During a yearly shutdown in April 2022 at a block plant, work was planned to be carried out by the operators to dig out the vac crust pit located under the vac and cutting line. Operators had taken out the castell key to enter the vac area and put into the lock box. All the operators individually locked off to the box securing the area to work in, they then entered the area and began to dig out the crust pit. While carrying out a walk of the area, a safety rep and maintenance manager identified the agitators within the area were switched off (To “Manual”) on the MCC panel on the mezzanine floor but the panel was not fully isolated, and no isolation document had been completed.
Key Factors
Although a LOTOTO SOP for this task was present and clear, including all the isolation points, the responsible person had failed to own the isolation process and to make sure all the measures were in place before the work commenced.
