jig learning from incidents (lfis) toolbox meeting pack · 2017-07-05 · jig learning from others...

JIG Learning From Others (LFOs)Toolbox Meeting Pack

Pack 21 - June 2017

Joint Inspection Group Limited - Shared HSSE Learnings 105/07/2017

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.

Learning From OthersHow to use the JIG 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 & depot operators and maintenance technicians) during regular, informal safety meetings

▪ No need to review every slide in one Toolbox meeting. Select 1 or 2 slides 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 at

www.jigonline.com

05/07/2017 Joint Inspection Group Limited - Shared HSSE Learnings 2

http://www.jigonline.com/

Learning From OthersFor every slide in this pack, ask yourself the following…

▪ What impact could this issue have on our site?

▪ How do our risk assessments identify and adequately reflect these issues?

▪ What prevention measures are in place (procedures and practices) and how effective are they?

▪ What mitigation measures are in place (safety equipment/emergency procedures) and how effective are they?

▪ What can I do personally to manage this type of issue?


If you would like further assistance or information relating to the contents of this pack, or if you have any information you feel will help others, then please contact JIG at

http://www.jigonline.com/contacts/

http://www.jigonline.com/contacts/

Aircraft Incident – Fueller hits A320LFO 2017 01

Incident Summary

An operator tried to drive a vehicle under an A320 wing in an attempt to position directly underthe aircraft adaptor to avoid having to use the towable fuelling steps. Whilst moving under thewing the vehicle collided with the plane wing. This resulted in a delayed departure.


Can you think of a similar situation that you have experienced or witnessed and did you report it?

Causes

• The operator did not apply the approved approach procedure to the aircraft at this parking stand .

• The operator did not use the towable fuelling steps which he should have done for this vehicle on this aircraft type

• The operator was not aware of the profile of the vehicle he was driving and therefore did not appreciate that the vehiclewas not low profile (Lower height vehicle) enough for fuelling the A320 aircraft.

• Investigation identified that the training time on this particular vehicle was not sufficient. Most training on A320’s wasprovided using a vehicle with a lower profile (height).

Discussion point

• Does your training take into account complex fuelling operations according to various vehicle/plane/parking combinations ?

• Could additional information be provided to operators to avoid this type of incident? E.g. vehicle height, planes that are notauthorised to be fuelled with the vehicle displayed within fuelling vehicle cabin.

•Would stand plans have helped in avoiding this incident?

SpillLFO 2017 02

Incident Summary

A spillage of approximately 5 litres took place while fuelling an ATR 72 aircraft. It was found that during fuelling thecoupling had leaked. Due to the position of the fuelling point and presence of wind this leak was blown towards thelanding gear of the aircraft. The Operator reported that leak was first seen by a member of the flight crew as heapproached from the front of the aircraft. At this point fuelling was immediately stopped, the alarm was raised andAirport Fire Service called out. After clearing up the spill with approx. 3 – 4 spill pads from his vehicle the Operator wasrequested to check the equipment and complete fuelling. Under observation from the Fire service, the Operatordisconnected and checked the aircraft adapter as well as the fuelling coupling. As there was no sign of wear or damageunder close observation and with improved light from the Fire Service, the Operator reconnected and completed thefuelling. There were no leaks problems or issues from the connection after this. The aircraft was taken out of service forchecks in daylight.

05/07/2017 Joint Inspection Group Limited - Shared HSSE Learnings 5Can you think of a similar situation that you have experienced or witnessed and did you report it?

Causes

• The coupling was not seated correctly. This could have been from poor connection with the seal not complete. Asa result when fuelling commenced the coupling leaked.

• The picture showing the fuelling point indicate that the spillage was being blown away directly below theconnection towards the nose of the aircraft and was initially not seen by operator.

Toolbox Discussion Points

• Does your training include awareness of the angle of fitment on ATR 72 aircraft?• Are your staff made aware to check a greater area for potential spills in windy conditions? i.e. Not just expect a leak to fall direct to ground• Do you conduct targeted fuelling observations on aircraft with non standard connections to check the seating ? e.g. angled connection on

ATR 72

Aircraft Incident LFO 2017 03

Incident Summary

Following a fuelling the operator drove away from the aircraft with the vehicle's pantograph in a raisedposition. Before departure, the platform had last been lowered by the aircraft engineer following final checksat the fuel panel gauges, with the fuelling operator standing on the ground. After driving for about 600m tothe next stand, the pantograph made contact with the flap fairing of the aircraft at the new stand. Aircraftwing flap fairing was damaged with a small hole in it resulting in a delayed departure.


