Listen Up, Communicate: Shocking Close Call Could Have Negative Outcome
Marine Safety Forum reports a recent incident on board a vessel which
highlights the importance of close interface between contractors working
onboard and the vessel crews.
During the demobilization of contractor equipment, the equipment had to be
Locked Out and Tagged Out (LOTO) to ensure that a "ZERO ENERGY STATE" had been
achieved before work commenced.
The contractor visited the ECR and with vessel crew locked and tagged out the
system and started work. The power was verified to be locked out at the
equipment and isolated at the breaker in the deck distribution box and work
commenced.
During work scope the lock out key was passed to another member of the
contractor team who proceeded to the ECR to remove the LOTO and re-energised
the system.
The de-energised cable from the equipment had been disconnected and placed on
the chassis but when the LOTO was removed from the ECR switchboard the cable
became live with 440 volts and 100 amps going through it. Assessing that the
cable remained de-energized, another contractor employee had to move the cable
to access the work and in that movement and action, his hand was very close to
the live cable ends, the cable ends touched the chassis and arced causing a
loud bang.
An immediate safety stand down was enforced by the contractor.
No one was injured as a result of this incident but there are a number of
Causal Factors identified from the event:
No vessel involvement in job content or planning and no contractor Project
Manager designated for work
No Job Safe Analysis developed as per bridging document requirements
Permit required but was not raised for isolation
No contractor work permit completed for LOTO #1 as required by the established
bridging document
Multi LOTO not used. Single key passed to Team Member
Voltage discrepancy for breaker isolation results in contractor's inability to
confirm zero voltage
Deck Cabinet exposed to elements and not easily accessible. Not fit for purpose
Electrical drawing not a controlled document. No drawn by, Checked by or
approved by and no class/type approval
No recognition of Labelling on adjacent breakers. Labelling insufficient
Engineer not involved in isolation of deck electrical cabinet #2
Superintendent did not follow up on concern with isolation of correct breaker
Superintendent has a dual role, supervising one ROV crew and overseeing all ROV
personnel
Verification incorrect due to ECR LOTO #1
Supervisor #2 removed LOTO with 4TH Engineer as witness
As a result of this incident, eighteen corrective actions have been identified
and are in the process of being implemented.
This was an incident that that could have resulted in a fatality. It should not
have happened and could have been prevented if all of the proven processes
already in place had been used.
======= fm Maritime Accident Case Book =====
------------------------------------
1. Moderator tidak bertanggung jawab atas kebenaran isi dan/atau identitas
asli pengirim berita.
2. ATTACHMENT akan dibanned, krmkan ke pelaut-owner atau upload ke FILE.
Yahoo! Groups Links
<*> To visit your group on the web, go to:
http://groups.yahoo.com/group/pelaut/
<*> Your email settings:
Individual Email | Traditional
<*> To change settings online go to:
http://groups.yahoo.com/group/pelaut/join
(Yahoo! ID required)
<*> To change settings via email:
[email protected]
[email protected]
<*> To unsubscribe from this group, send an email to:
[email protected]
<*> Your use of Yahoo! Groups is subject to:
http://docs.yahoo.com/info/terms/
