Documenti di Didattica
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Meeting Pack
Pack 5 May 2012
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and (iii) nothing in this document constitutes technical advice, if such advice is required it should be sought from a qualified professional adviser.
3 pin holes
found under
the Ushaped
small bore
pipe
Root Causes
Lessons Learnt
Annual entry into the chamber would have enabled a more detailed
visual examination which may have meant this defect would have been
detected earlier. Any entry must be in accordance with confined space
entry requirements.
Any valve chambers with defects should be addressed as a matter of
urgency.
The leaking part was made of carbon steel. The replacement part is
made of stainless steel to eliminate the risk of corrosion.
A sufficient maintenance/repair programme of the top covers of valve
chambers should ensure that valve chambers remain leak-tight.
Implement a method for identifying the presence of fuel in the chamber
before pumping out any liquid e.g. dip rod with water-finding paste.
Level sensors could be installed in the chamber that will trigger an alarm
in the control room if flooding exceeds the pre-set maximum level.
(LFI 2011-05)
Incident Summary An operator was lowering a platform when it stopped unexpectedly. When he
then tried to raise it, it suddenly dropped 1.5 metres to its lowest position. The 2
chains on the fork lift type platform had failed. The sudden drop resulted in the
operator having muscular pain in this back. When he visited the doctor the
following morning, he was given 2 days medical leave to rest his back.
Root Causes
The maintenance contractor was not accredited
for the maintenance of such lifting platforms.
Incorrect tools were used which may have
weakened the pins
The new chains were delivered without new pins
and linkages, a deviation from normal procedure.
The new chains were installed using the old pins
as it was perceived to be an urgent need to get
the platform back in service
Although the repaired platform was inspected by
maintenance before being brought back into
service, there was no formal procedure or
checklist for this.
A previous report of jamming of the platform had
not been investigated and potential issues
therefore missed.
Lessons Learnt
Check that maintenance contractors for
platforms are assessed using a prequalification evaluation and trained by the
original
equipment
manufacturers
in
maintenance procedures.
Only approved replacement parts should be
used for maintaining and repairing lifting
devices. Spare parts procured and delivered
should have parts lists detailing exactly what
parts should be included.
Ensure that all platforms are thoroughly
checked and approved by a competent
person before being returned to service
Incident and potential incident reports must
be investigated.
Overtaking Incident
(LFI 2011-06)
Transporter
Hydrant
Servicer A
Hydrant
Servicer B
Hydrant
servicer
B
sounded its horn and
began
to
overtake
hydrant servicer A and
the
transporter.
As
hydrant servicer B did
this
the
transporter
slowed in preparation for
turning left.
Hydrant
servicer
A
pulled out and collided
with hydrant Servicer B.
Both vehicles sustained
major
damage
but
luckily nobody was
injured.
Discussion Points
The driver of hydrant servicer B was running late for his scheduled fuelling as he had not copied his
fuelling schedule correctly. How do you ensure you know what fuelling you have to complete during your
shift?
Would you ever consider overtaking two vehicles on the apron? What hazards could this action present?
What Driving Safe Practices, if obeyed, could have prevented this incident?
Can you think of a similar situation that YOU have experienced or witnessed? Did you report it?
Drive Away
(LFI 2011-07)
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.
Damaged
connector ring
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 Walkaround have prevented this incident? Does
your Walkaround include looking up to check aircraft couplings?
If distracted while completing a 360 Walkaround what should
you do?
Is the aircraft coupling always easily seen during your 360
Walkaround?
Aircraft Strike
(LFI 2011-09)
Root Causes
The Operator was distracted by having fuelled the wrong aircraft.
An ineffective 360 Walkaround was completed so the operator
failed to notice the fuelling cabinet door was open.
He did not notice the warning interlock lamp.
The vehicles interlock system was ineffective due to the design.
Lessons learnt
Damage to aircraft
When your routine is interrupted stop and take time to assess the situation (last-minute risk assessment).
Always complete a thorough 360 Walkaround.
The interlock lights were not positioned in a prominent position making them difficult to see.
The interlock-system only activated the brakes on the trailer axle and this provided insufficient braking to
prevent the drive away.
Can you think of any similar Near Misses that YOU have
experienced or witnessed? Did you report them?