Cause & Consequence
- Slip, trip or fall on same level
- Change management
Description of Process
The plate pack heat exchanger was to be investigated due to flow issues. After the plate pack had been split out, the end plate and pack plates were moved to allow internal investigation. This revealed floor mounted securing plates that were, under normal circumstances, integrated into the plate pack heat exchanger.
Description of Incident
During the work scope, the inspection phase required pictures to be taken via an iPad. A technician was looking through the iPad trying to get the right image and was walking backwards to get all the elements into the picture. As the technician walked backwards the individual lost situational awareness of the exposed hazards, tripping and falling backwards. The technician landed on the elbow, which resulted in a fracture.
Good Practice Guidance
- When using digital cameras / tablets / iPads on site, only read / use it whilst standing still in a safe location.
- Take your time when moving, look out for new hazards and when in the new location try to take the photo again.
- Carry out a dynamic risk assessment and implement controls/ barriers to prevent / minimise injury.
- Be aware of hazards that have been exposed as part of the work scope.