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JIG ‘Learning From Incidents’ Toolbox Meeting Pack Pack 3 – August 2011.
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JIG ‘Learning From Incidents’ Toolbox Meeting Pack Pack 3 – August 2011 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.
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.
Learning From Incidents • For every incident in this pack, ask yourselves the following questions: • Is there potential for a similar type of incident at our site? • Do our risk assessments identify and adequately reflect these incidents? • Are our prevention measures in place and effective (procedures and practices)? • Are our mitigation measures in place and effective (safety equipment, emergency procedures)? • What can I do personally to prevent this type of incident?
Fueller Leak - Apron Spill (LFI 2010-09) Incident Summary – During very hot weather (45 °C) one of the sight glasses on a fuelling vehicle cracked during a refuelling operation, spraying Jet fuel around 5 metres into the surrounding area. No one was injured and the spill (45 L) was contained. Later all of the sight glasses were replaced with aluminium. Sight glasses replaced with aluminium • Root Cause – • Thermal expansion of the pipe-work around the sight glass caused deformation and cracking. The equipment was in operation outside of expected environmental limits. • Lessons Learnt – • Need to be aware of the effect of extreme hot or cold temperatures on equipment – especially where different materials connect, such as sight glasses. • The operator acted correctly and the spill kit was adequate Original cracked sight glass
Forklift Incident (LFI 2010-10) Incident Summary -A haulage company, on behalf of a waste disposal company, was loading a waste container onto a flatbed lorry using a Moffett truck-mounted forklift at a JIG JV site. When the container was lifted to the height of the flat bed the forklift tipped forward losing the load. The forklift was forced backward into a parked tanker. • Root Causes – • The waste container was too large for the forklift putting the centre of load outside the lifting range of the Forklift truck • The lifting arrangements had been left to the haulage company and operator of the Forklift truck. • The haulage company had not assessed the load correctly for this forklift • The responsibilities for a safe system of work had not been defined • The container company had not defined the weight of the container or the load to be collected • Lessons Learnt – • The company responsible for the site should ensure that all suppliers engaged to perform a task at the site provide evidence of a safe system of work before work begins. • Waste container company had not ensured that the haulage company had a safe system of work to deliver and collect their containers • A competent person was required to assess this lifting activity rather than a ‘rule of thumb’ approach used by the haulage company • Waste container company had not ensured that the containers weight and payload were clearly defined.
Hydrant Spill (LFI 2010-11) Incident Summary-On completion of works to install a new fuel hydrant pit, a ball valve inside the pit box was left open during the re-flooding process, which resulted in a fuel spill into the excavation. Although the need to close the valve had been identified in the verbal procedure, the contractor forgot to close the valve and the supervisor forgot to check that the valve was closed. • Root Causes – • Procedures not available – No written procedures were created. All instructions were verbal. • Memory failure – The contractor forgot to close the valve and tighten the bolts. The supervisor forgot to check the valve. • Ineffective work oversight and monitoring. • The work method did not ensure someone was stationed at the new pit box while re-flooding took place to allow the air to be vented and then to close the valve when product appeared. • Lessons Learnt – • Unless covered by written procedures, all non-routine works should be accompanied by a Work Permit, Method Statement and Risk Assessment. • When installing pit boxes consider having a bleed valve in the blind flange to allow all the bolts to be tightened up and to allow swift closure at the end of the venting (as product emerges). • Consider methods to reduce the time taken to drain down the hydrant, which will allow more time to be spent on task and give a greater margin of time safety within the critical shutdown period. • Position spill clean-up material at the worksite for the duration of the works.
Engine Fire on Hydrant Servicer(LFI 2010-12) Incident Summary – An operator parked the hydrant servicer under the wing of the aircraft in line with operating procedures. After attaching the bonding wire to prepare for a fuelling operation, he noticed some light coming from under the cab of the vehicle. When going to his vehicle to investigate, he noticed flames coming from the left-hand side of the engine. Immediate actions of the operator: He took the extinguisher from the cab in order to put out the fire. Then he detached the bonding wire and moved his vehicle to a safe area. He alerted the station supervisor by radio who in turn informed fire brigade. He then pressed the emergency stop button. Following this he once more used the extinguisher to put out the fire that had re-ignited. In the presence of the fire brigade, the vehicle was towed to the station Injection pump leak • Root Causes – • Failure of a diesel injection electro-valve led to a diesel leak which burst into flames on contact with the hot engine. Defect not detected during the last periodical mechanical check. • Lessons Learnt – • Review of the preventive maintenance program and further identification of equipment failure • importance of training on emergency preparedness • . Operator action with extinguisher Can you think of any similar situations that YOU have experienced or witnessed? Did you report it?
