Disregard for Energy Isolation Procedures Results in Amputation

Cause & Consequence

• Moving machinery or material being machined

Incident Location

Drilling unit

Incident Activity

Drilling, workover

Lessons Identified

WHAT CAUSED IT:

 Improper hand and finger placement when fitting the cover back in place.

 The derrick man did not follow the company permit to work and Lock Out/Tag Out procedures in place for the job.

 The cover did not have a handle for the derrick man to grip and reinstall the cover.

 No JSA or Risk Assessment was conducted for the job because he stated, “we’ve always done it this way.”

Incident Recommendations

CORRECTIVE ACTIONS: To address this incident, this company instructed rig personnel to:

 Develop a JSA and risk assessment for this job.

 Place signage at all augers “Work only performed under Permit to Work and Isolation Certificate”.

 Place handles on all auger covers to remove and reinstall safely without hands near augers.