Response to Surabaya incident

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2 Response to Surabaya incident 13 th April 2010 Flight CX 780 from Surabaya to Hong Kong with 320 crew and pax Experienced engine thrust control problems in flight Made a high speed landing in HKG, but very nearly catastrophic Issued JIG Bulletin 39 in January 2011 on Fuel Hydrant Commissioning Issued JIG Bulletin 52 in June 2012 on Filter Vessel sizing, flow rates and dp monitoring and recording Gathered feedback on dp switch performance Issued JIG Bulletin 58 with requirement to install dp switches on hydrant dispensers by end 2013, and with guidance on actions to be taken in the event of switch activation Are working with the EI Filtration Committee on trials of bulk water sensors 2

3 Pit coupler knock offs September 2010 Changi Airport, Singapore August 2010, Middle East July 2011 Johannesburg Airport April 2012 Santiago Airport, Chile October 2012 Johannesburg Airport Incidents reported from JV operations 3

4 Pit coupler knock offs 4

5 Pit coupler knock offs Very infrequent but potentially serious release of fuel under aircraft Highlights the importance of EI 1584 compliance can result in clean break away and minimal spillage Poor airport driving habits a major factor Greater training and control required of ground service providers Maintenance standards also implicated - must have processes to ensure trained and competent maintenance staff JIG 11 mandates use of dual pilot pit valves on new builds Also allows for installation of radio operated ESBs mounted on vehicles to reduce response time 5

6 Pit coupling hit by Water Vehicle with Spill (LFI ) Summary During a fuelling of a Boeing 767, the hydrant pit coupling was hit by a 3rd party truck being used to supply water to the aircraft. The 3rd party truck driver engaged reverse without using a guideman and reversed into the pit coupling. After the truck hit the pit coupling, there was a spill of about 1,200 litres due to hydrant pit valve and lanyard damage. Both pit and dispenser were upgraded to the API1584 3rd edition and pit valve was one year old. Causes 1) 3rd party reversing without guidesman 2) Hydrant pit valve did not fully close (further investigation in progress - Manufacturer of couplers recommends use of dual pilot pit valves). Damage to pit coupling Toolbox Talk Discussion Points Does Airport Authority and on the ground staff training include positions and activations of ESBs?. Do site tasks include operator vigilance during fuelling operations, ensure pit visible and stop fuellings before potential situations develop. Does your site have dual pilot pit valves? Resulting spill Can you think of any similar situations that YOU have experienced or witnessed? Did you report it? Joint Inspection Group Limited Shared HSSE Incidents 6

7 Driveaway Incidents since 2006 Date Location Aircraft August 2012 Ataturk Airport, Turkey A th May 2011 Singapore B th January 2011 Santiago, Chile A th January 2011 Gatwick, London A th October 2010 Vienna, Austria A th April 2009 Bauerfield Airport, Vanuatu B th February 2009 Dar es Salaam, Tanzania A st August, 2008 Adelaide Australia A th December 2007 Manchester, UK A th November 2006 Paris, France A nd September 2006 Stansted, UK A nd February 2006 Heathrow, UK A th March 2006 Palma, Mallorca A th February 2006 San Juan, Puerto Rico A 300 Incidents reported from Air BP and JV operations 12 out of 14 drive aways involved Airbus aircraft 7

8 Drive-aways Specific issues with Airbus aircraft Low wing height of A319/320/321 Location of fuelling panel causes procedural break to close it Operator training specifically for Airbus Embedding walk around and look up Improvements to vehicle brake interlock design Rigorous checks on hose stowage interlock functionality Sharing of lessons learned 8

