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.

Joint Inspection Group Limited

Shared HSSE Incidents

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)
Joint Inspection Group Limited

Shared HSSE Incidents

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?

Joint Inspection Group Limited

Shared HSSE Incidents

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 Ushaped
small bore
pipe

Root Causes

Lessons Learnt

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.

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.

Joint Inspection Group Limited

Shared HSSE Incidents

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.

Joint Inspection Group Limited

Lessons Learnt
Check that maintenance contractors for
platforms are assessed using a prequalification 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.

Shared HSSE Incidents

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 its 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?

Joint Inspection Group Limited

Shared HSSE Incidents

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?

Example of an underwing flag

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.
Can you think of any similar Near Misses that YOU have
experienced or witnessed? Did you report it?

Joint Inspection Group Limited

Shared HSSE Incidents

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 vehicles interlock system was ineffective due to the design.

Lessons learnt

Damage to aircraft

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.

Can you think of any similar Near Misses that YOU have
experienced or witnessed? Did you report them?

Joint Inspection Group Limited

Shared HSSE Incidents