JIG Learning From Others (LFOs) Toolbox Meeting Pack Pack 25 - November 2018

Transcription

1 JIG Learning From Others (LFOs) Toolbox Meeting Pack Pack 25 - November 2018 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. 02/11/2018 Joint Inspection Group Limited - Shared HSSE Incidents 1

2 Aircraft Damage Fueller Hits Engine Cowling LFO An operator made a reversing manoeuvre with the assistance of a guide person/banksman to position a fueller under the wing of a Boeing After positioning the vehicle in the initial fuelling position the operator applied the parking brake but the banksman asked him to reposition to place the elevated platform, at the rear of the vehicle, closer to the aircraft fuelling panel. After stopping the vehicle for the second time, the operator was immediately approached by a security agent so he exited the vehicle to show the required security documents. The operator then went back to the vehicle and tried to engage the PTO but it didn t work. After a few attempts he realised that the reason it was not engaging was because the parking brake had not been applied. At the same moment he felt a slight impact as the vehicle hit the aircraft. The vehicle moved due to the slight gradient of the ramp area. The impact resulted in damage to the aircraft engine cowling (exhaust area) which after inspection was allowed to depart with a slight delay. Only minimal damage was caused to the fueller which was returned to service. A reversing manoeuvre was performed due to the restricted layout of the stand which meant that the vehicle was positioned up slope of the stand in a direction that took it towards the aircraft The operator s normal routine was broken due to being distracted (Human Factors) by the immediate approach of the security agent Failure to apply the parking brake Do your vehicles have an alert system or equivalent to indicate that the handbrake is disengaged when the operator leaves the vehicle cab? Image showing damage to the aircraft Have you performed gate mapping at your operation to determine whether the most appropriate stand is being used and the fuelling operation can be performed with lowest possible risk? Do you give specific training to your operators in how to handle breaks in standard routines? Do you provide behavioural based safety (BBS) training to operators covering the issues associated with broken routine activities/abnormal situations? 02/11/2018 Joint Inspection Group Limited - Shared HSSE Incidents 2

3 High Potential Near Miss Aircraft Refuelling Accident LFO While fuelling a B at stand No. 6, the fuelling operator noticed another aircraft was approaching on adjacent stand No. 7. A marshal was in place marshaling the aircraft. The aircraft was approaching its final position when the pilot suddenly applied the brakes and stopped the aircraft, despite the fact that the marshal did not signal him to stop. At the same time, the fueling operator was waving his hands to the marshal to stop the aircraft. It was then realized that the aircraft wingtip/winglet was too close to the Fueller tank. An incident could have occurred if the pilot had not stopped the aircraft on time. The aircraft was finally positioned to the parking stand No. 7, only after the fueller moved from stand No. 6. Apron Layout had been recently modified by the airport operator in order to increase the number of aircraft parking positions, resulting in limited space for aircraft maneuvering. No safety lines for fueling equipment were marked on the aircraft stands. Management of Change / Risk assessment of the new layout failed to capture this potential hazard. No involvement of ground handling users took place during design phase. Apron layout on stand 7 does not provide adequate visibility to the Marshal whilst fueling is performed on stand 6 How do you manage changes at your airport? Are you actively involved in airport safety meetings? Do you raise concerns and propose solutions? Do you revise Stand plans when changes occur? Do you always maintain awareness of your surroundings during fuelling? 02/11/2018 Joint Inspection Group Limited - Shared HSSE Learnings 3

4 Refuelling Vehicle Accident - Collision LFO Summary At 6:20 am an operator started preparing for his next fuelling activity and drove a dispenser from the airport satellite station towards the stand. The operator drove behind another dispenser that suddenly came to a full stop. A collision between the two vehicles could not be avoided. Analysis showed that the sudden stop of the first dispenser was caused by the activation of a brake interlock. The speed of both vehicles was around 25 km/hr. The operator did not apply a proper following distance therefore did not have enough time to stop the vehicle and avoid the collision. A malfunction of the interlock was identified as the cause of the activation. The investigation did not reveal other factors such as fatigue or time pressure as having contributed to the incident. (following formal investigation) Insufficient space between 2 vehicles while driving in slightly congested area and defensive driving principles not applied. Interlock activation while vehicle is in (high speed) motion, no design to avoid sudden stop while driving, Vehicle design failure as vehicle should have progressive braking or interlock system isolation upon interlock activation whilst vehicle travelling at greater than 10KPH (JIG 1 Issue 12 ref 3.1.7) Maintaining safe distance concept was not fully understood Are you maintaining proper safe distance from the following vehicles, that allows time for the driver to react regardless of the speed? Do you adjust this when in congested or busy areas? Do your vehicles comply with JIG 1 requirements for progressive application of brakes, if interlocks are activated inadvertently when the vehicle is in motion? Or are they equipped with a system that de-activates the interlocks at more than 10km/hr as required in JIG 1? Are you aware of any fuelling vehicles at your location where this type of incidents could occur? 02/11/2018 Joint Inspection Group Limited - Shared HSSE Incidents 4

