LESSON LEARNED

Multiple injury – hit by

Location: Refinery
Accident description

Accident description

During planned maintenance works, a

boring activity was carried out in an
exchanger. Surfacing Toolpost
arm
At the end of this activity, during the
assembly
disassembly of the boring bar, executed
with the support of a crane, the equipment
suddenly came out with its fixing
mechanical expanders hitting 2 workers
involved in this task. Mounting
base
The 2 IPs were immediately first aided and Drive hub assembly
then sent to the hospital. One was assembly
dismissed after the first medical treatment
whilst the second was hospitalized in
reserved prognosis.
Pic. 1 – Boring bar parts.

2
3D Accident Scene

Boring
bar

Injuried Crane
persons

3
Pictures

Accident location Detail of the exchanger

Boring bar once fallen Break of the eyebolt Detail of the eyebolt bent

4
Identification of causes

 The boring bar came out from its location: the boring bar
was untimely lifted due to a wrong signal and/or crane
maneuver.

 Human factor: task performed not in compliance with what

planned and authorized and wrong crane maneuver during
operations.

 Procedure not followed: the boring bar disassembly

operations, detailed in the manufacturer’s Use & Maintenance
Manual, were not followed.

 Lack of coordination: during disassembly operations an

unauthorized crane was used, therefore the activity was neither
planned nor coordinated.

 Lack of training: no evidence was provided on the training

about the use of the boring bar for the personnel involved in
the task. Moreover no evidence provided on the knowledge of
the conventional signals to be used during lifting operations
with crane.
 Working equipment: the boring bar used in the operations
was different from the submitted documentation.

5
Actions for the Contractors involved
Areas of
Identified Actions
improvement

• To issue an operational instruction in local language, considering

roles, responsibilities, competences, training plan and equipment for
Procedure
the suitable use of the boring bar in compliance with the
manufacturer’s Use & Maintenance Manual and provide training to
all the operational personnel.

• Improve the Operational Safety Plan with the identification and the
Risk Assessment
description of the tasks related to the use of the boring bar and the
associated risk assessment.

Training/
Awareness • Training refreshment for all Contractor Supervisors on the site
safety procedures.
• Training refreshment on the proper use of lifting equipment.

• To conduct a review among the site operational personnel to

Organizational identify flagmen and riggers during lifting operations and provide
them the relative training.

6
Areas of improvement
Areas of
Actions identified
improvement

Tecnichal • Request all specialized Contractors in boring bar activity to use only
hoists or similar equipment for any lifting. The possible use of a
crane shall always be required in advance and authorized officially
by the Company.

• Request all Contractors which could, by contract, use lifting

Procedure equipment to provide evidence of a proper procedure which clearly
identifies roles, responsibilities, competence, training plan and
equipment.

Training/ • To organize a random check campaign on the knowledge of the site

PTW procedure for the Contractor workforce involved in the
Awareness
signature of the permits.

Organizational • To perform in-depth analysis in order to define all aspects related

the scaffolding management (engineering and erection, changes,
conformity, use, etc.) and the management of activities in line with
the health and safety regulations for roles and responsibilities, site
findings management and suitable coordination methods.

7
Lesson learned

Lesson Learned

All activities shall be carried out in compliance with

what detailed in the Permit to Work without taking
any unauthorized initiative neither planned nor
coordinated.

Abide thoroughly by Ensure a strict Ensure that all personnel

what planned and compliance with what involved in lifting
authorized. Any stated inside the activities with crane
deviation from what reference documents (crane operator and
defined shall be (SIMOPS, site operation flagman) is duly trained
adequately analyzed plan and Permit to and a suitable and
and permitted. Work). efficient visual and verbal
communication system is
in place.