DOIRC Lateral Learning 18'06'07

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DOIRC Lateral Learning 18.06.07

• 18/6/2007 Actual1P Potential B4P
• INCIDENT Midwesco LLC. Hoist 12
• During rigging up mud tanks the Mechanic and
  roustabout were tightening the flange on the
  shaft of the agitator. At the same time driller
  started power in the distribution panel for mud
  system to switch on lights. He also switched on
  the agitator by mistake which caused the impeller
  to rotate. Both mechanic R/A moved away but the
  mechanic fell down between the impeller and the
  suction pipe. The rotating impeller cut his
  coverall in 2 places causing minor bruises above
  his right knee left arm. The splashing muddy
  water entered his eyes despite his safety glasses
  causing burning sensation.
• ROOT CAUSES
• No Permit To Work in place
• No Lock Out/Tag Out in place
• Inadequate Planning and Organisation
• LATERAL LEARNING
• Strictly adhere to the PTW Manual
• Review the isolation/de-isolation procedures
• Discuss the hazards in a structured Toolbox Talk

• Strictly adhere to Permit to Work Manual
• Review isolation/de-isolation procedures
• Discuss all hazards in a structured Toolbox Talk