Incident alert


Damaged Isolator Switches
United Kingdom
During the last few months month there have been series of incidents at Torr Works were electricians working for YES have found defective equipment during routine inspections.

On 8th July 2002 an 110V socket by Conveyor 104 was found to have been ripped out of its casing leaving the wires exposed. Had these been touched by an individual they would have led to the person being electrocuted.

On 22nd August 2002 the cable on a 110V kango hammer drill used on the Via Nova Coating Plant was found to have been worn through by the handle. Again this could have lead to any person using the equipment being electrocuted.

On 9th September 2002 an isolator switch on the Via Nova mixer panel was found to be broken. This can be seen on the switch on the right hand side which is compared against a normal switch.

The damage to the isolator casing meant that it was totally ineffective. If a padlock had been fitted to the isolator in this condition it could have been turned to the on position with the padlock still in place!!!!!

In all of the 3 incidents described above it is not known how the damage occurred or if anyone had continued to use the equipment in its damaged state. All that is known is that they were discovered during routine inspections by YES personnel.

It is vitally important that you report any damage that occurs to equipment you use and if you find anything in a damaged condition then please report it. Any of the above incidents could easily have lead to someone being seriously injured or killed.

Click image to enlarge

The 3 incidents described under the damaged isolator incident alert demonstrate that incidents are still occurring around the quarry and not being reported. It might have been that they seemed of little consequence at the time but they could have lead to something much more dangerous occurring to someone in the future and it was only by good fortune that they were picked up and repaired before someone was killed or seriously injured.
It is it vitally important that that all incidents are reported and thoroughly investigated. To this end a formal incident reporting procedure has been devised which is set out in TQ/SM1701.
1. All incidents which occur at Torr Works Quarry will be recorded on form QM/F1807-10. This applies to incidents relating to both health and safety and environmental matters.
2. Anyone can fill out the forms and these should be given to the Departmental Manager of the person initiating the form. Should the Departmental Manager be away then the form should be sent direct to the Quarry Manager.
3. The Departmental Manager will arrange for the form to be sent to the Quarry Manager and should the form relate to something occurring in another department will speak to the manager of that department to inform them of the incident.
4. The Quarry Manager will arrange for the incident to be logged onto the Quarry and Foster Yeoman Incident Reporting System. A manager will be allocated with responsibility for ensuring that the matter is thoroughly investigated and the FY incident number (where appropriate) will be entered onto the form.
5. A copy of the incident form will be kept in the Quarry Office and the original given to the Safety Officer to assist with the incident investigation.
6. The Safety Officer will work with the responsible manager to ensure that the incident is thoroughly investigated and all the relevant issues are considered. Records of this investigation will be entered onto the form together with the learning points and actions being carried out by the Departmental Manager to prevent any possible re-occurrence.
7. Once the Safety Officer and responsible Manager are satisfied that the investigation has been completed then the incident form will be brought forward to the Quarry Manager for signing off.
8. At any point during the investigations the Quarry Manager may produce an Incident Alert which will be distributed to all staff at Torr Works Quarry. Departmental Mangers will need to ensure that all staff are aware of the alert and have understood the actions required to prevent any re-occurrence. This will be by way of a Toolbox talk, the attendance of which will need to be recorded on the individuals training file. The decision to produce an Incident Alert will be made on the basis of the seriousness of the incident or through a trend becoming apparent.
9. All incidents which have occurred in the Quarry will be discussed at the monthly Managers Meeting and at the quarterly Safety Committee Meeting. Managers and Safety Representatives should inform quarry staff of these discussions and make them aware of all the incidents occurring around the Quarry.
What you need

Copy of Tool Box Talk
Copy of TQ/SM 1701 Incident Reporting Procedure
Copy of QM/F1807-10 Incident Report Form

Learning Points
Importance of reporting incidents
Who reports incidents
Importance of Investigations

Familiarise staff with:
TQ/SM 1701 Incident Reporting procedure
QM/F1807-10 Incident Report Form

Importance of reporting incidents

Makes others aware of possible hazards
STOPS incidents reoccurring in other departments

Who reports incidents?

Person witnessing the incident not just the Manager

Importance of Investigations

To find cause of incident not necessary blame
Give Management information to look for tends of incidents
To improve the requirement of extra resources needed to the board


What was a small incident to one person may become a maj

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