JIG ‘Learning From Incidents’ Toolbox
Meeting Pack
Pack 16 – November 2015
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)
Joint Inspection Group Limited
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?
If you would like further assistance or information relating to the information
contained in this pack please contact JIG via http://www.jigonline.com/contacts/
Joint Inspection Group Limited
Shared HSSE Incidents
3
Lost Time Injury
LFI 2015-09
Incident Summary –
An Operator sustained an injury to his back and ribs after his left leg gave way as he was descending a Hydrant Servicer
telescopic ladder that connected the elevating fuelling platform to the fixed lower level vehicle platform. After visiting
hospital he was advised to take time off work to recover.
Causes –
• The Operator had a previous medical condition with his left knee that
had not been disclosed to his employer. The Operator sustained an
injury 15 years prior to the incident and had surgery to rectify the
problem allowing him to carry out his normal duties.
• The Operator had been experiencing some discomfort before the
incident but did not report this. He was determined that this discomfort
should not impair his ability to carry out his duties.
• The norm at the location is for the fuelling platform to be raised to
provide support for the refuelling hoses while connected to the aircraft.
However, a Pantograph, designed to provide this support , is installed
on this vehicle. Although implemented with good intentions, raising
the platform unnecessarily introduced an additional risk of climbing up
and down the telescopic ladder.
Discussion Points –
• Discuss Fitness to Work requirements with your Operators. Fuelling aircraft is a physically demanding job. A culture of
openness should be encouraged to allow site personnel to advise on personal medical issues that may affect their
ability to safely carry out their activities without fear of a negative response. For example, reporting and addressing
Musculo Skeletal Disorders early may prevent a more serious injury later on.
• If your location has Hydrant Servicers equipped with a Pantograph, discuss the system with your Operators. Are they
fully aware of how the system works and what it is designed to achieve? Is there a consistent approach to Hydrant
Servicer fuelling at your location?
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
High Potential Incident – Overwing Fuelling
LFI 2015-10
Incident Summary –
An Operator fuelled a DA42 aircraft with Jet A-1. The following morning the
aircraft owner notified the operations room that the fuel cap on the port wing
tank had been left off. Following heavy rain the previous night, it was
suspected that rain water may have contaminated the fuel in the tank. This
was subsequently emptied and replenished with fresh fuel.
Causes –
• The fuel cap on the port wing was found not to be in position. However, the
investigation did not establish the root cause. The Operator stated that he
could not remember not replacing the cap and that he had followed the
correct overwing fuelling procedure.
• It is possible that another party may have opened the cap as the aircraft
was left on the apron over night. But this cannot be substantiated as there
was no CCTV footage or independent witnesses.
Tool box Discussion Points –
• Always follow procedures and avoid complacency. This aircraft type had been fuelled a number of times on that
day by the same operator. Procedures are developed where strong controls are required to protect from
misfuelling or product quality risks.
• Re-enforce with all operators that the correct fuelling sequence should always be followed.
• Think about control barriers and the critical role operators play in ensuring that controls and barriers work as
intended. Do you carry out overwing fueling operations? Could this happen at your location? What control
barriers do you have in place to ensure this does not happen (think equipment barriers; human barriers etc.) and
how do you ensure your barriers are functioning as intended?
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
Loss of Primary Containment
LFI 2015-11
Incident Summary –
A 2.8m3 ISO container was overfilled resulting in a 1.6 m3
LOPC (Loss of Primary Containment) incident (Jet A-1).
The overfilled product was contained in the site interceptor
and recovered. There was no spill to the environment and
there were no injuries.
Causes –
• The pre-set meter had failed so did not shut off the flow of product as intended. The Operator advised that he did
not check that the meter was counting down once the filling process had commenced. The pre-set meter had been
checked and calibrated annually.
• The overfill prevention device had not been installed in the tank as required by the ISO tank filling procedure. This
has to be manually installed in the tank by the operator. The Operator could not explain why he had omitted to
carry out this vital aspect of the process.
• The filling operation was left unsupervised as the operator had gone for shelter due to heavy rain and wind (18mm
fell that day). The ISO container could not be observed from this position.
Discussion Points –
• Always follow procedures. Procedures are developed where strong controls are required to protect operators from
harm when performing complex or high-risk tasks and/or for situations with no tolerance for errors. Distractions can
cause key procedural steps to be missed. If you get distracted, use the “Stop, Think Do” philosophy to ensure that
sufficient time is taken to check or re-check that key procedural steps have not been missed.
