reliance ATF department near miss report

1. Near Miss- Analysis-2019-20- ATF Business

2. Near Miss- Analysis-2019-20
Total Number of Reported near miss are 174Nos.
Near Misses are Analyzed on three basic categories,
1. Place of Incident (Gantry, Office, Tank Truck, OWS, Tank Farm, Refueller, Apron, Pump area, Work at Height and
Miscellaneous)
2. Risk Or Potential Risk (Electrical shock, Fall from Height, Fall of Material, Fire, LOPC, Slip/Trip, Traffic Congestion,
Injury& Accident)
3. Potential Root Cause (Error in Driving, Faulty Construction, Faulty Design, Wear and tear, Lack of Housekeeping/Slippery
Surface, Lack of Inspection, Lack of awareness/Procedure, Unsafe Act & Port side Engine “ON” By customer)

3. Near Miss- Analysis- Place of Incident
Place of
Incident
Number of
Incident
Refueller 61
Office 13
Apron 11
Pump Area 10
Tank Truck 10
Gantry 7
Tank Farm 7
Dispenser 7
Work at
Height/Ladder
5
Miscellaneous 4
OWS PIT 3

4. Near Miss- Analysis- Risk/Potential Risk
Risk or Potential Risk Numbers
Accident 24
Fall from Height 23
Slip/Trip 23
Injury 23
LOPC 19
Fall of Material 10
Electrical shock 4
Fire 4
Traffic Congestion 4

5. Near Miss- Analysis- Potential Causes
Potential Root Causes Numbers
Lack of Inspection 52
Unsafe act 26
Faulty Design 23
Lack of
Housekeeping/Slippery
Surface
13
Wear and tear 11
Error in Driving 7
Port side Engine on By
customer
2
Faulty Construction 2
Lack of
awareness/Procedure
1

6. Near Miss- Analysis-2019-20

7. Near Miss- Analysis- Place of Incident
 Refueller is the Major Area
where the Most of the
Incidents were Happening.
 Hence We will Bifurcate the
various causes and Various
Risks elements pertain to
Refueller in the Upcoming slide.
 Next Major contribution is
Office, But by Considering the
Potential Risk, “Apron” area
is of Major concern, Hence
Apron Area analysis done in the
Upcoming slides.

8. Place of Incident(Top 2 Places) vs Potential Risk
Electrical
shock, 1 Fall from
Height, 13
Fall of
Material, 5
Fire, 2
LOPC, 8
Slip/Trip, 4Traffic
Congestion, 3
Injury, 10
Accident, 15
REFUELLER - POTENTIAL RISK
Accident, 3
Injury, 3
LOPC, 3
Slip&Trip, 1
APRON - POTENTIAL RISK

9. Place of Incident(Top 2 Places) vs Potential Risk
Example Cases: Refueller- Potential
Risks(Accidents)
 AFE stepped down from the refueller but forgot to put
parking brake
 AFE about to hit the Fire hose box during reversing
 R-10 & R-23 having small size side view mirror-
Hence whole area is not covering-
 Refueller modular door open automatically
 AFE lost control over clutch pedal, with sudden jerk
vehicle stopped
 While reversing the refueller slightly hit the Fire
Extinguisher
Example Cases: Apron- Potential Risks(Accidents,
Injury & LOPC)
 While coming back to parking after fueling, AFE crossed
Bay no-32 At the same time a flight was taxing in on same
bay which may have resulted to an incursion into aircraft
path.
 D-04, R-03 wheel choke and earthing plate not placed .
 At Bay no-56, pit cover was raised up due to wind flow of
approaching A/C EK-527as it was not in locked position
 During fueling AFE observed R-H Engine ( Eng -2) started
cranking without any prior intimation from the engineering
team- Twice
 QRV ring was in partially damage. "O" ring got worn out

10. Top 2 Place of Incident vs Potential Cause
Error in
Driving, 6
Faulty Design,
7
Lack of
Inspection, 31
Unsafe act, 7
Wear and
tear, 8
REFUELLER- POTENTIAL ROOT
CAUSE
Potable
Engine"ON",
2
Faulty Design,
2
Lack of
Inspection, 1
Unsafe act, 3
Wear and tear,
2
Slippery
surafce, 1
APRON- POTENTAIL CAUSES

11. Example Cases: Refueller- Potential root Cause(Lack Of
Inspection)
 R075 driver side seat lock arrangement found loose
 R054 cover of Handle fitted for easy climbing broken
 RDH interlock automatically activated due to loose connection of
system leading to sudden stoppage of refueller
 R040 driver cabin foot rest has been broken
 While descending from refueller (R060) ,footstep of refueller
broken
 IPC bracket (Holder) screw were found loose of refueller R014
 While going for refueling refueller modular door open
automatically
 Side handle of Refueller R-58 was in rusted condition and chances
of breaking off
Example Cases: Apron- Potential Causes(Unsafe Act,
Engine “ON”& Wear and Tear)
 During fueling AFE observed R-H Engine ( Eng -2) started
cranking without any prior intimation from the engineering
Team- Twice
 D-04, R-03 wheel choke and earthing plate not placed .
 AFE observed at Bay no-56, pit cover was raised up due to wind
flow of approaching A/C EK-527. (On investigation it was found
pit cover was not in locked position and marking was not
aligned).
 Pit cover was not in locked position and marking was not aligned
 QRV ring was in partially damage. "O" ring got worn out
Place of Incident(Top 2 Places) vs Potential Causes

12. Brain Storm session for Solution
Causes Barriers Current
Status
Analysis Recommendations
Yes No
Lack of
Inspection
of
Refuellers
Daily
Inspection,
weekly
inspection
and etc.
360deg
safety
walk
Yes
(partially
Yes)
Not
adhering
100%
Lack of
Awareness
Willful
omission
Strict Adherence of Inspection
schedules and 360 deg safety walk.
Through Investigation of the incident
if causes related t Lack of
investigation.
Behaviour Training to address the
behavioural changes and improve
HSE culture.

13. Brain Storm session for Solution
Causes Barriers Current
Status
Analysis Recommendations
Yes No
Un safe
Act
Behavioral
Training
Awareness
Training
No
(partially
No)
Lack of
awareness/
Knowledge
Willful
omission
Continuous Training and awareness
creation
Through Investigation of the incident
if causes related to unsafe act and
find out the root causes
Behaviour Training to address the
behavioural changes and improve
HSE culture.

14. Brain Storm session for Solution
Causes Barriers Current
Status
Analysis Recommendations
Yes No
Same way for all other causes, AFS need to conduct brain storm session and identify the
barriers and do the analysis, to find out where it failed and recommend accordingly.

15. Thank You