Preventing Driveaways

Monthly Safety Topic

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Contents

• What is a driveaway?

• How do we prevent driveaways?

• So why are they still happening? How can they be prevented?

• Immediate global actions to reduce the risk of driveaways

• Discussion on how driveaways could happen at this site + feedback

What are we going to do?

1. Too many drive ways - unacceptable. Our final barrier which is a walk around has failed too often

2. Introducing a revised walk around procedure

3. All staff are to adopt this and will be observed doing this.

What is a driveaway?

• A driveaway is where a refuelling vehicles leaves to aircraft without disconnecting the hose connection from the aircraft fuelling adaptor. This results in the fuelling adaptor breaking away. These adaptors are designed to break away but there is potential for more serious damage to the aircraft and/or a spill or a fire. Airport emergency services are normally required to respond.

Damaged Aircraft Adaptor

following driveaway

What does a driveaway mean to others?

• Customers unhappy with Air BP service – this could ultimately be reflected in loss of contracts

• Flight delays

− Passengers may miss connecting flights or one off important events such as weddings and funerals

• Reputation impact

− VIP’s etc may be effected.

− Journalists may be on board

• Potential for spills and environmental damage

• Potential for significant damages claims for direct and consequential loss

Current preventive measures

• Task Breakdowns: developed over many years of experience which are enhanced with local specific information (Site Specific Task Breakdowns)

• Training to a consistently high standard

• Competency assessment of all operators

• Vehicle interlocks to warn the operator if a hose is still connected.

• Brakes interlocked to prevent the operator driving away - even if the above warning is ignored.

• Gate by Gate risk assessment output incorporated into operating procedures

Then why are driveaways still Then why are driveaways still happening?happening?

13th February 2009 – Dar Es Salaam: A340

Hydrant inlet coupling disconnected first (out of sequence).

Forgot to disconnect the deck hoses. Distracted. No walkaround.

1st August, 2008 – Adelaide Australia: A320

Hydrant inlet coupling disconnected first (out of sequence). Forgot to disconnect the deck hoses.

Distracted. Walkaround completed – but no “look up”.

16th March 2006 – Palma: A319

Hydrant pit coupling disconnected first (out of sequence to help the baggage handlers). Forgot to disconnect the deck hoses.

17th February 2006 – San Juan: A300

Interrupted disconnection routine (provide paperwork to pilot).

Forgot to disconnect the deck hoses.

27th August 2005 – Dar Es Salaam: A340

Hydrant inlet coupling disconnected first (out of sequence).

Forgot to disconnect the deck hoses

Recent Driveaway Incidents

Lessons from Adelaide Driveaway

• The following link allows a video produced after the Adelaide driveaway to be downloaded (it is too large to include in this presentation pack).

• This video should be downloaded BEFORE this presentation is made as it provides valuable insights into the Adelaide driveaway – many of which are common to other driveaway incidents.

Download linkDownload link

Need to add link to global site….

Analysis of reasons for recent driveaways…

1. Disconnection procedure not followed (should be deck/plane hose first)

2. Operators now at ground level during fuelling

3. Mid-height wings e.g. Airbus 320.

4. Fuelling panels on fuselage - remote from the hose connection points e.g. Airbus

5. Interlocks faulty or ineffective

6. Interruption to routine

7. Walkaround and "look up" not completed or effective.

In the general order of the disconnection procedure:

Disconnection procedure

• Correct disconnection and stowage procedure for dispensers (note TB 0/19 needs revision):

− Disconnect hose couplings from aircraft− Check aircraft adaptor(s)− Stow hoses and lower platform− Disconnect dual pilot air line (if fitted) then dispenser intake coupling, place

adjacent to pit− Disconnect lanyard, remove pit warning marker, replace pit valve cover and

hydrant pit lid− Stow intake hose and coupling (note: also stow lanyard)− Stow ancillary equipment e.g. platform steps− Remove bonding (and earthing if used) cables and stow− Zero the meter− Complete Walkaround

• The aircraft hoses shall ALWAYS be disconnected first. Failure to do so will be viewed very seriously and will usually result in disciplinary action.

