JIG

1
JIG Learning From Incidents Toolbox Meeting
Pack Pack 1 January 2011
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only and on the condition that (i) it may not be
relied upon by anyone, in the conduct of their
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(iii) nothing in this document constitutes
technical advice, if such advice is required it
should be sought from a qualified professional
adviser.
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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.

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Learning From Incidents

• For every incident in this pack, ask yourselves
  the following questions
• Can we apply the lessons learnt from this
  incident and 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
UST Hot Work Fatality (LFI 2010-1)

• Incident Summary - A subcontractor removed two
  petrol and one diesel Underground Storage Tanks
  (USTs), as part of a routine site closure
  project. The subcontractor started to cut up the
  tanks onsite. No work permits were issued for
  this process. Diesel truck exhaust was used to
  degas the tanks (unapproved degassing method) and
  no gas testing was conducted. The first tank was
  successfully cut without incident however, when
  the welder began cutting the second tank, an
  explosion occurred. This explosion resulted in
  one fatality, two workers hospitalized with burns
  and one first aid case.

• Root Causes
• Subcontractor performed high risk out-of-scope
  work.
• Did not follow procedures for tank degassing and
  demolition.
• Gas testing was not conducted.
• No pre-job safety briefing, risk assessment, or
  job-safety analysis was conducted.
• Insufficient oversight of subcontractor

• Lessons Learnt
• High risk work to be performed only if within
  contracts scope-of-work.
• Stop Work Authority needs to be effectively
  cascaded to subcontractor workforce.
• Critical equipment (gas tester in this case)
  should always be available, functioning and used.
• Robust verification and validation of adherence
  to policies and procedures is required at both
  the contractor and subcontractor level.
• Contracted work at remote locations has a higher
  risk profile and potential risks need to be
  assessed, communicated, and mitigated.

Tank that exploded
Can you think of any similar situations that YOU
have experienced or witnessed? Did you report it?
Tank end that struck and killed subcontract worker
5
Fueller MVC Spill (LFI 2010-2)

• Incident Summary - A crewman left a Fuels Depot
  to supply jet fuel to an International Airport
  that was 2 miles away. While manoeuvring through
  the entrance gate at the airport, the trailer
  unit hit the vertical gate support. The driver
  was notified by airport personnel at the site
  that the trailer made contact with the gate. Upon
  getting down from the vehicle cab he observed a
  scratch and dent on the rear right-side of the
  trailer where a small hole had been created from
  which product was seeping out. He stopped the
  leakage with a temporary nylon plug and then
  notified the Fuels Depot. He did not await
  instructions, however, and instead immediately
  drove back to the Depot. Upon returning, the
  trailer then hit the Depot gate support beam
  while the driver was attempting to manoeuvre
  through the entrance gate. This had the effect of
  widening the existing rupture in the Trailer.
  Product gushed from the trailer onto the concrete
  depot forecourt. The resulting spill was
  contained with spill trays and sand.

• Root Causes
• Drivers did not communicate the airport gate
  change to management consequently, the risks
  were not addressed and shared with all depot
  crewmen.  
• The drivers actions after the initial collision
  contradicted the Emergency Response Plan.
• After the initial incident, the driver was
  anxious to return to the Depot and took the wrong
  angle of approach and did not use his mirrors
  while driving through the Depot gate.
• The driver was found to have poor eyesight, this
  was not identified during periodic eye tests.

• Lessons Learnt
• Journey Plans must be updated frequently to
  address new risks
• Need to provide periodic refresher training on
  emergency response procedures with emphasis on
  effective communication.
• Confirm if driver's vision exam provided under
  Fitness for Duty is adequate.

Can you think of any similar situations that YOU
have experienced or witnessed? Did you report it?
6
Personal Injury (LFI 2010-4)

• Incident Summary - An operator bumped his head on
  the centre tank vent of an A-320 aircraft whilst
  walking under the aircraft to access the fuel
  panel. The operator took a different route than
  normal under the aircraft because he was
  concerned that the deadman cable would become
  tangled in the aircraft wheels. The operator was
  wearing a bump cap and sustained a small red mark
  to the head, a slight headache and pain in their
  neck for a short period. When back in the depot
  the operator applied ice to the affected area.
  The operator did not need to visit a doctor and
  was able to continue performing all normal work
  duties.

• Discussion Points -
• If the operator in this case had not been
  wearing a bump cap, what injuries could he have
  sustained?
• What hazards do you consider when you have to
  walk underneath an aircraft?
• Do you follow a safe route under the aircraft
  based on the hazards you identify in your last
  minute risk assessment?
• Does your location have pre-defined safe routes
  for walking under aircraft? If so, do these take
  into account hot engine parts, hot air vents and
  bump hazards?

Can you think of any similar situations that YOU
have experienced or witnessed? Did you report
it?
7
Fueller Strikes Aircraft Wing (LFI 2010-5)

• Incident Summary - An operator had positioned a
  fueller under the wing of an A-321 aircraft in
  order to perform a platform fuelling. After
  completing a 360 Walkaround at the end of the
  fuelling, the operator realised that a luggage
  tractor was blocking his exit so he waited
  approximately 2 minutes in the cab until the
  luggage tractor moved. The operator failed to
  complete a second 360 Walkaround and did not
  realise that the aircraft wing-flaps were
  lowered. When the operator started to drive, the
  mirror bracket on the roof of the fueller cab
  contacted with the casing of the wing flap
  mechanism causing a 5cm crack. An aircraft
  technician inspected the damage and temporarily
  fixed it with metal tape. The aircraft departed
  after a 1 hour delay. The fueller cab sustained
  minor damage to the mirror bracket.

• Discussion Points
• Discuss why it may not be safe to drive a
  fuelling vehicle under the wing of an A-320
  series aircraft what could go wrong?
• After doing your 360o Walkaround, if you are
  delayed in driving away do you repeat the 360o
  Walkaround in case the situation around you has
  changed?
• If the operator had looked up when doing his
  360o Walkaround, do you think he would have
  noticed the danger?

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