Electrical Isolation Incident

Permit to Work and Isolation Incident

• An electrician was installing fuses on a live 930V DC electrical system
• Under-deck carousels had mechanical and electrical isolation as a safety measure for maintenance
• Other critical vessel systems were powered by the same drive cabinet
• Electrical isolation involved removing fuses for the carousel drive unit
• Initially, the vessel was in port when the fuses were removed, and no other systems from the drive cabinet were powered
• Breakers were isolated, and fuses removed to completely cut power to the drive cabinet
• Fuses were left at the cabinet's bottom without tags, and the cabinet remained unlocked
• Another electrician re-installed the fuses after maintenance
• The electrician who re-installed the fuses believed the cabinet was isolated
• A fuse insertion tool rated to 1000V was used to remove the protective mesh before the fuses were installed
• An arc flash occurred, and the fuse blew when the second fuse was inserted
• The electrician was not injured

Factors that contributed to the incident

• No Permit To Work (PTW) was in place for activity control, communication, and coordination
• The work team did not understand the company's required control levels for electrical work and isolations
• Isolations were incorrectly applied
• Vessel Standard Operating Procedures (SOP) did not account for long-term isolations
• The SOP's should have included a safety requirement to protect multiple workers in the area
• Security protocols for the electrical cabinet were not followed
• The electrician did not lock and tag the cabinet after removing fuses
• Toolbox Talk (TBT) regarding isolation requirements were not followed
• The electrician re-installing the fuses failed to verify the drive cabinet's isolation before starting work
• The electrician also failed to follow cabinet instructions and work instructions

Recommended Actions

• Review procedures, work instructions, and risk assessments for Permit to Work and electrical isolations
• Review Toolbox Talks to ensure they encompass all Permit to Work and isolation-related aspects
• Verify system isolation BEFORE starting any work
• Adhere to workplace instructions and warning signs

Fall from Height Incident

• A Marine Safety Forum report detailed an incident where someone fell from the bridge deck to the deck below
• Two teams of four crew members performed vessel superstructure maintenance
• One team worked on the monkey island, the other on the bridge level gantry
• The bridge level gantry team removed gratings and worked on the gantry's steel frame
• The monkey island team moved to the bridge level after finishing their task
• A crew member removed his safety harness
• The crew member saw a paint drip and decided to address it and do a final check before break
• Space constraints forced the crew member to walk backward without looking for hazards
• A 3m fall occurred when the crew member stepped backwards through an opening left by a removed grating section
• The grating was located on the boat deck
• The MSF’s member reported an LTI

Causes for the fall

• Control of Work and Permit to Work systems were not effectively implemented
• There was inadequate situational awareness, risk perception, Simultaneous Operations (SIMOPS) awareness
• The deck personnel in charge and the deck crew had inadequate communications
• There weren't any barriers or signage present in the incident area
• The removal of bridge gantry gratings created a fall hazard

Recommended Actions

• Conduct more effective toolbox talks and pre-task risk assessments, with a focus on non-routine tasks
• Apply a more thorough review of SIMOPS
• During work planning, identify any combined operations and SIMOPS-related hazards
• Determine whether SIMOPS can be avoided or tasks can be executed at different times
• Assess the level of risk associated with SIMOPS
• Evaluate whether planned control measures are adequate
• Implement additional risk reduction measures and update risk assessments if planned controls are inadequate
• Keep Incident records to prevent recurrence
• Contribute to the Permit to Work and Control of Work process, and integrate any identified changes

UK HSE: Poor Control of Work Incident

• An individual supervisor was sentenced for safety breaches
• A worker became entangled in a conveyor belt, suffering serious hand and arm injuries

What happened

• A worker started repairing a damaged conveyor belt
• The conveyor belt started moving and his arm became entangled, causing muscle and tissue damage

Causes

• The site supervisor was responsible for completing a Permit to Work and isolating the line, but failed to do so due to a distraction
• The conveyor belt restarted during the repair work, leading to the employee's injury
• The site supervisor did not implement company policy and procedures for Permits to Work and isolation
• The inspector stated that the incident could have been easily avoided by doing correct control measures and safe work practices

Fracture during metal plate handling

• While working on deck, a crew member suffered a pinch injury
• The injury was to the right hand baby finger, resulting in a distal fracture and laceration
• Sutures were required to close the finger's laceration

Causes

• Heavy weather damaged deck plates
• The injured person suffered a finger pinch injury between the plate and frame
• An X-ray showed a distal fracture to the tip of the finger and the wound required stitches
• The design of the plate had no considerations for safe manual handling
• The plate installation had a permanent risk of finger entrapment
• Risk assessments and toolbox talks were generic and not specific to the task
• The JSA covered hot work only, and did not cover manual handling

Lessons Learned

• Safety by Design: Modify plates with temporary handles to maintain finger safety
• Utilize magnetic lifting handles
• Take care with generic risk assessments
• Modify them to suit the task, or use a dynamic risk assessment or toolbox talk for a full and thorough review of the task
• Use the toolbox talk or JSA to define and understand areas of risk if the task is slow, uncomfortable, or inconvenient

UK HSE: Liquid Petroleum Gas (LPG) Leak

• The operator of the UK’s largest oil refinery was fined for health and safety breaches
• A leak of liquid petroleum gas (LPG) was discovered by a worker cycling home at the end of their shift

What happened

• Around 15 tonnes of LPG was released through a valve near a roadway used by LPG road tankers visiting a refinery in Fawley, Hants, UK
• The leak was undetected for around four hours before being discovered by an employee on his way home
• It took a further hour to find the source of the leak and reset the valve via on-site emergency personnel

What went wrong

• LPG was put through the pipe work at too high a pressure for the valve
• There was no process to detect discrepancies in the flow in the pipe
• The company failed to take necessary measures to prevent the major incident
• The inspector said required prevention measures should be proportionate to the risks
• Where companies handle large quantities of substances that can cause major incidents, such as LPG, they are required to have layers of protection in place to prevent incidents
• A number of protection layers either failed or were not in place
• Even though there was no fire or injury that occurred, there was potential for a high severity incident
• The prosecution has been brought to highlight the importance of maintaining the layers of protection and preventing incidents </