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Lesson Learned-HIPO Near Miss - Energy Isolation

An electrical worker was found working inside an isolator switch box without first isolating or locking out the live 415V power feed cable entering the switch. The worker had been instructed by the plant machinery vehicle engineer to disconnect the power to a rebar bending machine that was being repaired. However, permit to work and lock out/tag out procedures were not followed to isolate the live power source. An investigation found that equipment was commissioned for use without proper inspections, electrical workers and foremen lacked competency training in lock out/tag out procedures, and responsibilities between construction and operations teams were not clearly defined. This near miss exposed the worker to potential electrocution and highlighted the need to ensure safety procedures are followed and all personnel are

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248 views1 page

Lesson Learned-HIPO Near Miss - Energy Isolation

An electrical worker was found working inside an isolator switch box without first isolating or locking out the live 415V power feed cable entering the switch. The worker had been instructed by the plant machinery vehicle engineer to disconnect the power to a rebar bending machine that was being repaired. However, permit to work and lock out/tag out procedures were not followed to isolate the live power source. An investigation found that equipment was commissioned for use without proper inspections, electrical workers and foremen lacked competency training in lock out/tag out procedures, and responsibilities between construction and operations teams were not clearly defined. This near miss exposed the worker to potential electrocution and highlighted the need to ensure safety procedures are followed and all personnel are

Uploaded by

Mukesh
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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HIPO NEAR MISS– ENERGY ISOLATION

Region Middle East (Oman)


Incident Location: Khazzan CPF Project (onshore)
Incident Date: 10-Mar-2015
Main Golden Rule Breached: Energy Isolation

415 V live power


feed

Power out cable


which was
removed from
isolator switch box

Summary:
The pre-cast area foreman requested the Plant/Machinery/Vehicle (PMV) area engineer to repair a rebar
bending machine which was not working properly. After assessing the bending machine, the PMV
engineer instructed his electrical foreman to disconnect the machine and transport it to the PMV shop. He
further instructed the area Electrical Worker (EW), by phone, to disconnect the machine’s power from the
isolator switch box at the precast area.
The EW turned off the isolator switch and proceeded to work inside the isolator switch box to disconnect
the “power out” cable to the machine. The EW was observed by a client representative and found that the
415 V power feeding the isolator switch had not been isolated or locked out. Permit to Work (PTW) or
other control of work documentation was not in place for the activity.
Outcome: It was found that the 415V power feed cable going into the isolator switch had not been
isolated or locked out thus exposing the worker to a high potential serious consequences, which could
have resulted in electrocution.
Root Causes & Contributory factors Lessons Learned
 Poor condition equipment mobilized to site and  All equipment shall be identified and inspected
commissioned for use: No pre-mobilisation inspections by contractor
for Pre-cast yard equipment  Develop proper checklists for inspection of
 No process in place for inspection of miscellaneous miscellaneous equipment
equipment: PMV department does not currently have a  Ensure a qualified and authorized electrical
process, checklists, etc. to inspect miscellaneous person is assigned for commissioned areas
equipment/ machines  Ensure awareness training for all electrical
 Training and competency of electrical foreman workers on PTW and LOTO
Foreman & Electrical Worker did not have the proper  A process for handover of area from construction
competency level to perform the role they were given. to operations PMV needs to be defined under
They were not trained in Project Lockout-tagout (LOTO) Management of Change and implemented
Procedure and even did not question absence of Control  Refresher training to be completed for all Permit
of Work documents holders and competency assessments must be
 Organizational responsibilities not properly defined conducted before assigning personnel a
Area was not properly handed over from construction to leadership role in their discipline
responsible area engineer after commissioning; no
documentation & procedures in place

More information and details can be found on Synergi – Case 14891

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