SAFETY CONTACT

LEFT THUMB OF A TECHNICIAN GOT CRUSHED SE 2.4

Incident Summary: While checking operation of on-off butterfly valve during shutdown in microfiltration
unit, contractor technician sustained crush injury with fracture on left hand thumb.

Algae filtration unit was under

shutdown for cleaning activity, One
1 XV-5803 was being dropped to check
the functioning (as there was problem
during normal operation).

As actuator was problematic,

Actuator from nearby valve (XV-
5702) was fixed on XV-5803 to check
2 the functionality. Technician held
the XV-5803 by his hands &
supporting the valve on the pipe.
These valves are pneumatically
driven valves.

Another technician (Not authorized to work on panel) went to the local panel (3 m away) to operate
3 the valve. Technician operated XV- 5802 instead of XV-5702 which lead to gush of Sea water from the
open spool piece which was not blinded after dropping of XV-5803.

4 Due to sudden gush of water, the operator holding valve got distracted and shifted his grip on the
valve.

At the same time, technician near the panel realising his mistake, closed XV-5802 and operated XV-
5 5702 at the same time. Technician’s left thumb got crushed while operation of XV, as his position of
hand changed due to distraction.

6 Permit was issued for work on another valve while job was started on the stated valve without HITRA.

LEARNING AND RECOMMENDATIONS

S.N Recommendations Responsibilities
Each job to be planned & job specific HITRA to be carried out prior to starting the Maintenance
1
job. Manager
Work permit to be obtained for each job rather than mutually agreeing to execute Production
2
the job against available work permit. This results in elimination of Risk Thinking. Manager
SMP for valve testing to be prepared incorporating all steps including separate Maintenance
3
supply of air and proper support to valve. Lead
4 Competent & authorized contract workmen to be deployed for execution of job. Maint. Engineer

This One Page Safety Contact prepared by SEZ Safety Team