Ensuring Integrity of Refuelling Operations

A focus on Assurance

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3 Questions we must ask ourselves

“From the Board room down companies must ask themselves these questions:

do we understand what could go wrong;

do we know what our systems are to prevent this happening; and

are we getting the right information to assure us they are working effectively."

Kevin Myers, HSE's Deputy Chief Executive July 2010 after successful prosecution of 5 companies due to the Buncefield terminal explosion in

the UK in December 2005

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Refuelling Operations

• Aviation refuelling operations is overwhelmingly safe

• We have trained people

• Good industry standards

• Invest in equipment

• There are thousands of aircraft everyday that uplift fuel, take off and land safely

• Regular operations are therefore our forte - we do it well

However it is those unforeseen events that we may not be prepared for, where there is over-reliance on equipment with out assurance and complacency that lets us down. With appropriate processes, we can firstly ensure that these do not happen and secondly recover much more quickly if it does.

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‘Swiss Cheese’ Barrier Model: Plant, Process, People.

Assessment of barriers to deliver continuous risk reduction and move

towards operational compliance that is “systematic and in control”

Review Informed by :

•Incident Trends

•Near Miss Trends

•Audit compliance trends

•Technical Competence

STRONG WEAK

STR

ON

G

● Maintaining high quality procedures, standards and practices to keep strong barriers strong.

● Functional audits and critical barrier checks at front line to provide assurance.

● Barriers may become weak due to emerging risks and changing activities.

● Develop actions to address emerging risks and changing activities.

WEA

K

● Weak or degraded barriers.

● Develop actions to barriers strong.

● Some weak barriers may remain weak where there are adequate strong barriers in place to control the risk.

● No Action.

Future State

Cur

rent

Sta

te

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Prevention of delivery of grossly contaminated fuel to aircraft.

Emergency landing of CX 780 in Hong Kong following delivery of grossly

contaminated fuel in April 2010

Barriers strengthened

• Filter monitor elements meeting EI 1583 Edition 6 introduced

• SAP migration was a major issue with the earlier edition. These came from the element manufacturing process

− Increased resistance to media migration

− Greater ability to withstand salinity of water in fuel

− Better adhesion of end-caps

• Filter monitors shall be operated at least 50% of the time are flow rates clos eto the maximum design flow rate

− New maximum DP measurement and tracking sheets introduced

• DP limiting devices have been introduced. These provide the best defence against high DP. If the DP reaches a set point – refuelling is automatically ceased.

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Prevention of hydrant pit valve to refuelling vehicle system failure.

Above – Auckland 1995

Right – Sydney Pit coupler failure 1997

Barriers strengthened – Edition 2 pit valve

• Edition 2 pit valves • Edition 3 pit valves

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The Edition 3 Pit valve

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Management System audits evaluate Air BP’s Operating Management System for conformance with the requirements of OMS and legal compliance

Policy, Standards and Procedures audits evaluate the effectiveness of Air BP’s PSPs (ie Air BP Regs, Training System, misfuelling prevention, HSSE and Engineering Policies) in managing risk and assuring compliance.

Critical Barrier checks evaluate the operation of specific risk controls at a site level. They verify that the Critical Barriers will work when required to do so.

Critical Barrier Checks

Policy, Standards and Procedures audits

Management Systemaudits

Levels of Assurance Activities

Reflecting on the past for a safer future

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Conclusion

• Industry is committed to safety

• High degree of awareness of risks

• Key is to continue to momentum and ensure lessons learnt stay fresh in peoples memories