Cause & Consequence
- Moving machinery or material being machined
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.”
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.