JIG Learning From Others (LFOs) Toolbox Meeting Pack Pack 24 July 2018

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1 JIG Learning From Others (LFOs) Toolbox Meeting Pack Pack 24 July 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. 09/07/2018 Joint Inspection Group Limited - Shared HSSE Learnings 1

2 Learning From Others How to use the JIG 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 & depot operators and maintenance technicians) during regular, informal safety meetings No need to review every slide in one Toolbox meeting. Select 1 or 2 slides 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 at 09/07/2018 Joint Inspection Group Limited - Shared HSSE Learnings 2

3 Learning From Others For every slide in this pack, ask yourself the following What impact could this issue have on our site? How do our risk assessments identify and adequately reflect these issues? What prevention measures are in place (procedures and practices) and how effective are they? What mitigation measures are in place (safety equipment/emergency procedures) and how effective are they? What can I do personally to manage this type of issue? If you would like further assistance or information relating to the contents of this pack, or if you have any information you feel will help others, then please contact JIG at 09/07/2018 Joint Inspection Group Limited - Shared HSSE Learnings 3

4 Injury Guide Person Crushed By Reversing Fueller LFO An operator acting as a guide person was injured during the reverse of a fueller from the Vehicle Servicing Bay (VSB). His leg was crushed when caught between the fueller and a van parked in its allocated parking space opposite. The operator required hospital treatment. Human factors failing to follow training. Guide person did not wear Hi Viz. Driver decided to proceed even though guide person did not wear Hi Viz and could not see him. Increased size of vehicles since Vehicle Service Bay was originally designed. Complicated activity for driver & guide person; danger areas alternate extremely quickly from back to front and back during movement. When operations change do you perform a review of the suitability of existing infrastructure (management of change)? Have you recently reviewed where reversing is performed to determine if it is necessary or can be avoided? Where reversing is unavoidable, are task specific procedures established to control the activity? What training and competency assessments are provided for guide persons and drivers? Should a last minute risk assessment had been performed by the driver (e.g. assess whether the guide person is clearly visible) and by the guide person (e.g. assess whether the standing position is safe) would had this incident occurred? 09/07/2018 Joint Inspection Group Limited - Shared HSSE Learnings 4

5 Refueller Vehicle Incident Drive Away LFO During the fuelling of an aircraft at peak hour operation, an operator noticed that two other aircrafts landed and were waiting for fuel. At that moment the operational schedule at the apron was somewhat delayed. To avoid more delay the operator asked his colleague to take over the paperwork for his fuelling. When the operator finished the fuelling, he released the dead man to stop the pump and closed the valve. He did not disconnect the fuelling hose and the bonding cable. He handed over to his colleague, entered the refuellers cabin and drove off. After a few meters the operator heard a loud click and stopped the refueller. He found that the loading hose had been torn off (predetermined breaking point) causing a small leak and the bonding cable to be pulled loose. There was no aircraft damage. The operator was distracted and did not carry out the 360º walk around check The deck hose interlock system failed due to the malfunction of a pneumatic valve, brakes were released as if interlock was working normally. Daily interlock testing did not include the functionality of the (stuck) pneumatic valve. Similar incident learnings and followup were shared withstaff in the past. Found Defect Found OK Are we confident that both human barriers (e.g. adherence to the 360 walk around procedure) and technical barriers (e.g. properly maintained and tested interlock system) are always in place? Do we take the appropriate time to discuss and review learning opportunities from incidents occurred in the industry? Are we confident that operational pressure will not jeopardise the safety of the operations? 09/07/2018 Joint Inspection Group Limited - Shared HSSE Incidents 5

