440V electrical shock incident
- Safety Flash
- Published on 8 September 2014
- Generated on 26 December 2024
- IMCA SF 15/14
- 3 minute read
A member has reported an incident which a technician received a 440V electric shock.
What happened?
The incident occurred during an investigation of a power distribution unit (PDU) located in the ROV control room onboard a vessel. The purpose of the investigation into the PDU unit was to conclude whether the observation ROV being powered from this PDU was able to provide output data of a certain quality. The person who was shocked was not harmed and did not require any medical follow up.
Our member’s investigation revealed the following:
- The task was not a planned operation and it was performed by personnel with inadequate training/knowledge of the dangers associated with this work.
- The PDU was not properly labelled with warning signs, and had no top cover.
- There were two separate power supplies to the PDU; this was not identified due to the low level of familiarisation of involved personnel.
- The ROV supervisor was not notified about the operation.
- There was no job-specific permit to work (PTW) or any management of change. However, a generic PTW was made.
- There was a risk assessment but it was neither suitable nor sufficient – not according to requirements in regards to details, attendees and quality.
Our member noted the causes:
- The direct cause of the incident was that the technician touched or came near equipment that was powered to 440 V.
- The root causes identified were as follows:
- Rescheduling of work tasks caused personnel to carry out ad-hoc investigations inside the PDU unit – There was poor safety awareness related to ongoing work – The PDU was inadequately labelled as being a place where there was danger of electrical shock.
- There was no detailed PTW completed – There was inadequate risk assessment underpinning the work on the PDU unit. The risk assessment was not performed to such a level of detail that it allowed actual risks to be disclosed.
- The persons doing the work were inadequately trained on this particular ROV system.
- There was inadequate quality and safety verification of equipment received onboard.
- It was not clear to personnel how the organization works offshore.
The following lessons were identified:
- Stop the job if you feel unsafe.
- Follow the requirements as defined in management system.
- Always inform supervisor.
- Always complete familiarisation.
- Always make a detailed risk assessment and be compliant with the control of work system.
- There should be thorough verification and site acceptance of new equipment, particularly with regard to quality, labelling, design and location on board.
Our member took steps to:
- Revise bridging document with focus on clear communication lines.
- Ensure control of work system was understood by all crew on board.
- Revise risk assessment, training matrix and amended procedures to avoid repetition.
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