JIG Learning From Others (LFOs)

Toolbox Meeting Pack
Pack 26 March 2019

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 
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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.

28/03/2019 Joint Inspection Group Limited ‐ Shared HSSE Incidents 1

Near Miss ‐ Fuel Additive Incorrect Dosing
LFO 2019‐01

Incident Summary
Whilst overwing fuelling a twin engine turbo prop aircraft, the fuelling technician was informed that the crew would add Fuel System Icing Inhibiter
(FSII). The flight crew then proceeded to add half a bottle of the FSII into each wing prior to fuel being added.
The aircraft was fuelled and departed shortly afterwards. A short time into the flight the cock pit warnings and audible notifications initiated indicating a
problem with the fuel system.
The aircraft managed to land safely and upon drains of the fuel tank being taken it was apparent that the FSII added prior to the fuelling had not mixed
with the fuel as per the FSII manufacturers procedure, but had settled in a mass within the fuel tanks.

Causes
• Flight crew were unaware of the correct FSII dosing and mixing requirements of the new bottle type
FSII that they were using.
• Dosing Instructions with the FSII were not clear and concise as to the correct dosing methods.

Toolbox Discussion Points

• Are your refuelling technicians aware that it is the sole responsibility of the flight crew to add
additive and not the fuelling technician?
• If asked to add additive during the fuelling what are your procedures and is everyone aware of
them?
• Do you have procedures in place for staff to express concerns over the application of the FSII by
the flight crew to management or supervisors?
28/03/2019 Joint Inspection Group Limited ‐ Shared HSSE Learnings 2
Can you think of a similar situation that you have experienced or witnessed and did you report it?
Lost Time Injury – Wrist Fracture
LFO 2019‐02

Incident Summary
An Operator was connecting a loading hose coupling on the loading island to the vehicle’s loading point 
when the valve handle on the coupling recoiled, injuring the operator’s right wrist. The operator reported 
that this occurred as a result of pressure build up in the vehicle loading pipework creating resistance to 
allow the nozzle to open. The Operator sustained a fracture that resulted in time off work.

Causes
• The valve handle had not been pushed into the fully open position.
• The valve was difficult to operate as it was a warm day and the fuel in the installation had heated up, creating a pressurised system.

Toolbox Discussion Points
• Pressure build up in installations is site and weather dependable and pressure relief is installation specific. Has the potential for pressure 
build up been considered at your installations?
• In general, there is no clear process in place to manage this issue and consequently installations require an individual approach. Is there a 
clear understanding at your location on which part of the installation pressure relief could be safely achieved in these circumstances?
• Are your Operators empowered to stop work if they encounter an unsafe situation and report it?
• Never take things for granted, avoid complacency and “risk normalisation”. Do you report hardware issues and discuss potential solutions?

28/03/2019 Joint Inspection Group Limited ‐ Shared HSSE Incidents 3

Can you think of a similar situation that you have experienced or witnessed and did you report it?
Spill and Equipment Damage
LFO 2019‐03

Incident Summary
An Operator drove away from the loading rack with the fueller still connected to the loading arm. This resulted in a small 
spill (<2 litres) and slight damage to the loading rack arm and fueller coupling. There were no injuries.

Causes
• The Operators did not not follow the correct procedure for disconnecting from the loading arm.
• Wheels had not been chocked (a local requirement).
• Contrary to the local procedures, the 360 walkaround (“Look up, Look Down, Walk around”) had not been conducted before driving away.
• The interlock had been over‐ridden by the Operator in order to drive away.

Toolbox Discussion Points
• Are all staff familiar with the correct fueller loading / unloading procedures at your location?
• Remind staff that moving a vehicle, even for a short distance, requires the correct procedures to be followed at all times and seat belts must be worn.
• Re‐emphasise the “Stop, Think, Do” or “Last Minute Risk Assessment” principle and take a few minutes to re‐assess all procedures should any 
distractions affect the normal routine.
• Are all staff familiar with the purpose and importance of brake interlocks and the consequences of over‐riding them?
• Are all staff familiar with emergency response procedures and what to do in the event of an spill incident?
• Is an effective Management walkabout process in place? (Safety walks by management and supervisors)

28/03/2019 Joint Inspection Group Limited ‐ Shared HSSE Incidents 4

Can you think of a similar situation that you have experienced or witnessed and did you report it?
First Aid Case – Hand Injury
LFO 2019‐04

Incident Summary
After completing a fuelling operation on an aircraft, an Operator was rewinding the fuel hose. The automated hose reel 
stuck in the “on” position and his hand, which was guiding the nozzle, was pinned against the hose reel guard rails. He 
sustained a minor injury to his hand (bruised and swollen knuckles).