• Operators are ultimately accountable for driveaways

Operator now at ground level

• Refuelling is now controlled from ground level.

• The operator is therefore no longer immediately adjacent to the aircraft couplings at the end of the fuelling.

• Instead, the operator is closer to the hydrant pit connection. Is this why the hydrant pit connection is sometimes (incorrectly) disconnected first, and the aircraft hose disconnection overlooked?

MAKE SURE YOU MAKE SURE YOU ALWAYSALWAYS FOLLOW THE CORRECT FOLLOW THE CORRECT DISCONNECTION PROCEDURE. DISCONNECTION PROCEDURE.

IT IS IN THAT ORDER TO HELP YOU PREVENT A IT IS IN THAT ORDER TO HELP YOU PREVENT A DRIVEAWAY.DRIVEAWAY.

Mid-height wings

• Driveaways more likely when underwing fuelling - use of elevating platform and deck hoses.

• Mid-height wing aircraft are more prone to driveaways.

• Fuelled underwing

• Platform in lowered position or raised slightly.

• Hose connection less obvious from ground level.

Which aircraft that you refuel are Which aircraft that you refuel are more prone to driveaways? more prone to driveaways?

Can we make hoses more visible?Can we make hoses more visible?

What can you do to reduce the What can you do to reduce the risk of driveaway?risk of driveaway?

Standoff fuellings

•The reel hose is more easily seen from ground level during the walkaround.

•Driveways don’t tend to occur in these situations

Fuelling panel on fuselage

• Some aircraft have the fuelling panel on the fuselage

Does this create an “interruption” to routine?Does this create an “interruption” to routine?

Do your SSTB’s consider these aircraft?Do your SSTB’s consider these aircraft?

Airbus range…

Interlocks faulty or ineffective.

•The dispenser interlock systems should ensure that driveaways cannot occur.

•Interlocks systems have failed on several occasions

Always complete a full WALKAROUND and DON’T RELY Always complete a full WALKAROUND and DON’T RELY totally on interlockstotally on interlocks

Review integrity of interlock design and maintenance Review integrity of interlock design and maintenance

Interrupted routine

• Disconnecting from an aircraft after a refuelling and the stowing of hoses and equipment requires a routine process to be consistently applied to avoid mistakes.

• Most operators carry round a mental check-list of what needs to be done, but this check list can be fooled if the routine is interrupted.

• A common feature in some driveaways (e.g. Adelaide, Dar es Salaam) is that the operators routine was interrupted by request for help or assistance from other ramp workers e.g. pilots wanting paperwork to be signed.

Don’t let your routine be interrupted if you can Don’t let your routine be interrupted if you can reasonably do soreasonably do so

If interrupted , always start your Walkaround If interrupted , always start your Walkaround again from the beginningagain from the beginning

Walkaround and "look up" not completed or effective

• Although walkarounds were carried out in some of the driveaways, that were not effective and did not identify that the aircraft hose was still connected.

• A walkaround is a full walkaround of the vehicle, starting in one place and moving round the vehicle, checking to ensure that everything is stowed properly, before returning to the start point.

• A full walkaround, with look up, is a simple but effective control. There is no reason why it should not be completed fully before entering the cab to depart.

• We are therefore introducing a new WALKAROUND PROCEDURE on the following slide.

New Air BP Walkaround Process

During the Walkaround

• The benefitsThe benefits of this process are that the Operator:

• is not looking up while walking.

• rigorously applies the walkaround and “look up” procedure in a systematic and effective manner

• will be more likely to carry out a thorough walkaround and spot things out of place

• Look for:Look for:• Hoses disconnected and

stowed?• Aircraft fuel caps on and

panel closed ?• Input hose disconnected

and correctly stowed (should be in boom raised position)?

• Lanyard disconnected and stowed?

• Bonding lead disconnected and stowed?

