Joint Inspection Group LimitedShared HSSE Incidents 1 JIG ‘Learning From Incidents’ Toolbox Meeting Pack Pack 10 – November 2013 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?

Joint Inspection Group LimitedShared HSSE Incidents 4 Misfuelling LFI Incident Summary – A misfuelling took place when 26 litres of Avgas was delivered to a Robin DR TDI Ecoflyer. On landing the pilot asked the ground controller to pass a message to the fuelling operator for Jet A-1. However,the ground controller did not hear the message clearly and called the fuelling operator stating that the pilot required Avgas. When approaching the aircraft the operator was distracted due to the fuelling orifice being located on the fuselage in a position that was awkward to reach. The aircraft had a small decal located just above the fuelling orifice stating Jet A -1 and Diesel. The operator did not check the grade and started to fuel the aircraft with Avgas. The Operator detected his error after 26 litres had been fuelled into the aircraft. The fuelling staff flushed the wing tanks in accordance with instructions in the aircraft manual, and the pilot departed. Discussion Points – Ensure procedures are clear and followed (does site have written verification processes for grade identification? Minimise the numbers of links in the fuel order taking process. Where possible, does the pilot place the fuel order directly with the fuelling staff? Review JIG 1, Ref Overwing Fuelling for clarification of requirements Can you think of any similar situations that YOU have experienced or witnessed? Did you report it? Causes – The Ground Controller relayed the fuel order from the pilot stating the incorrect grade – requesting Avgas rather than Jet A-1. The fuelling operator did not carry out fuel grade verification processes before starting the fuelling, including verification that the grade marked on the aircraft and the grade marked on the over wing nozzle were the same. Fuelling personnel should never make an assumption about the grade of fuel required and shall always confirm the grade of fuel. The design of decal was not in compliance with EI 1597

Joint Inspection Group LimitedShared HSSE Incidents 5 Manual Handling Injury – Shoulder LFI Incident Summary – A fuelling operator was assigned a Bombardier Dash 8 to refuel. He completed refuelling and began the disconnection process. Whilst disconnecting he stretched his arms above the shoulders and in the process of removing the coupling felt a very sharp pain and discomfort in his right shoulder. The injury caused the operator to be placed on light duties. Discussion Points – Apart from the obvious injury caused, if you look at the picture opposite what other issues do you think may arise by carrying out the task as shown? Think about his positioning, with regards to both personal safety and operational requirements. What does JIG IP ask you to do? What arrangements do you have in place to ensure the rehabilitation and return to work of personnel following a work-related injury, illness or other adverse health effects (JIG HSSEMS 6.9) Can you think of any similar situations that YOU have experienced or witnessed? Did you report it? Causes – In this incident the operator did not follow site procedures and use steps to carry out the fuelling.

Joint Inspection Group LimitedShared HSSE Incidents 6 Not watching Step Causes Injury LFI Incident Summary – Early in the morning, before the opening of the depot, a contracted night guard fell while descending a set of steps. He lost his footing on the second step from the top of a flight of steps and, even though he was holding the handrail, he fell down the rest of the stairway to the ground (several more steps). He suffered a back injury and was unable to get up. He only received aid 2 hours later when the depot manager arrived at work. Discussion Points – Are there any lone worker activities in your location? How are you managing lone working? What things need to be considered? How are the activities of contractors managed to ensure their health and safety? Are inductions given appropriate to the nature of their work and the hazards to which they may be exposed? (see JIG HSSEMS 9.5) Can you think of any similar situations that YOU have experienced or witnessed? Did you report it? Causes – Lack of attention probably due to tiredness towards the end of his shift. Not fully following the “three points of contact” rule when using stairways. Undertaking activities outside of his role.

Joint Inspection Group LimitedShared HSSE Incidents 7 First Aid Case –Trip on Fuelling Hose (LFI ) Incident Summary – After fuelling an aircraft near the end of his shift an operator tripped over the fuelling hose. The operator fell on his left elbow, shoulder and thigh. He was taken to the hospital for X-rays with the results showing no broken bones.. No medication was prescribed and there was no lost work time. Discussion Points – What do you do to remind staff to have constant slip/trip awareness in mind? A number of trip incidents arise where the hazard is of a temporary nature (e.g. a hose lying across the ramp, equipment / tools used when maintenance activities are being done) rather than permanent obstacles in the workplace. Do Management and Supervisors undertake site observations and interviews with employees or other information gathering techniques to identify unsafe behaviours and working conditions? (see JIG HSSEMS 1.9) Are your staff practicing Situational Awareness? Staff should remember that ‘walking is still working’ and should think through their entire work activity carefully and be constantly aware of the dynamic nature of their environment. Avoid being on “auto pilot” when performing routine tasks. Look up, down and around for hazards. Did you know ? Slips trips and falls are the most common cause of major injury at work 95% of major slips result in broken bones Can you think of any similar situations that YOU have experienced or witnessed? Did you report it? Causes – The investigation and viewing of CCTV revealed that the operator tripped over the hose when he momentarily looked up at the nose of the aircraft.