Causes
• The automated reel activation button was stuck in the “on” position. Automated reel activation buttons due to malfunction.
• The Operator did not test the function of the automated reel activation button before, or during reeling in the hose.
• The Operator did not remove his hand from the “line of fire” as he became aware of the failure. He tried to protect the equipment from 
damage.

Toolbox Discussion Points
• Do you check automated reel activation buttons as part of the routine vehicle checks and maintenance procedures?
• Test the automated reel activation button every time as you reel in the hose; pulse the button on and off as the nozzle gets closer to its resting 
place.
• Always keep hands out of the line of fire.
• Apply the “Stop, Think, Do or Last Minute Risk Assessment principal at all times.

28/03/2019 Joint Inspection Group Limited ‐ Shared HSSE Incidents 5

Can you think of a similar situation that you have experienced or witnessed and did you report it?
Spill ‐ RVI Trailer Roll Over
LFO 2019‐05
Incident Summary
An operator was driving a fuelling truck and trailer combination on the apron en‐route to fuelling an aircraft. The fuelling 
truck tank was full and the trailer tank half full. While negotiating a turn he lost control and the trailer overturned (rollover). 
The combination came to a stop after 15 metres. A significant volume of Jet A1 was released from a puncture in the trailer 
tank. The operator was uninjured.
Causes
• The rollover occurred from a combination of speed, heavy moving load (product) and turning a corner. Vehicle rollovers 
can occur at low speeds.
• Movement of liquids (surging) in the tank can cause a rollover. At the time of the incident, the trailer was half full of 
product. Half full tanks have a greater risk of product surge from side to side than full tanks (even if the centre of gravity 
is lower) increasing the lateral force on the tank (see diagram). 
• The truck and trailer combination had already stopped and started a few times before the incident occurred which may 
have contributed to the surge risk. 
Toolbox Discussion Points
• Are all Operators familiar with the factors that can cause a rollover, such as speed, surge effects, tight corners, last minute decision to turn etc?
• Apply the Last Minute Risk Assessment principal at all times.
• Have you as a team had discussions on where the potential risk of roll over could occur at your location? If so, have they been captured in your stand 
plans and apron access plans? Familiarize all with the “black spots” and mitigations required to manage the risk.
• Just adhering to a speed limit is not enough to avoid a rollover. Greater speeds and sharper bends lead to higher rollover risk. Therefore, drive slowly 
on bends and corners, do not brake heavily whilst turning. Do you adapt your driving behaviour for specific circumstances?
• Have you considered Defensive Driving Training at your location? 
28/03/2019 Joint Inspection Group Limited ‐ Shared HSSE Incidents 6
Can you think of a similar situation that you have experienced or witnessed and did you report it?
LTI ‐ Medical Treatment Injury
LFO 2019‐06
Incident Summary
An operator injured his nose while refuelling a Beech King B350. The operator had just finished refuelling the
left inner‐tank and was standing with his back in the direction of the propeller. He turned his body around so
he could return to his vehicle. After turning he took a few steps forward and hit the propeller with his nose.
He did not experience any pain but noticed a lot of blood. After realizing he had injured his nose he went in to
the office seeking help from colleagues. He was immediately transported to the doctor for medical treatment.
The operator received a total of 9 stitches.

Potential Causes
 Propeller risks for operator fuelling between propeller blade and aircraft wing is not included in the basic HSSE training
material, Task Risk Assessment, Task Breakdown or other Training Material.
 Turning propellers manually done by fuelling operators, is not procedurised.
 There is no protection that prevents the blades from injuring personnel working around the propellers. In all possible
positions, feathered blades can inflict damage on operators and equipment.
 Propeller blades were strapped/locked in vertical position and could not be rotated freely