6 Spill - Hydrant Pit Cap Tether LFO The operator arrived to refuel an A320 aircraft. When making the input coupler connection he did not observe that the dust cap tether cable was jammed between the input coupler and pit valve. There was no resistance to the input coupler locking collar engagement or when operating the poppet handle. About 2½ minutes after fuelling started the operator noticed that the pit box was overflowing with fuel. He released the deadman and pulled the lanyard to manually close the pit valve. He then decided to shut down and isolate the vehicle by turning the vehicle master switch off and moved away from the spill. The shift supervisor was informed and the Airport Emergency Services called. The area around the spill was secured from sources of ignition and people. The hydrant emergency shutdown was activated. The spill was cleaned up and the aircraft moved to another gate. The hydrant pit valve was inspected, mechanically tested, found ok and returned to service. The hydrant dispenser was returned to the depot and tagged out of service. Upon inspection, the hydrant dispenser input coupler was found to have the pit valve dust cap tether wire lodged between the poppet and seal, which caused some scuffing to the poppet (see photo). Potential Operator did not notice the position of the cap tether while he was connecting the input coupler to the hydrant pit valve. The design of the hydrant pit cap tether does not prevent coupling of a hydrant input coupler. Are operators aware of the risk and check that the pit cap tether is clear of the hydrant pit valve prior to fittingthe input coupler? Do we walk to and check the pit valve once flow is initiated? is the design of the pit cap tether subject to review? Do we share best practice? 09/07/2018 Joint Inspection Group Limited - Shared HSSE Learnings 6

7 Aircraft Damage Pilatus Aircraft LFO A fuel order was received for a Pilatus aircraft. The Pilatus was parked at the apron and was due to receive Jet A-1 from the kerbside dispenser. At the day of the incident there was a technical problem with the kerbside dispenser and a small bowser had to be used to serve the Pilatus. This small bowser is pulled by a tractor and is primarily used for remote helicopter fuellings. As the Pilatus is an aircraft with high wings the operator thought he had enough space to drive under the aircraft s wing. While manoeuvring slowly to get the bowser in the best position he hit the wing. This resulted in some minor damage to the aircraft (flap and control of the flap movement) and some scratches on the bowser. Potential This specific bowser fuelling operation was not in the training program as it was not perceived as applicable for daily operation. The change from Dispenser into Bowser fuelling was not managed sufficiently, new risks were not identified, no MOC followed. Are all specific fuelling operations covered in specific task breakdowns and training plans? Is a change in operation always risk assessed before being executed? Are the changed (or new) risks managed such that they are acceptable? Are changes documented and approved by people authorized to do so? 09/07/2018 Joint Inspection Group Limited - Shared HSSE Learnings 7

8 LTI Slip Trip Injury LFO An Operator finished an aircraft fuelling, stowed the fuelling hose and while he was walking back to the refueler, he slipped on black ice. He took the brunt of the fall on his back, which caused his bump cap to fall off. His neck whiplashed and his bare head hit the ground resulting in a 1.5 laceration. The Operator also sustained a concussion. The aircraft had been moved to the outer edge of the apron following a request from the pilot. Chemical de-icing compound had been applied to the high traffic areas, missing the outer apron area. Black ice had formed on the outer apron area due to the uneven nature of the surface collecting water and sub zero temperatures the previous night. The temperature was above freezing and the apron appeared wet; ice was not noticeable. The outer edge of the apron had only been assessed for vehicle traffic as part of the Black Spot Mapping/Stand Plan process. The Black Spot Mapping assessment in place was limited to vehicular hazards and did not include other hazards such as poor road surface conditions. The additional risk introduced as a result of refueling the aircraft on the outer edge had not been recognised (risk normalisation). Is there a process or procedure at your site that defines which areas of the apron are to be de-iced and how this is communicated to other apron stakeholders? Are any Black Spot Mapping assessments carried out at your location and do these include all hazards i.e. not limited to vehicular traffic hazards? Is a review frequency set for your Black Spot Mapping, e.g. as conditions change? Re-emphasise Stop Think Do before undertaking a task and be aware of Risk Normalisation (or complacency). 09/07/2018 Joint Inspection Group Limited - Shared HSSE Incidents 9