5 LTI Dislocated Shoulder LFO Work was being undertaken to re-configure hydrant pits on the apron. While working in an excavation (pictured) to level off a new hydrant pit with the apron in readiness for backfilling, the contractor had to step over the hydrant pipe inside the excavation. He subsequently tripped over the pipe and suffered a dislocation of the shoulder. Following medical treatment, the contractor returned to work on restricted duties. The excavation was very narrow and restricted movement whilst inside. Not all options had been considered to reduce the trip risk. The location attempted to meet multiple work permitting requirements (Own company / Airport authority) in a non-structured way, resulting in a sub-optimal approach to safely manage the activity. There was a general attitude of we have always done it like this. Do you have situations where multiple work permitting requirements are required as in this incident? It is essential to have a clear line of sight to meet all requirements. Additional risks may be introduced due to the lack of clarity on these requirements and good understanding and communication by all parties involved is required to ensure safe ways of working. How do you ensure that all HSSE requirements and processes from all parties are clearly understood by all involved in the work? How do you avoid Risk Normalisation? At your location, are there processes in place to ensure that: People are empowered to speak up and to stop work if they feel unsafe (Human Factors)? Complacency is avoided and processes and procedures are challenged to ensure that HSSE is kept front of mind (Human Factors)? Contractors are engaged to ensure you partner with them in order to utilise and understand best practices and the latest technologies, standards and industry best practices to ensure safe working and to reduce risks? If the incident was worse, how would you have recovered the injured person from the excavation? 02/11/2018 Joint Inspection Group Limited - Shared HSSE Incidents 5

6 LTI Slip on Ice/De-icing Fluid LFO An Operator was pulling the bonding cable out to an aircraft he was about to refuel when he slipped on the apron. As he slipped and went down backwards, his right leg bent back, the toes were bent forward and the steel cap of his boot compressed in onto the toe joint of the foot. This caused some bruising to the toe joints and moderate swelling to the right instep. A transparent coating of ice had formed on the apron as a result of severe winter weather conditions. The condition of the apron had not been thoroughly assessed prior to refuelling to determine if the application of salt was necessary. Ethylene Glycol (anti-icing fluid) was applied to the aircraft immediately before refuelling and dripped onto the apron which added to the slippery conditions. Do Site Managers review the sequence of applying de-icing fluid to the aircraft and refueling? Can the refueling process be completed first? Have discussions taken place with the Airport Authority to see if aircraft de-icing / anti-icing can be carried out in a designated area away from the apron or if arrangements are in place to clean up areas affected by de-icing / anti-icing fluid? How do you ensure that apron areas and other areas used by the Refuelling Operators are assessed to determine if de-icing / anti-icing is required? Are your Operators empowered to stop work if they feel that refuelling is unsafe due to slippery conditions caused by ice or aircraft de-icing fluid? Do you have the relevant Safety Data Sheets available for the de-icing fluids used at your airport? Have all risk reduction requirements been implemented? 02/11/2018 Joint Inspection Group Limited - Shared HSSE Incidents 6

7 Refueller Vehicle Incident - Parking Brake Forgotten LFO Whilst parked on the apron awaiting crew permission to approach the aircraft into the safety zone in order to refuel the aircraft, the driver, impatient after waiting a while, decided to leave the cabin to meet the captain. Leaving his engine running, he left the vehicle unattended and unfortunately forgot to set the vehicle hand brake. When outside of the vehicle he observed the fueling vehicle moving away due to the slope of the apron. He desperately try to jump back into the vehicle in order to bring it under control, but his attempts were unsuccessful. The refueling vehicle came to a halt upon impacting a lighting stanchion. Impatience, lack of awareness, unnecessary haste in an ordinary none urgent situation Failure to apply the parking brake Vehicle exit procedure not applied Incomplete assessment of vehicle condition before exiting the cabin, no verification of safe status. Risky behaviour and complacency Are your procedures up to date, regularly reviewed, tested and strictly applied by all fueling operators? How do you explain the lack of hand brake activation which is a daily routine automatic gesture? What could you implement to avoid such an accident ever happening at your site? Would it be useful to implement the LMRA within your own organization? What were other potential consequences of this incident, person or aircraft impact? Do all of your vehicles have door / handbrake alarms installed (JIG 3.1.7)? 02/11/2018 Joint Inspection Group Limited - Shared HSSE Learnings 7

