JIG

1
JIG Learning From Incidents Toolbox Meeting
Pack Pack 4 January 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
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resulting directly or indirectly from any use
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there was a failure to exercise reasonable care
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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.
2
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.jointinspectiongr
  oup.org)

3
Learning From Incidents

• For every incident in this pack, ask yourselves
  the following questions
• Is there potential for a similar type of incident
  at our site?
• Do our risk assessments identify and adequately
  reflect these incidents?
• Are our prevention measures in place and
  effective (procedures and practices)?
• Are our mitigation measures in place and
  effective (safety equipment, emergency
  procedures)?
• What can I do personally to prevent this type of
  incident?

4
Aircraft Refuel Adaptor Failure (LFI 2011-10)

• Incident Summary - The Operator could not get
  fuel to flow at the start of a defuelling
  operation. The aircraft engineers used the
  aircraft fuel tank boost pumps to start the fuel
  flow and soon heard a banging noise come from the
  Hose End Control Valve. The aircraft refuel
  adaptor cracked upstream of the shut-off valve,
  which resulted in significant fuel spill as the
  leak couldnt be stopped. The path for some of
  the leaking fuel was onto the engine exhaust
  pipe. The exhaust pipes were cool at the time of
  the incident.

• Lessons Learnt
• The aircraft manufacturer issued a newsletter in
  2002 and again in 2009 warning of refuel adaptor
  failures when using aircraft boost pumps during
  defuelling. The aircraft manufacturer recommends
  locking the HECV open during defuelling to
  prevent sudden closure and pressure shockwaves.
• JIG 1 section 6.6 also requires the HECV to be
  locked open for defuelling.

The crack in the adaptor resulted in the spill

• Root Causes
• Not following manufactures and other industry
  guidelines relating to this type of operation

Can you think of any similar situations that YOU
have experienced or witnessed? Did you report it?
5
Misfuel (LFI 2011-08)
Summary - An aircraft arrived at an Airport and
requested fuelling - the grade required was not
stated or requested. On arrival at the kerbside
dispensers the Operator found a Beech twin
engined plane parked in the Jet refuelling
position (the airport has two kerbside dispensers
Avgas and Jet) with the fill port caps removed.
The pilot asked for the plane to be refuelled.
The Operator did not confirm the grade required,
nor did he check the plane's grade decals or
complete a Fuel Grade Verification Form (FGVF).
After putting 8 litres of Jet into the planes
tank he saw an Avgas grade decal on another fill
port and immediately realised his mistake and
stopped fuelling. The plane was towed to a safe
position without starting the engines and the
tank drained and refilled.
Close up of fill port showing cap over grade decal

• Root Causes
• There was no grade verification on taking the
  order, or when talking to the pilot. No grade
  decals check took place, and no Fuel Grade
  Verification Form completed
• The plane was parked in front of the Jet
  dispenser because the Avgas position was still
  occupied by the previous customer.
• The pilot removed the fill caps because, at
  another site, they had not been closed properly
  and had come loose in flight.
• The pilot had placed the fill port cap over the
  red Avgas grade decal, which had been stuck on to
  a red paint stripe on the plane, so it was
  camouflaged (see picture).
• The kerbside dispensers are operated by grade
  selective keys. Authorised self-service
  customers are given a grade selective key, but
  Operators carry keys for both grades.
• The plane was fitted with a large fill port
  opening which meant that the larger duckbill
  spout (if fitted) would not have alerted the
  Operator.

Can you think of any similar situations that YOU
have experienced or witnessed? Did you report it?
6
Drive Away (LFI 2011-01)
Incident Summary - After completing the fuelling
of an A320 the operator was distracted while
following the disconnection procedure. He thought
that he had disconnected the deck hose to the
aircraft. He then closed the deck panel from the
ground using another piece of equipment. The deck
panel operated the vehicles deck hose anti-lock
system, which was now ineffective. The operator
then drove away from the aircraft, as the hose
was still connected the aircraft coupling point
sheered and approximately 5 litres of fuel was
spilt from the hose. There was no further damage
to the aircraft and the spill was fully contained.
Panel
Antilock operated by magnet

• Toolbox Talk Discussion Points -
• If you become distracted whilst following the
  disconnection procedure what would you do?
• During your 360 Walkaround you spot a panel on
  the elevating work platform that has been left
  open. Would you try and close it from the ground?
  Or would you return to the platform to ensure it
  was safe to close the panel?
• The failure of the interlock design played a
  large part in this incident. Are the interlock
  systems regularly inspected at your location to
  ensure they are working correctly? Is everyone
  aware of the correct operating procedure for
  interlocks at your location?

Pin should have stopped panel lowering
Can you think of any similar Near Misses that YOU
have experienced or witnessed? Did you report it?
7
Defective Coupling Wrist injury (LFI 2010-13)

• Incident Summary An operator was starting a
  fueller loading operation. When locking the
  coupling of the loading facility hose to the
  fueller connection, he felt a strong pain in his
  right wrist. The pain persisted so the next day a
  medical check was made and a sprain with partial
  tearing of ligament of his wrist was diagnosed.
  This resulted in a 2 week absence from work.

• Root Causes
• Use of defective equipment. An investigation
  discovered that the couplings were known to have
  been very hard to manoeuvre for several months/
  This recurrent technical problem had not been
  recorded on a register.
• An incomplete preventive maintenance program
  meant that these items were not inspected.

• Lessons Learnt
• A suitable method for reporting all technical
  problems on equipment is needed and these
  should be recorded in order to identify any
  deviation and to prepare on time, appropriate
  corrective/preventive action.
• Preventive maintenance programmes must be
  reviewed to ensure all appropriate site equipment
  is included.

Can you think of any similar situations that YOU
have experienced or witnessed? Did you report it?
8
Aircraft Incident (LFI 2011-02)
Incident Summary An operator was approaching an
Embraer aircraft to perform a fuelling, it was
late evening and raining with strong winds.
Normally the aircraft used for this flight was an
A320. The operator assumed that the aircraft was
an A320 and did not check the type aircraft as he
approached. The operator attempted to reverse
under the wing of the aircraft without a guide
person and contacted with the wing of the
aircraft with the fuellers elevating work
platform. There was minor damage to both the
aircraft and the elevating work platform.
Minor damage to aircraft wing
Minor damage to the elevation work platform

• Toolbox Talk Discussion Points-
• When you approach a stand to refuel an aircraft
  what do you consider in your Last Minute Risk
  Assessment?
• The operator could not get into the correct
  refuelling position because of other apron
  traffic, so decided to try and reverse into
  position. What would you have done in this
  situation?

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