See Something, Say Something

FOD Alert

Fuel cap found on taxiway

Apron Controllers in Providenciales have over the years reported multiple incidents of Foreign Object Debris (FOD) on the airside. Yesterday, however, the particular FOD found was an aircraft fuel tank cover. This, of course, is of concern to the Airports Authority which is responsible for maintaining safe operations at its facilities.

The fuel cap found appears to have originated from an Airbus aircraft, but such incidents are not aircraft specific. Observations in the USA and Canada reveal that the aircraft most susceptible have pressure-refuelling systems in which the fuel caps are mounted underneath the wing without a cover panel. Fuel caps have lanyards to keep them attached to the aircraft; however they can become damaged, detached or even removed.

A report from Transport Canada suggests that there are two possible scenarios which give rise to this issue:

1. Fuel caps have not been re-installed after aircraft refuelling, and during take-off the fuel cap falls to the surface.
2. Fuel caps are improperly engaged or locked when re-installed and during take-off or landing, the subsequent vibration causes the caps to detach.

Perhaps personnel carrying out aircraft refuelling in the Turks and Caicos Islands can learn from this and take additional care to ensure that the fuel caps are properly engaged and locked into position. Any instance where it is noticed that the fuel cap is missing should be reported to the operator so that the appropriate investigation can be carried out.

Lessons to be learned

TCIAA employees do not engage in refuelling operations, but we can all learn from this. How so?  MEASURE TWICE, CUT ONCE!

Captain Sullenberger, famed by the Hudson River ditching of an Airbus 320, credits the principle of “measure twice, cut once” to the successful ditching and advises all of us to use it.

When we are travelling on jetliners, we often hear the instructions for the flight attendants to close the doors and cross check.

Quite often, we attend to activities that necessitate us check and double check, but as humans, we tend to take shortcuts. No suggestion is being made that shortcuts are often taken, but one must highlight that natural human tendency which always gets in the way. We just need to constantly remind ourselves that we naturally “expect things to be” but actually have to work to “ensure that they are”.

In air traffic control, the advice is: NEVER ASSUME, ALWAYS DETERMINE. The words used by different individuals or groups may be different, but the intent is the same.

SMS Reporting

The filing of an SMS report for this observation must be applauded. It is important that these instances of FOD be recorded so that the Airports Authority can proactively handle issues that are prejudicial to safety, as well as to measure any progress that is made. To improve safety performance, one must measure. Measuring requires recording the events as they occur. Your responsibility is simple: See Something, Say Something.”

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So, what message does this article give the team?

“Something happens when I report” and “I think I made a difference”

“I did this”

“Hey, I want to find something too and say it was me this time”

“I’m surprised, I wasn’t blamed, quite the opposite”

“That was easy and even I can have a voice”

“That was interesting, I never knew that”

“Wow, I really am involved in safety”

“I know something more about this and feel I can talk to someone about it”

“I’ll tell that person to report it”

… all that it took

• Accessible Reporting Channel.
• Someone to constructively analyse the report (within a just culture).
• Someone to create a timely constructive/knowledgeable/respectful response to all staff.

… does the Safety Management System benefit? Sure:

• Safety Culture.
• Trust and buy in.

… is this an SMS?

• Yes – pretty much.  The “engine” of the SMS is the management of the data which can be “tuned” to meet SMS output expectations, but it is nothing without the “fuel”.  Plant this seed of a simple reporting system and the SMS will naturally grow.

So, if you see something, say something.