9 Refueller Vehicle Incident - Drive Away Whilst Connected To Aircraft LFO After completing the fuelling of an Airbus A320, an operator attempted to disconnect the hose coupling but found issues with the elevator platform lifting mechanism. He switched the fuelling vehicle ignition off and on again which resolved the issue and in the process forgot to disconnect the coupling. He attempted to move the fuelling vehicle which moved a short distance before he realised that he had not disconnected. The aircraft adaptor was damaged but there was no loss of product (spill). Operator did not follow the correct procedure for disconnecting from the aircraft and did not conduct a 360 walk around ( Look up, Look Down, Walk around ) before driving away from the aircraft. A lack of situational awareness by the operator. He was also fasting during Ramadan and it was towards the end of an almost 13 hour fast. There was a possible technical issue with the elevator platform which may have affected the vehicle interlock system. However, operators that later used the vehicle for fuelling after the incident did not report any issue with the interlock. The operator was experiencing family problems at the time and had reported more than an hour late for his shift. This had not been made known to the site manager. There was another fuelling vehicle on site that had experienced pressure drop issues in the past that required the vehicle to be re-started in order to build up pressure. The Operator was aware of this issue which explained his action of switching the vehicle ignition off and on again during this incident. However, vehicle reliability issues had not been reported and addressed. Are all staff trained and aware of the correct aircraft fuelling procedure including the requirement to complete a full 360 walkaround before driving off? Emphasise the Stop, Think, Do principle and re-assess the fuelling procedure should any distractions affect the normal routine. Is there sufficient focus (and possible intervention) on Fitness to Work from site managers? If there is a suspicion of any personal issue that may have an adverse effect on an Operator s ability to maintain situational awareness and concentration are there alternative temporary arrangements available? The elevator platforms on site had issues related to them freezing in some situations which had not been reported and addressed. The site had a work around by switching the engine off and back on again which resolved the immediate issue, but did not resolve the underlying issue. There had been historic malfunction issues reported but they had not been addressed 09/07/2018 Joint Inspection Group Limited - Shared HSSE Incidents 10

10 LTI Sprained Knee Ligaments LFO A Refuelling Operator sustained a sprained knee ligament whilst stepping down off a ladder during a refuelling operation, resulting in a lost time incident. The incident was not reported to the Supervisor right away. The Operator may have been pivoting to walk away as his foot was landing on the ground creating a strain on the knee. A lack of situational awareness and care while undertaking a routine activity resulted in an injury. Frequent use of ladders increases the risk acceptance in the use of this potentially hazardous piece of equipment. The risk is consequently ignored. How can you combat this? Maintaining good situational awareness while fuelling in tight spaces and adopting a good body position and posture when ascending/descending ladders is essential. Is this an issue at your location? Review your manual handling procedures for handling hoses while ascending/descending ladders. Are there any improvements that can be made? Reiterate the requirement for all staff to immediately report incidents or potential incidents to their Supervisor. Can this be improved at your site? Review aftercare management once an incident has been reported to ensure that appropriate medical attention can be provided in order to mitigate the possible adverse consequences. 09/07/2018 Joint Inspection Group Limited - Shared HSSE Incidents 11

11 Product Quality Jet Fuel Contamination Event LFO Refuelling Technician inadvertently put diesel exhaust fluid (DEF) into the PRIST mixing tank on two Fuel Trucks. DEF is a Urea-based chemical intended for injection into exhaust stream of diesel engines to reduce NOx emissions, not approved for use in jet fuel (or any aviation fuel). DEF reacts with long-chain n-paraffins to form crystalline deposits in the fuel system, which may accumulate on filters, fuel metering components, other fuel system components, or engine fuel nozzles, and may potentially become dislodged over time and accumulate downstream in the fuel system. 7 Civilian Aircraft were serviced with jet fuel containing DEF and 6 Civilian Aircraft were serviced using refuelling equipment that had been exposed to DEF. Reported events include 4 In-Flight Engine Shutdowns and a Lear 45 Filter Bypass Diversion. It is believed the cause of the contamination event was a procedural error by refuelling technician. Are your various additives fully segregated? Are they clearly labelled and identifiable? What reconciliation and checks do you have in place to ensure that this situation couldn t happen at your site? Filter Deposits 09/07/2018 Joint Inspection Group Limited - Shared HSSE Incidents 12

