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.