Confined space work being done without proper procdures in place
What was wrong?
- Workers of the fuel technology company were not recorded in the Daily Log
- There was no proper site induction;
- no clear instructions to workers were provided by their work manager.
- The Site Manager was not aware of confined space works taking place on the site.
- Confined space work was carried out without a Permit
- Only one worker was wearing a hard hat.
- No evidence of conducting a gas test.
- No emergency and evacuation plan or equipment (e.g. lifeline and tripod, DSU, RPE, etc…);
- Only 2 man crew was available (3 is the minimum);
What was done?
- The activities on site were stopped;
- The main contractor was required to replace the Site Manager. (That contractor will be omitted from the next project)
- Consequence Management was applied to the fuel technology contractor, as it was identified as a breach of the LSR’s (No’s 1,2 and 4):
- The 2 workers and Work Manager have been permanently excluded from Coteba projects;
- HSSE re-accreditation to be successfully completed before any new order;
- The head office and local affiliates of the fuel technology company will be notified and the company has been suspended until the investigation and agreed actions are completed. These actions are:
- retraining all the staff dedicated to Coteba projects on PTW system and LSR’s;
- nominate a new Works Manager (to be interviewed, trained and accepted by Coteba);
- update JHA’s for all works according to the PTW system;
Lessons Learnt
- Work Managers must identify the scope of work to be done, risks and controls (“eliminate, isolate, minimize”), select the best work methodology and instruct accordingly the workers. The works must be properly planned and prepared in advance;
- Site Managers have to understand they are responsible for the HSSE for all the activities on their site;
- The proper site induction must be in place – to remind workers of HSSE requirements, site rules and the current days work activities on the site;
- L3 contractors must periodically retrain their staff to avoid routine and mistakes;
- L3’s cannot change Site Managers without ensuring they have the correct training and experience, and the change is approved in advance by Coteba.
- Source: Coteba October 2010