Joint Inspection Group LimitedShared HSSE Incidents 1 JIG ‘Learning From Incidents’ Toolbox Meeting Pack Pack 14 –April 2015 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 Loss of Containment 10,000 litres Jet A-1 LFI Incident Summary – Two maintenance technicians at an airport depot were performing a routine pressure test on an underground pipeline that connects the storage tanks to the fueller loading island. The pressure test is completed annually with the last test conducted with a satisfactory result. Jet A-1 was being topped up into the underground pipe to enable the test to commence. The technicians observed the fuel level in the line dropping rapidly as the pipe was being pressurised with fuel. The test was repeated and the same observation was made. The technicians then checked the on-site interceptor and found fuel in it. The manual valve for the interceptor was immediately shut off. Technicians reported the incident to the Maintenance Manager and Airport Manager. The remaining fuel in the underground pipe was pumped out and alternative fueller loading arrangements were set up to ensure business continuity. 3rd Party oil spill response contractors were called upon to commence site remediation work. An incident investigation was subsequently conducted. The leak came from the main underground pipe located beneath the loading island. A pin hole was found in the underside of the pipe where a small bore low point pipe descends vertically from the main pipe. This may have been leaking for over a week – based on stock calculations. The cause of failure was pitting corrosion over time. Discussion Points – How often do you check/ test your underground lines? Would your stock control process identify a leak such as this? Does your interceptor have shut off valves and alarms? Is your site drainage checked and in good condition? Can you think of any similar situations that YOU have experienced or witnessed? Did you report it? Causes – The cause of pipe failure was localised corrosion. The underground pipe had been in situ for more than 30 years with no secondary containment and/or additional protective system such as cathodic protection in place. Bore and Interceptor inspection was not completed at required frequency

Joint Inspection Group LimitedShared HSSE Incidents 5 Misfuelling Prevention Near Miss LFI Incident Summary Site Supervisor was informed by a customer that the inbound plane required ‘full wings’ and this order was communicated to a fuelling operator. The operator drove a Jet A-1 fueller to the aircraft and noted that there was no grade ID at the aircraft fill points. He assumed the aircraft required Jet A-1 since ‘everyone knows the site sells only Jet A-1’ (no Avgas at this FBO but it is available at alternate supplier) The grade selective, flared spout did not fit the fuelling port so the operator changed from flared to a non-grade selective, round spout. This was observed by the Pilot but it was not until a passing 3 rd party noticed the wrong fuel being added to the type of aircraft that the fuelling was stopped. By this time the first wing of this piston-engine aircraft had been filled with Jet fuel. The aircraft was quarantined, had the tanks drained, was inspected and then fuelled with the correct grade of fuel by an alternative supplier. Potential Consequence Aircraft may have had enough residual avgas to depart, but engines could have stalled in flight. Can you think of any similar situations that YOU have experienced or witnessed? Did you report it? Toolbox Talk Discussion Points –  Do your current procedures ensure this could not happen to you?  Have you a robust process for checking the correct grade is delivered?  Are all site staff fully familiar with all Overwing Fuelling procedures?.  If the fuel grade decals on the wing are not clear what is your procedure?  Are you confident that your staff feel empowered to refuse to fuel an aircraft if there are any doubts around fuel grade.?

