Late last year an incident was brought to IMCA’s attention relating to a confined space entry hot work fatality in a shipyard.
What happened?
A welder entered a 86cm (34”) pipe through a 50cm (20”) opening to check on welding being carried out. He was found unconscious by another worker who had noticed his absence, and called the emergency team. First aid was provided by the shipyard rescue teams and he was then taken to a local hospital, where, though care was continued, he was pronounced dead.
Probable cause
The report seen by IMCA identifies the following issues:
- Poor Communications: There was no signage at the pipe warning of a confined space or prohibiting entry.
- Physical entry into the confined space was not blocked.
- There was a failure of leadership – inadequate supervision.
- There was a failure in planning and risk assessment – whilst the Permit to Work was comprehensive for all welding activities at the site, it did not address or warn about the specific risk of inert gas (argon) related to the task being performed.
- Motivation: There was a lack of clarity in the criteria for evaluating welders’ performance, which generated doubts about possible consequences due to failed welding. In addition, though the welders had been told not to enter the pipe, they were not fully made aware as to why this was: conditions inside the pipe were not known by the welders.
- Procedures were inadequate: The welding procedure did not clearly address the welders’ performance criteria, nor did it address the specific risks associated with the use of inert gas.
Actions taken
- Installed physical barriers at all temporary pipe openings with diameters equal to or greater than 40cm (16”), with signage prohibiting entry into the pipe.
- Amended procedure for restricted space requirements for pipes with a diameter equal to or greater than 40cm (16”).
- Provided specific additional input to risk assessment and Permit to Work for activities involving inert gases.
- Ensured better communication to welders of the criteria impacting the evaluation of their performance, and reiterated awareness of the Life-Saving Rules and safety with regard to confined space entry.
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Source: IMCA
