ICAMs that our consultants have facilitated and carried out.
Large Steel making Operation.
Equipment failure 8 hours downtime - lost Production
- Significant Plant damage
- Many days lost production.
- Additional hazards creating potential for injury.
The investigation team using the ICAM process identified the
root cause of the incident and why the equipment failed.
Recommendations were made to prevent reoccurrence, with responsible
persons identified to carry out the fix, by agreed deadlines.
- Develop Standard Operating Procedure for managing and repair
of critical equipment:
- Removal and replace
- Rotation strategy for spares
- Equipment planned maintenance
- Equipment repair standard
- Tracking maintenance critical equipment.
- Develop emergency procedure
- Train Operators in use of alarm systems
- Stores department to review the standard for storage of critical
- Purchase critical spares.
- Investigate the use of remote equipment to detect deterioration
thinning of the pipe work walls. (x-ray, ultra sonic etc.)
- Source local manufactures for bowl replacement
As well as recommendations the ICAM also identified vulnerabilities
in the overall system. Further recommendations were developed
to build in a tolerance for error.
Serious Harm Injury
Heavy Machine Driver Head Injury.
High potential for more severe injury.
Carrying out unusual operation with heavy machinery.
Operator Error or Organisational Factor?
Due to injuries received the investigation team where unable
to determine the exact cause of the incident. However using the
ICAM process operating and safety procedures where interrogated,
gaps in the system were found. Recommendations were made to prevent
the reoccurrence of the incident.
- Update SOP to reflect the actual operation.
- Reposition location and placement of radios and other equipment
- Check seatbelt design what is new on the market.
- Communicate on injury management procedure to all employees.
- Company review management and care of injured parties.
- Design of operating area to be reviewed WRT size and lighting.
Review pecking of bowls possibilities after hours Who: PS
- Investigate elimination of hazardous part of the task.
- Communicate to company workforce the incident, and the importance
of reporting Near Miss Incidents
Plant Damage and High Potential Near Miss
20 Tonne Lifter dropped from Overhead Crane.
Extensive Plant damage when lifter dropped from Crane
Potential for Fatality.
The investigation team consisted of various levels in the organisation
and skills ranging from operators, crane drivers to specialised
engineers, with a common goal to find the root cause and the prevent
reoccurrence of the incident.
The ICAM process using the array of skills of the team was able
to design out the weakness in the attachment connection. Also
recommend other operating and procedural changes to increase the
safety within the operating area.
- Redesign lifter attachment remove ability for lifter to self
- Audit all other attachments, redesign as necessary.
- Update training records and SOP's after modifications have
- Audit training is per the new standard.
- Review current training methods including assessment methods.
- Conduct interview with crane trainer.
- Repair clamp closed indicator light.
- Institute integrity of operation of indicator light into operator's
Key Learnings to be shared with other plants, company sites,
and industry crane association.
Plant Damage, Lost Production and High Potential Near Miss Incident
3.3KV Switchgear Explosion
Increase recommend other evaluate other were able to identify
High potential for more severe injury
Company assisted or totally independent we will investigate and
make recommendations to assist improve your business performance.