JIG

1
JIG Learning From Incidents Toolbox Meeting
Pack Pack 10 November 2013
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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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 in the
  publications section of the JIG website
  (www.jigonline.com)

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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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MisfuellingLFI 2013-05

• Incident Summary A misfuelling took place when
  26 litres of Avgas was delivered to a Robin
  DR.400-135TDI Ecoflyer. On landing the pilot
  asked the ground controller to pass a message to
  the fuelling operator for Jet A-1. However ,the
  ground controller did not hear the message
  clearly and called the fuelling operator stating
  that the pilot required Avgas. When approaching
  the aircraft the operator was distracted due to
  the fuelling orifice being located on the
  fuselage in a position that was awkward to reach.
  The aircraft had a small decal located just above
  the fuelling orifice stating Jet A -1 and Diesel.
  The operator did not check the grade and started
  to fuel the aircraft with Avgas. The Operator
  detected his error after 26 litres had been
  fuelled into the aircraft. The fuelling staff
  flushed the wing tanks in accordance with
  instructions in the aircraft manual, and the
  pilot departed.

• Causes
• The Ground Controller relayed the fuel order from
  the pilot stating the incorrect grade
  requesting Avgas rather than Jet A-1.
• The fuelling operator did not carry out fuel
  grade verification processes before starting the
  fuelling, including verification that the grade
  marked on the aircraft and the grade marked on
  the over wing nozzle were the same.
• Fuelling personnel should never make an
  assumption about the grade of fuel required and
  shall always confirm the grade of fuel.
• The design of decal was not in compliance with EI
  1597

• Discussion Points
• Ensure procedures are clear and followed (does
  site have written verification processes for
  grade identification?
• Minimise the numbers of links in the fuel order
  taking process.
• Where possible, does the pilot place the fuel
  order directly with the fuelling staff?
• Review JIG 1, Ref 6.5.5 Overwing Fuelling for
  clarification of requirements

Can you think of any similar situations that YOU
have experienced or witnessed? Did you report
it?
5
Manual Handling Injury ShoulderLFI 2013-06

• Incident Summary A fuelling operator was
  assigned a Bombardier Dash 8 to refuel. He
  completed refuelling and began the disconnection
  process. Whilst disconnecting he stretched his
  arms above the shoulders and in the process of
  removing the coupling felt a very sharp pain and
  discomfort in his right shoulder. The injury
  caused the operator to be placed on light duties.

• Causes
• In this incident the operator did not follow site
  procedures and use steps to carry out the
  fuelling.

• Discussion Points
• Apart from the obvious injury caused, if you look
  at the picture opposite what other issues do you
  think may arise by carrying out the task as
  shown?
• Think about his positioning, with regards to both
  personal safety and operational requirements.
• What does JIG IP 6.5.4 ask you to do?
• What arrangements do you have in place to ensure
  the rehabilitation and return to work of
  personnel following a work-related injury,
  illness or other adverse health effects (JIG
  HSSEMS 6.9)

Can you think of any similar situations that YOU
have experienced or witnessed? Did you report
it?
6
Not watching Step Causes InjuryLFI 2013-07

• Incident Summary
• Early in the morning, before the opening of the
  depot, a contracted night guard fell while
  descending a set of steps. He lost his footing
  on the second step from the top of a flight of
  steps and, even though he was holding the
  handrail, he fell down the rest of the stairway
  to the ground (several more steps). He suffered
  a back injury and was unable to get up. He only
  received aid 2 hours later when the depot manager
  arrived at work.

• Causes
• Lack of attention probably due to tiredness
  towards the end of his shift.
• Not fully following the three points of contact
  rule when using stairways.
• Undertaking activities outside of his role.

• Discussion Points
• Are there any lone worker activities in your
  location?
• How are you managing lone working? What things
  need to be considered?
• How are the activities of contractors managed to
  ensure their health and safety? Are inductions
  given appropriate to the nature of their work and
  the hazards to which they may be exposed? (see
  JIG HSSEMS 9.5)

Can you think of any similar situations that YOU
have experienced or witnessed? Did you report
it?
7
First Aid Case Trip on Fuelling Hose(LFI
2013-09)

• Incident Summary After fuelling an aircraft
  near the end of his shift an operator tripped
  over the fuelling hose. The operator fell on his
  left elbow, shoulder and thigh. He was taken to
  the hospital for X-rays with the results showing
  no broken bones.. No medication was prescribed
  and there was no lost work time.

• Causes
• The investigation and viewing of CCTV revealed
  that the operator tripped over the hose when he
  momentarily looked up at the nose of the aircraft.

• Discussion Points
• What do you do to remind staff to have constant
  slip/trip awareness in mind? A number of trip
  incidents arise where the hazard is of a
  temporary nature (e.g. a hose lying across the
  ramp, equipment / tools used when maintenance
  activities are being done) rather than permanent
  obstacles in the workplace.
• Do Management and Supervisors undertake site
  observations and interviews with employees or
  other information gathering techniques to
  identify unsafe behaviours and working
  conditions? (see JIG HSSEMS 1.9) Are your staff
  practicing Situational Awareness?
• Staff should remember that walking is still
  working and should think through their entire
  work activity carefully and be constantly aware
  of the dynamic nature of their environment.
  Avoid being on auto pilot when performing
  routine tasks. Look up, down and around for
  hazards.
• Did you know ?
• Slips trips and falls are the most common cause
  of major injury at work
• 95 of major slips result in broken bones

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