Incident alert

LOCATION:
OTHER
ACTIVITY:
MAINTENANCE & HOUSEKEEPING
SUB ACTIVITY:
N/A
ALERT STATUS:
Normal
DATE ISSUED:
06/03/2009
INCIDENT No:
00217

TITLE
Inadequate Isolation and Immobilisation
COUNTRY OF ORIGIN
United Kingdom
ACCIDENT / INCIDENT DETAILS
Health, Safety & Fire Department – Scunthorpe Cast Products

Inadequate Isolation and Immobilisation leads to fatality at non Corus site

What happened:

A maintenance team leader was fatally injured when a hydraulically operated, scissor style, lift table fell pinning the deceased between the lift arm and the bottom frame.

The deceased and a co-worker (Mechanical Maintenance Inspector) entered the basement below the hot rolling light gauge shear line in order to perform an inspection of the hydraulic lift table. During the inspection it appears that the deceased placed his upper torso under the lift arm and attempted to tighten a fitting on the hydraulic hose connected to the hydraulic lifting table cylinder. At this time the fitting became disconnected from the cylinder causing pressure to be lost from the system. This in turn caused the table to fall approximately 1.5 metres to the lifting table base structure. The employee was fatally crushed between the scissor arm of the lifting table and the base of the lifting table structure.
ACCIDENT / INCIDENT IMAGES
Click image to enlarge



LEARNING POINTS / ACTIONS TAKEN
Findings:

An adequate lockout involving mechanical pinning and bleeding-off of hydraulics was not performed.
The hydraulic hose underneath the lifting table was found to be disconnected from the lifting cylinder.
A 36 mm wrench was found underneath the hydraulic lifting table. The size of the fitting on the hydraulic hose was 36 mm.
The deceased and the Mechanical Inspector were both sprayed with hydraulic fluid when the scissor arm fell.

Incident investigation direct recommendations are:

1. Isolation/Immobilisation Procedures must ensure that pressure must be bled off prior to repair or service work on hydraulic, steam, gas, air, oil or water lines or connected equipment.
2. Flow valves must be closed and locked and pressure relief valves must be locked in the open position.
3. Accumulators must be discharged.
4. Before any piping system is opened, procedures must be established to safely reduce equipment to a zero energy state, and verify that this has been done, for the section to be worked on.

Recommendations:

Plant Engineers in Corus Departments to review and confirm that their Isolation and Immobilisation Procedures contain all of the above requirements, to be completed by 20th January 2009.

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LEARNING POINTS / ACTIONS IMAGES




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