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On May 2, 2008 at 1010 hours, during plant start-up towards the end of plant turnaround, an incident occurred in a cooling water cell where a contractor suffered several cuts resulted multiple injuries on his forehead, fractured elbows and collar bone after being hit by the fan blade. The fan was energized without notice and aware of contractor still working inside the cooling water cell.
The root cause as identified :
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On May 2, 2008 at 1010 hours, during plant start-up towards the end of plant turnaround, an incident occurred in a cooling water cell where a contractor suffered several cuts resulted multiple injuries on his forehead, fractured elbows and collar bone after being hit by the fan blade. The fan was energized without notice and aware of contractor still working inside the cooling water cell.
A TOTAL COMMUNICATION BREAKDOWN !!!
The root cause as identified :
- Communication breakdown between different parties (the contractor working at the fan blade, safety watch and the personnel who activated the push button).
- Insufficient understanding on the typical confine space safety requirements and the need to develop specific Job Safety Analysis (JSA) for the job.
- Procedure not comprehensive to address safe work method while performing the job.
- Inadequate lock-out tag out (LOTO) for in situ balancing trial run.
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Lessons Learnt:a) Enhance communication and to physically reconfirm that nobody is in the confine space prior to start-up of any equipment
b) Provide refresher briefing to all operation and maintenance staff on the typical confine space and JSA requirements.
c) Review procedure and include safe job method statement for in-situ balancing trial run.
d) Strengthened the LOTO mechanism for in-situ balancing trial run
e) Implement key-interlocking system where fan will not be energized until key kept by contractor is released.
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