Transcript Slide 1

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
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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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Shared HSSE Incidents
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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.
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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?
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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 nondriver’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.
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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.
Shared HSSE Incidents
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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?
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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?
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Shared HSSE Incidents
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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
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Can you think of any similar situations that YOU
have experienced or witnessed?
Did you report it?
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