JIG ‘Learning From Incidents’ Toolbox
Meeting Pack
Pack 1 – January 2011
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
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and (iii) nothing in this document constitutes technical advice, if such advice is required it should be sought from a qualified professional adviser.
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Shared HSSE Incidents
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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.
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Shared HSSE Incidents
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Learning From Incidents
For every incident in this pack, ask yourselves the
following questions:
•
Can we apply the lessons learnt from this incident and is there
potential for a similar type of incident at our site?
•
Do our risk assessments identify and adequately reflect these
incidents?
•
Are our prevention measures in place and effective (procedures and
practices)?
•
Are our mitigation measures in place and effective (safety equipment,
emergency procedures)?
•
What can I do personally to prevent this type of incident?
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Shared HSSE Incidents
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UST Hot Work Fatality (LFI 2010-1)
Incident Summary - A subcontractor removed two petrol and one diesel Underground Storage Tanks (USTs),
as part of a routine site closure project. The subcontractor started to cut up the tanks onsite. No work permits were
issued for this process. Diesel truck exhaust was used to degas the tanks (unapproved degassing method) and no
gas testing was conducted. The first tank was successfully cut without incident; however, when the welder began
cutting the second tank, an explosion occurred. This explosion resulted in one fatality, two workers hospitalized
with burns and one first aid case.
Root Causes –




Subcontractor performed high risk out-of-scope work.
Did not follow procedures for tank degassing and demolition.
Gas testing was not conducted.
No pre-job safety briefing, risk assessment, or job-safety
analysis was conducted.
 Insufficient oversight of subcontractor
Lessons Learnt –
 High risk work to be performed only if within contract’s scope-of-work.
 Stop Work Authority needs to be effectively cascaded to subcontractor
workforce.
 Critical equipment (gas tester in this case) should always be available,
functioning and used.
 Robust verification and validation of adherence to policies and
procedures is required at both the contractor and subcontractor level.
 Contracted work at remote locations has a higher risk profile and potential
risks need to be assessed, communicated, and mitigated.
Can you think of any similar situations that YOU have experienced or
witnessed? Did you report it?
Joint Inspection Group Limited
Tank that
exploded
Tank end that struck
and killed subcontract
worker
Shared HSSE Incidents
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Fueller MVC Spill (LFI 2010-2)
Incident Summary - A crewman left a Fuels Depot to supply jet fuel to an International Airport that was 2 miles
away. While manoeuvring through the entrance gate at the airport, the trailer unit hit the vertical gate support. The driver
was notified by airport personnel at the site that the trailer made contact with the gate. Upon getting down from the
vehicle cab he observed a scratch and dent on the rear right-side of the trailer where a small hole had been created
from which product was seeping out. He stopped the leakage with a temporary nylon plug and then notified the Fuels
Depot. He did not await instructions, however, and instead immediately drove back to the Depot. Upon returning, the
trailer then hit the Depot gate support beam while the driver was attempting to manoeuvre through the entrance gate.
This had the effect of widening the existing rupture in the Trailer. Product gushed from the trailer onto the concrete
depot forecourt. The resulting spill was contained with spill trays and sand.
Root Causes –
• Drivers did not communicate the airport gate change to management;
consequently, the risks were not addressed and shared with all depot
crewmen.
• The drivers actions after the initial collision contradicted the Emergency
Response Plan.
• After the initial incident, the driver was anxious to return to the Depot and
took the wrong angle of approach and did not use his mirrors while driving
through the Depot gate.
• The driver was found to have poor eyesight, this was not identified during
periodic eye tests.
Lessons Learnt –
• Journey Plans must be updated frequently to address new risks
• Need to provide periodic refresher training on emergency response procedures with emphasis on effective
communication.
• Confirm if driver's vision exam provided under Fitness for Duty is adequate.
Can you think of any similar situations that YOU have experienced or witnessed? Did you report it?
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Shared HSSE Incidents
5
Personal Injury (LFI 2010-4)
Incident Summary -
An operator bumped his head on the centre tank vent of an A-320 aircraft whilst
walking under the aircraft to access the fuel panel. The operator took a different route than normal under the
aircraft because he was concerned that the deadman cable would become tangled in the aircraft wheels.
The operator was wearing a bump cap and sustained a small red mark to the head, a slight headache and
pain in their neck for a short period. When back in the depot the operator applied ice to the affected area.
The operator did not need to visit a doctor and was able to continue performing all normal work duties.
Discussion Points • If the operator in this case had not been wearing a bump
cap, what injuries could he have sustained?
• What hazards do you consider when you have to walk
underneath an aircraft?
• Do you follow a safe route under the aircraft based on the
hazards you identify in your last minute risk assessment?
• Does your location have pre-defined safe routes for
walking under aircraft? If so, do these take into account hot
engine parts, hot air vents and bump hazards?
Centre tank vent
Can you think of any similar situations that YOU
have experienced or witnessed?
Did you report it?
Joint Inspection Group Limited
Shared HSSE Incidents
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Fueller Strikes Aircraft Wing (LFI 2010-5)
Incident Summary - An operator had positioned a fueller under the wing of an A321 aircraft in order to perform a platform fuelling. After completing a 360°
Walkaround at the end of the fuelling, the operator realised that a luggage tractor was
blocking his exit so he waited approximately 2 minutes in the cab until the luggage
tractor moved. The operator failed to complete a second 360° Walkaround and did not
realise that the aircraft wing-flaps were lowered. When the operator started to drive,
the mirror bracket on the roof of the fueller cab contacted with the casing of the wing
flap mechanism causing a 5cm crack. An aircraft technician inspected the damage
and temporarily fixed it with metal tape. The aircraft departed after a 1 hour delay. The
fueller cab sustained minor damage to the mirror bracket.
Discussion Points –
• Discuss why it may not be safe to drive a fuelling vehicle under the wing of
an A-320 series aircraft – what could go wrong?
• After doing your 360o Walkaround, if you are delayed in driving away do you
repeat the 360o Walkaround in case the situation around you has changed?
Damage to Aircraft
• If the operator had looked up when doing his 360o Walkaround, do you think
he would have noticed the danger?
Damage to fueller mirror bracket
Joint Inspection Group Limited
Can you think of any similar situations that YOU
have experienced or witnessed?
Did you report it?
Shared HSSE Incidents
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