Incident alert
LOCATION:
AGGREGATE DREDGER
ACTIVITY:
MAINTENANCE & HOUSEKEEPING
DATE ISSUED:
01/02/2016 12:49:05
TITLE
Isolation lock out equipment near miss
COUNTRY OF ORIGIN
United Kingdom
ACCIDENT / INCIDENT DETAILS
Failure of the lockout equipment used to isolate switch consoles in the engine control room of a marine aggregate dredger resulted in a near miss during a recent maintenance stop at a ship yard.
Prior to entering the shipyard the company’s isolation procedures and equipment were reviewed and an isolation procedure was agreed with the ship yard operator.
As part of the review some of our lockout equipment being used was updated and replaced. The equipment at the centre of this near miss was brand new and being used for the first time.
The equipment being isolated is switched on/off using a Bakelite switch, and the lockout equipment fits over the switch when it’s in the off position. The equipment is fastened to the switch by a screw which grips switch and prevents the lockout from being removed. To prevent the screw being unscrewed a padlock is fitted which shields the screw head from a screw driver.
The lockout was fitted following procedure, however on inspection when the lockout equipment was touched and moved it slid off the switch completely.
On investigation it transpires that because the switch is made of Bakelite which is hard and also brittle, it is not possible to screw the screw down on to the switch with sufficient purchase to gain enough grip to secure the lockout equipment in place.
A solution to this problem is currently under investigation.
This type of Bakelite switch is common on a lot of old plant, not just within the marine industry.
ACCIDENT / INCIDENT IMAGES
Click image to enlarge
Click image to enlarge
LEARNING POINTS / ACTIONS TAKEN
Highlights the importance of testing and checking all aspects of the lock out process.
Highlights example of an unexpected problem when new elements introduced to lock out procedure.
LEARNING POINTS / ACTIONS IMAGES
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