Cut finger

Proper LOTO procedures not followed resulting in injury

An L3 worker was conducting statutory testing on a dispenser. As per the Life Saving Rules, this is required to be done with the power switched off to the dispenser and the electrical board locked and tagged.

As the test failed it was necessary to switch on again the dispenser to run the diagnostic test. During this test the technician was holding a cleaning rag in his hand. Contrary to the job steps in the JHA he was wearing additional gloves. The belt pulled the rag, the glove and the worker’s finger into the moving equipment resulting in a finger cut that required 5 stitches.

 What went wrong?

Once the statutory test failed, it was necessary to switch on again the dispenser to run the diagnostic test.

This is considered as “Live Electrical Work” under the PTW system, classified as medium risk work (see below).

Definition of “Live Electrical Work” (Medium Risk) in the PTW system: (Includes fault finding/trouble shooting/diagnostics on pumps (including turbine pumps) and dispensers where the equipment will be live to allow this.)

The worker failed to recognize that this was a significant change in the work scope. He failed to stop and assess the hazards associated while working on live equipment. This is part of the “Management of Change” procedure, i.e. he would have had to stop the work and rethink about the risks he is facing doing works at running pumps.

As an outcome of the rethinking he would have had to adjust the JHA based on the circumstances of working at live equipment.

As a result, the worker failed to follow the JHA instructions during the live work including the need to remove loose fitting clothing and gloves, the need to remove the rag from his hand and the need to keep his hands in a safe distance from moving parts.

Lessons learned

Managing change is a critical component of managing safety on site. When the work scope changes it is critical that you STOP and ASSESS the hazards associated with the new work and the controls you have to use to protect yourself. This assessment should be documented in the JHA as appropriate.

 If the work is not safe, don’t do the work!

This finding is not only applicable for fuel-pumps; it is as well valid for compressors, workshop equipment, cooling compressors, elevators and so on

Source: Johnson Controls