A contractor carrying out inspection work at the bottom of a bucket elevator was not in control of the isolation and had not applied their personal padlock to the local isolator. Confirmation of isolation was being undertaken using a two-way radio to the person located at the top of the elevator. This failure to apply the company’s isolation procedures exposed the contractor to the possibility of sustaining a very serious injury or worse.

KEY FINDINGS

• Breach of isolation procedures
• Inadequate perception of risk.

• Activity stopped until isolation procedure implemented including personal lock off. Additional controls also implemented to bottom of elevators to allow moving of buckets.
• Internal investigation regarding code of conduct.
• All plants were asked to review the positioning of isolation points, ensuring local isolation points are accessible.