JIG ‘Learning From Incidents’ Toolbox Meeting Pack Pack 7 – October 2012

1. 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 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.

2. 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.jointinspectiongroup.org)

3. 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?

4. 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?

5. 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 (LFI2012-05) 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(LFI2012-12) 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?