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What happened?
Workers were replacing a brake resistor fan motor on a drilling rig.
The equipment was locked out, the old fan motor removed and the new one installed.
Before fully securing the fan, the rotation direction was tested, and the fan motor breaker was locked out again.
One worker was securing the fan when an alarm sounded.
The other worker left to investigate the alarm.
When they returned, they found the first worker unresponsive on the ground.
They used an automated external defibrillator (AED) which identified that no shock was needed.
One chest compression was administered, the worker became alert and was taken to the hospital.
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Why did it happen?
Procedure / sequence of steps was not followed, although procedures were correct and available:
- Injured worker did not apply their own locks, nor verify that the equipment was correctly locked out.
- Second worker did not stop the work or ask the first worker why they were not applying their own locks.
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What did they learn?
Apply barriers and warning signs to any energised equipment.
Work areas should be secured before energising any source.
All workers should employ the complete lockout/tagout (LOTO) procedure:
- Update LOTO log
- Verify equipment is de-energised
- Apply a lock with tag
- Store key, permit and job safety analysis (JSA) at designated location and notify all relevant personnel.
Ensure all personnel involved verify, review and sign the relevant documents (JSA, LOTO).
Provide refresher training to all workers on LOTO, JSA and permit requirements.
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Ask yourself or your crew
What is your LOTO procedure?
How do you confirm energy isolation?
Do you know all the relevant procedures you need to comply with for your task?
What should you do if you see someone working in an unsafe manner?
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What happened?
Workers were replacing a brake resistor fan motor on a drilling rig.
The equipment was locked out, the old fan motor removed and the new one installed.
Before fully securing the fan, the rotation direction was tested, and the fan motor breaker was locked out again.
One worker was securing the fan when an alarm sounded.
The other worker left to investigate the alarm.
When they returned, they found the first worker unresponsive on the ground.
They used an automated external defibrillator (AED) which identified that no shock was needed.
One chest compression was administered, the worker became alert and was taken to the hospital.
Why did it happen?
Procedure / sequence of steps was not followed, although procedures were correct and available:
- Injured worker did not apply their own locks, nor verify that the equipment was correctly locked out.
- Second worker did not stop the work or ask the first worker why they were not applying their own locks.
What did they learn?
Apply barriers and warning signs to any energised equipment.
Work areas should be secured before energising any source.
All workers should employ the complete lockout/tagout (LOTO) procedure:
- Update LOTO log
- Verify equipment is de-energised
- Apply a lock with tag
- Store key, permit and job safety analysis (JSA) at designated location and notify all relevant personnel.
Ensure all personnel involved verify, review and sign the relevant documents (JSA, LOTO).
Provide refresher training to all workers on LOTO, JSA and permit requirements.
Ask yourself or your crew
What is your LOTO procedure?
How do you confirm energy isolation?
Do you know all the relevant procedures you need to comply with for your task?
What should you do if you see someone working in an unsafe manner?
Workers were replacing a brake resistor fan motor on a drilling rig. The new one was installed but not secured – whilst securing it, the fan motor caused an electrical shock to a worker.