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10 Drive Away (LFI ) Summary An operator drove his fueller away from an aircraft while still connected, breaking the aircraft connector ring. The operator did not follow the disconnection process in the correct order, and was distracted by the aircraft captain and fire brigade representative. He did not complete a 360 Walkaround and when he entered the cab of the vehicle, he did not investigate why the interlock warning light was on. The interlock did not work, allowing the operator to drive away still connected. Discussion Points The operator made many errors leading up to this incident. At what point could the operator have used a last-minute risk assessment to avoid this incident? Could a 360 Walk-around have prevented this incident? Does your Walk-around include looking up to check aircraft couplings? If distracted while completing a 360 Walk-around what should you do? Is the aircraft coupling always easily seen during your 360 Walk-around? Has your location considered using underwing flags or other coupling identification measures? These are designed to attract attention to hoses still connected to aircraft after fuelling has completed. Can you think of any similar Near Misses that YOU have experienced or witnessed? Did you report it? Damaged connector ring Example of an underwing flag Joint Inspection Group Limited Shared HSSE Incidents 10

11 JIG Inspections JIG Inspections reports generated via an internet-based data base Enables tracking of action closure by the Inspector and all JV participants Also enables inspection findings to be analysed for trends Many findings are location specific but others are more common, suggesting systemic weaknesses The following slides highlight some of the more common findings from the last 12 months of inspection reports

12 JIG Audit Findings 1 Is the maximum achievable flow rate marked on the body of each vessel and is it less than the rated flow for the vessel? At several locations the maximum achievable flow rate was not recorded onto the filter vessels. At one location the vehicle filters were too large for the aircraft types fuelled. Is the hose test performed correctly and are results satisfactory? Hoses being tested at the incorrect pressure. Hose found badly worn with thread of carcass showing. Supervisor had to remind operator to carry out low pressure test after high pressure test. The visual inspection using a loop being carried out at 15 bar instead of 3.5 bar.

13 JIG Audit Findings 2 Pressure Control tests Test rig design and construction no deck hose connections (vehicles circulated), gate valve takes over 30 seconds to close, PCV gauge different measurement units to master gauge pressure gauges not of the correct type, stairway used that is not suitable as not secure, during testing the pressure reading fluctuates too much, PRV fitted to the test rig that cannot be isolated. Test procedures No back pressure applied during test Rapid close test too fast all hoses shall be connected for ILPCV test.

14 JIG Audit Findings 3 Internal Filter Inspection Evidence of microbial growth and failure of the water test, elements replaced. Lack of procedure and equipment incorrect when carrying out the water test. Evidence that the coalescer elements were damaged during installation. Incorrect spacing between elements. On inspection several events recorded of coalescer elements suffering microbiological contamination and One event of poor maintenance with 15 nuts and washers found at the bottom of the filter vessel Evidence of contamination from hand prints and separator failure.

15 JIG Audit Findings 4 Differential Pressure (DP) readings Vehicle flow rate exceeding filter rated flow. Incorrect records including out of date with the calendar and rated flow on paperwork different to rated flow on the vessel Weekly dp readings recorded but it is not the correct flow rate to be used and training is required, A drop in dp was observed but no action taken dp is being recorded but not corrected.

16 JIG Audit Findings 5 Are procedures and equipment available to prevent over-filling of fuellers? Fuellers are loaded via a Hydrant servicer with only one overspill protection, the procedure needs to be risk assessed and secondary protection implemented. Many findings related to fuellers with only one high level shutoff device Fuelling Procedures - Does fuelling operator check (visually) the condition of the aircraft adaptor before connecting hose? Events included not visually inspecting the aircraft coupler before connection. Not checking that the fuelling nozzle is securely fixed to the aircraft coupler post connection (ie wiggle check not being performed.) 17

17 JIG Audit Findings 6 Low point flushing and sampling procedure: - No bonding to Low Point? - Is flushing achieved by drawing litres of product plus the capacity of sampling pipework at full flush when the system is under pressure? - Is a sample drawn near the end of the flush under full flow (running sample) for Visual Check? Low point flushed product is QC tested but there is no record of this before returning back to storage The low point flushing vehicle did not have a meter so it was not possible to establish the volume require for the task During low point flushing the low point dry break was found to be leaking. Several examples of bonding being carried out during hydrant low point flushing 18

18 Thank you