GhubrahIncidentInves.. - authority for electricity regulation, oman

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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. Page 7 / 11
Report Number: R 8991 Issue: 1.1 6 RECOMMENDATIONS No further work is to be undertaken on the hypochlorite cylinders until a thorough Risk Assessment has been carried out and a new Permit To Work system has been instigated that has a check list and calls for electrical and mechanical isolations and gas detections. It should also state that hydrogen gas should always to be assumed to be present and not expected to be in ‘trace’ amounts only. No work orders should be allowed to fall under a ‘general’ cold PTW. Each process should be considered to require a new PTW along with rigorous Risk Assessments. A Safety representative should be present as the Risk Assessment is being undertaken and should be a signatory to the permit to work. If possible, pneumatic tools should be used and where this is not possible, a rigorous risk analysis and gas detection regime should be in place if electrical tools are to be used. All tools should be fit for purpose and inspected regularly. All portable electrical devices should fall under a Portable Appliances test regime. If contractors are used, any tools used should conform to the above standards and should be verified as part of the permit to work system. On issuing of a PTW a ‘tool box talk’ should be carried out by the permit issuer to inform personnel assigned to carry out the activity of the risks involved and ensure that the risks are fully understood and that all possible safety precautions have been carried out. During activity, management should periodically inspect the job along with the safety representative. The PTW system should be re-assessed regularly by management in liaison with the safety representatives, operators, and maintenance personnel. Job site-specific fire risks should be carried out and the correct equipment put in place prior to work commencing. Note: A recent independent ISO audit of Al-Ghubrah also pointed out inadequacies in the PTW system. The Sogex management were, at the time of the incident, reviewing the PTW system they had received from another operator. From the author’s brief inspection of this third party PTW system, it appeared to be on the lines of Al-Ghubrah’s requirement. The new PTW system should be agreed upon by Sogex management, checked by a third party and instigated with all speed. Scaffolding construction and inspection regimes should be reviewed and practices improved as soon as possible. Page 8 / 11
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GhubrahIncidentInves.. - authority for electricity regulation, oman

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