Work management review following recent incidents
Article published in the Regulator | Issue 4: 2017
During the last 90 days, NOPSEMA has received multiple notifications of dangerous occurrences which have resulted in serious injuries and other incidents which could have resulted in death or serious injury. NOPSEMA has identified similarities between a number of these incidents, related to work management.
During the planning phase of work, operators need to give consideration to the task that is to be performed, including:
whether or not the task is standard or routine and has been performed before
whether there are differences or new requirements that need to be accommodated.
For example, there were two incidents where the work environment and ergonomics of the task, or the task itself, were either new or somewhat different to those previously experienced, or anticipated in pre-developed and generic work procedures/instructions and their associated job safety analysis/job hazard analysis.
Before commencing work, operators must undertake a detailed review of the actual task to be performed and the operational conditions that will be present when the task will be performed.
Development and review of work procedures/instructions
Offshore petroleum organisations invest a lot of resources in developing work procedures/instructions for personnel to use. However, they are generally developed in advance and are generic in nature. Therefore, work procedures/instructions may not be aligned to the actual task and the operational conditions at the time of use.
NOPSEMA reminds facility personnel to undertake a detailed review of work procedures/instructions as part of their work planning. This will ensure that procedures/instructions are specific to the task.
In one incident, NOPSEMA found no clear work instruction or procedure for the task being undertaken. In another incident, personnel failed to follow the work procedure.
While considerable effort is normally taken in the development of work instructions and procedures, it is incumbent on personnel to then adhere to them in order to work safely.
Development and review of job safety analysis/job hazard analysis
Offshore petroleum organisations often develop a job safety analysis/job hazard analysis (JSA/JHA) well in advance of work. These generic JSA/JHAs can only attempt to anticipate hazards and their control measures.
As such, a detailed review of the JSA/JHA should be undertaken as part of work planning, before commencing work. Specific tasks to be performed and changes in operational conditions need to be captured. A review of the JSA/JHA during a toolbox talk should also be undertaken where work has recommenced after a delay or period of inactivity.
In one recent incident, a task-specific JSA/JHA had not been developed. In another, the personnel failed to adhere to the precautions identified in the JSA/JHA.
NOPSEMA reminds facility personnel to adhere to JSA/JHAs in order to undertake work safely.
Initiation and approval of permit to work
In two recent incidents, the permit initiator did not include adequate details about relevant controls for work activities in the permit. Furthermore, permit approvers and issuers did not carry out a detailed review of the permit prior to approval and issue.
In another incident, no permit was raised for electrical work undertaken. The responsible person was reported to be unfamiliar with the permit to work system.
Facility operators are reminded that personnel involved in the initiation, approval and use of a permit should ensure that adequate details of the work activities and relevant controls are documented in the permit. Further, facility management should ensure compliance with the permit to work system.
In two incidents, NOPSEMA identified that personnel failed to positively confirm electrical isolations prior to commencing work. In three incidents, personnel failed to test that electrical cables were ‘de-energised’ and safe prior to commencing their work.
NOPSEMA requests that facility operators:
ensure that electrical isolation procedures clearly identify the preferred method of electrical isolation
confirm that the electrical isolation is effective
confirm that the circuit is de-energised, safe and, where appropriate, arrange independent verification of electrical isolations.
As a result of these incidents, NOPSEMA issued Safety alert 66 about the potential for fatalities from electrical incidents. A copy is available at www.nopsema.gov.au/safety/safety-alerts.
In two incidents, NOPSEMA identified that supervision of work was inadequate. In another incident, we identified a lack of supervision in the verification of electrical isolations. NOPSEMA reminds facility operators to provide adequate work supervision to ensure that work is performed safely.