only occur through productive working relationships with all stakeholders that
operate at an airport.
Can you think of any similar situations that YOU have experienced or witnessed? Did you report it?
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Shared HSSE Incidents
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