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FHU - Lock Out/ Tag Out Event - Coggle Diagram
FHU - Lock Out/ Tag Out Event
Management
Systems Organisational Management
Policies
FHU policy do not self perform - e.g. do not 'do' the work
UU required to isolate plant for FHU, which overtime, has verbally been instructed to be completed by FHU
FHU follow internal FH Process for isolating plant, equipment and assets
Process
FH Isolating plant, equipment and assets process involves responsible persons to determine whose permit to work process is to be adopted
FH isolation process requires the isolation responsibility to be determined which was initially UU but overtime became left with FHU
Permit to Work
FHU permit to work template provided and used for mechanical and isolation works
Permit form comprises inconsistent terminology with FHU process, including the permit issuer and authorised isolator.
Permit to work has weekly duration as per FH isolation process
Permits were separate for electrical and mechanical tasks which were required to be combined
Management Decisions
FHU Management decisions involved taking the responsibility of the isolation process from UU based on unclear verbal direction, previous inconsistency, and uncertainty of compliance from UU's ability
Worker decisions involved trusting all workers who were required to work in the dry well were familiar with sign in/out and LOTO processes
Decision was made to keep isolation and mechanical permit separate which should have been reviewed and combined prior to LOTO and entering dry well/ commencing works
Job Design
Work Schedule
Work schedule followed normal weekly structure
Workload
Additional workload pressures were present due to end of year time restrictions/ expected shutdown of tasks
Other workload pressures increased individual stress for workers
Job requirements
Permit to isolate mechanical and electrical works
Permit issuer (also authorised isolator) to transfer permit to holder for each individual permit to work
Information Transfer
Communications
Written
Written permit recorded in register and on permit template
Oral/ verbal
Verbal instruction/ authorisation from UU to FHU for daily isolation permits (both electrical and mechanical)
Numerous work instructions from UU to FHU regarding isolation and LOTO is verbally communicated
Instructions
Verbal instruction of safety elements and other task requirements in prestart, induction, and Toolbox Talk prior to entering the dry well
People
Individual Factors
Knowledge
All personnel involved in the event have adequate knowledge of the process
Workers involved did not have clear/ adequate knowledge of whose responsibility (UU or FHU) for isolation
Expectations
'Work as Imagined'
UU have responsibility of isolating the asset
FHU work under UU responsibility for isolation and proceed with FHU permit
Permit to work would be developed, issued, and held according to FHU process and monitored/ reviewed accordingly for compliance and accuracy
'Work as Done'
UU verbally expressed to FHU that isolating assets is FHU responsibility
Clarity and confirmation of isolation responsibility has not been established
FH isolation process has been followed and applied for the task
Permit form required under isolation process has inconsistent terminology for roles of permit issuer and authorised isolator that is not included in the FH process
Health & Wellbeing
Fatigue management
Normal roster and working schedule followed
Potential contributing factor relates to end of year period which involves increased workload, pressures, and stress from other unrelated tasks
Culture
Safety Attitudes
There was a lack of responsibility and ownership as it relates to documentation control and review, permit process compliance
Knowledge of whose responsibility it was to isolate the plant was unclear, and remained unclear for a considerable period of time, which was not addressed before event occurred
Awareness
There was a lack of awareness of task conditions, policies and permit requirements as it relates to responsibility between UU and FHU
Attention
Lack of role responsibility in relation to supervisory controls and attention to detail (e.g. thorough inspection of the task and workplace)
Training & Competency
All FHU employees and BDR contractors have the required training for isolation and inductions completed
All required training and competency requirements have been recorded in the FHU internal system (PDP AU)
Workplaces
Workplace Design
Lock box kept in server room on open-access table to all who enter the room
Lock box does not have strict supervision or monitoring control for verification of key removal and tag completion
Process for LOTO, which comprises location of lock box and considers worker access/ use, should be reviewed for compliance
Employment Design
Feedback/ Consultation
UU required to, and responsible for, isolation of plant/ assets
Overtime UU allowed and verbally stated that isolation requirements are to be completed by FHU which created an unclear process for whose responsibility it was to complete isolation tasks
Work Environment
Culture
Safety components of task are unclear as it relates to isolation permit process for signing in/ out compared to confined space permit
Organisational influence from FHU to follow policies and procedures as required and in place
Less than adequate application of process and document reviews (e.g. SWMS, permits open, number of permits for specific tasks etc.)
Overtime the requirements and responsibility for isolation permits and process had become unclear between contract requirements (UU responsible for isolation which FHU have completed on various occasions)