During a Take One Risk Assessment training session it became apparent that there had recently been a breach of the site LOTOTO procedures.

Following repairs to a cement sock an employee asked the contractors to wash the loading chute down to remove the residual cement spillage. To enable this to happen the isolation had to be removed so the water system could be energised. The contractors passed their lock-off keys to the employee who removed all 3 keys from the isolator lock and re-energised the plant. The contractors then washed down the chute with the head drum guard removed and the conveyor energised but not running.

Site management only became aware of this incident because it was brought to their attention by the employee involved.

Whilst nobody was injured, this failure in procedure had the potential to cause serious injury if the someone had restarted the conveyor.

Key Findings - root causes

• The conveyor could not be isolated locally so it was not possible to use the water hose without energising the plant.
• No one recognised that the additional task required an additional risk assessment to fully control the hazard.
• Site staff and the contractors failed to follow the site LOTOTO procedure for the additional task.

• Provide a local isolator to batch belt to prevent re-occurrence of the incident.
• Review all plants within the company with the employee involved in the incident to establish whether there are any maintenance activities which require additional local isolators.
• Employee to complete additional RAMS, LOTOTO, Control of Contractors & Permit to Work training prior to being re-authorised to manage such tasks.
• All contractor company employees to update their RAMS and LOTOTO training along with delivery of the HM Take One Risk Assessment TBT.