Joint Inspection Group LimitedShared HSSE Incidents 6 Drive Away from aircraft LFI Causes - The operator did not follow the company safety procedures which include a requirement for a 360 degree walk around together with a positive confirmation technique designed to ensure the walk around is effective. The operator did not acknowledge the indicator lamp showing the interlock was engaged and instead applied full throttle to the engine to move the vehicle. Toolbox Talk Discussion Points - Are follow up on-the-job observations undertaken at a suitable frequency and coverage to be effective at identifying where staff may be deviating from standard safety procedures? (JIG HSSEMS Guidelines 5.6) Are your existing disconnection procedures consistent with the JIG standard? (JIG , & Appendix A9) Are staff adequately trained in the function of safety critical equipment such as vehicle interlocks? Is adequate refresher training provided? What other additional controls can be considered in reducing the risk of a driveway e.g. the use of audible warning devices (buzzers) in the vehicle cab in addition to the interlock indicator lamp. Review previously issued LFI & LFI for other Drive Away related discussion points. Incident Summary – After completing the fuelling of an Airbus A the operator drove away with the fuelling hoses still connected to the aircraft. The aircraft underwing fuelling connectors were broken and there was a minor spill from the aircraft. The flight was cancelled due to the incident. Can you think of any similar situations that YOU have experienced or witnessed? Did you report it?

Joint Inspection Group LimitedShared HSSE Incidents 7 Lost time Injury from stepping off platform LFI Incident Summary – A Fuelling Operator stepped up onto the helicopter platform (without the use of a ladder or hop up ladder) and started fuelling. When the tank was full he realised that there was nothing to physically hold on to, or to maintain 3 points of contact while climbing onto and off the platform. With the fuelling nozzle in his right hand he took a grip inside the fuelling orifice with his fingers and stepped down, backwards off the platform, with one foot on the platform and the other trying to find firm ground. The nozzle and hose fell to one side and he fell to the other on his elbow, hip and knee. The operator felt some pain but finished the fuelling procedure and drove back to the depot. During the night, the pain increased and he attended hospital the next morning and was examined by a doctor who diagnosed no fractures or sprains but advised the operator to take a few days off work to recover fully. He was given painkillers. He returned to work 7 days later. Causes – Operator failed to report the fact that he felt uneasy about his one previous fuelling operation with this type of aircraft If this had been reported as a Potential Incident (PI) or Near Miss (NM) at the time, the airport supervisor would have had the opportunity to investigate and implement appropriate control measures. The Operator believed that he had the physical capability of carrying out the refuelling operation safely. It was only when he was on the platform that he realised that the platform was higher than he thought. He did not carry out a last minute risk assessment (e.g. Stop, Think, Do) before undertaking the activity. Toolbox Talk Discussion Points - Discuss any tasks or operations where Operators can over-estimate their capability of carrying out that task e.g. opening tight valves, reaching up to open a fuel panel etc. Ensure that operations that are unsafe or where the operator feels uneasy are discussed, addressed and reported. Can you think of any similar situations that YOU have experienced or witnessed? Did you report it?

Joint Inspection Group LimitedShared HSSE Incidents 8 Discharge of Fire Extinguisher LFI Incident Summary – Operator was driving a fuelling vehicle and arrived at the security checkpoint to transit airside. The Operator proceeded through security personnel checks before beginning his vehicle security checks accompanied by an Airport Security staff member. Upon reaching the offside fire extinguisher the Operator identified that the security pin was hanging loose. With the extinguisher partially in its container the Operator attempted to place the security pin back through the holes. At this point the extinguisher was partially discharged, the pressure of which caused the hose to spray out toward both Operator and Security staff member. As a result, the Security staff member may have inadvertently ingested some of the dry powder from the extinguisher. The investigation team inspected fire extinguishers and a further two were found to be defective on other vehicles. A full inspection was carried out by the motor inspector. During inspection it was found that the standard of fire extinguishers on site, and in particular the mechanism that secures the safety pin in place, was not good. It was found that there appeared to be a mixture of methods used to secure pins in place ranging from break tags to small rubber poppets. Discussion Points – The site manager and airport security agreed to review and agree a procedure that reduces or eliminates the requirement to constantly handle the extinguisher. Are the extinguishers at your site fit for service or are they being damaged Do your checks also assess the condition of handles and pins Can you think of any similar situations that YOU have experienced or witnessed? Did you report it? Causes – The manual handling of fire extinguishers was reviewed and evidence was found that constant handling by operators in and out for security checks was having a detrimental effect on extinguisher handles