Electrical Isolation Incident

An electrician installed fuses on a live 930V DC electrical system
Under deck carousels were mechanically and electrically isolated as a maintenance precaution
The electrical isolation involved removing fuses for the carousel drive unit
Several other important vessel systems were powered by the same drive cabinet
The vessel was in port and other vessel systems were not powered when fuses were initially removed
The electrician isolated the power to the entire drive cabinet by isolating breakers and removing fuses, then left fuses at the bottom of the cabinet
Tags were not applied, and the cabinet was not locked
Another electrician re-installed fuses, believing the cabinet's power was isolated
The second electrician opened the cabinet, removed the protective mesh, and installed fuses using a 1000V-rated fuse insertion tool
An arc flash occurred, and the fuse blew during the second fuse installation, but the electrician was not injured

No Permit To Work (PTW) was in place to control, communicate, or coordinate activities
The work team didn't understand or apply the necessary level of control for electrical work and isolations
Isolations were incorrectly applied
Vessel Standard Operating Procedures (SOP) for work on equipment powered by the drive cabinet did not consider long-term isolations to protect multiple workers
Procedures were not followed including the electrician not locking and tagging the cabinet when removing fuses
Electrical cabinet security was not in accordance with company procedures
Additional work team requirements regarding isolations were discussed in the Toolbox Talk (TBT) but not implemented
The electrician re-installing fuses failed to verify the drive cabinet's power was isolated

Review procedures, work instructions, and task risk assessments for Permit to Work and electrical isolations
Review Toolbox Talks to ensure they cover all aspects of work, including PTW and isolations
Verify the system you are working on is isolated BEFORE starting work
Adhere to workplace instructions and warning signs, and ask questions if unsure

Two teams of four crew members maintained the vessel superstructure
One team worked on the monkey island
The other team worked on the bridge level gantry, removing gratings and working on the steel frame
The team from the monkey island came down to the bridge level, and one member removed his safety harness
The crew member spotted a paint drip and decided to check the bridge before break
Restricted space forced the crew member to work backwards without looking for obstacles
Although aware of another team working on gratings, he didn't confirm their location
The crew member stepped backwards and fell 3m through the opening from the lifted grating to the boat deck
The incident was considered an LTI (Lost Time Injury)

Work and Permit to Work Systems weren't correctly implemented
Lack of situational awareness, risk perception, awareness of Simultaneous Operations (SIMOPS), and poor communication among deck personnel
No barriers or signage marked the area of the incident
Removal of bridge gantry gratings introduced a fall hazard

Conduct more effective toolbox talks and pre-task risk assessments
During scope of work planning, identify combined operations and additional hazards introduced by SIMOPS and assess if SIMOPS can be avoided
Assess risk associated with the SIMOPS
Determine if planned control measures are adequate, and update if not
Keep a record of incidents

A supervisor was sentenced for safety breaches after a worker got his arm entangled in a conveyor belt
The worker was repairing a damaged conveyor belt
The conveyor line started, and his arm got entangled, causing muscle and tissue damage
The site supervisor was responsible for completing a Permit to Work and isolating the line but got distracted
The Permit to Work and isolation were not completed, causing the conveyor belt to restart

The site supervisor did not implement company policy for Permits to Work and isolation and the injury could have been avoided with correct control measures

A crew member suffered a pinch injury to his finger while working on deck
The injury resulted in a distal fracture to the finger tip and a laceration requiring sutures
Heavy weather damaged welded plates on deck
While manually handling the plate with another crew member, the injured person's finger was trapped between the plate and frame

Apply safety by design, modifying plates with temporary handles to keep fingers away from pinch points
Use magnetic lifting handles
Tailor risk assessments or use a dynamic risk assessment/toolbox talk for a full task review
Assess if tasks are slow, uncomfortable, or inconvenient and use the toolbox talk or JSA to define and reduce risks

The operator of the UK's largest oil refinery was fined for health and safety breaches
A worker discovered a liquid petroleum gas (LPG) leak while cycling home
Around 15 tonnes of LPG released through a valve near a roadway used by LPG road tankers at a refinery in Fawley, Hants, UK
The leak went undetected for about four hours without detection by on-site staff
It took another hour for on-site emergency personnel to identify and stop the leak

A Health and Safety Executive (HSE) investigation found that LPG was put through the pipe work at too high a pressure
No process existed to detect flow discrepancies in the pipe
The company failed to take necessary measures to prevent a major incident

Measures to prevent incidents should be proportionate to risks
Companies handling large quantities of hazardous substances must have layers of protection
The incident occurred because multiple layers of protection failed or were not in place, resulting in a major leak
The prosecution highlights the importance of maintaining layers of protection