8 Hydrant Shutdown due to Floating Suction Failure LFO For stock management purposes a storage tank was lowered to below the normal fuel Low Levels. The next day the tank was stated to be filled again; at a prescribed level the floating suction was purged of air and all samples flowed freely to indicate the floating suction was filled with fuel. The following day the tank was put into service. Approximately 6 minutes after placing the tank into service, a pressure loss to 0 Bar in the hydrant system was indicated. A different storage tank was placed into service but the hydrant pressure did not increase. During the day it was identified that the floating suction of the original storage tank was not free moving and had filled with air; this had created an airlock in the hydrant pump system. Some hours later the site managed to purge the air from the system to allow normal hydrant pressure to be restored. Although every effort was made to fuel aircraft using mobile refuellers the hydrant shutdown led to aircraft delays and cancellations. Floating suction swivel failed in the raised position Seals and bearings within the swivel were found to be damaged and incorrectly installed as per design specification. The damaged and incorrectly manufactured seals and bearings allowed fuel to enter the joints leading to excessive wear and failure of the swivel movement. Do you regularly check your floating suctions for free movement as per JIG ? Do you have a regular service regime for floating suction swivels during tank maintenance? Do you have a site procedure for the refilling of floating suctions post draining? Are you aware of the swivel manufacturers maintenance requirements for the equipment you have? 02/11/2018 Joint Inspection Group Limited - Shared HSSE Learnings 8

9 Near Miss Unsafe Bonding Point of B787 (Dreamliner) LFO While connecting the bonding cable to the landing gear of a B787 (Dreamliner) the operator was bending forward and stretching his arm between the two wheels of the landing gear. Due to the unfavourable position of the bonding point the operator overstretched his arm/shoulder and almost touched hot parts of the brakes. This could have resulted in an injury. In addition, the cable insulation was partly scorched as it came into contact with hot surfaces of the brakes. The un-ergonomic position of the bonding point at the landing gear of a B787 poses an increased risk of injury resulting from an unfavourable body posture or possible contact with hot surfaces (brakes). The bonding cable was damaged as it was improperly routed over the hot surface of the brakes, which is located very close to the bonding point. Are all operators aware of the hazards posed by the unfavourable position of the bonding point at the landing gear of a B787? Is there an operating instruction about the correct and safe bonding procedure for B787 refuellings, respectively the routing of the bonding cable after connection (preferably parallel to the wheels without touching hot parts)? Are all operators instructed to wear safety gloves while bonding? Are damaged bonding cables immediately replaced or repaired and properly tested for conductivity? 02/11/2018 Joint Inspection Group Limited - Shared HSSE Learnings 9

10 Near Misses Fuelling Operations During Thunderstorms LFO Near misses occurred at different airports where fuelling activities were carried out during severe thunderstorms. An operator was standing on a fuelling step during an over-wing fuelling, when a loud thunder clap and an electrical discharge occurred in close proximity to his fuelling position. He felt a slight tingling in his hand. Another operator observed that the vertical fin of an aircraft was struck by lightning just a few moments after he disconnected the fuelling equipment from that aircraft. Every thunderstorm with lightning at/above the airport poses the potential risk of serious or fatal injury as electrical discharges can result in heart or respiratory failure, unconsciousness and severe burns. The thunderstorm warning from the Airport Control Centre, which is normally received by the shift supervisor (as text message on the dispatching screen, or as call) when lightning is detected within a certain radius around the airport (often 5 km), was missing or came too late. In one case, the lightning warning system displayed the flash lights indicating an acute hazard on the apron (detected lightning) was defective. In addition, the internal alerting system and communication process of the fuelling service was ineffective. The responsible supervisor either did not notice the weather warning as he was busy with other tasks, or he was unsure about the correct behaviour and internal procedure in case of a thunderstorm warning. There were no clear operating instructions defining the internal alerting system and decision-making process in case of an incoming thunderstorm warning. Is there an effective and reliable warning system and communication process to ensure that thunderstorm warnings from the airport or a weather service are received and immediately noticed by the shift supervisor at any time (normally as warning message and/or call)? In case of a thunderstorm warning, are all operators immediately alerted and clearly instructed to stop any operational activity, stay in a protected area (building or driver s cab) and wait for further instructions, if there is an increased risk of lightning (e.g. if lightning was already detected within a 5 km radius)? Are there clear operating instructions for hazardous weather conditions, including thunderstorms, which are based on the location s risk assessment? Are the airport regulations for thunderstorms known, and all operators briefed to strictly follow related instructions from the Airport Security/Apron Supervision? 02/11/2018 Joint Inspection Group Limited - Shared HSSE Incidents 10