JIG Learning From Incidents (LFIs) Toolbox Meeting Pack · 22/03/2018 Joint Inspection Group...

JIG Learning From Others (LFOs)Toolbox Meeting Pack

Pack 23 – February 2018

Joint Inspection Group Limited - Shared HSSE Learnings 122/03/2018

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

22/03/2018 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/

Injury – Shoulder Strain Whilst Connecting To Aircraft

Incident SummaryOperator injured his right shoulder while connecting to a B767. Operator was employing poorergonomic positioning when trying to connect, B767 requires “significant” force to open thepoppet which resulted in him being in a weak body position to open the poppet. Operator feltpain when he opened the first nozzle poppet and again on the second one.


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

Causes• As per operator’s comment, pain may have increased with time.

• Handling the valve placed inside the fuelling panel requires stretching out one’s arm. This handling has been achieved after a significant staticposition period during flowing of the fuel.

• Fuelling equipment doesn’t appear to be the cause of the incident even though the operator emphasised the fact that the valve was rather hardto manipulate.

• Incorrect / poor platform positioning to enable good ergonomic approach to the fuel panel.

Toolbox Discussion Points• Position the equipment correctly rather than placing your body in an uncomfortable or unergonomic / unnatural position

• What may have been the best solution to avoid such a shoulder pain?

• Are you aware of your personal habits which may place your body in unsafe working positions?

• If you injure yourself, don’t continue to work if you feel it may make the injury worse.

LFO 2018-01

Incorrect Positioning

Near Miss - High High Alarm ActivationIncident SummaryDuring a tank filling operation, the depot experienced a High High alarm that resulted in automatic depotshutdown.

The control room operator had acknowledged a number of preceding alarms during the filling process butdid not respond to these in sufficient time, resulting in the incoming pipeline supply being shut down toolate. This ran the tank level up to the tank High High level, activating a depot safety shutdown.

22/03/2018 Joint Inspection Group Limited - Shared HSSE Incidents 5


Causes• The operator was working on other activities and alarms and was not paying sufficient attention to the critical alarms.

• The operator had acknowledged 3 previous set point tank level alarms and not taken action.

• He reacted after the High level alarm but reacted too late to stop the level reaching the High High alarm and automaticshutdown.

• The annunciator sounds did not differentiate between different types of alarm.

Toolbox Discussion Points• Are all Operators aware of the requirement to maintain tank levels within the safe operating level? Re-iterate the requirements and procedures for tank

filling at your location.

• Can operators be distracted with other activities putting demands on them?

• Is there a potential for “risk normalisation” with respect to alarms i.e. they activate so regularly that they become the norm?

• What are the alarm management procedures at your location? Are all Operators familiar with the requirements?

• Has the facility consulted API2350 latest edition (Overfill Protection for Storage Tanks in Petroleum Products) to professionally manage tank overfillhazard?

LFO 2018-02

Spill – Pit Valve Spill

Incident SummaryDuring the refuelling of an aircraft, the hydrant pit valve in use leaked rapidly whichresulted in the pit box overflowing with fuel spilling approximately 20 litres of fuelonto the apron before the leak was stopped. The hydrant pit box filled with fuel over aperiod of several minutes.



Causes• The pilot block had worked loose on its mounting bolts.

• The movement of the pilot block on the loose bolts allowed the O rings sealing the hydraulic ports to become dislodged under thehydrant pressure. This in turn allowed fuel to be released rapidly from the pilot block ports.

• The manufacturer had supplied a revised lanyard arrangement for the facility that could apply more force to the pilot block when usingthe lanyard.

Toolbox Discussion Points• What are the installation and maintenance requirements related to pit valve pilot blocks? Are they followed at your location?

• Are bolts tightened to the correct torque settings?

• Have any changes been made to the arrangement at your location without an approved Management of Change?

LFO 2018-03

Spill – Hydrant Re-Commissioning

Incident SummaryAn engineering team were reinstating a section of hydrant and the line was prepared forinitial ‘fill up’ using only storage tank static head pressure. The manually operated sectionvalve was opened and a release of fuel was observed from the main vent point on the line. Arelease of fuel was observed to a height of 2.5m from the vent point pit lid. Approximately 80litres were lost before the supply valve could be closed.



Causes• The vent point was left in the open position following the previous night’s work and this had not been checked as per the agreed methodstatement.

• Staff briefing was superficial and resulted in poor supervision of resources.

Toolbox Discussion Points• Are there sufficient and appropriate work controls in place (LOTO) to manage activities related to hydrant maintenance activities at yourlocation e.g. Permit to Work and Isolation?

• Is the competence and experience at the required level to manage such activities?

• Are roles and responsibilities clear with regard to managing hydrant maintenance activities?