12 Other - Damage to Pit by Others LFO Summary A ground service equipment (GSE) driver, carrying four pallet dollies, made a U-turn maneuver at an aircraft parking stand in order to park at the staging area. 3 of the 4 pallets of kg disconnected and moved uncontrolled against the hose of a fuel dispenser, that was already connected with the hydrant fuel pit valve, causing damages to the fuel pit and the dispenser. Aircraft fuelling had not yet commenced. No fuel spillage occurred. Repairs amounted ca Mechanical disconnection of GSE baggage dollies (first pallet dolly from other three pallet dollies). Safety lock couldn t ensure that the metal vertical pin barrier would not be moved in case that the dolly was moved with high speed. GSE Company installed additional lock on top of the vertical pin to avoid the tow pin raising during driving. Metal ring of the second dolly was distorted from continuous use contributing to the disconnection of the two dollies. Related preventive maintenance checks added. Baggage dollies were not inspected properly by ground handling staff to verify the safe connection of the trailing group of dollies, though driver had long working experience and was well trained (human factor). GSE speed checked by CCTV was not within a walking speed pace, as per Aerodrome Operations Manual, which in combination with the sharp U-turn, resulted in the disconnection of dollies. Are similar pieces of GSE equipment vulnerable to being disconnected during driving? Are apron drivers trained to check them before using them and to drive them as per airport manual instructions? Is there effective GSE preventative maintenance in place? Is there an inspection scheme to assess the proper application of the above? Is the fuel pit area colour marked as no-go/no-park area? Are apron drivers aware of this requirement? Are pit valves and pit couplers in compliance with EI rd edition? Are hinged type pit covers modified/due to be modified by end 2018 to lay flat? Consider the impact in case of fuel spillage. Release of hydrant pressure might be catastrophic. Is the airport community prepared to manage major spillage? 09/07/2018 Joint Inspection Group Limited - Shared HSSE Incidents 13

13 09/07/2018 Joint Inspection Group Limited - Shared HSSE Learnings 14 Other - Tank Vacuum Equipment Damage LFO An existing Avgas storage tank that had been used as a self serve dispenser was undergoing a change in service to allowfor the loading of refuelling vehicles. Tank and pipework modifications had been completed and the first refueller was being loaded. Whilst loading the refueller a large bang was heard and the loading stopped. Upon investigation it was noted that that the tank domed end had vacuumed into the tank. Meter proving for the planned increased flow rate of the new activity for this tank created far more vacuum thanthe tank was originallydesigned for. The tank P+V vent was not capable of allowing sufficient airflow into the tank to allow for the product being removed at the higher flowrate. It was unclear if the P+V vent was working to its full potential For any change to equipment service has a full engineering review taken place as part of the Management of Change? Never presume existing equipment is fit for new service without testing. Ensure the correct people are involved in the Management of Change for the project. Existing P+V New Higher volume P+V arrangement.

14 09/07/2018 Joint Inspection Group Limited - Shared HSSE Learnings 15 Aircraft Damage Wing Damaged By Fuelling Platform LFO Whilst raising the platform under the wing of an aircraft the platform proximity sensor (wand) came into contact with the flap track fairing of the aircraft. The flap track fairing was punctured by the wand mounting bracket as the interlock system of the platform did not stop the movement quickly enough after being activated by the sensor. Ineffective sensing device: The activation of the platform s interlock system via the wand sensor and a pneumatic control unit triggering the hydraulics of the platform was ineffective (too slow). The wand was mounted to a metal support bar to raise it above the highest fixed structure within the platform. Due to the specific design of the vehicle this height was far above the platform railing. The fuelling vehicle was incorrectly positioned under the wing, with the platform partly under one of the flap track fairings (not between them), which enabled the wand to make contact with the wing. Are your wand sensors checked monthly for correct operation as per JIG , ? Does the platform stop following activation by applying a downward pressure on the wands quickly enough? Would an electronic beam system (without pneumatic control unit) work better than wand type sensors?