Joint Inspection Group LimitedShared HSSE Incidents 1 JIG ‘Learning From Incidents’ Toolbox Meeting Pack Pack 13 – Oct 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.

Joint Inspection Group LimitedShared HSSE Incidents 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 in the publications section of the JIG website (

Joint Inspection Group LimitedShared HSSE Incidents 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? If you would like further assistance or information relating to the information contained in this pack please contact JIG via

Joint Inspection Group LimitedShared HSSE Incidents 4 Emergency Response (LFI ) Summary – A fuelling operator connected a servicer to the hydrant system and aircraft and awaited authorisation from the airline’s engineer to commence fuelling. Whilst waiting, the operator saw that a 3 rd party vehicle positioned at the rear of the aircraft was engulfed in fire. The operator immediately instructed the dispatcher via two way radio to call the airport fire service. The dispatcher alerted the duty supervisor who then contacted the hydrant operating company to shut down the hydrant system. In the meantime the operator considered using an extinguisher from his vehicle to tackle the fire but realised it was out of control and decided not to. Instead, he returned to his vehicle and deactivated the hydrant valve. The fire service arrived at the scene and immediately started extinguishing the fire. Can you think of any similar situations that YOU have experienced or witnessed? Did you report it? Toolbox Talk Discussion Points –  Discuss if the actions of the operator were correct in this situation. What would you have done?  Do your emergency procedures consider this type of scenario?  Are you confident that your staff feel empowered to activate emergency equipment e.g. Emergency Shutdown Buttons (ESBs) and fire alarms?  Have you liaised with relevant stakeholders when developing your procedures, e.g. Fire service, hydrant operators?  Have you established clear instructions on how to act in such a situation and are they effectively communicated to staff?  Do you periodically test your emergency procedures to evaluate their effectiveness and the competence of staff?  Do you review and, when necessary, update your emergency plans after a real emergency situation or test/drill?

Joint Inspection Group LimitedShared HSSE Incidents 5 Summary – A fuelling operator whilst acting as a reversing Guide Person to a fellow operator walked backwards whilst directing the driver of the refueller. In doing so, and trying to maintain eye contact with the refueller driver, he failed to check the ground area behind him. The Guide Person tripped over a reversing stop bar falling heavily to the floor sustaining injuries to the back and side of his body. Causes – Guide person did not follow the correct procedure of remaining stationary whilst directing the driver. Guide person had no awareness of what was behind him as his focus was on the reversing vehicle. Guide person should have stopped the reversing vehicle whilst he re- positioned himself. Toolbox Talk Discussion Points - Does your site have a vehicle reversing requirement? If yes, do you have a vehicle reversing policy / procedure? Does your policy / procedure detail key requirements such as remaining stationary whilst acting as a Guide Person? Reversing should always be avoided but, if there is no alternative, it should be done with the aid of a competent Guide Person. Can you think of any similar situations that YOU have experienced or witnessed? Did you report it? Reversing a Refueller - Guide Person/ Banksman walking backwards fell (LFI )

Joint Inspection Group LimitedShared HSSE Incidents 6 Aircraft Incident - Damage to Aircraft (LFI ) Summary – In the process of approaching an ATR-42 aircraft, a hydrant servicer struck a blade of the aircraft propeller, causing damage to the vehicle windscreen and requiring the aircraft to be substituted while checks and repairs were carried out on the aircraft. Nobody was injured in the incident. Can you think of any similar situations that YOU have experienced or witnessed? Did you report it? Toolbox Talk Discussion Points –  What training or instruction have fuelling operators had from the airline on aircraft types?  Are your operators suitably empowered to delay fuelling or to instruct other ground handlers to move obstructing equipment before approaching the aircraft?  Is your risk assessment process sufficient to identify hazards such as a protruding propeller blade.  Have you developed suitable stand plans to identify the safest approach and exit routes to/from the aircraft fuelling position? (See JIG )  Do you conduct sufficient safety walks/observations to assess the driving skills of your operators? Causes –  The driver had to manoeuvre around a catering truck to approach the aircraft reducing the area available to make visual alignment with the propeller.  Whilst moving forward the driver was looking at the aircraft fuelling point instead of the direction of movement of his servicer.  Cones placed by the ground handling agent close to the aircraft engine were used incorrectly by the operator as distance markers for vehicle positioning.  The operator failed to carry out an adequate assessment of the fuelling area prior to approaching the aircraft.  The operator did not receive any training from the airline (but did receive training from the JV HSE Manager during his initial training). Damaged windscreen

Joint Inspection Group LimitedShared HSSE Incidents 7 Shoulder injury resulting from lifting Road Traffic Cones (LFI ) Summary – A fuelling operator was setting up road cones to establish the fuelling working area. In order to do so, the operator positioned himself slightly off-centre to the cones, see figure 1 below. He then lifted a cone (approx. 2.3kg) from a stack of three from the rear holder of the truck. The operator applied a single arm lifting technique which involves lifting the cone at an angle off the holder. While performing the task he felt a slight pain in his shoulder. He completed the fuelling of the aircraft and then went back to the office. He reported the shoulder discomfort to his supervisor. An assessment by medical staff resulted in restricted work for the operator. Causes –  The lifting technique resulted in lifting the cone above shoulder height.  Cones were lifted off the cone holder at a steep angle. The close proximity to the aircraft engine resulted in a cramped workspace which contributed to a steep lifting angle, adversely affecting shoulder rotation as well as lifting above shoulder height.  Lifting and movement of single cones was not recognised as a manual handling activity that could cause an injury if not performed correctly. Figure 1 : Non-recommended Manual Handling of cones Toolbox Talk Discussion Points –  Are operators aware of the potential hazards and associated risks when performing manual handling tasks, irrespective of the weight of an object?  Have you formally assessed best manual handling techniques as part of your manual handling training?

Joint Inspection Group LimitedShared HSSE Incidents 8 Incident Summary – there have been a several recent incidents in the industry involving failed and overheated electrical components. All of them have resulted either in small fires or overheated cables. There have also been major issues with overheated old pumps / motors at airports which have resulted in fires. Causes - Old components, wiring and equipment. Component /system not included in yearly site electrical inspections. Inadequate hydrant pump sequencing leading to one pump working all of the time. No thermal measurements being taken whilst equipment is in operation. Incorrect rating of electrical equipment for the defined hazardous area. Toolbox Talk Discussion Points - Does your site have old poorly maintained equipment / components? Do you have equipment / wiring that looks inadequate / unsafe? Do you have regular electrical equipment inspections of your site? Electrical failure in components and fires LFI Can you think of any similar situations that YOU have experienced or witnessed? Did you report it?