JIG ‘Learning From Incidents’ Toolbox Meeting Pack Pack 5 – May 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.

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)

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?

Hydrant Leak Inside Valve Chamber (LFI 2011-04) Incident Summary – A valve chamber was found completely flooded by what was believed to be surface water. As the water was being pumped out of the chamber it was discovered to be a mixture of water and Jet A-1 so an approved contractor was instructed to remove the remaining liquid from the chamber as ‘hazardous waste’. After a period of daily monitoring to try and detect the source of the leak it was decided to instruct an approved contractor to enter and inspect the chamber. A leak was located on the small bore pipework forming the Safety Bleed/Differential Thermal Relief System. The pipe had corroded in 3 places so was removed and temporarily sealed off until a replacement part was fitted. It was estimated that approximately 5,500 litres of jet fuel was removed from the chamber before the repairs were completed. 3 pin holes found under the U-shaped small bore pipe Root Causes – The top covers of the valve chamber were not leak-tight leading to frequent flooding. The hydrant tightness control system which should have detected this leak earlier was not operational. Monthly Internal inspections were done without entry to the chamber which limited the ability to identify the three pin holes in the pipework. Relying on visual inspection to identify the content of a flooded valve chamber resulted in an oily water spill on the apron. Lessons Learnt – Annual entry into the chamber would have enabled a more detailed visual examination which may have meant this defect would have been detected earlier. Any entry must be in accordance with confined space entry requirements. Any valve chambers with defects should be addressed as a matter of urgency. The leaking part was made of carbon steel. The replacement part is made of stainless steel to eliminate the risk of corrosion. A sufficient maintenance/repair programme of the top covers of valve chambers should ensure that valve chambers remain leak-tight. Implement a method for identifying the presence of fuel in the chamber before pumping out any liquid e.g. dip rod with water-finding paste. Level sensors could be installed in the chamber that will trigger an alarm in the control room if flooding exceeds the pre-set maximum level.

Platform drop due to chain breakage (LFI 2011-05) Incident Summary - An operator was lowering a platform when it stopped unexpectedly. When he then tried to raise it, it suddenly dropped 1.5 metres to its lowest position. The 2 chains on the fork lift type platform had failed.  The sudden drop resulted in the operator having muscular pain in this back. When he visited the doctor the following morning, he was given 2 days medical leave to rest his back. Root Causes – The maintenance contractor was not accredited for the maintenance of such lifting platforms. Incorrect tools were used which may have weakened the pins The new chains were delivered without new pins and linkages, a deviation from normal procedure. The new chains were installed using the old pins as it was perceived to be an urgent need to get the platform back in service Although the repaired platform was inspected by maintenance before being brought back into service, there was no formal procedure or checklist for this. A previous report of jamming of the platform had not been investigated and potential issues therefore missed. Lessons Learnt – Check that maintenance contractors for platforms are assessed using a pre-qualification evaluation and trained by the original equipment manufacturers in maintenance procedures. Only approved replacement parts should be used for maintaining and repairing lifting devices. Spare parts procured and delivered should have parts lists detailing exactly what parts should be included. Ensure that all platforms are thoroughly checked and approved by a competent person before being returned to service Incident and potential incident reports must be investigated.

Overtaking Incident (LFI 2011-06) Transporter Hydrant Servicer A Hydrant Servicer B Two hydrant servicers were following a slow moving transporter on the apron. The operator in hydrant servicer B was running late for a refuelling. Hydrant servicer B sounded it’s horn and began to overtake hydrant servicer A and the transporter. As hydrant servicer B did this the transporter slowed in preparation for turning left. The driver of hydrant servicer A did not realise that hydrant servicer B was in the process of overtaking. Hydrant servicer A did not signal and began to move out to pass the transporter. Hydrant servicer A pulled out and collided with hydrant Servicer B. Both vehicles sustained major damage but luckily nobody was injured. Discussion Points – The driver of hydrant servicer B was running late for his scheduled fuelling as he had not copied his fuelling schedule correctly. How do you ensure you know what fuelling you have to complete during your shift? Would you ever consider overtaking two vehicles on the apron? What hazards could this action present? What Driving Safe Practices, if obeyed, could have prevented this incident? Can you think of a similar situation that YOU have experienced or witnessed? Did you report it?

Drive Away (LFI 2011-07) Summary – An operator drove his fueller away from an aircraft while still connected, breaking the aircraft connector ring. The operator did not follow the disconnection process in the correct order, and was distracted by the aircraft captain and fire brigade representative. He did not complete a 360° Walkaround and when he entered the cab of the vehicle, he did not investigate why the interlock warning light was on. The interlock did not work, allowing the operator to drive away still connected. Damaged connector ring Discussion Points – The operator made many errors leading up to this incident. At what point could the operator have used a “last-minute risk assessment” to avoid this incident? Could a 360° Walkaround have prevented this incident? Does your Walkaround include looking up to check aircraft couplings? If distracted while completing a 360° Walkaround what should you do? Is the aircraft coupling always easily seen during your 360° Walkaround? Has your location considered using underwing flags or other coupling identification measures? These are designed to attract attention to hoses still connected to aircraft after fuelling has completed. Example of an underwing flag Can you think of any similar Near Misses that YOU have experienced or witnessed? Did you report it?

Aircraft Strike (LFI 2011-09) Incident Summary - Following a pre-fuelling operation an Operator discovered he had fuelled an aircraft out of the planned sequence. Upset about the mistake he stowed the deck hose, completed the delivery certificate, removed the bonding cable and performed a Walkaround check before getting into the vehicle. He did not realise the fuelling cabinet door was still open. In the cab, he did not notice the flashing interlock warning light and drove the vehicle away, even though the brakes of the trailer were still applied by the interlock. After hearing a noise, he realised that the cabinet door had struck the aircraft engine cowling. Root Causes The Operator was distracted by having fuelled the wrong aircraft. An ineffective 360° Walkaround was completed so the operator failed to notice the fuelling cabinet door was open. He did not notice the warning interlock lamp. The vehicle’s interlock system was ineffective due to the design. Lessons learnt When your routine is interrupted stop and take time to assess the situation (last-minute risk assessment). Always complete a thorough 360° Walkaround. The interlock lights were not positioned in a prominent position making them difficult to see. The interlock-system only activated the brakes on the trailer axle and this provided insufficient braking to prevent the drive away. Damage to aircraft Can you think of any similar Near Misses that YOU have experienced or witnessed? Did you report them?