Causes• The electro pneumatic switch was not activated due to improper positioning / stowage of the deck hose to its

position• The pantograph hydraulic oil had leaked due to worn seals but had not been noticed, due to lack of an

effective preventative regime for pantographs• The operator stayed on the ground and allowed the aircraft engineer to lower the platform• The operator failed to complete a 360 walk around and Look-Up before departure.• Absence of brake interlock on Pantograph.

Toolbox Discussion Points• Does your maintenance regime include thorough testing of the pantographs’ hydraulics?• Does your local procedures consider operation of elevating platforms by airline personnel?• Does you training emphasise the need for an effective 360 walkaround including a look up and down?• Would additional interlocks e.g. on the Pantograph prevent this type of incident?• What maintenance checklist is utilised for Pantograph hydraulic and pneumatic systems?• Would placing high visibility marking on the pantograph and deck hose couplings have helped avoid this

incident?• Would any markings on the elevated platform have identified that it was not in a fully lowered position?• Where pantographs are installed on vehicles are staff aware of how they function?

Non Fuelling Related Incident – FatalityLFO 2017 04

Incident SummaryA baggage handler bled to death after his leg got pinned by two baggage carts. The handler wasdisconnecting two dollies when another driver with a tractor crashed into one of the dollies,slamming it into the other. The handlers right leg got pinned between the dollies and it bledprofusely. Medical services were unable to save the handlers life.

More information is available at:• https://www.youtube.com/watch?v=uSHeQ3i0zDM&feature=youtu.be• http://www.thestandard.com.hk/section-news.php?id=179819



Causes• Results of the incident investigation are not known by JIG


• What could have led to this collision? e.g. careless driving, mechanical failure, crowded working environment, insufficient training• Would your emergency arrangements have provided a timely and suitable first aid/medical provision to the victim?• What fuelling equipment could be impacted by a 3rd party vehicle? What are the potential consequences of such impact and how can the risks

be controlled? Consider especially a Hydrant Servicer (e.g. pit intake coupler knock off, hose being ruptured etc.). Such an incident occurred inSydney in 1997 resulting in a 7500 litre spill.

• Do your staff report near miss incidents involving baggage carts and other 3rd party vehicles? Do you discuss these with key stakeholders e.g.airport safety committees, 3rd party vehicle operators?

https://www.youtube.com/watch?v=uSHeQ3i0zDM&feature=youtu.be

http://www.thestandard.com.hk/section-news.php?id=179819

LTI – Back strain whilst using fuelling step ladderLFO 2017 05

Incident Summary

An operator placed his fuelling steps in an offset position from the aircraftcoupling point. Consequently he had to reach across to connect the hoseto the aircraft and as a result he injured his back whilst using force tomake the complete the connection. This resulted in a loss time injury


Causes• The operator did not take the time to evaluate his task

• The operator did not correctly position his stepladder

• The twisting motion reduced the safe lifting weight as the operatorsarms were extended further from the body (Safe lifting ability isreduced if handling is done with arms extended)


• Have you assessed the manual handling and other ergonomic riskswithin your operation?

• Are staff provided training on the safe use of ladders and steps?

• Are there any factors that may prevent the ladder being positionedcorrectly?

Incorrect Positioning

• Operator has to reach across tocomplete the connection

Correct Positioning

• Operator is positioned inline with the hose

Lost Time Injury – Operator hit by fuel panel LFO 2017 06

Incident Summary

An operator struggled to open a jammed fuel panel which then opened unexpectedly and hit him in theface. He sustained a cut on the nose which subsequently became swollen and prevented the wearing ofsafety glasses essential for safely carrying out this task.

05/07/2017Joint Inspection Group Limited - Shared HSSE Learnings

9Can you think of a similar situation that you have experienced or witnessed and did you report it?

Causes• The fuelling vehicle was not positioned correctly to allow safe access to the fuel panel via the elevating

platform. This resulted in the Operator standing on the wrong side of the fuelling panel putting him inthe “line of fire” with the panel opening towards the face.

• There was pressure from the pilot to complete the fuelling operation quickly as the flight crew wereapproaching their maximum working hours.

• The Operator was unfamiliar with this aircraft type (B777).• A Management of Change process was not followed for a new aircraft type that would have identified

and managed potential risks arising from this change.

