JIG Learning From Incidents Toolbox Meeting Pack. Pack 6 August 2012

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1 JIG Learning From Incidents Toolbox Meeting Pack Pack 6 August 2012 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. Joint Inspection Group Limited Shared HSSE Incidents 1

2 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 on the HSSEMS section of the JIG website ( Joint Inspection Group Limited Shared HSSE Incidents 2

3 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? Joint Inspection Group Limited Shared HSSE Incidents 3

4 LTI resulting from poor housekeeping LFI Incident Summary - Technician working nights was walking towards the bunded area when he tripped over a cable tray left on site by a contractor. Technician hit his elbow against the bund wall but did not suspect anything serious. He attended hospital a few days later after experiencing pain. This resulted in a 14 day absence from work due to a fractured elbow Causes - Work area left in an unsafe condition by contractor. Lessons - Contractors should have ensured all tools were removed from work site and stored away safely. A responsible person should complete a site safety walk-around at the end of the day to ensure the site is safe for normal operations to be conducted. If the Technician had completed a sufficient last minute risk assessment he may have identified the hazard. A sufficient permit system should have identified that the work area had been left in an unsafe condition. If you see a hazardous situation don t ignore. Put it right if safe to do so and ensure it is properly reported. Stay focussed at all times. Unsecured cable tray where technician tripped and fell Bund wall where injury occurred Can you think of any similar situations that YOU have experienced or witnessed? Did you report it? Joint Inspection Group Limited Shared HSSE Incidents 4

5 LTI resulting from tripping over hose LFI Incident Summary - An operator descended the ladder from the elevated platform and tripped on the inlet hose. With the fall he suffered grazes and an injury to both his knee and ankle. This resulted in 2 weeks absence from work. Operator descending lifting platform Causes - The hose had not been positioned safely The operator did not follow acceptable practices in the past although no incident occurred. The operator did not perform a last minute risk assessment. Operator did not pay attention to where he was walking. Lessons - Plan work properly. The operator should have rolled the inlet hose completely clear of the bottom of the platform access ladder. All operators should be instructed to follow this practice where possible. Complete a last minute risk assessment for all activities even routine tasks. Be aware of your surroundings when walking. Entrance to control room now free Can you think of any similar situations that YOU have experienced or witnessed? Did you report it? Joint Inspection Group Limited Shared HSSE Incidents 5

6 Driveaway due to overriding interlock LFI Incident Summary - After connecting to an aircraft with a hydrant servicer, the operator was unable to fuel due to a faulty deadman. The operator decided to return to the depot to report the fault. He drove off with the hose still attached to the wing of the aircraft, causing minor damage to the aircraft. Causes The normal fuelling procedure was interrupted by a faulty deadman. The operator did not follow procedures and activated the interlock override by mistake. The operator did not follow the post fuelling procedure and left the hose connected to the aircraft after failing to conduct a 360 walkaround. Toolbox Talk Discussion Points What would you have done if your deadman had failed to function properly? Are your operators fully aware of the meaning of the interlock warning lights? What is your procedure for overriding the interlock system? (refer to JIG 1, 3.1.7) What constitutes a thorough 360 walkaround and in which circumstances would you conduct one? How would a last minute risk assessment have helped avoid this incident? (refer to JIG 1, 8.2.2) 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 LTI from pulling fuelling hose LFI Summary - On the first fuelling operation of the day, an Operator proceeded to pull the fuelling hose from the Hydrant servicer towards the aircraft. While pulling the hose he suddenly felt a slight pain in his back. However, he managed to fuel the aircraft as scheduled and also completed fuelling the next aircraft. After fuelling the second aircraft, he contacted the doctor and visited for a consultation. He was prescribed 8 days sick leave (that was later extended). The Operator has a history of back related issues and had taken more than 40 days sick leave during the year. The manual handling technique used by the Operator in this incident was acceptable and he had been fully trained. No faults were found with the equipment used. Causes Controls related to the early identification of sickness/ health issues for the injured Operator concerned, and the initiation of appropriate response actions, were not in place. Sickness rates are relatively high at the Site. Management failed to address high sickness rates. The Operator in question has suffered chronic back problems resulting in extended sick leave in the past. The driver s pre-existing back condition almost certainly contributed to the severity of the incident. Toolbox Talk Discussion Points Are your current pre employment checks, fitness to work programmes and sickness management programmes in place and sufficient? (Refer to element 6 JIG HSSEMS) Do your risk assessments consider all potential risk factors in this manual handling task? (Refer to element 2 JIG HSSEMS) Have you considered measures to minimise the risk of manual handling injuries such as performing warm-up exercise at the start of shifts? Are staff encouraged to report any equipment issues that could impact manual handling e.g. sticking hose reels? Can you think of any similar situations that YOU have experienced or witnessed? Did you report it? Joint Inspection Group Limited Shared HSSE Incidents 7