JIG

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JIG Learning From Incidents Toolbox Meeting
Pack Pack 7 October 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
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furnishing information or data used herein (A) is
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any advice given in or any omission from this
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implied, that acting in accordance with this
document will produce any particular results with
regard to the subject matter contained herein or
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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.
• All published packs can be found on the HSSEMS
  section of the JIG website (www.jointinspectiongr
  oup.org)

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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?

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Damaged Aircraft Fuelling Adaptor (LFI 2012-10)
Incident Summary A B777 aircraft arrived with
no external information about unserviceable
couplings. The operator positioned Rig Steps to
check fuel levels prior to any request for fuel.
Once at the panel the operator noticed the damage
to the aircraft fuelling adaptor and questioned
the crew who said they were aware of it and it
was in the Tech Log. The aircraft was not
fuelled.
Causes Aircraft not maintained correctly.
Damaged Adaptor Ring

• Toolbox Talk Discussion Points
• Are your procedures robust enough to ensure an
  operator would be paying attention for this type
  of fault and would be as aware in dark
  conditions (JIG requirement 6.5.4)?
• Are your operators sufficiently empowered to
  refuse fuelling if they discover this type of
  fault and instructed to report it to management?
• Do you have procedures in place to alert the
  supplying company so that they can request the
  customer to take corrective action?

Can you think of any similar situations that YOU
have experienced or witnessed? Did you report it?
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Fueller Collision (LFI 2012-11)
Incident Summary - Against company procedures an
operator was loading 2 fuellers at the same time.
After loading both vehicles the operator
intended to move the first vehicle. He put the
vehicle in gear (automatic gear box) and released
the handbrake. The vehicle did not move due to an
activated interlock. He got out of the cab to
check the interlock, leaving the vehicle in gear
and without applying the handbrake. He fixed the
defective interlock and then, to save time, left
the first vehicle unattended to build up air
pressure, and started the engine of the other
vehicle. Whilst doing this the first fueller
built up sufficient air pressure to move unmanned
down the yard where it hit a parked fully loaded
fueller.

• Causes
• By loading of 2 fuellers at same time the
  operator was not in full control of the
  operation.
• First vehicle was left in gear with handbrake
  off.

• Key lessons
• Focus on one task at a time to ensure operator
  remains in full control of the operation. (JIG
  reference 5.8.1)
• Ensure handbrake is applied before leaving the
  cab.
• Consider seat interlock (JIG reference 3.1.7)
• Could a 360 walk around have prevented this
  incident?

6
LTI Fall From Height (LFI 2012-05)

• Incident Summary - While fuelling an MD11 cargo
  aircraft the operator noticed the nose wheel of
  the aircraft begin to rise. He stopped fuelling
  immediately and tried to warn the cargo loader.
  He was not heard and in a panic the operator
  began climbing the high loader ladder so he could
  stop the loading operation. Near the top of the
  ladder the operator missed the last step and fell
  approximately seven meters onto the apron. The
  operator suffered a broken leg, muscle damage to
  his shoulder and cuts and bruises.

• Causes
• Operator put himself in danger by intervening and
  accessing third party equipment.
• No clarity regarding access to third party
  equipment.

• Toolbox Talk Discussion Points
• Are your Operators instructed not to access or
  use third party equipment?
• What would you do if you saw an aircraft tipping?
  
• Do your emergency procedures consider the
  scenario of unbalanced or tipping aircraft during
  fuelling?
• What other events can you think of that could
  cause the aircraft to move? Are these also
  considered in your emergency procedures?

Can you think of any similar situations that YOU
have experienced or witnessed? Did you report it?
7
High potential LTI (LFI 2012-12)
Incident Summary - Two mechanics were attempting
to fix a small leak in the hydraulic circuit on a
portable elevating platform. After an initial
repair was attempted, the platform was elevated.
Because there was still a leak and to gain better
access, one of the mechanics lay underneath the
platform to repair the leak. Whilst he was
attempting to tighten the nut where the leak
appeared to be coming from, an elbow connected
to the nut broke and the platform fell down
hitting his face. A safety device which was
present to control the speed of descent of the
platform did not work due to an
installation/design issue. The mechanic was
immediately treated on site and sent to the
hospital for evaluation.

• Causes -
• Mechanic misdiagnosed source of leak and wanted
  to do a quick fix.
• The mechanics did not physically secure the
  platform in an elevated position
• Reliance on a safety device that was not designed
  to provide the protection required for this task.
• Two mechanics did not conduct a last minute risk
  assessment

• Key Lessons -
• Equipment with the potential to cause injury
  should be suitably secured to prevent it falling
  before working underneath (physically secured
  where needed).
• Conduct a last minute risk assessment (8.2.2) and
  reference the job safety analysis/task procedure
  before undertaking the work.
• Do you have a full understanding of what all
  safety devices are intended to do and how they
  work? (e.g. JIG reference 3.1.16)
• Are all safety devices tested?
• How could a permit to work have prevented this
  incident?
• How could the second mechanic have intervened to
  prevent this incident?