• Think about control barriers and the critical role operators play in ensuring that these barriers work as intended.
Could this happen at your location when filling storage tanks, fuellers etc? What control barriers do you have in place
that will ensure this does not happen at your location (think equipment barriers; human barriers etc.) and how do you
ensure your barriers are functioning as intended?
• Avoid complacency and an over-reliance on mechanical barriers. This operation had been carried out countless
times before with no incidents of this nature. Always check that mechanical barriers are working as intended.
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
Manual Handling Injury
LFI 2015-12
Incident Summary –
Following the submission of near miss reports regarding stiffness of some tank valves in a depot a project was commenced to
complete the installation of new valves. Stem extension handles were fitted as an aid to Manual Handling activities. Without these
extensions, operators would have to bend or kneel down to operate the valves. The project was undertaken by a competent
contractor under the permit system and all work fully completed. The facility was handed back to the operator by the airport and
contractor. Some days later an operator sustained an injury to his back whilst operating one of the valve stems.
Causes –
•
•
•
The stem extensions were of an incorrect bore such that when being fully opened
the spindles began to jam inside the housing causing resistance.
The operator, being used to the resistance of the older valves, continued to apply
more force
resulting in a muscle strain.
The propensity for the spindle to jam in the housing was not experienced on the
commissioning trial and therefore not considered during the handover meeting.
Discussion Points –
•
•
•
•
•
•
Are project completion and handover meetings correctly and diligently completed
at your site?
Is infrastructure fully tested for serviceability before being placed back into
service?
Are defective items correctly defected if a problem is noted?
Do you continue to operate equipment if you are used to it being difficult to
operate?
Have you correctly identified manual handling risks within your facility?
Does your location complete manual handling training?
Can you think of any similar situations that YOU have experienced or witnessed? Did you report it?
Joint Inspection Group Limited
Shared HSSE Incidents
7
Spill during Bridger discharge activity
LFI 2015-13
Incident Summary –
• A spill occurred during a Bridger discharge operation when an underground tank was overfilled due to miscalculation of tank
ullage. The hi alarm systems failed to warn or shut off the system resulting in a spill of 690 litres of Jet A1.
• Towards the end of the offloading process the Bridger driver heard the High high level alarm and he immediately shut off the
Bridger pump and valve, his positioning during the offload meant he was not able to see the hi level alarm beacon flashing.
When he looked in the offloading cabinet he could see product flowing out of the tank vent pipe onto the cabinet floor.
Causes –
• Miscalculation of delivery quantity
• No ullage calculations prior to discharge
• Bridger discharge operation undertaken without procedures and
training.
• System was intended for gravity filling not designed to be used for
Bridger pump-off
• Vent pipe design meant product discharged into fuelling cabinet
Discussion Points –
•
•
•
Are tank gauges calibrated at your site?
How do you check ullage before product receipt?
How does your Hi and HiHi level system work, do you test it?
Can you think of any similar situations that YOU have experienced or witnessed?
Did you report it?
Joint Inspection Group Limited
Shared HSSE Incidents
8
Hot Brakes when Bonded during refuel of B787
LFI 2015-14
Incident Summary –
A recent incident has taken place whilst the bonding cable has been connected to a B787 aircraft bonding spigot. The
proximity between the hot brake casing and bonding spigot are very close. On completion of the fuelling when the
bonding clip was disconnected it was noticed that the hot brakes, although covered, had caused the protective cable to
melt and had been a potential fire hazard during the fuelling operation.
Causes –
• Aircraft brakes can reach extreme temperatures. Hot brakes are a
hazard that are not only a potential fire hazard, but could also result
in a personal injury that could cause a serious burn during the
bonding sequence.
Bonding
Spigot
Location
Discussion Points –
Hot Brake Casing
• Have you identified and made staff aware of heat sources on an aircraft
that have the potential to cause personal injury, equipment damage or
pose a fire risk during fueling operations.
• Are your equipment checks and inspections robust enough to identify
damage such as that caused in this incident or gradual damage caused
by persistent heat exposure over a period of time
Can you think of any similar situations that YOU have experienced or witnessed? Did you report it?
Joint Inspection Group Limited
Shared HSSE Incidents
9