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JIG Learning From Incidents (LFIs) JIG Learning From Incidents (LFIs)

JIG Learning From Incidents (LFIs) - PowerPoint Presentation

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JIG Learning From Incidents (LFIs) - PPT Presentation

Toolbox Meeting Pack Pack 18 June 2016 Joint Inspection Group Limited Shared HSSE Incidents 1 08062016 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 neith ID: 695765

operator aircraft fuelling 2016 aircraft operator 2016 fuelling fuel incident incidents vehicle grade limited joint inspection jet shared similar toolbox hsse group

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Slide1

JIG Learning From Incidents (LFIs)Toolbox Meeting PackPack 18 – June 2016

Joint Inspection Group Limited - Shared HSSE Incidents

1

08/06/2016

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 document, or for any consequences whatsoever resulting directly or indirectly from any use made of this document by any person, even if there was a failure to exercise reasonable care on the part of the issuing company or any other person or company as aforesaid; or (B) make any 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.Slide2

Learning From IncidentsHow to use the JIG Toolbox Meeting PackThe intention is that these slides promote a healthy, informal dialogue on safety between operators and management

Slides should be shared with all operators (fuelling & 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 at

www.jigonline.com

08/06/2016

Joint Inspection Group Limited - Shared HSSE Incidents

2Slide3

Learning From IncidentsFor every incident in this pack, ask yourself the following…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

(procedures and practices) and

 how effective are they?

What mitigation measures are in place

(safety equipment/emergency procedures) and

 how effective are they?

What

can I do personally to prevent this type of incident?

08/06/2016

Joint Inspection Group Limited - Shared HSSE Incidents

3

If

you would like further

assistance

or information relating to the contents of this pack,

or

if you have any information you feel will help avoid the reoccurrence of such

incidents,

then please contact JIG at

http

://www.jigonline.com/contacts

/Slide4

Spill whilst sampling LFI 2016-7Incident Summary

A spill occurred while an Operator was taking a

fueller filter outlet sample at the beginning of a shift. When the cap on the sampling pipework was removed to perform

the pre sample flush, product under pressure splashed into the sample bucket and subsequently splashed into the Operator’s face and clothes. The Operator was wearing the required PPE and did not sustain any splashes into the eyes. The Operator subsequently returned to the office to clean himself and no First Aid was required.

08/06/2016

Joint Inspection Group Limited - Shared HSSE Incidents

4

Can you think of a similar situation that

you

have experienced or witnessed and did you report it?

Causes

The Operator failed to notice that the filter vessel outlet valve was in the open position when the cap was removed.

The outlet filter valve should have been spring loaded.

Sampling the filter outlet is preferable via a closed sampling system. This was not installed on the vehicle.

Toolbox Discussion Points

Always follow procedures and avoid complacency. Do you check that valves are in the correct position before removing “

camlock

” caps?

Do you check that sampling lines on any filter vessel are installed at the lowest point to comply with requirements?

Are all filter inlet and outlet sample valves clearly labelled and self closing e.g. spring loaded? – JIG 1 Appendix A 6.1

Do you perform other operations where a similar incident could have occurred e.g. tank draining?

Could your sampling

systems be modified to become closed

systems? Slide5

Spill within hydrant valve chamber LFI 2016-8

Incident Summary

17,900 litres of liquid was discovered in a 63m3 airside hydrant valve chamber

at a major airport. The composition of the liquid was determined to consist of 2,500 litres of rainwater and 15,400 litres of Jet A-1. A leaking flange joint in the below ground concrete

valve chamber was identified. Product was completely contained and recovered. Repair work on the flange was carried out under permit and the hydrant system returned to operation.

08/06/2016

Joint Inspection Group Limited - Shared HSSE Incidents

5

Can you think of a similar situation that

you

have experienced or witnessed and did you report it?

Causes

Gasket seal failure, probably caused by stud bolts (securing the flange) not being torqued correctly when the gasket was first installed. Additionally, un-seasonally cold weather conditions may have contributed to further relaxation of stud bolt tightness over time.

Operators did not fully understand how the leak detection system operated and how to interpret results.

Toolbox Discussion Points

No formal records existed for torque setting on flange joints. It is critical that when works are completed on site a thorough procedure is followed which will ensure the construction and commissioning is complete and compliant and all records are signed off and filed for future reference. Do you have such records at your facility?

