Workplace Incident Analysis

• IMCA Safety Flashes summarize key safety matters and incidents to facilitate learning and prevent recurrence.
• The effectiveness of the system relies on members sharing anonymized/sanitized information.

Permit to Work and Isolation Procedure

• An electrician installed fuses on a live 930V DC electrical system.
• The system powered under deck carousels and other vessel systems from the same drive cabinet.
• The electrical isolation was done by removing fuses for the carousel drive unit.
• The vessel was in port, and systems driven by the cabinet were not powered when fuses were initially removed.
• The electrician isolated the cabinet by isolating breakers and removing fuses, leaving the fuses at the bottom of the cabinet without tags and an unlocked cabinet.
• A second electrician re-installed fuses, believing the cabinet was isolated, which resulted in an arc flash and a blown fuse; no injury occurred.
• There was no Permit To Work (PTW) in place.
• The work team failed to understand and apply the required level of electrical work and isolation controls.
• The SOP for work on the equipment powered by the drive cabinet did not consider long-term isolations to protect multiple workers.
• Procedures were not followed regarding the security of the electrical cabinet as an electrician did not lock or tag the cabinet when the fuses were removed.
• Additional work team requirements for isolations discussed in the Toolbox Talk (TBT) were not carried out.
• The electrician re-installing fuses failed to verify the drive cabinet was isolated before starting work, which is contrary to instructions.
• Review procedures, work instructions, task risk assessments for Permit to Work and electrical isolations.
• Review Toolbox Talks to ensure they cover all aspects of the work including PTW and isolations.
• Ensure the system to work on is isolated BEFORE starting work; Follow workplace instructions and warning signs.

LTI - Fall from Height (control of work during SIMOPS)

• The Marine Safety Forum published Safety Alert 21-18 about a fall from the bridge deck to the deck below.
• A team working on the monkey island went to the bridge level after finishing work.
• A team member removed his safety harness and spotted a paint drip needing attention.
• While dealing with said paint drip, and working backwards in a restricted space, he fell 3m through an unguarded opening left by the lifted grating to the boat deck.
• Control of Work and Permit to Work Systems were either implemented incorrectly or were not implemented at all.
• There was a lack of situational awareness, risk perception, awareness of SIMOPS, and communication between deck personnel.
• No barriers or signage was present in the area, and a fall hazard was introduced by removing bridge gantry gratings.
• Implement more thorough toolbox talks and pre-task risk assessments.
• Identify combined operations and additional hazards introduced by SIMOPS to determine if it can be avoided or executed at different times and assess the risk level.
• Keep records to prevent recurrence and input changes into the Permit to Work/Control of Work process.

UK HSE: Poor Control of Work - Serious Injuries

• A supervisor was sentenced for safety breaches after a worker became entangled in a conveyor belt, which resulted in serious injury to his hand and arm.
• A damaged conveyor belt needed repair.
• The worker began repair work before the supervisor completed the Permit to Work or isolated the line.
• The supervisor was distracted by another matter, leading to an incomplete Permit to Work, which allowed the conveyor belt to restart during repair work.
• The supervisor failed to implement company policy and procedure for Permits to Work and isolation.

Fractured Finger When Handling Metal Plates

• A crew member suffered a pinch injury to their right hand baby finger as a result of working on deck and fractured the tip of the finger and required sutures.
• Heavy weather damaged welded plates.
• In the process of manually repositioning the plate with another crew member, the injured person sustained a pinch injury to their finger when it was trapped between the plate and frame
• An X-ray confirmed a distal fracture that required stitches.
• The plate design did not allow for safe manual handling.
• The plate installation had a permanent risk of finger entrapment.
• Risk assessments and toolbox talks used were generic, not task specific, focusing on hot work and not including manual handling.
• The plate was modified to have temporary handles to keep fingers away from the pinch points.
• Sourcing magnetic lifting handles is a long term solution.
• Ensure that generic risk assessments are modified for the task with either a dynamic risk assessment or toolbox talk for a full assessment of risk.
• To improve the process and make it safer, use the toolbox talk or JSA to improve the task by defining and understanding risks and reducing the probability and/or severity.

UK HSE: Liquid Petroleum Gas (LPG) Leak

• The UK Health and Safety Executive (HSE) reported that a fine was issued to the operator of the UK's largest oil refinery for health and safety breaches involving a liquid petroleum gas (LPG) leak.
• Approximately 15 tonnes of LPG were released through a valve near a roadway at a refinery in Fawley, Hants, UK.
• The leak went undetected for around four hours and was discovered by an employee cycling home.
• It took over an hour to find the leak source, and on-site emergency personnel had to reset the valve.
• LPG was put through the pipe work at too high a pressure for the valve.
• There was no process in place to detect the discrepancy in the flow in the pipe.
• The company failed to take all measures necessary to prevent a major incident.
• Measures to prevent incidents should be proportionate to the risks where companies are required to have layers of protection in place to prevent incidents with large quantities of substances.
• Layers of protection failed or were not in place, resulting in a significant leak, where there was no fire or injury, there was potential for a major incident.
• Emphasis has been brought to light to highlight the importance of maintaining the layers of protection and preventing leaks like the one that occurred.