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Description (What Happened?): Employee was assigned to check bolt elongation, it was found 9 (nine) bolts needed to be tightened so employee was assigned.

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Presentation on theme: "Description (What Happened?): Employee was assigned to check bolt elongation, it was found 9 (nine) bolts needed to be tightened so employee was assigned."— Presentation transcript:

1 Description (What Happened?): Employee was assigned to check bolt elongation, it was found 9 (nine) bolts needed to be tightened so employee was assigned the task to tighten left side steam interceptor valve castle nuts. In the process of preparing the nut to be final tightened, the employee was slowly tightening the nut using a 4lb (1,8Kg) hammer and a hammer wrench. Hammer movement was up down direction. When hitting the hammer wrench the hammer accidentally hit a valve piece and got deviated impacting the employees left thumb resulting in a contusion laceration. Employee received standard first aid by a trained employee; after being checked and agreed with the site leadership and employee returned to work. At the end of the shift the employee was taken to a local hospital for review and diagnosis. Additional Information / Contributor Factors: First Aid Check @ Site: movements with no pain; no signs of fracture. This is the 7 th bolt / nut the employee was tightening, not used during disassembly nor assembly – night shift only to check elongation. Employee was holding the hammer wrench (castle wrench) with the left hand. Hammer travel distance ~ 20cm ~ 8” Work was being done in a congested / reduced space. Employee had to bent changing the normal conditions of the job being done before. Employee is mostly assigned to Gas Turbines, not Steam Turbines. Employee was executing task at a scaffolding ~4 feet height (1,2mts). Employee was using cut resistant gloves for that task, impact resistant gloves would be used when it was needed to tight the nuts with a stronger force and bigger hammer. Employee was dealing with personal concerns. Day shift never reported if finger savers were available on site. Day shift was in charge of assembly and disassembly. Before the incident it was identified the use of finger saver but not found on site. No rope, nor other device fit the space. Start up was scheduled for 8AM – task needed to be finished that shift. Field Engineer requested a Tool Container at Steam Turbine, but both were left on Gas Turbine. Causes (How did it Happen?): Employee placed his hand in the line of fire in case the hammer deviates. Finger Savers or tool holders were not available on the Steam Turbine deck but available on site inside Gas Turbines Tool containers. Lack of STOP Work Authority to stop the job when the conditions changed, reassess and execute. Time pressure to deliver the unit on time. Lessons Learned: 1. Every task must be effectively hazard analyzed when any of the job conditions has changed. 2. If proper conditions are not met to execute safely, the task must be stopped until the safe conditions are met. 3. Every incident must be properly reported complying with end customer, GE & Granite Reporting and Communication protocol. 4. Never get complacent on the task nor put time against safety. Case Number: 2403 Site Name / Location: CCC Tamazunchale / Mexico Injury Type / Body Part: Contusion, Laceration / Left ThumbDate: Apr 12 th 2016 Recordability Rationale: Suture Stitches / Prescription Meds Management System Failure: Stop Work Authority / Complacency SEVERITY LEVEL (C) DAFW: No RWA: No INCIDENT LOCATION: Steam Turbine Ulises Ventura /David Malvaez

2 ROOT CAUSES ANALYSIS Contusion, Laceration / Left Thumb Environment  Congested and reduced work space.  In a MI valve remained uncovered.  Lagging not removed. Material  Tool container not assigned to Steam Turbine.  Finger Saver not found in Steam Turbine. Manpower  Lack of Stop work Authority.  Complacency Methods / Procedures:  It is needed a slight hammering before placing the nuts on its final position. Case Number: 2403 Site Name / Location: CCC Tamazunchale / Mexico Injury Type / Body Part: Contusion, Laceration / Left ThumbDate: Apr 12 th 2016 Recordability Rationale: Suture Stitches / Prescription Meds Management System Failure: Stop Work Authority / Complacency SEVERITY LEVEL (C) DAFW: No RWA: No INCIDENT LOCATION: Steam Turbine Incident Timeline 7:00PM / Apr 12 Shift Started Injury occurred GSII SM is Informed. 8:20 PM / Apr 12 Task started 10:45PM / Apr 12 8:30 AM / Apr 13 0:30AM / Apr 13 GSII EHS Takes Notice by SM 7:50 AM / Apr 13 GE Formal Communicate d 11:47 AM / Apr 13 First Aid @ Site Site Leadership Communication 11:00PM / Apr 12 EE receives Medical attention ACN Submitted 11AM / Apr 13

3 Corrective Action (How do we prevent this from happening again?) Responsible Person ATS #Target Date / Date Closed Disciplinary actions to Supervisor, Site EHS and Injured Employee Evelyn Santana11540April 27 2016 GE EHS Team is not always involved on the 3-6 months planning phase, nor Granite. The EHS Team shall be part of the planning phase for every planned outage. Nicolas Prunotto / Viviane Di Santo 11541June 2016 Improve Kick Off Meeting Material including Site Risk Profiling on every outage. Nicolas Prunotto11542May 15 th 2016 Communicate and Train Granite & GE employees on Incident Reporting Protocol & Guidelines during kick off meetings. Reg EHS Managers 11543May 1 st Increase join site safety audit / site visits with GE EHS Mgrs. Encourage Partnership. Nicolas / Viviane11544May 15 th Implement the use of Castle Socket Hytorc Tool. Best practice from US. Juan Carlos Perez / Carlos Astudillo 11545June 2016 Implement and communicate to Iberdrola a communication flow chart and best practices. Arturo Solis11550June 2016


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