DTS-AW-201627-EU-SA Trading & Supply Operations August 2016

Hand Injury - Restricted Work Case

Target audience for this alert

 Terminal Managers
 Engineering Community
 Permit Issuers
 Engineering Contractors

What happened
Four contractor workers were carrying out a cutting activity on idle pipeline
(~1200 m of length at total) which was going to be relocated to another terminal
for use in a different project. Cold cut and grinding tool were being used for
cutting the pipes. One of the contractors was cutting the bottom section of a pipe
with the grinder. Due to a sudden kick back movement of the tool, he lost fully
control and his left hand (wrist) touched the abrasive wheel and resulted in a cut
in the glove and wrist. The first aid was applied (wrap the wrist and compress to
stop bleeding) by the certified first aider (contractor foreman). Then he was immediately hospitalized to the nearest
hospital as per ERP.

Why it happened
Underlying Causes:
 The worker believed that he was performing the cutting activity properly as it was stated at MS, JSA, PtW
documents, however he was not able to see his working area.
 The workers believed that the cutting method was correct as it was in accordance with MS, JSA, PtW however as
it was a difficult position, assessment should be made and a different method should be identified.
 Due to similar repetitive work, perception of worker was that the protection guard was in place and tight enough.
 The worker was not supervised to which hand position shall be used on side hold
Systematic Causes:
 Repetitive/routine works yields to decreased risk awareness
 Supervisors on site had a perception of control according to MS, JSA & PtW rather than actively assessing risks
 Line of fire understanding is to stay away from others works, not to keep their body parts from their own work
Lessons learned
 All contractors should know that MS can be challenged due to specific positions, conditions etc. It shall be treated
as a plan, not an order. Whenever needed, the work should be stopped and the plan can be revised with the
approval of MS issuers.
 For routine/repetitive works, it is useful to
i. have a "go & see" toolbox for 5-10 % of works to increase the level of risk perception of the workers,
ii. have training sessions for Permit Holders «risk and precautions in repetitive/routine works».
 Prior to execution of projects, accountability on decision making phase should be clearly defined.
 All grinding activities should be avoided as much as possible and considered if it is the last option and there is no
other alternative. Any grinding activity must be covered in detailed MS/JSA and PtW issued to ensure adequate
controls are in place and followed.
 MS & JSA must be specific to the work and provide sufficient information for the PtW to identify controls required
to complete work safely on site.
 Site Supervisor accreditation program should be implemented to increase the competency level.
 LOF trainings should be refreshed focusing on keeping your body safe from your own work as well as other’s
activities.
 Having a first aider in the team improves the speed and quality of the first response to injuries.

Further information
Huseyin Doganay - T&S Turkey Senior HSSE Advisor
Irem Yuzec - T&S Turkey HSSE Advisor
Alican Celikten - T&S Project Manager Turkey