LFO 2018-04


Injury – Apron CollisionIncident SummaryA trainee operator, driving a hydrant dispenser together with their supervising operator, were waitingat a designated waiting area for their flight to arrive at the parking bay. They felt an impact to thevehicle and noticed that a tractor unit towing 3 pallet dollies had hit them in the rear. The supervisorreceived injuries and requested to see the doctor and was given three days medical leave.

Causes• A concrete crash barrier had been installed to protect an airbridge and was placed by the side of the road which narrowed an already narrowroadway. This hazard had not been identified by the dispenser drivers while parking in the designated parking area.

• The tractor driver did not slow down when passing through a narrow gap between the crash barrier and the hydrant dispenser andmisjudged the width of the dollies relative to the space available.

Toolbox Discussion Points• Discuss with Operators the need to identify something that’s out of the normal situation and the maintenance of situational awarenessat all times. The concrete crash barrier had been in position for some time but had not been identified as a hazard while parking in thedesignated area.

• Discuss if Operators have similar experiences to the conditions that led to this incident? Have additional hazards been introduced on theapron as a result of construction work, temporary diversions or barriers etc. that have not been communicated or fully risk assessed?

• Review the site hazard mapping or black spot mapping for your location in conjunction with the Airport Authority. Are they current andreflect any changes introduced at the apron?

• Whip lash injuries may have a delayed reaction; people may not immediately feel pain. Re-iterate the importance of reporting incidentsimmediately and to check at regular intervals for any discomfort and to seek medical attention if required.

LFO 2018-05



Lost Time Incident – Apron pot hole

Incident SummaryDuring an aircraft refueling on the apron, an operator was walking towards the refueller to stow away thedeadman when he stepped into a small pot hole and twisted his ankle. This resulted in 6 days off work.The injured Operator did not report the incident immediately to the site manager. There was a delay of 1hour in applying first aid and an ice pack to the injured ankle.


Causes• The appearance of potholes and apron surface damage is a well known occurrence following a winter season. The change of season should haveheightened awareness of possible slip and trip hazards on the apron.• A lack of situational awareness and no proactive reporting of potential incidents from apron stakeholders. There were several potholes identified atthe location.• The airport had not taken any proactive steps to inspect the status of the apron. Known potholes could have been marked with paint while awaitingrepair.• Damaged apron surfaces pose a hazard to taxiing aircraft. Engagement with airlines/pilots could have supported the requirement for immediateremedial action.

Toolbox Discussion Points• Do your Operators maintain good situational awareness on the apron and remain alert to slip and trip hazards? Potholes on the apron (and in depotareas) are a hazard to all personnel working on the apron and can appear suddenly following a severe winter.• Do you report all potential incidents in a timely manner and follow up on any agreed actions to address the hazards?• Do you engage with the Airport Authority and other stakeholders in a timely manner to address identified hazards?• Re-iterate the requirement for all staff to immediately report incidents or potential incidents to their Supervisor. Injuries should also be reportedimmediately so that appropriate medical attention can be provided in order to mitigate the possible consequences.

LFO 2018-06

Spill - Apron Spillage


Incident SummaryDuring preparation for the refuelling of an Airbus A320 a baggage loader vehicle manoeuvringbackwards on the starboard side of the aircraft hit the pit coupler of the hydrant dispenser. Theimpact resulted into damage to most of the coupler lugs resulting in a clean disconnect from the pitvalve. The disconnect was not obstructed by the CLAD. An estimated leak of 40 litres of jet fuel wasspilled from the dispenser intake hose. A limited amount overfilled the pit chamber onto theapron.

Causes• The lack of due care and attention by the baggage loader driver during reversing caused the vehicle to hit the pit coupler.

Toolbox Discussion Points• Are hydrant pit valves and dispenser pit couplers in full compliance with EI1584, 3rd edition?

• Understand importance of the prompt and efficient behaviour of operators dealing with the emergency situation and effective incidentcommunications.

• Always be aware of the situation and be able to identify dangerous situations and avoid or minimise consequences resulting from a possible incident.

• A possible contributing factor is the congested stand. Are there similar situations in your operations? How do you keep the gate assessments up todate, and informed? Are you accepting difficult working environment? How can you engage Airport Authority, Airlines, Ground Handler to solve anyissues?

LFO 2018-07


Injury - Restricted Work Injury (RWI)


Incident SummaryOperator decided to wash a 20m³ refueler using a (3 rung) step ladder with a platform and handrail (this is notpermitted by local procedure). During the procedure the Operator positioned a water hose on the ladder (with thehose on top of the ladder rungs). He stepped down to collect a wet cloth with soap to rub the cabin. As he climbedthe ladder (first rung) his foot slipped on the hose on the step and he fell to the ground. The Operator used his lefthand to support his body in the fall. This movement created a cut / sprain on his left wrist bone and his forearm hadto be partially plastered. The Operator was reviewed by the company doctor as ‘able to perform administrativetasks until his full recovery’.It was identified that the activity of washing vehicles moved from a non-routine activity (managed under Control ofWork (CoW) with proper risk assessment and few people trained) to a routine (weekly) activity that would haverequired more people to be trained and monitored.Site management failed to perceive this change and apply maintained control to the task.

