Transcript JIG LFI Toolbox Pack 10 - Joint Inspection Group

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
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and (iii) nothing in this document constitutes technical advice, if such advice is required it should be sought from a qualified professional adviser.
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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)
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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?
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Misfuelling
LFI 2013-05
Incident Summary – A misfuelling took place when 26 litres of Avgas was delivered to a Robin DR.400-135TDI 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.
Causes –
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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
Discussion Points –
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•
•
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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 6.5.5 Overwing Fuelling for clarification of requirements
Can you think of any similar situations that YOU have experienced or witnessed?
Did you report it?
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Manual Handling Injury – Shoulder
LFI 2013-06
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.
Causes –
•
In this incident the operator did not follow site procedures and use
steps to carry out the fuelling.
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 6.5.4 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?
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Not watching Step Causes Injury
LFI 2013-07
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.
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.
Discussion Points –
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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?
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First Aid Case –Trip on Fuelling Hose
(LFI 2013-09)
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.
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.
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?
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