Where a Leak Detection System (LDS) is installed in a hydrant system, the LDS should be supported by: periodic maintenance procedures; an operator competency / training regime; a definition of the operating envelope; escalation, contingency and resolution procedures. Are these in place at your facility?

If you have a Leak Detection System in operation, do you fully understand how it works, how to interpret results and how to manage any identified issues? Are there procedures in place and are the appropriate people trained?

Are your

inspection checks

of hydrant valve chambers performed at a frequency sufficient to assist with the timely identification of leaks, water ingress

etc.?

– JIG 2 8.10Slide6

Drive Away LFI 2016-9

Incident Summary

A Drive Away (while still connected to an aircraft) incident occurred after an Operator refuelled an Airbus 319. The damage was limited due to the break away aircraft coupling functioning as designed.

08/06/2016

Joint Inspection Group Limited - Shared HSSE Incidents

6

Can you think of a similar situation that

you

have experienced or witnessed and did you report it?

Causes

The Operator did not follow the correct procedure before driving off after completing the fuelling operation – Walk Around was not carried out as required, and he did not look up and notice that the fuelling hose was still connected to the aircraft.

The interlock (a key barrier) failed to operate as the air line had melted as a result of being in contact with a hot hydraulic line.

Toolbox Discussion Points

What barriers (both human and hardware) do you have in place to manage the drive away risk?

How do you make sure your barriers are effective and working as they should? What checks are in place?

Discuss what Human Factors could have contributed to this incident e.g. Attitudes; Behaviours; Complacency; Fatigue; Competency

How do you ensure that your Operators perform an effective 360

walkaround

which includes a look up to the fuelling hose to aircraft connection point? JIG 1 6.5.1(n)

Is your training sufficient to achieve the desired human behaviours

When developing a new vehicle design do your management of change procedures require the consideration of lessons learnt from previous incidents?Slide7

Misfuelling LFI 2016-10

Incident Summary

The pilot of “Aero Commander“ AC90 called Air Traffic Control (ATC) tower requesting Jet A-1. The request was relayed to the fuelling Operator who received the call from the Tower whilst out in the AVGAS

fueller

. It is unclear if the grade was mentioned at this point. The Operator approached the aircraft in the AVGAS fueller and completed the fuelling. Upon fuel delivery of 276 litres of AVGAS the operator requested a signature from the pilot to confirm the transaction, using the colour coded AVGAS delivery receipt. The pilot failed to notice the incorrect fuel receipt form used for the fuelling.

The next day, the site fuel Supervisor, whilst checking aircraft sales using the airports “Aircraft Management System” identified the AC90 had received a fuel delivery of AVGAS. The Supervisor realised the error, confirmed a

misfuelling

had occurred and immediately contacted his Manager and the customer. The aircraft was immediately quarantined and the fuel removed. The Aircraft had remained grounded due to changing weather conditions

08/06/2016

Joint Inspection Group Limited - Shared HSSE Incidents

7

Can you think of a similar situation that

you

have experienced or witnessed and did you report it?

Causes

The operator did not carry out any fuel grade confirmation. This should have confirmed the fuel order as Jet A-1. The decals on the aircraft clearly showed Jet A-1.

No fuel

grade confirmation

form was

completed.

The pilot and the Operator appeared distracted and not focused on the process.

Toolbox

Discussion Points

Do you always confirm fuel grade for over wing

fuellings

?

Are fuel

grade confirmation forms available and used if required?

Do you undertake a post fuelling check to ensure correct grade has been delivered?

Aero Commander AC90 JETA1

Similar Aircraft - the AC50 AVGAS Slide8

MisfuellingLFI 2016-11

Incident SummaryFuelling Operator received a call from the Airport Dispatching Operation ordering Jet A-1, this order came from a handling agent in face to face contact with the pilot. The

order was documented.

The Operator then used a Jet A-1 grade marked

truck to fuel the PA46 aircraft with 403 litres of Jet A-1. The pilot signed the delivery ticket stating that the aircraft was fuelled with Jet

A-1.

He then parked the aircraft for 2 days.

After the aircraft next took off, engine concerns forced the pilot to attempt an emergency landing and he was able to ditch in the sea about two hundred metres from the shore. The pilot and the passenger were safe and rescued by boats sailing in the area. Subsequently the PA46 sank to the seabed. The Airport Authority and the Into-Plane

provider were informed of the incident and immediately stopped fuelling operations.