Causes• Procedure was performed without training.

• Site leadership (Site Manager and Supervisor) did not apply the procedure rigorously.

• Site leadership (Site Manager and Supervisor) did not perform enough supervision on non into-plane activities.

• Site leadership did not identify the emerging risk associated with the frequent increase of a non-routine activity (from non-routine to weekly)

Toolbox Discussion Points• How much rigour on adherence to rules and procedures at site management and operational level do you have at site?

• Do you correctly use stepladders for every kind of operation (routine or non-routine) with the need to keep 3 points of contact?

• Is site leadership visible on all operations (into-plane or non into-plane)?

• Do you identify any type of changes that could lead to a blind spot and maintain a state of chronic unease?

• Don’t use step ladders for washing vehicles.

LFO 2018-08


Near Miss – AC Damage


Incident SummaryAn operator was refuelling an aircraft when he noticed that an aircraft was being towed onto the adjacentstand. The aircraft was being towed quite quickly for the proximity of the aircraft and tanker in refuellingposition. The operator let go of the dead man to stop the fuel flow, quickly walked in front of the tanker toget a better view of clearance between incoming aircraft and the tanker. He was expecting the tow tug driverto have stopped with ample safety clearance but he had kept going. He had slowed down but continued togo forward and with 1 meter available the operator signalled with his arms crossed above his head andyelled “Stop”! He slammed on the brake and came to a sudden stop bouncing on the shocks. It is estimatedthat the tow tug driver stopped with 5-10cm clearance between the cab windscreen and passenger mirror ofthe truck and wing tip. Approximately 30-50cm of the leading edge of the wing-tip would have struck thetanker cab and windscreen.

Causes• The tow tug driver misjudged the distance, he had never had an issue with this bay before and said it was difficult to judge the distance at wing tips.

Toolbox Discussion Points• Can this happen in your local operations?

• Gate by Gate risk assessments are critical. Are they up to date and constantly reviewed with the airport team?

• Remaining vigilant whilst on the apron and maintaining an awareness of the activity taking place around your work area provides a better opportunity to interveneto stop unsafe acts.

• Proactively address issues you deem high risk and escalate if necessary.

LFO 2018-09


The operator challenged the driver as to why he hadn’t stopped earlier; he said that he had never had an issue with this bay before and that it was difficult to judge thedistance at wing tips.

Fuelling Hazard - A737 Winglets


Incident SummaryMore airlines have started using the new Boeing 737 Max 8 aircraft, which has the new type ofwinglet called max feather winglet. There is a safety risk whilst approaching the aircraft forrefuelling and care needs to be taken, so that vehicles aren’t driven under the wing or close tothe winglets.

The clearance height on bottom of the winglets facing downward is 3.05 metres (10 feet)

Toolbox Discussion Points• Have staff been made aware of this hazard and have control measures been implemented to reduce the risk of collision?

• Have the contents of JIG Bulletin 67 (May 2014) been shared with relevant staff?

• Are there any communication protocols in place for airlines to inform operations of changes to aircraft types?

LFO 2018-10


First Aid - Battery Leaked


Incident SummaryFollowing regular preventive maintenance on a Programmable Logic Controller (PLC) the two 3,6 Volt size AA lithiumbatteries should be replaced (see 1st photo). Batteries were ordered and received having an unusual little pin at eachedge (see 2nd photo), so that extension cables could be connected to them. The specific PLC application couldn’taccommodate these batteries, so the electrician responsible for the task called the battery vendor who recommendedto remove the little pins, so that the battery could then fit to the PLC power unit. A trainee engineer approached himto observe this task. During pin removal, an invisible hole was created and a little jet of the enclosed chemicalsubstance spilt out of the battery and hit the trainee in the area of his left eye. The electrician immediately used thespare portable eye wash station located at the control room of the facility to wash the trainee’s eye and he continuedfor another 15 minutes washing his eye at the fixed water eye wash station of the facility. They then both visited theairport first aid center for further check by doctor who confirmed that there was no damage to the trainee’s eye andface. The trainee returned to his work and drove home at the end of the working day.

Causes• The removal of the pin damaged the battery enclosure and the chemical was released.• Both the Electrician and the trainee did not think that there would be a risk and did not wear any eye protection.

