Although no injury occurred, an operator exposed himself to potentially fatal injuries by failing to follow LOTOTO and working at height procedures when undertaking maintenace work on equipment.
It was concluded that the individuals involved showed complacency whilst completing the task, the task not been planned and therefore RAMS had not been completed prior to the task starting, this included no assessment of the hazards associated with the work area.
Corrective action
- Ensure that responsible person is suitably trained, assessed as competent and authorisations are appropriately recorded on a roles and responsibilities form. This to include confirmation that company personnel are responsible for all contractor actions and remain owners of work being undertaken by contractors on site
- Revisit the Take/Check One process to understand when and how these should be used. this shoud be rolled out by mamangers across all regions
- Deliver and emphasise that there is never any reason not to follow the correct safe working process, this message to be delivered to all staff and reinforced in video by senior management
- All District Managers to review their lockout, tagout, try-out (LOTOTO) matrix at all sites to ensure that all required isolation points have been correctly identified and captured on the isolation matrix
- Ensure that LOTOTO procedure is followed as detailed on site including "Try Out"•
- Safety Conversations to always include working at height (WAH), LOTOTO and risk assessment/method statement (RAMS)
- Safety Conversation topics to be reviewed quarterly as well as numbers
- Confirm who the company authorised investigators are for concrete by year Q4
- All District Managers will receive training and be signed off as competent investigator by end of 2024