• Platform lowered?• Steps or ladders stowed or

safely parked in agreed storage area?

• Any third parties and other equipment in the vicinity?

• Clear exit path?

Reminder of the HSSE Rules

In 2004 we set out some simple rules:

• Air BP’s goal is to ensure the health, safety and well being of everyone who works for, with us or who may be affected by our work. To achieve this, Air BP requires your personal commitment to the following HSSE Rules.

• I will perform all tasks exactly as I was trained to do them

• I will always wear the right PPE for the job

• I will never leave a product transfer unattended

• I will never over-ride safety devices (*)

• I will do a thorough walk around and look up check before driving away

• I will always confirm the correct grade of fuel for overwing fuellings

• (*) Unless authorised to do so by my Supervisor or in an emergency situation

Summary #1

A driveaway is serious incident that could result in injuries, fires or even fatalities.

All driveaways are preventable providing the following steps are followed:

For Operators

• Always follow the correct disconnection procedure i.e. plane/deck hose first

• Always do a complete walkaround and “look up” after each and every underwing refuelling following the new walkaround and “look up” procedure.

• Don’t let your routine be interrupted if you can reasonably do so. If you are interrupted, always start again from the beginning of your mental checklist and ensure no steps have been missed.

• Don’t rely on interlocks to prevent a driveaway. They are the last line of defence.

Summary #2

For Site Managers, Supervisors and visiting Managers

• Carry out checks to ensure that the correct disconnection procedures are being followed. Recognise good practice.

• Observe end of fuelling walkaround and look ups for compliance with the new procedure. Recognise good practice.

• Rigorously enforce compliance with the above.

• Support your team if they are pressurised by others to take short cuts.

• Use themed SOC conversations to asses operator understanding of the controls around driveaways, recognising good practice and instigating action where required.

• Discuss driveaway risk periodically in Team meetings to monitor changes and trends.

•Do your SSTB’s and Gate by Gate Risk Assessments adequately address the risk?

•Recruitment should stress compliance with procedures for repetitive operations

Team Discussion and Feedback

Having been through this presentation, we are keen to learn from your personal experience and knowledge.

• Do you agree with what has been said?

• Are there any areas you would challenge or emphasise?

• Any suggestions on how we could further reduce the risk of driveaways?

Your Asset Manager will soon be holding a teleconference to discuss and collate your ideas and suggestions

Driveaway Back Up Slides

Specific Driveaway Incidents

Adelaide – August 2008

• On 01/08/2008, an operator had finished refuelling a Jetstar A320.

− He uncoupled the ground input coupler and re-stowed it,

− Then completed a walk-around but did not look-up.

− Then climbed into the dispenser cab, released PTO and handbrake, checked the interlock lights and as none were on/active he proceeded to drive off slowly.

− He next saw something in the rear vision mirror, stopped and looked behind, noticing the deck hose was hanging down.

− He realised he had left the deck hose attached to the aircraft.

• On investigation it was discovered that the interlock counter weight on the R/H hose was missing. Due to its design this resulted in the coupling stowage arm interlock not activating. This was the reason why the interlock light didn’t activate in the cab when the deck hose still remained un-stowed.

• There was no damage to the hydrant dispenser except for a requirement to re-weld the counter weight back onto the stowage point.

• The aircraft was grounded due to damage to the fuel couple-up ring.

Adelaide: Photos

FuellingThe damage Fuel panel location

28

Dar Es Salaam 2005

This incident involved a self propelled

dispenser, however a tractor was used to

tow it away from the aircraft. The tractor

was powerful enough to tow the dispenser despite its interlocks.

Palma March 2006

Operator disconnected hydrant pit coupling first (out of sequence to help the baggage handlers) on Easyjet A319 and then forgot to disconnect the deck hoses

Palma – 16th March driveaway

• This Easyjet A319 is positioned for fuelling in the same way as the aircraft in the incident

• You can see that the platform is not extended

• A walkaround must entail looking to see if the hoses are connected

• Don’t rely on seeing the platform stowed