Fatal 1 - LOTOTO - Failure To Implement Isolation Procedure
COUNTRY OF ORIGIN
ACCIDENT / INCIDENT DETAILS
- Whilst discharging a marine aggregate dredger, a cargo conveyor hopper became blocked with material.
- The Discharge Operator started work to clear the blockage without informing the Duty Officer or Duty Engineer (Manager In Charge).
- The Discharge Operator closed and padlocked the control cab door using a security padlock; but did not isolate energy at source.
- The Discharge Operator then requested assistance from a co-worker, who was a recently appointed temporary employee.
- The co-worker asked if the system had been made safe, to which the Discharge Operator replied that it had been.
- The Discharge Operator was a long service employee familiar with isolation procedures.
- The Discharge Operator had placed himself under time pressure as it was approaching the end of the working day.
- The newly employed co-worker understood the need for isolation, and was correct to question the isolation status.
- The Discharge Operator provided a false and invalid isolation assurance to their co-worker.
- Upon observing the task, the Duty Officer Stepped-in, issued a stop work order and informed the Master and Duty Engineer.
- The Discharge Operator confirmed that he had not been time pressured by his Manager(s) (Master or Officers) and was unable to account for his non-compliance.
- Correct procedures were invoked before work resumed.
ACCIDENT / INCIDENT IMAGES
LEARNING POINTS / ACTIONS TAKEN
HOW COULD THIS HAVE BEEN AVOIDED?
- The Discharge Operator’s breach of isolation requirements was addressed through disciplinary procedures and they no longer work for the company.
- The co-worker received further training in LOTOTO procedures, inc. manager-in-charge / one-person-one lock requirements etc; following exposure to non-compliant isolation procedures.
KEY REVIEW POINTS
- The Manager-in-Charge requirement overseeing isolations is critical to the process, ensuring machinery is correctly and effectively isolated.
- Experienced employees must set an exemplary standard to less experienced or newly employed personnel.
- Security locks must never be used for isolation, there may be more than one key in circulation, or be a combination padlock.
- The Duty Officer was effective in monitoring activity on board, and pro-actively stepped-in to halt hazardous circumstances.
LEARNING POINTS / ACTIONS IMAGES
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