HPI alert - Breach of tagging and isolation procedure (August 2016)

Driving incident iconIsolation

HPI Alert #496

Date of Event: 31 August 2016

Organisational Factors

  • Inadequate Management Systems - work order closed but job incomplete
  • Lack of a formalised process for the review of safe job planning by technical experts.

Absent/Failed Defences

  • Procedure not followed (WC-OSH-109 Tagging and Isolation and S487 Safe Work on Low Voltage Electrical Equipment and Installations).

Task/Environmental Conditions

  • Risk perception/management (District Electrical Technician [DET] risk perception)
  • Complacency/cutting corners (by DET).

Individual/Team Actions

  • Correct procedure not followed
  • Inadequate Safe Job Planning (Step Back not JSEA)
  • DET did not consider others’ tasks relating to the switchboard.

Key Learnings

  • Never work on equipment that is not isolated. The Safety Essentials exist to prevent fatalities in the workplace, and compliance with the procedures is not negotiable
  • On a periodic basis a sample of high risk Safe Job Planning tools and work methodology should be reviewed by personnel who have technical expertise
  • Where systems and processes are adapted for remote regions including offshore islands, we need to ensure robustness and compliance with mainland standards.

Questions for Leaders

  • How do we confirm the effectiveness of review of safe job planning and work methods for specific high risk activities that require technical expertise?