Toolbox Discussion Points
 Are all of your staff aware of the risks associated with this model of aircraft?
 Would a Last Minute Risk Assessment have identified the position of the propellers?
 Has a risk assessment of the PPE requirements been considered?
 Do you have a specific procedure for fuelling aircraft with inboard fuel tanks i.e. support of a second person that could provide protection from the the specific risks?
 Would you share this incident and its risks with the airport community?
 Could a similar incident occur on another aircraft type?
28/03/2019 Joint Inspection Group Limited ‐ Shared HSSE Learnings 7
Spill ‐ Loss of Containment
LFO 2019‐07
Incident Summary
During meter proving of a fueller conducted by a newly appointed third party contractor, the technician (a new employee of the 
contractor) performed a wetting run prior to commencing the meter proving process. After the wetting run, the technician did 
not completely drain the prover tank nor did he check the tank ullage before before starting a new run of 1,000 litres. 
As a result, 760 litres overflew and spilt on the ground, before the techician observed the overflow and stop fuel flow. The fuel on the ground was collected into the airport's 
interceptor system. The interceptor system piping closure balloon activated and contained the overflowed fuel, preventing the fuel from entering the rain water collector 
and/or the environment. 

Causes
• A new contractor was at work without any specific depot manager supervision.
• Basic prover tank filling procedures had not been duly respected, ie. prover tank checked for ullage.
• Lack of vigilance when carrying out the second test, not resuming the procedure from the beginning again.
• Lack of continuous vigilance during testing (likely to be caused by the van parked in between the fueller under test and the prover tank)

Toolbox discussion points
• Did the depot manager review the procedure with the contractor when filling the work permit document?
• When third party contractors perform meter proving, are their procedures subject to review by the location management to verify suitability and compliance with JIG 
standards? (Ref: JIG 1 Section 4.9.2)
• From your point of view, how critical is a close supervision during fuel transfer?
• Are there technical measures that could be installed i.e. high level cut out?
• Is the working area kept clear of obstacles that can obstruct the view?
• Which aspect of the JIG HSSE Management System should be applied when contractors are working on site?
28/03/2019 Joint Inspection Group Limited ‐ Shared HSSE Incidents 8
Can you think of a similar situation that you have experienced or witnessed and did you report it?
Fire
LFO 2019‐08
Incident Summary
During cutting and grinding operations on screws and pipes, an ignition occurred in an open fuel drain that had previously been used for filter and had been unused
for two years (replaced by a centralised purge installation). It was situated six meters away from the current cutting and grinding work area.
A work permit was issued for the task, the atmosphere testing had been carried out with a portable gas detector during the early afternoon just before resuming
works and a fixed, continuous gas detector added at the work area. According to the daily hot work permit, two 9kg ABC extinguishers had been placed within the
work area. An ignition was initiated by a spark from the work carried out. The foreman who noticed the fire used a fire extinguisher to put out the fire and raised the
alarm. Immediate corrective action was initiated and the grid was disassembled and cleaned the oil‐laden dust area.

Causes
• The grid‐covered drain gutter was no longer used due to a technical change but still contained residues containing 
undetected hydrocarbon traces. 
• The gutter had not been identified as a confined space and as such not identified as a hazard.
• A spark had been generated in the work area and initiated the fire.

Toolbox discussion points
• In spark‐generating operations, is the immediate perimeter of the area systematically assessed and isolated?
• Are we always aware that gutters in an oil depot that would not be periodically cleaned could potentially still contain hydrocarbons?
• As the gutter (and grid) was no longer of any use after the refurbishing of the depot, does it still represent a permanent risk?
• What other consequence could be imagined if this gutter would have still been in use? Is it still indicated on the latest drawing of the depot?
• Are we vigilant enough with our risk assessment processes involving hot work on site?

28/03/2019 Joint Inspection Group Limited ‐ Shared HSSE Incidents 9

Can you think of a similar situation that you have experienced or witnessed and did you report it?
Good Practice (Positive Observation of Aircraft 
Damage During Fuelling Operation)
LFO 2019‐08
Incident Summary
During an airplane refueling operation, as passengers had already boarded, the operator during his 360 walk around discovered impact damage on the
underside of the aircraft wing. He immediately informed the crew.
The captain took the decision to disembark the passengers and cancelled the flight due to the damage on the aircraft.
Two days later, a representative of the airline delivered an award letter to the fueling operator of the into‐plane company for his excellent behaviour
and immediate alert to the crew.

Toolbox discussion points
• Are we alert to third party equipment and facilities and their condition?
• What could have been the responsibility of the into‐plane company if the operator had not immediately 
relayed the information authorising the aircraft to take off?
• What lesson can be learned from such a situation?
• Do you have a recognition programme for positive intervention?
• Do you encourage staff to report abnormal situations?
Example

28/03/2019 Joint Inspection Group Limited ‐ Shared HSSE Incidents 10

Can you think of a similar situation that you have experienced or witnessed and did you report it?