The PA46 is an aircraft which can be fitted with Turbine or Piston engine. Checking the Aircraft Data base with the aircraft registration the aircraft was identified as a PA46 Malibu Mirage 350 P which is fitted with an Avgas 100LL engine. Subsequent analysis of aircraft wings confirmed that the aircraft had acceptable Avgas 100LL decals and that the Jet A-1 duckbill spout couldn’t fit into the filling port. The Fuel Grade Confirmation Form was not used as required when the Operator removed the duckbill spout.

08/06/2016

Joint Inspection Group Limited - Shared HSSE Incidents

8

Can you think of a similar situation that

you

have experienced or witnessed and did you report it?

Causes

The operator did not confirm the fuel grade

A Fuel Grade

Confirmation form

was not completed although the fuelling nozzle was changed

(removal of the Jet A-1 duckbill spout).

Toolbox Discussion Points

Do you always confirm fuel grade for

overwing

fuellings

?

Are fuel grade confirmation forms available and used if required?

Do

you follow a nozzle change procedure (large / small spout)

Do you undertake a post fuelling check to ensure correct grade has been delivered?Slide9

Roll away – Spill LFI 2016-12

Incident Summary

A spill of approximately 30 litres of Jet A-1 occurred following an aircraft coupling break-off during a fuelling caused by the fuelling vehicle rolling backwards. The vehicle movement was created by the reverse gear being engaged simultaneously with the PTO.

The Operator was under time pressure due to earlier communication issues. Also, the fuelling space was narrow due to various ground service vehicles already in position beside the aircraft. The Operator approached multiple times to ensure his fuelling position would be safe.

Following positioning he left the vehicle and started the fuelling in accordance with procedures. Whilst activating the

deadman

, and thus increasing the engine revolutions, the vehicle started to move backwards. The Operator released the

deadman immediately when he realised the vehicle was moving. However, due to the delay of the mechanism, the vehicle moved approximately 1.5 metres. The vehicle movement led to the hose being strained and the aircraft coupling to break at the designed breaking point.

08/06/2016

Joint Inspection Group Limited - Shared HSSE Incidents

9

Can you think of a similar situation that

you

have experienced or witnessed and did you report it?

Causes

Time pressure and stress led to incorrect gear setting.

Fuelling

space was limited by aircraft ground service vehicles.

The

gear lever was engaged in R

(Reverse) at

the same time as the PTO was engaged.

Handbrake

and interlock did not stop the vehicle from moving backwards.

Toolbox Discussion Points

Are your vehicles designed so that

the interlock system operates in accordance with the requirements of JIG 1 3.1.7 and prevents the vehicle moving when the PTO is selected?

When under time pressure how do you avoid distractions and maintain your procedures?

Spill absorbent material deployed with aircraft fitter fixing the aircraft adapter

(using airline ladder/platform - note no guardrail)Slide10

Lost Time Injury from Motor Vehicle Incident 2016-13

Incident SummaryAn Operator was en route to refuel his 6th flight of the day. While making a left turn at a junction, he lost control of the vehicle and hit the kerb and side railing. The Operator suffered a whiplash and knee injury that resulted in time off work. No other vehicles were involved. The vehicle’s general condition was good including the tyres and braking system.

08/06/2016

Joint Inspection Group Limited - Shared HSSE Incidents

10

Can you think of a similar situation that

you

have experienced or witnessed and did you report it?

Causes

There was no Road Hazard Mapping (or Black Spot Mapping) available for the site.

There is a high probability that the operator had exceeded the speed limit - post incident simulations at 30 KPH (designated speed limit of the area) did not reflect any potential of loss of control. There was no speed limiter or monitoring device on the vehicle (although not mandatory).

The operator was on probation due to behavioural issues but there was no specific action plan for improvement.

Toolbox Discussion Points

Are you aware of potential accident black spots at your location?

Have you considered the use of a

black spot map that is regularly reviewed and discussed with site staff?

How do you ensure that airport speed limits are adhered to? What barriers do you have in place and are they effective?

Are your vehicles regularly checked and maintained to ensure that they are functioning as required?

Are Supervisors spending sufficient time on the apron to witness and review driving behaviours and to provide feedback to the Operators?