Compliance verification activity type: Field Inspection
Team:
Regulated company: Trans Mountain Pipeline ULC
Operating company:
Province(s) / Territory(s):
Discipline(s):
Related events:
Rationale and scope:
Response to serious injury reported by the company [INC2021-155]. CV was performed to ensure that the company was following incident response process, not allowing workers to operate the equipment until immediate mitigations were implemented to mitigate risks and verify company's oversight of tunnel boring operation.
Compliance tool(s) used:
Facilities:
Facility Types
Life-cycle Phases
Regulatory requirements that apply to this activity:
Regulatory instrument number(s):
Observation 1 - General Observation - Tunnel Portal
Date & time of visit: 2021-10-19 16:20
Discipline: Safety Management
Categories:
Facility:
Observations:
CER Inspection Officers (IO) responded to a serious injury reported through INC2021-155 on October 18, 2021. IOs arrived at Westridge Marine Terminal on October 19, 2021 and conducted an incident scene visit. IOs note that the worksite was accessible and all workers in the area were observed to be wearing proper personal protective equipment (PPE), including face coverings as per COVID-19 protocols. Kickoff meeting was held with site management team who briefed the IOs on injured worker status, incident scene scene security and internal investigation status. During the inspection, tunnel boring machine was in recirculation mode to prevent grout from hardening. The incident location was at the segment handler portion of the machine. No work was being performed in this section while company's internal investigation had been initiated. CER IOs were taken through the portal entry orientation which covered entry/exit procedures, escape rebreather, and the brass badge entry and exit system. CER IOs observed that there were multiple operating phone lines on the tunnel boring machine (TBM) which were connected with a control location outside the tunnel. IOs were informed that McNally had arranged for an onsite counselor. Trans mountain provides oversight of the tunnel boring activities through a site inspector who routinely interacts with tunnel boring crew. The company provided sign off sheets documenting such interaction. However, more recent documentation will be reviewed as part of the incident review of INC2021-155.PTI (Pre-Task inventory) document from the October 18, 2021 night shift was shared with the IOs and showed that appropriate hazards and controls were indeed identified by the crew. Detailed Execution Plan 14A (DEP) was shared with the IOs. McNally Job Hazard Analysis included in the DEP did not clearly identify or highlight communication protocols pertaining to segment handling. IOs reviewed TBM operating procedure by the manufacturer and identified need for further alignment with the manufacturer's procedures. The company had already initiated a document update review process and were in the process of incorporating the identified changes. Preliminary corrective actions were identified by the company and were implemented during the inspection (as captured in the Corrected Non Compliance). Westridge Site Construction Manager, TMEP provided a commitment letter to the IOs indicating further steps the company and its contractors were in the process of implementing to further mitigate the risk associated with segment handling task.
Compliance tool used: No compliance tool used
Observation 2 - CNC 1- Tunnel Boring Machine Segment Handler modification
Date & time of visit: 2021-10-19 17:05
Preliminary investigation identified vertical bars on the segment handling mechanism as one of the factors in the injury. The worker was pinched between these vertical bars and a fixed gate on the Tunnel Boring Machine (TBM) platform. The manufacturer's procedure identified risks of crushing at various portions of the segment handling and feeder loading process. Risk associated with potential crushing or pinching due to the bars was unclear and not identified in the job safety analysis of the operational procedure for TBM segment handler.
Compliance tool used: Corrected Non-compliance (CNC)
Regulatory requirement:
Relevant section(s):
Company action required:
Company to explore relocating the vertical bars in consultation with the equipment manufacturer.
Due date: 2021-10-22
Date closed: 2021-10-21 Note: the date closed is the date that the inspector completed their review of the company corrective actions for adequacy and determined that no further actions are required.
Reason closed: Requirement met
Compliance achieved: Yes
Observation 3 - CNC 2- Tunnel Access
Date & time of visit: 2021-10-19 18:45
Company shall replace damaged sand bags for tunnel access and place additional sand bags where gaps existed to make a continuous walkway. Company shall also replace or secure existing plywood to ensure a secure walkway.
Due date: 2021-10-20
Date closed: 2021-10-22 Note: the date closed is the date that the inspector completed their review of the company corrective actions for adequacy and determined that no further actions are required.
Observation 4 - Information caviardée conformément au paragraphe 144(5) du Code canadien du travail
This information has been redacted pursuant to Section 144(5) of the Canada Labour Code
Identified non-compliances to company plans or procedures are non-compliances either to:
- the condition of an authorization document that requires the implementation of that plan or procedure; or
- the relevant section of the regulations that requires implementation of that plan or procedure including those sections that require implementation of plans or procedures as a part of a Program
