JIG ‘Learning From Incidents’ Toolbox
Meeting Pack
Pack 4 – January 2012
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
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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.
• All published packs can be found on the HSSEMS section of the
JIG website (www.jointinspectiongroup.org)
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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:
•
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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Aircraft Refuel Adaptor Failure
(LFI 2011-10)
• Incident Summary - The Operator could not get fuel to flow at the start of a defuelling operation. The aircraft engineers
used the aircraft fuel tank boost pumps to start the fuel flow and soon heard a banging noise come from the Hose End
Control Valve. The aircraft refuel adaptor cracked upstream of the shut-off valve, which resulted in significant fuel spill
as the leak couldn’t be stopped. The path for some of the leaking fuel was onto the engine exhaust pipe. The exhaust
pipes were cool at the time of the incident.
The crack in the adaptor resulted in the spill
Root Causes –
•
Not following manufactures and other industry
guidelines relating to this type of operation
Lessons Learnt –
• The aircraft manufacturer issued a newsletter in 2002
and again in 2009 warning of refuel adaptor failures
when using aircraft boost pumps during defuelling. The
aircraft manufacturer recommends locking the HECV
open during defuelling to prevent sudden closure and
pressure shockwaves.
• JIG 1 section 6.6 also requires the HECV to be locked
open for defuelling.
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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Misfuel
(LFI 2011-08)
Summary - An aircraft arrived at an Airport and requested fuelling - the grade
required was not stated or requested. On arrival at the kerbside dispensers the
Operator found a Beech twin engined plane parked in the Jet refuelling position
(the airport has two kerbside dispensers – Avgas and Jet) with the fill port caps
removed. The pilot asked for the plane to be refuelled. The Operator did not
confirm the grade required, nor did he check the plane's grade decals or complete
a Fuel Grade Verification Form (FGVF).
After putting 8 litres of Jet into the plane’s tank he saw an Avgas grade decal on
another fill port and immediately realised his mistake and stopped fuelling. The
plane was towed to a safe position without starting the engines and the tank
drained and refilled.
Close up of fill port showing cap
over grade decal
Root Causes –
• There was no grade verification on taking the order, or when talking to the pilot. No grade decals check took
place, and no Fuel Grade Verification Form completed:
• The plane was parked in front of the Jet dispenser because the Avgas position was still occupied by the
previous customer.
• The pilot removed the fill caps because, at another site, they had not been closed properly and had come loose
in flight.
• The pilot had placed the fill port cap over the red Avgas grade decal, which had been stuck on to a red paint
stripe on the plane, so it was camouflaged (see picture).
• The kerbside dispensers are operated by grade selective keys. Authorised self-service customers are given a
grade selective key, but Operators carry keys for both grades.
• The plane was fitted with a large fill port opening which meant that the larger duckbill spout (if fitted) would not
have alerted the Operator.
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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Drive Away
(LFI 2011-01)
Incident Summary After completing the fuelling of an A320 the operator was distracted
while following the disconnection procedure. He thought that he had
disconnected the deck hose to the aircraft. He then closed the deck
panel from the ground using another piece of equipment. The deck
panel operated the vehicles deck hose anti-lock system, which was
now ineffective. The operator then drove away from the aircraft, as the
hose was still connected the aircraft coupling point sheered and
approximately 5 litres of fuel was spilt from the hose. There was no
further damage to the aircraft and the spill was fully contained.
Panel
Antilock
operated by
magnet
Toolbox Talk Discussion Points -
Pin should have stopped panel lowering
•
If you become distracted whilst following the disconnection procedure what would you do?
•
During your 360 Walkaround you spot a panel on the elevating work platform that has been left open.
Would you try and close it from the ground? Or would you return to the platform to ensure it was safe to
close the panel?
•
The failure of the interlock design played a large part in this incident. Are the interlock systems regularly
inspected at your location to ensure they are working correctly? Is everyone aware of the correct
operating procedure for interlocks at your location?
Can you think of any similar Near Misses that YOU have experienced or witnessed? Did you report it?
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Shared HSSE Incidents
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Defective Coupling – Wrist injury
(LFI 2010-13)
Incident Summary – An operator was starting a fueller loading operation. When locking the coupling of the
loading facility hose to the fueller connection, he felt a strong pain in his right wrist. The pain persisted so the next
day a medical check was made and a sprain with partial tearing of ligament of his wrist was diagnosed. This
resulted in a 2 week absence from work.
Root Causes –
• Use of defective equipment. An investigation discovered
that the couplings were known to have been very hard to
manoeuvre for several months/ This recurrent technical
problem had not been recorded on a register.
• An incomplete
preventive maintenance program
meant that these items were not inspected.
Lessons Learnt –
• A suitable method for reporting all technical problems on
equipment is needed and these should be recorded in order
to identify any deviation and to prepare on time, appropriate
corrective/preventive action.
• Preventive maintenance programmes must be reviewed to
ensure all appropriate site equipment is included.
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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Aircraft Incident (LFI 2011-02)
Incident Summary – An operator was approaching an Embraer aircraft to perform a fuelling, it was late evening and
raining with strong winds. Normally the aircraft used for this flight was an A320. The operator assumed that the aircraft
was an A320 and did not check the type aircraft as he approached. The operator attempted to reverse under the wing
of the aircraft without a guide person and contacted with the wing of the aircraft with the fueller’s elevating work
platform. There was minor damage to both the aircraft and the elevating work platform.
Minor damage to aircraft wing
Minor damage to the elevation work platform
Toolbox Talk Discussion Points•
When you approach a stand to refuel an aircraft what do you consider in your Last Minute Risk Assessment?
•
The operator could not get into the correct refuelling position because of other apron traffic, so decided to try and
reverse into position. What would you have done in this situation?
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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