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Safety Alert February 2013 #3

What occurred?

On Monday February 25th, while lifting the ventilation ductof the Generating Set G2, the end flange got a slightsurface damage due to a blocked screw. mechanicalmaintenance technician wanted to level back the ductingsurface with hammers. !nfortunately, he missed his targetand the hammer hit one of his fingers, left hand. "he lattercontinued to work and only noticed that he was in#ured onthat same finger u$on removing his gloves. minor fracture was diagnosed. "he doctor recommended% days off to facilitate the worker&s treatment and recovery,

but also stated that the worker could go back to work$roviding he would do light tasks only. "he worker wentback on site the following day and was given restrictedduty.

Identified causes (based on 5 'hy&s analysis attached(

"here was one screw left and not removed before liftingthe first half of the ducting, resulting in a damage of theend surface.

"he worker used 2 hammers, one below and one above,

to hit the blocked screw, which is not a$$ro$riate.

"he worker reacted $rom$tly and didn&t take the time to

think about the methodology or to discuss it with hissu$ervisor before starting the #ob.

)o a$$ro$riate control or su$ervision during the

dismounting $hase.

)o $ro$er communication between the team leader and

the technicians. "he instructions given to the em$loyeeto wait and not to do the #ob was not received $ro$erlydue to noisy environment in the engine hall.

Actions

*rior to such un$lanned activity, the team has been

instructed to review all the ste$s.

+efore embarking in such un$lanned activities, toensure that the technicians are fully aware of the$rocedures.

m$lement a checklist for the critical tasks.

-nsure that either the main tasks are done bye$erienced technicians or closer su$ervision for thesetechnicians.

nvestigation on the $ossibility of having ear defenders

with integrated /0 radios.

Lessons learned

+efore embarking in un$lanned activities, to ensure

that the technicians are fully aware of the $rocedures.

m$lementation of $ro$er checklists for critical tasks.

'hen a worker is sent to the hos$ital following an

Yves-Arnaud Peres HSE Director April 2013

ACCIDENT KEY

INFORMATION'hat 3evel back the ductingsurface with hammers

'here "OGO

'hen 25424267, 86$m

1ontet lternator ns$ection

ctivities 3ifting the ventilationduct of the Generating Set G2

SAFETY INFORMATION

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Monthly re$orts

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latter. "his is to ensure that the doctor understands theworking environment of the worker so that a$$ro$riaterecommendations can be $rescribed.