Lessons learned: Obligation to exercise stop work authority must be clearly communicated

The incident

During pipe coating application work at a third-party sub-contractor worksite, a worker received serious burns to both forearms, that resulted in an lost time injury (LTI).

The injury occurred at the start of the operation when the pipe was being coated with the first layer. During this operation the transition between pipes required the manual application of a spatula to mark the pipe cutting area.

While marking the pipe, the injured person’s arm touched the pipe due to an unexpected movement of the pipe assembly, causing serious burns to both forearms.

This injury was seen by another employee who activated the line emergency stop and helped the injured person away from the line of fire situation to a safe place.

First aid was given before the casualty was taken to hospital for further treatment.

Probable cause

The final investigation is still to be released, but preliminary findings from this incident and other recent third-party incidents have identified the following issues:

• The task was deemed to require manual intervention using a spatula as a marking tool, thus exposing people to possible injuries;
• The task was seen as routine, to be undertaken on a regular basis. There was no challenge to re-engineer the task by those performing it or supervising it;
• There was no consideration of hierarchy of risk controls, or specifically automated or engineered methods to eliminate human exposure;
• Company management had paid a visit and had previously identified the risks associated with the task and provided improvement suggestions to the sub-contractor.

Lessons learned

• Ensure that the obligation and expectation to exercise the stop work authority is clearly communicated and understood by all, particularly third-party and sub-contract personnel;
• Ensure there are clear expectations in respect of controlling risk and identifying tasks that can be reengineered to remove the risk of human intervention or manual handling;
• Dare to challenge the “norm” with a fresh set of eyes as to how tasks are actually being conducted.