JIG ‘Learning From Incidents’ Toolbox Meeting Pack Pack 2 – May 2011 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.

Learning From Incidents For every incident in this pack, ask yourselves the following questions: Is there potential for a similar type of incident at our site? Do our risk assessments identify and adequately reflect these incidents? Are our prevention measures in place and effective (procedures and practices)? Are our mitigation measures in place and effective (safety equipment, emergency procedures)? What can I do personally to prevent this type of incident?

Vehicle Accident: Front Collision (LFI 2010-3) Incident Summary – An operator having completed a refuelling with a hydrant servicer was driving on a road from the apron to the office. During a right bend in the road, an oncoming passenger car lost control, cut the corner and hit the servicer head on. The operator performed emergency braking prior to the collision when he saw the airport authority passenger car driving towards his servicer on the wrong side of the road. The road has a 60 Km/h speed limit. It appears that the passenger car driver was distracted as he was bending over searching for something on the non-driver’s side of the vehicle. The driver of the passenger car suffered serious head, leg and foot injuries. It is believed that the driver was not wearing the seat belt and hit his head on the front windshield. Lessons Learnt – The hydrant servicer operator was wearing his seat belt and therefore protected himself from injury. The operator’s defensive driving and alertness in stopping quickly so as to reduce the crash impact from approximately 100 Km/h to around 60Km/h most likely saved the other driver from being thrown from the vehicle and sustaining life threatening or fatal injuries.

Ankle Sprain on Uneven Surface (LFI 2010-6) Incident Summary - After loading a fueller, the operator drove forward approximately 4 metres to position the vehicle alongside the diesel dispenser. When descending from the cab the operator placed his right foot on the ground on an expansion joint between two slabs of concrete. As the operator shifted his weight onto the right leg, the outside of his foot fell into the crack causing him to twist his right ankle and fall to the ground. An ice pack was applied to the ankle and the operator was taken to hospital. It was confirmed that the operator had sprained his ankle and he was placed on restricted work duties for 1 week. An operations notice had previously been issued at the airport highlighting this hazard, however the operator was unaware of the notice. Discussion Points – Do you always conduct a last minute risk assessment in everything you do at work, even the routine tasks (such as descending from the cab)? Are there any areas of your airport depot that have cracks and uneven surfaces which could pose a hazard? What steps are taken at your site to ensure that all operators are familiar with every operations notice that is issued? Can you think of any similar situations that YOU have experienced or witnessed? Did you report it?

Broken Step Causes Injury (LFI 2010-7) Incident Summary - An operator was refuelling a Boeing 737-300 aircraft and due to the height of the wing he was using a portable step to access the fuelling panel. Having finished fuelling the aircraft, the operator stepped onto the portable step to remove the coupling from the wing of the aircraft. As the operator was doing this, one leg of the portable step snapped, causing him to fall to the ground and injure his left shoulder. The operator suffered limited arm movement (couldn’t lift arm above shoulder height) as a result of the incident and was placed on restricted work duties. The investigation found that the leg of the portable step had sheared on a welded aluminium joint where it had previously been repaired. Discussion Points – What checks do you conduct of steps and ladders each time before you use them? How regularly are steps & ladders inspected at your facility? Is this frequent enough? How thoroughly do you perform checks of steps and ladders? What do you look for when inspecting your steps and ladders? Do you think you would have detected this weld fault before the incident occurred? Can you think of any similar situations that YOU have experienced or witnessed? Did you report it?

Hose on Steps Causes Injury (LFI 2010-8) Incident Summary - An operator was requested to perform an underwing refuelling of an A-319. The fuelling vehicle used by the operator was too large to go under the wing of the aircraft so he chose to use chariot stairs to complete the refuelling instead. The operator positioned the hose incorrectly so that it ran up the steps rather than hanging from the rear of the stairs. As the operator descended the stairs after connecting the fuelling hose to the aircraft, he stepped on the hose and stumbled causing a sprain to his ankle. The operator was wearing safety boots with ankle protection. The operator was taken to hospital and a doctor advised that he stay off work for the next 3 days. Discussion Points - When performing a refuelling using ladders or steps, how do you ensure the hose is in a safe position? Do the ladders and steps at your location allow you to position the hose correctly? Are modifications needed? Would you approach someone if you saw them using a ladder or steps in an unsafe manner? How would you approach them? Trip Hazard Can you think of any similar situations that YOU have experienced or witnessed? Did you report it?