How Does Routine Maintenance Have a Fatal Outcome?
IOGP (The International Association of Oil & Gas Producers) was recently alerted to two separate incidents, both with fatal outcomes and related to routine maintenance and changing of tires on vehicles.
“These routine maintenance incidents represent opportunities to highlight risk areas that were insufficiently recognized in our industry” — IOGP.
- On September 12, 2021, a contracted tire technician was fatally struck by a heavy vehicle tire and a tire rim which ejected after a sudden failure.
- On December 23, 2021, an employee was fatally struck by a heavy vehicle tire rim during maintenance.
Both incidents happened during routine maintenance — both activities were in controlled logistics environments.
The trucks involved were heavy and used in rough terrain. Tire inflation pressures were as per manufacturer’s’ recommendations, in the order of 130 psi.
In the first event, a new tire was already mounted on the one-piece rim after having been previously inflated inside a safety cage, and it was resting outside the cage, awaiting installation on a truck. A maintenance technician noticed some air leaking from it and approached it. While the technician was inspecting/troubleshooting the tire, the wheel parted, releasing the rim which hit the technician on the head.
In the second event, a driver was loosening the lug nuts of a heavy vehicle wheel that had been reported defective by a previous shift driver, with the intention of replacing it with a spare. The rim catastrophically failed and cracked in two, releasing the tire and part of the rim with explosive force
and projecting the driver several meters away.
Following these routine maintenance incidents, prior damage was noted on the tire rims in both cases.
This may either have occurred through wear and tear during rough terrain driving or potentially through driving with a partially deflated tire. Subsequent wider inspection of tires and tire rims revealed that such cases are not limited to the incident vehicles in isolation.
What went wrong?
• In both incidents, workers were in the line of fire from a pressure hazard and had not recognized this as a risk.
• In both incidents, the tires were not deflated prior to troubleshooting task commencing.
• In one incident, substandard practice was noted, in that the wheel was removed from its cage without inspection of the rim seat area.
• In both incidents, tire rim damage had been sustained and not recognized. Subsequent inspection of other vehicles found cases of cracks and damage.
• In first incident, OEM recommendations for tire rim inspection had not been followed.
• In the second incident, learnings from the first incident had been insufficiently embedded.
Corrective actions and recommendations
- Reinforce line of fire awareness with all personnel and the importance of avoiding body positioning in the of line of fire.
- Procure and raise awareness of tools and methods that enable humans to perform any activities related to tires, such as inflation and deflation, away from the line of fire.
- Perform immediate tire and tire rim inspections across the fleet of vehicles and verify inclusion of both tires and tire rims in vehicle inspection programs.
- Reinforce the hazard of tires and tire rim damage through reflective learning or similar activities.
- Raise awareness of the need to deflate tires before removal from the vehicle.
- Raise awareness of the general risk of pressure release from tires and different modalities where such release can occur.
- Attain a deeper understanding of tire rim construction, types and inspection requirements as per OEM recommendations.
- Reinforce the requirement to monitor for weak signals with respect to tire and tire rim construction during driving. Stop the job in case anomalies are noted.
- Reinforce the availability of learnings from previous incidents.
Source: IOGP, IOGP Alert 331, “Technician fatalities,”Feb. 2022.”
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