Serious injury caused by energy isolation failure
- Safety Flash
- Published on 23 August 2018
- Generated on 26 July 2026
- IMCA SF 18/18
- 2 minute read
A yard worker was cleaning debris from underneath a hydraulic pipe.
What happened?
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:
- Line of fire (video)
- In the line of fire (video, IMCA HSS036)
- Guidelines for management of change (IMCA HSS001)
Related Safety Flashes
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IMCA SF 08/17
12 April 2017
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IMCA SF 09/12
4 September 2012
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IMCA SF 07/08
10 April 2008
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