GhubrahIncidentInves.. - authority for electricity regulation, oman

Report Number: R 8991
Issue: 1.1
There were no job-specific fire precautions (i.e. Portable fire extinguishers) in place.
Also of note, although not a direct contributory factor to the incident, was the poor
conditions of the scaffolding erected to allow work on the cylinder to take place. The
scaffolding had no inspection tags, the scaffold boards were not fixed, the safety rail
(if that is what is was supposed to be) was at knee height, no kick boards were in
place, no secondary means of escape was installed and access to the work area
was by using the cylinders built-on ladder making it difficult to get on and off the work
area.
5 CONCLUSIONS
The principle cause of the incident was a systemic failure of the permit to work
procedure.
Under the directive of a ‘cold’ permit, issued to carry out painting, which clearly
stipulates that isolations were NOT to be carried out, a work order was issued to the
mechanical department to carry out what should have been considered ‘hot’ work
and a new permit considering the new risks should have been required.
There was no evidence of periodic management site inspections being carried out
and there were no representatives of the Safety department.
Risk Assessments were not carried out and the general statement in the procedures
that ‘maintained, where applicable, by the Discipline Engineer who issued the
Internal Work Order. Safety of the employees working on the Internal Work Order is
taken care of’ is clearly insufficient.
The ‘cold’ permit states that ‘civil to take all safety precautions’ in an attempt to place
the safety onus on the employees, rather than the management assessing the risks
involved before signing.
There should clearly have been a separate permit to work issued following a
thorough Risk Assessment, that insisted upon mechanical and electrical isolations,
draining and venting the cylinder, and gas testing prior to any work commencing.
The work procedures are on the whole generic, and little work has been carried out
to codify tasks and note inherent risks in the differing operation and maintenance
protocols.
The tools in use during the maintenance activities on the hypochlorite cylinders were
not fit for purpose (drill brushes causing sparks in hazardous area, electrical
connections badly made, extension lead coiled etc.).
Additionally, the poor condition of the scaffolding erected to allow work on the
cylinder is of concern.
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