Serious injury caused by energy isolation failure

What happened?

A yard worker was cleaning debris from underneath a hydraulic pipe. Whilst performing this task, the worker placed his forearm on a hydraulically operated pipe stand. This put the forearm in the line of fire between a lift pocket and a recently modified plate. A serious injury occurred to the worker’s forearm when the pipe stand (see photograph) was lowered by another worker operating the hydraulic lowering mechanism.

What went wrong? What were the causes?

• There were no energy isolation routines to prevent the lowering operation from occurring inappropriately, though this was covered and required by our members’ permit to work (PTW) system;
• There were simultaneous operations (SIMOPS) taking place and these presented risks which had not been properly assessed;
• There had been modification of this equipment and this had not been fully risk assessed;
• The task plan was not detailed enough to define all of the hazards in the work area;
• The injured person did not notice that his task placed him ‘in the line of fire’.

What actions were taken? What lessons were learned?

• All activities require a risk assessment. Where simultaneous operations have the potential to expose a person to harm, the PTW and isolation process should show that a higher level of control, communication and mitigation is in place;
• Use the MoC process to ensure that modifications to equipment are assessed and do not introduce a new hazard.

Members may wish to refer to the following:

• Fatal accident in connection with the operation of an A-frame based launch and recovery system (LARS) used for ROV operations (casual factor: failure of isolation)
• Inadvertent lowering of lifeboat (casual factor:failure to identify hazards)
• Serious finger injury: procedures during engine maintenance (injured person was in the line of fire)
• Line of fire (video)
• In the line of fire (video, IMCA SEL 036)
• Guidelines for management of change (IMCA SEL 001)