Mitigating Human Error in Jet Fuel Contamination

Environmental sustainability in the aviation industry is becoming an area of both research and concern. Reducing our carbon footprint is becoming a necessity as natural resources are depleted faster than they are created. However, some protocols intended to improve the safety of the industry have resulted with unintentional consequences. In 2014, diesel-powered ground support equipment, used to support flight operations, began utilizing diesel emissions control systems to improve air quality and reduce emissions for ground service providers. Diesel exhaust fluid (DEF) effectively reduces the emissions of the two most critical components of diesel exhaust, particulates and NOx. While DEF is effective at reducing pollution, it has also been the subject of several contamination incidents that have led to inflight emergencies. DEF is a colorless liquid, similar to fuel system icing inhibitor (FSII). In all three incidents, DEF was confused with FSII and inadvertently added to aviation fuel which was then pumped into the aircraft. While none of these incidents resulted with catastrophic outcomes, the potential for such an event is clear. In 2019 an industry working group was established to perform a safety risk assessment and propose recommendations for mitigating this hazard. While each of these incidents was thoroughly investigated the recommendations provided were broad, high-level, and general in nature. Recognizing the need for additional research which examined the underlying organizational and environmental factors, the authors considered these elements in light of the recommended strategies proposed by the working group. It was found that a proactive and reactive approach to mitigating human error was needed to minimize the potential for jet fuel contamination. A learner-centered approach to training that accounts for generational differences and levels of expertise, combined with a hazard reporting tool that proactively identifies potential DEF contamination hazards both have the potential to minimize the occurrence of human error in jet fuel contamination.