Toolbox Discussion Points• Are all Operators aware of the procedure for positioning a fuelling vehicle correctly to ensure a safe fuelling operation? Clarify and re-emphasise your

local procedures and requirements. What procedures do you have in place to manage a new aircraft type arriving at your airport to refuel?• Are there instances of flight crew applying “pressure” to refuel quickly? Are Operators empowered to delay or stop a fuelling operation due to a safety

concern and is this policy supported by the airport?• Are there similar issues with aircraft fuelling panels at your airport? Are Operators putting themselves in the “Line of Fire”? Do you adopt the “Last

minute Risk Assessment” approach to tasks? Could this incident have been avoided if this approach was used?• Are you sufficiently familiar with what to do in the event of a medical emergency. Ensure that injured personnel receive first aid as soon as practicable

for assessment. Also ensure that all incidents are reported immediately and investigated.


High Potential Near Miss LFO 2017 07

Incident Summary

While excavation work was in progress to expose buried piping within a depot area, an 11 kV HighTension electrical cable was hit by a contractor using a pick axe. This resulted in a short circuit andoutage of electricity at the depot. No personal injury resulted from the incident.

Causes

• The Permit to Work process was not implemented effectively and the controls for the hazards and risks identified e.g. buried electrical cableswere not adequate. For example, the use of scanners to detect underground services was not specified.

• The facility was old (dating from the 1960’s) and Engineering standards, Asset Integrity & Process Safety requirements including as builtdrawings and piping layouts etc. had not been updated and / or were not accurate. This was specified as a key control requirement.

• There were time pressures to complete the work. A project was being undertaken that required excavation of buried pipework to checkintegrity.


• Are “As built drawings” for process piping and service lines reviewed and updated regularly at your facility (JIG HSSE MS Standard Element 4)?

• Does you facility have a Business Continuity Plan (BCP) that covers “worst case scenarios” for similar incidents that can potentially severelydisrupt or even stop fuel supplies to airports to ensure continued operations.

• Are staff sufficiently familiar with Permit to Work requirements and competence requirements for Permit Issuers?

• Is Electrical Isolation (and LO/TO) ensured before contractors work on electrical systems or in areas where cables are expected/identified?

• Are Permit Issuers and contractors empowered to stop work if they feel that the task cannot be completed safely?



Safety Issue – Fuelling B777LFO 2017 08

Summary

The fuelling of the B777 introduces two specific safety issues that need to be considered and assessed.The height of the aircraft fuelling adaptor introduces issues regarding working at height, manualhandling and vehicle design. The location of the aircraft fuelling adaptor and the control panel bringthe fuelling in close proximity to the aircraft engine whilst positioning introducing the risk of an aircraftincident.

For further information on this issue please refer to:

• https://www.youtube.com/watch?v=m3XgSZqJgmg

• JIG Bulletin 103

Toolbox Discussion Points• Have you developed stand plans for this aircraft type that consider amongst other things the

fuelling vehicle access/exit routes and fuelling vehicle parking position during fuelling?

• Have you communicated these issues to your operators?

• Do you have a programme of targeted safety walks that would have identified this type of issue?

• Do your staff have the opportunity to report such safety concerns e.g. Near miss reporting, safetymeetings?


https://www.youtube.com/watch?v=m3XgSZqJgmg

http://www.jigonline.com/wp-content/uploads/2017/06/Bulletin-103-VehicleModificationsfor-new-aircrafts.pdf


Emergency Exercise Scenario – Immobilised FuellerLFO 2017 09

Summary

An operation recently performed an emergency exercise aimed at testing the reaction of the operationto the event of a fueller becoming immobilised in an underwing position. Three scenarios wereconsidered:• 1st scenario: Small air system leakage preventing the handbrake from being disengaged• 2nd scenario: Severe air system leakage preventing the handbrake from being disengaged• 3rd scenario: Engine shut down and air system leakage leading to the inability to produce air for

disengaging the handbrake and to move the fueller under it’s own power

Note : The exercise tested a fuelling vehicle with a typical air-to-open / spring-to-close (double action)drum brake system without an ABS system. Additional actions may be needed for a fueller equippedwith an ABS system and disc brake system

Key Learnings• Need to raise awareness of operating staff on brake systems function and own equipment type.• Arrange to receive training from the brake system engineer• Consider quick disengage drum brakes for future alterations / upgrades / overhauls• Prepare a business continuity plan in collaboration with the airport authority keeping in mind the

probable loss of two fuelling vehicles for some time• Calculate the impact of aircraft delays and airport congestion due to the disruption• Equip operations with at least one air hose of suitable length fitted with universal quick connect-

disconnect couplings at both ends. Same type couplings to be installed at selected locations of thevehicles’ air system. Ensure these hoses are suitably stored and maintained.

• Liaise with other into plane companies as required• Check available towing equipment for compatibility of towing bars and kingpins with your vehicles

jig learning from incidents (lfis) toolbox meeting pack · 2017-07-05 · jig learning from others...

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