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SMA SAFETY SUMMIT 2020K+S POTASH CANADA - BETHUNE MINE
Medium Voltage – Electrical/Loto IncidentGene Cochrane
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BACKGROUND TIMELINEROOT CAUSE ANALYSIS FINDINGSOLUTIONS RECOMMENDATIONS
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BACKGROUND
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BACKGROUND• Brownfield Project • Issues with Contractor safety performance• Safety measures in place:
− Safe Work Permitting Process (SWP)− Lock out/Tag Out Program(LOTO)− Processes and Procedures in place to protect
people and physical assets
• Incident occurred on August 13, 2019.− Task…re-route cables for makeup air unit to
allow new construction− LOTO placed on wrong MakeUp Air Unit, LOTO
steps not followed through to local disconnect, verification process not followed at local disconnect resulted in electrician receiving 347 volt shock
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TIMELINE
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TIMELINE (I)
• Aug 9 – Discuss cable re-route plan• Aug 12 – Prepared LOTO, no SWP provided• Aug 13 – SWP & LOTO reviewed for 2 isolations
− Went to both MCC disconnects− Contacted Operations− Opened the disconnect for each device…confirming loss
of power on the PCS.− LOTO confirmed at MCC location.
• LOTO complete on 2951-FCL-902 vs 2970-FCL-902
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TIMELINE (II)
• Continued activity at work face (i.e. local disconnect) required:− Electrician removed ‘C’ phase lead…no issue− Busy area…requested to disperse while an overhead lift
was completed− Lift complete…electrician resumed work− Tried ‘B’ phase wire but still tight− Used allen wrench and received a shock− Stopped and checked LOTO− Immediate investigation and medical assessment of
worker
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ROOT CAUSE ANALYSIS
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ROOT CAUSE ANALYSIS
ROOT CAUSE: LOTO process not followed to ensure zero energy state!• Contributing factors…processes not followed:
− Pre-walkdown to verify scope of work prior to requesting work permit− Safe work permitting…requestor to fill out SWP which kicks off successive
steps
• Verification step…walkdown of lock out− Review of documentation at work front− Includes testing to ensure zero energy by competent personnel at all areas
necessary.(MCC and/or workfront)
• Special note…numbering convention (similarities)− Example…2970 FCL 902 vs 2951 FCL 902
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ROOT CAUSE ANALYSIS(2)
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FINDINGS AND SOLUTIONS
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FINDINGS• Findings:
No pre-job planning walkdown SWP not initiated as first step (verbal
request initially, then SWP filled out later)
• LOTO steps not followed: No confirmation of zero energy at local
disconnect No involvement by a competent
electrician No field tag verification of field
equipment with paperwork (i.e. drawings w SWP)
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SOLUTIONS(I)
Solutions: Implement mandatory pre-job
planning walkdowns for all CP&T construction LOTO’s.
First step for all LOTO needs begins with SWP.
Mandatory steps to final element or local disconnect for all CP&T Construction LOTO installations.
LOTO retraining for contractors and CP&T CMT.-
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SOLUTIONS(II)
Solutions: Competency requirements for field
verifications to be completed by:− Contractor SI or GF, accompanied
by Permit Issuer.− Field verification of paperwork to
field device tag. − Contractor to review manpower
skillset according to ability and experience.
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RECOMMENDATIONS
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RECOMMENDATIONS
Contractors/Owner:
Training review of the LOTO process− Confirm training records
• Training review of SWP process
− Documentation review for clarity and completeness
• Owner review of LOTO program for gaps
• Owner review of equipment numbering convention
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RECOMMENDATIONS
Contractors:
• Mandatory pre-job walkdown for all scopes of work
• Review contractor electrical org structure− Competency testing of
contractor manpower− Additional contractor expertise
added to bolster current team and to review processes
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