Incident alert

LOCATION:
CONCRETE PRODUCTS PLANT
ACTIVITY:
OCCUPATIONAL HEALTH
SUB ACTIVITY:
AIR AND DUST
ALERT STATUS:
Normal
DATE ISSUED:
20/07/2006
INCIDENT No:
00065

TITLE
Breach of isolation procedure results in discipline
COUNTRY OF ORIGIN
United Kingdom
ACCIDENT / INCIDENT DETAILS
Three employees, two Operatives and their Supervisor, were working on automated machinery (a palletiser) within distance guarding. They gained access to the area via a gate, fitted with a Castell interlock. In accordance with CEMEX UK Standards, local procedures required that before entering the area and working on the machine, each person must fit their own personal lock to the electrical isolator for the equipment.

Whilst in the area, a member of the management team checked the isolator to ensure that everyone had locked off, but found that only two personal locks were fitted. He called the Supervisor out of the area and established that one of the Operatives had not locked off. This Operative, who had his lock in his pocket, started to approach the isolator to fit his lock but met the Supervisor part way. The Supervisor then took the Operative’s lock and went to fit it on the isolator; the isolation procedure requires each person to fit his or her own lock.

This incident therefore involved two breaches of the site isolation standard:

1. The Operative had not fitted his personal isolation lock to the isolator, and;
2. The Supervisor fitted the Operative’s personal lock following the discovery of the first breach.

Both employees had been trained in the isolation procedures and had received a briefing only the day before about multiple fatalities on a competitor’s site arising out of failure to effectively lock off a cement mill.

Both employees were disciplined for their breach of the isolation standard
ACCIDENT / INCIDENT IMAGES




LEARNING POINTS / ACTIONS TAKEN
The company take breaches in isolation procedures very seriously. Only 3 years ago an employee suffered two fractures to the skull, which resulted in a stroke and paralysis, when he was crushed by machinery whilst working within distance guarding.

Employees must be trained in site isolation procedures, with understanding being verified through practical demonstrations.

Compliance with the procedures should be checked during formal audits, site inspections, injury prevention tours, etc.

Never take short cuts with isolation procedures, remember Safety Essential No. 8

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LEARNING POINTS / ACTIONS IMAGES




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