Aggregate Industries had an employee who thought he had isolated a piece of machinery and carried out a task with the equipment still live, this could have resulted in a fatality. When he realised the extreme risk he had exposed himself to, he felt sick. Although he knew that his failure to correctly follow the isolation procedures was a potentially dismissible offence, he chose to report the incident. He did not want any other colleague to put themselves in this position and recognised that there might be valuable lessons to be learnt from his experience.
The subsequent investigation revealed that the machine had a faulty isolator switch which would have been noticed if he had carried out the isolation procedure in full. Critically, he had not completed the compulsory test to confirm that the equipment was no longer live.
The isolation procedure was immediately reviewed and a brief cascaded to everyone to check their isolators on-site. Certain isolators were changed as a precaution to eliminate the possibility of this happening again. The standard was improved (now use LOTOTO) and revised to provide greater clarity about the lock off procedures. The objective was to ensure that it was fully understood and always followed by all employees.
A short video was made using an action cam. This approach was able to capture the noise and experience of operating in a difficult environment. However, the video can be viewed in a safe area where questions can be asked and answered clearly and without ambiguity. It is an ideal training tool. A register of employees who have watched the short video is maintained.
- Comprehensive understanding of the lock off procedure
- People more receptive to visual messages
- Video training ideal for noisy environments where difficult to confirm understanding
- Video is clear, comprehensive and easily accessible
- Action cam will be used for other training processes.