Toolbox Discussion Points• Are any changes to equipment handled via the Management of Change procedure?• Do you carry out risk assessment before any required modification to equipment? Is the equipment MSDS consulted?• Are operators used to perform LMRA (Last Minute Risk Assessment) any time they are facing something new?• Is there a functional eye wash station in vicinity of works execution? Are operators trained on its use? Is there a preventive maintenance program for eye wash stations?• Have you considered to have a spare portable eye wash station readily available by shift supervisor in case the affected operator cannot use the fixed eye wash station ofthe facility?• Is there an airport first aid center? Otherwise, how far away is the closest hospital if needed?

LFO 2018-11


Product Quality Serious Incident - Fuelling From An Out of Service Hydrant Pit


Incident SummaryDuring a routine observation, a Fuel Farm operator noticed an aircraft being refuelled via a hydrant dispenser using a newlyinstalled hydrant pit valve that had not yet been fully commissioned. The hydrant pit being used was on a stand in an areathat had been closed off for several months by the airport authority as part of an airport expansion project which includedthe installation of replacement and additional hydrant pits. The fuel farm operator intervened and the fuelling wassuspended. The aircraft captain decided to delay the departure of the aircraft (which was repositioning back to base afterbeing diverted into the airport the previous day) until he could be satisfied that there were no fuel quality issues.The hydrant system in that area had been fully flushed and soak tested, colourmetric millipores had been conducted withsatisfactory results and the ITP operator had completed his fuel quality control checks at the start of the aircraft fuellingwith no issues. However, the hydrant pit should not have been used for fuelling until the results of the final gravimetricmillipore tests had been received from the testing laboratory. The aircraft departed the following day as soon asconfirmation was received from the laboratory that the gravimetric millipore tests were satisfactory.Standard practice during projects at this airport is to keep any stands being redeveloped blocked off until the hydrantoperating company confirm that hydrant refuelling can commence. Unusually in this instance the airport authority hadremoved the barriers blocking off the stand in order to park the diverted aircraft on the stand without any consultationwith the hydrant operating company. The airport authority compounded the situation by failing to inform the airline ortheir handling agent that hydrant fuelling was not available on this stand.

Causes• Lack of communication between the Airport Authority, Hydrant Operating company and Into-Plane company as to the permission for the use of the stand / hydrant.• Removal of the barriers from the stand prior to permission for use of the stand being given.• Lack of Lock Out / Tag Out (LOTO)

Toolbox Discussion Points• Are all relevant parties associated with a project informed about the change processes?• On large projects are processes reviewed and refreshed with all parties for clarity?

LFO 2018-12




Product Quality - Delivery of Untested JET A-1

Incident SummaryA part of an airport hydrant system was shut down, as a preparation for a project to install new fuel pits. the isolating valveswere closed and the system was emptied. At the end of the project, the tie-in of the new underground pipe was carried outsuccessfully and the aforementioned isolated section of the hydrant system with new fuel pits was filled with fuel, pressurizedfor hydraulic test and kept under pressure for several days for soak testing. During the project execution, the aircraft stands atthat area where the hydrant was not in use, had been kept in use and aircraft were being fuelled by fuellers. While the systemwas still under soak testing, an operator used the hydrant pit – which was still OUT-OF-SERVICE- to fuel an aircraft, instead of afueller. The pit maintenance valve was not closed and an OUT-OF-SERVICE sign was not placed at the hydrant pit. The dispenserdelivered 6,500 lts to the aircraft, this was the total volume delivered until the hydrant section was fully depressurized.The aircraft had to be defueled, the remaining fuel in the aircraft passed all fuel quality tests until it was normally fueled by afueller. The aircraft with its 300 passengers were delayed by 6 hours. No injuries and material loss occurred.

Causes• Management of change (MoC) with a Risk Assessment for the project period while the hydrant pit was OUT-OF-SERVICE wasnot carried out jointly by all parties involved (Hydrant, Into-Plane, Airport)• Hydrant pit maintenance valve was not closed/locked.• An OUT-OF-SERVICE sign was not placed at the hydrant pit. Lock-Out/Tag-Out (LOTO) was not applied.• Lack of effective communication between the different interfaces (Hydrant, Into-plane, Airport)

Toolbox Discussion Points• Is any change on equipment handled via MoC procedure?• Is MoC carried out jointly with all parties involved?• Do you apply LOTO to ensure that fuel shall not be released to aircraft before hydrant is satisfactorily commissioned?• Do you use last minute risk assessment (LMRA) to eliminate potential underlying risks?• Is an OUT-OF-SERVICE blocking device installed at the fuel pit to avoid uncontrolled usage of fuel pit not in use (see example in the attached picture)?• See JIG Technical Bulletin number 39, from January 2011, which specifically addresses this issue.

LFO 2018-13

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