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.