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The Health and Safety Hub for the Mineral Products Industry - aggregates, asphalt, cement, concrete, contracting, dimension stone, lime, precast concrete, masonry, mortar, readymix, recycling, silica sand, transport & logistics

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Fatal 1 - Operative working in guarded area without following LOTOTO procedure (bypassing safety system)

LOCATION:
CONCRETE PRODUCTS PLANT
ACTIVITY:
GUARDING AND ISOLATION
SUB ACTIVITY:
NO SUB ACTIVITY AVAILABLE
ALERT STATUS:
High Potential
DATE ISSUED:
28/05/2024 16:23:18
INCIDENT No:
03711

TITLE
Fatal 1 - Operative working in guarded area without following LOTOTO procedure (bypassing safety system)
COUNTRY OF ORIGIN

WHAT HAPPENED

 

The plant supervisor at a concrete plant independently violated UKCP62 protocols by entering a guarded area to clean spillage, whilst the skip was still fully functional. Ignoring personal safety risks, they procured tools, unlocked a securely bolted hinged guard/panel, and proceeded to clear the spillage beneath the operational skip. Images below show the potential risk the operator was exposed to if the skip had become operational.

KEY FINDINGS - Root Causes

  • Breaching UKCP62 Isolation and Lockout Procedure, and not following LOTOTO Training requirements.

Below is an image of the securely bolted hinged guard that was used to bypass the Castell key exchange gate.

This a reverse view but showing the skip in its down position.

The final image shows the operator working in the skip area, the entrance gate in the top left of  the

image should have been used. The open gate behind the operator is how the operator gained entry.

ACCIDENT / INCIDENT IMAGES




LEARNING POINTS / ACTIONS TAKEN


  • UK communications to be developed to share learnings

  • Develop and roll out a UK wide safety video ‘I could have saved a life that day but chose to look the other way’

  • Proposal for bolt heads to be welded so they can only be removed from inside the interlocked guarded area to be shared with the projects team


LEARNING POINTS / ACTIONS IMAGES


LOCATION:
CONCRETE PRODUCTS PLANT
ACTIVITY:
GUARDING AND ISOLATION
SUB ACTIVITY:
NO SUB ACTIVITY AVAILABLE
ALERT STATUS:
High Potential
DATE ISSUED:
28/05/2024 16:23:18
INCIDENT No:
03711


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