JIG

1
JIG Learning From Incidents Toolbox Meeting
Pack Pack 2 May 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
own operations or otherwise (ii) neither JIG nor
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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
• 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?

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Vehicle Accident Front Collision (LFI 2010-3)

• Incident Summary An operator having completed a
  refuelling with a hydrant servicer was driving on
  a road from the apron to the office. During a
  right bend in the road, an oncoming passenger car
  lost control, cut the corner and hit the servicer
  head on.

The operator performed emergency braking prior to
the collision when he saw the airport authority
passenger car driving towards his servicer on the
wrong side of the road. The road has a 60 Km/h
speed limit. It appears that the passenger car
driver was distracted as he was bending over
searching for something on the non-drivers side
of the vehicle. The driver of the passenger car
suffered serious head, leg and foot injuries.
It is believed that the driver was not wearing
the seat belt and hit his head on the front
windshield.

• Lessons Learnt
• The hydrant servicer operator was wearing his
  seat belt and therefore protected himself from
  injury.
• The operators defensive driving and alertness in
  stopping quickly so as to reduce the crash impact
  from approximately 100 Km/h to around 60Km/h most
  likely saved the other driver from being thrown
  from the vehicle and sustaining life threatening
  or fatal injuries.

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Ankle Sprain on Uneven Surface (LFI 2010-6)

• Incident Summary - After loading a fueller, the
  operator drove forward approximately 4 metres to
  position the vehicle alongside the diesel
  dispenser. When descending from the cab the
  operator placed his right foot on the ground on
  an expansion joint between two slabs of concrete.
  As the operator shifted his weight onto the right
  leg, the outside of his foot fell into the crack
  causing him to twist his right ankle and fall to
  the ground. An ice pack was applied to the ankle
  and the operator was taken to hospital. It was
  confirmed that the operator had sprained his
  ankle and he was placed on restricted work duties
  for 1 week. An operations notice had previously
  been issued at the airport highlighting this
  hazard, however the operator was unaware of the
  notice.

• Discussion Points
• Do you always conduct a last minute risk
  assessment in everything you do at work, even the
  routine tasks (such as descending from the cab)?
• Are there any areas of your airport depot that
  have cracks and uneven surfaces which could pose
  a hazard?
• What steps are taken at your site to ensure that
  all operators are familiar with every operations
  notice that is issued?

Can you think of any similar situations that YOU
have experienced or witnessed? Did you report
it?
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Broken Step Causes Injury (LFI 2010-7)

• Incident Summary - An operator was refuelling a
  Boeing 737-300 aircraft and due to the height of
  the wing he was using a portable step to access
  the fuelling panel. Having finished fuelling the
  aircraft, the operator stepped onto the portable
  step to remove the coupling from the wing of the
  aircraft. As the operator was doing this, one leg
  of the portable step snapped, causing him to fall
  to the ground and injure his left shoulder. The
  operator suffered limited arm movement (couldnt
  lift arm above shoulder height) as a result of
  the incident and was placed on restricted work
  duties. The investigation found that the leg of
  the portable step had sheared on a welded
  aluminium joint where it had previously been
  repaired.

• Discussion Points
• What checks do you conduct of steps and ladders
  each time before you use them?
• How regularly are steps ladders inspected at
  your facility? Is this frequent enough?
• How thoroughly do you perform checks of steps
  and ladders? What do you look for when inspecting
  your steps and ladders?
• Do you think you would have detected this weld
  fault before the incident occurred?

Can you think of any similar situations that YOU
have experienced or witnessed? Did you report
it?
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Hose on Steps Causes Injury (LFI 2010-8)

• Incident Summary - An operator was requested to
  perform an underwing refuelling of an A-319. The
  fuelling vehicle used by the operator was too
  large to go under the wing of the aircraft so he
  chose to use chariot stairs to complete the
  refuelling instead. The operator positioned the
  hose incorrectly so that it ran up the steps
  rather than hanging from the rear of the stairs.
  As the operator descended the stairs after
  connecting the fuelling hose to the aircraft, he
  stepped on the hose and stumbled causing a sprain
  to his ankle. The operator was wearing safety
  boots with ankle protection. The operator was
  taken to hospital and a doctor advised that he
  stay off work for the next 3 days.

• Discussion Points -
• When performing a refuelling using ladders or
  steps, how do you ensure the hose is in a safe
  position?
• Do the ladders and steps at your location allow
  you to position the hose correctly? Are
  modifications needed?
• Would you approach someone if you saw them using
  a ladder or steps in an unsafe manner? How would
  you approach them?

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