JIG ‘Learning From Incidents’ Toolbox Meeting Pack Pack 11 –April 2014 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.

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)

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?

Vehicle hits hydrant servicer intake coupler (LFI 2014 -01) Incident Summary – At the beginning of a fuelling of a 737, while the operator was connecting to the aircraft, a third party vehicle (baggage trolley) hit the servicer intake coupler. Both sense lines on the coupler were damaged. There was no spill as the fuelling operation had not started, the deadman was not being operated and the pit was not “live”. Damage to the servicer intake coupler was severe and the Hydrant Company was called to check the hydrant pit valve . They decided to remove the pit valve and close the stand. The vehicle was put out of service and taken to the workshop where the damage to the intake coupler was investigated. The coupler was replaced and tested before the vehicle was taken back into service. Causes – Driving of third parties around aircraft being fuelled Discussion Points – How serious could this incident have been? How do you protect the pit and coupler and what measures do operators take to ensure vigilance around hydrant pits? Do you have stand assessments that highlight difficult pit positions? What awareness training do third parties undertake? Do your risks assessments, emergency preparedness and response procedures consider this type of incident? Can you think of any similar situations that YOU have experienced or witnessed? Did you report it?

Personal Injury - Pump Compartment Door (LFI 2014 -02) Incident Summary – A fuelling operator was attending an aircraft fuelling. He completed the fuelling, stowed the equipment, and then began to close the vehicle pump compartment door. As he did so, he held the door handle with his right hand and put his left hand on the underside of the compartment door to disengage the release lever in the normal manner. When he did this, the door dropped rapidly, scraped down his left arm and pulled him around as he was holding the door handle with his right hand. The panel failure occurred at a weld between hinge and support arm Causes – There was an earlier failure of the support arm on this vehicle which was repair welded. This was not investigated so it is difficult to determine the cause of that failure, but it was most likely due to metal fatigue of the weld over the 5 years the vehicle had been in service. The latest incident was the result of the repair weld failing. Over the years there have been other incidents at sites where such doors have caused various types of injury to personnel. Discussion Points – Do your vehicles have such doors? What other potential injuries can result? What checks and maintenance is carried out and are faults defect reported? Could they be removed or replaced with other types of cover (Roll up panels)? Simulation of incident Another reason for not having such doors is the potential for injury when support rams weaken and the doors are too low Option showing roller panel Showing weld on support arm Can you think of any similar situations that YOU have experienced or witnessed? Did you report it?

Fall down access ladder into valve chamber (LFI 2014-03) Incident Summary – An Operator slid approximately four metres down a ladder when entering a hydrant valve chamber. The ladder was comprised of a fixed lower part an upper part which is hauled up to aid easy access. The upper part of the ladder has a safeguard system installed to lock the upper part in place but, due to a design flaw, it did not function correctly on this occasion. As the Operator stepped onto the upper part it slid down the complete length of the fixed part into the valve chamber. This resulted in a lost time injury as the Operator was diagnosed with a fracture of the knee. Causes – Failure of the ladder safeguarding system (interlock). The test to check that the safeguard was functioning correctly before use was ineffective. Formal evaluation of the suitability of the ladder was not made before being put into service. Discussion Points – How do you assess whether the ladders you are using are suitable for the task? What issues could have been identified and addressed if a management of change process had been applied? How do you make staff aware of equipment safety features and how to operate them or check that they are functioning correctly? Can you think of any similar situations that YOU have experienced or witnessed? Did you report it?

Loose vehicle wheel (LFI 2014 -04) Incident Summary – On route to a fuelling stand, while carrying out a left turn to position the vehicle for a reverse manoeuvre, the operator noticed the banksman making a gesture to him. When he stopped, the banksman advised him his near side rear (2nd axle) wheel had become loose on the hub. The damage sustained to the assembly, the loss of 7 wheel nut indicators, 8 wheel collar washers and evidence of rusted metal particles around the hub and mud flap on only this wheel and guard could indicate that this vehicle had been used in a deteriorating condition for a number of days and possibly weeks. None of the daily checks and 360 walk rounds did not highlight any problem with this wheel. Causes – Maintenance checks, were not carried out at the required frequency, e.g. sometimes being carried out after only one month and, on occasion, after three months The Vehicle Safety Equipment Checks - are completed daily including the tyres, wheel nuts and wheel nut indicators: it could not be determined if the daily check had been conducted fully. Vehicle specialists said they were of the opinion that there had been a loss of clamping force between the nuts and the hub. Stud elongation may have occurred due to wheel nuts being over tightened with an air gun. Discussion Points – Does the site ensure thorough daily vehicle serviceability checks are undertaken? Are maintenance schedules clear and followed? Are wheel nut indicators used, do staff understand their purpose and are checks undertaken on their position and alignment? Examples of wheel nut indicators Can you think of any similar situations that YOU have experienced or witnessed? Did you report it?