1. Accident Reporting and Investigation
LESSONS
LEARNED
Bi-Weekly Safety Meeting
March 8, 2012

2. Accident Investigation
The purpose of any investigation procedure is to attempt to establish the facts surrounding a reportable occurrence (referred to as ‘event’) so that corrective action, if necessary, can be taken to prevent its re-occurrence. An investigation will involve:
Collecting data concerning the accident
Identifying injuries, property damage, and losses that resulted from the accident
Putting in place measures for preventing the event from re-occurring

3. Accident Investigation
A reportable occurrence or ‘event’ can include:
First Aid
Recordable Injury
Near Miss
Chemical Exposure
Equipment Damage
Production Interruption/Loss
Vehicle Citations
Vehicle Accidents
Theft
Vandalism

4. Accident Investigation
The focus is to filter through the information surrounding the event to determine why it occurred.
Pertinent facts are gathered: date, time, circumstances, environmental conditions, and other factors.
Individuals associated with the event under investigation are interviewed.
Who, When, Where, How and Why, and only the facts

5. Safety ‘Flash’ Report
The method for reporting an occurrence is Mangan’s Flash Report, mi-2105, Safety (Flash) Report
The form is located on the ADP Portal under Safety Forms.

6. Safety ‘Flash’ Report The report is ‘flashed’ (forwarded) to your:
Supervisor or Project Manager
Operations Manager
Regional Director
and Safety at
Management can determine any actions that are in the best interest of the employee(s), clients, or others involved.
Most of our clients have requirements for reporting any of these situations and it is our contractual obligation to adhere to their policies.

7. Following are some Mangan “Lessons Learned” from 2011…
Incidents can then be shared as a “lessons learned” to inform and educate others
The goal is to prevent the incident from occurring again in the future.
Following are some Mangan “Lessons Learned” from 2011…

8. Mis-communication of Live Electrical Exposure
During HCU Turnaround / Cutover execution there was potential for a hazardous (live electrical circuits) situation that was not communicated to the cutover field lead or the cutover lead until well after the fact.

9. Miscommunication of Live Electrical Exposure
The Mangan engineer who was working with client contractor electrician did not specifically inform the electrician of the potential for live power.
The Mangan engineer was not at the panel when the electrician became aware that there was live electrical in the panel.

10. Miscommunication of Live Electrical Exposure
The Mangan PM heard from the night shift that the potential hazard had occurred and may require a client incident form formally filed just prior to the 6AM meeting.
The Mangan PM on his way to the meeting took this information as fact and made an incorrect assumption.
There was no formal report or corrective action created but rather a communication breakdown.

11. Miscommunication of Live Electrical Exposure
Determined Cause / Lessons Learned
Failure to follow cutover communication steps and incomplete communication of roles/responsibilities/communication steps.

12. Miscommunication of Live Electrical Exposure
Follow Through - the following was communicated to all field personnel:
All safety issues, near misses, incidents, or otherwise will be communicated to the field lead and/or the cutover lead in order to insure proper reporting. This also ensures all parties are aware of potential harmful situations.
In addition, it is advised to refrain from such conversations until all facts are known and confirmed. All suspected incidents that are related to safety or risk should be fully investigated in a timely fashion.

13. H2S Monitor Alarm Event
During HCU Turnaround a client electrical contractor instrument tech was working to install an instrument on the V-997 tower (High Pressure Separator) when his H2S monitor went off.

14. H2S Monitor Alarm Event
He exited the tower and spoke to his foreman who notified the client Field Operator and Mangan engineer.
The Mangan engineer radioed to the Mangan console lead who informed the console operator of the occurrence.

15. H2S Monitor Alarm Event
The area H2S monitor screen showed a 0 ppm reading on the sensor at the base of the HP Separator.
The field operator climbed the tower to inspect and cleared the tower for re-entry.
The electrical instrument tech chose not to re-climb the tower until he was debriefed by his supervisor.

16. H2S Monitor Alarm Event Determined Cause Follow Follow Through
Probable H2S puff caused when the tech was working on the new instrument.
Follow Follow Through
Proper preventative action was taken. H2S monitor was worn and the tech followed proper procedure to exit the location to a safe area and notify operations and the cutover team.
Reinforce need for H2S monitors and good communication during shift change meeting.

17. Forklift Boom Hits Wall
Solar employees were working in the receiving area of the client facility with a 40’ boom lift during installation of the inverter.
While rotating the boom lift to the left it came in contact with the wall.

18. Forklift Boom Hits Wall
Determined Cause
There was a 4” conduit over mezzanine. The area was tight and when boom lift was rotating left it was too close to the wall.
Lessons Learned
Pay better attention to obstacles
Move slow in tight spaces
Utilize spotter

19. Crane Work Overhead
The Mangan employee wanted to enter client building 8 to connect to the PA10 PLC.
It was noted that there was presence of the crane in the alley near the entrance (truck and boom), and the area was taped off.
The employee was informed that they could use the door on the other side of the building.

20. Crane Work Overhead
The sign on the east PA9 door said do not enter because of the crane work. The sign on the east PA10 door said entry was available through PA6.
The employee was aware of previous crane and recent floor work in PA6, so entered through PA10 11:00am.
The employee left the building around 11:15am.

21. Crane Work Overhead
When the employee attempted to re-enter around 11:30am, they were stopped and warned that the whole building had been evacuated for the crane work.

22. Crane Work Overhead
The employee was not aware that the east PA10 door should not be used for entry, until they were told so around 11:30am as they were about to re-enter.
The employee then waited to re-enter until after the crane had departed.

23. Crane Work Overhead Determined Cause / Lesson Learned
The employee had insufficient information, and didn't seek clarification of the signage.
The sign on the door only warned them away from entering PA9, but not PA10, because of the crane work.
Follow Through
The client determined the following follow through steps:
Post a sign at the front

24. Crane Work Overhead Client Follow Through
Post a sign at the front desk when a crane is on site notifying visitors and contractors which areas are restricted access
Add a line item in expectations during crane lift checklist to remind the crane operator to put a sign at front desk
Take a look at SOP’s and determine whether or not verbiage is sufficient to prevent a re-occurrence
Formulate a contractor orientation plan
Request better signage for building access door to PA-10.