Disregard for Energy Isolation Procedures Results in Amputation
Incident date
24 January 2012
Summary
The derrick man was replacing a small hatch cover, which had been removed to clean out the auger on the horizontal conveyor in the sack room. With the system still running he began to reinstall the cover, which resulted in his left index finger coming in contact with the rotating auger and resulting in his losing the tip of his index finger.
Incident consequence
Injury
Cause of accident or incident
Moving machinery or material being machined
Location
Drilling unit
Activity
Drilling, workover
Description
WHAT HAPPENED:
The derrick man was replacing a small hatch cover, which had been removed to clean out the auger on the horizontal conveyor in the sack room. The conveyor had backed up due to chemicals absorbing moisture because of the humidity and heat. The chemicals blocked the operation of the auger and had to be “dug out” from the hatch cover by using a special tool fit for the job. To determine that the auger was free, the auger was engaged and the derrick man observed it through the cleanout opening. Once it was determined that the auger was operating properly, the derrick man decided to put the hatch cover back in place; however, he failed to shut down the auger with the E-stop prior to reinstalling the cover. With the system still running he began to reinstall the cover, which resulted in his left index finger coming in contact with the rotating auger and resulting in his losing the tip of his index finger.
Disregard for Energy Isolation Procedures Results in Amputation pdf
Lessons Learnt
WHAT CAUSED IT:
Improper hand and finger placement when fitting the cover back in place.
The derrick man did not follow the company permit to work and Lock Out/Tag Out procedures in place for the job.
The cover did not have a handle for the derrick man to grip and reinstall the cover.
No JSA or Risk Assessment was conducted for the job because he stated, “we’ve always done it this way.”
Recommendations
CORRECTIVE ACTIONS: To address this incident, this company instructed rig personnel to:
Develop a JSA and risk assessment for this job.
Place signage at all augers “Work only performed under Permit to Work and Isolation Certificate”.
Place handles on all auger covers to remove and reinstall safely without hands near augers.
Contact Details
Step Change in Safety