Incident alert

LOCATION:
CONCRETE PRODUCTS
ACTIVITY:
MAINTENANCE & HOUSEKEEPING
SUB ACTIVITY:
N/A
ALERT STATUS:
Normal
DATE ISSUED:
19/03/2019 13:00:36
INCIDENT No:
01509

TITLE
Fatal 6 – Employee enters hopper without PTW or Isolating
COUNTRY OF ORIGIN
United Kingdom
ACCIDENT / INCIDENT DETAILS
An employee entered a hopper below the mixer to start clearing out material that was going hard due to a conveyor belt failure underneath, without following the correct site procedures.

The mixer hopper is classed as an enclosed space and therefore no entry to this area is allowed without isolating the press conveyor belt and also being issued with a Permit to Work.

A second employee who was fully aware that a Permit to Work had not been issued, stood on the adjacent platform and watched his colleague enter the hopper without stepping in to stop him.

Just 4 days prior to this incident, both employees had signed to confirm they understood the mixer hopper clean down procedure and enclosed / confined spaces Safe Systems of Work.

The Works Manager went to the check on the job and found the employee inside the hopper. As he knew there had not been a Permit to Work issued, the job was stopped immediately. Whilst being subsequently interviewed, the employee admitted that he was also not personally locked onto the conveyor belt isolation.

Both employees were suspended pending an investigation and regrettably were both subsequently dismissed for gross misconduct. After all their efforts to ensure that isolation procedures were robust, the company had no other choice , if everyone is to kept safe.

Key Findings:
- The employee who entered the hopper was in a rush to leave site for personal reasons.

- Both employees involved were very experienced and fully aware of the Permit to Work and isolation procedures on site.

- There were contractors repairing the press conveyor under a Permit to Work and isolation. As a result, the employees felt they were safe to clean the hopper without personally isolating or getting a Permit.
ACCIDENT / INCIDENT IMAGES
Click image to enlarge

Hopper the employee entered
Click image to enlarge

Access platform from which other employee observed
LEARNING POINTS / ACTIONS TAKEN
How this could have been avoided:

- The employees should have followed the essential safety procedures, rather than allow their urgency to leave site for personal reasons to affect their behaviour.

- The second observing employee could have stepped in to prevent his colleague entering the hopper without a permit to work.
LEARNING POINTS / ACTIONS IMAGES




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