Office for Nuclear Regulation

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Investigation into a conventional health and safety accident

Executive summary

Purpose of intervention

To carry out an investigation into a conventional health and safety accident that occurred on 9 December 2015 at EDF Hinkley Point B (HPB). The accident happened in the XXXXX XXXXX XXXXX XXXX XXXX XXXX. It involved a shift operations engineer and resulted in a finger amputation injury. The injury was reportable under the Reporting of Injuries, Diseases and Dangerous Occurrences regulations (RIDDOR) and met the ONR criteria for investigation of conventional health and safety events.

The opportunity was also taken to undertake an inspection of arrangements for managing work at height activities, during the statutory outage, with particular focus on scaffolding. Scaffolding is the stations main method of providing temporary work at height access for outage activities.

One of ONR’s key strategic themes is influencing improvements in nuclear safety and security. The Cross ONR Programme strategic direction for 2015-2020 delivers its contribution to this theme by providing coherent support and advice to other ONR regulatory programmes in conventional safety. In addition, the ONR Conventional Health & Safety Team (CHST) sub-programme strategy has identified a number of priority conventional health and safety topics/activities to be covered during inspection activities.

Statutory outages inevitably result in significant increases in worker numbers and maintenance/construction type activities - which in turn result in an increase in the presence of conventional health and safety hazards. Therefore, proactive inspections covering selected priority conventional health and safety topics (examples include ‘setting to work’, control of contractors, and falls from height) during outages ultimately contribute to influencing improvements in nuclear safety and security.

Interventions Carried Out by ONR

The key regulatory activities undertaken during the two day inspection were based around:

The RIDDOR reportable accident involved the injury and subsequent amputation of the left hand ring finger of an EDF HPB operations engineer. The engineer was carrying out a check on the status of a damper in the XXXXX building when his wedding ring caught on a protruding bolt on the side of ducting as he stood down from a slightly elevated position. The effect of stepping down with the ring caught on the bolt caused a severe injury to the finger which was later surgically removed in hospital.

The EDF HPB investigation report into the RIDDOR reportable accident was reviewed. This Significant Adverse Condition Investigation report (SACI, number 967446) sets out the circumstances of the accident and identifies the cause and corrective actions. The SACI report analysis and identified corrections actions were explored and validated via direct accident ‘scene walk-down’ observation and interviews with the injured person and other relevant EDF HPB staff.  Consideration was then given to the Enforcement Management Model (EMM) and appropriate regulatory actions.

A proactive inspection to evaluate arrangements for controlling risks from working at Height took place with a particular focus on the use of scaffolding. A ‘site walk down’ took place in the Turbine Hall to sample outage activities underway at the time of the visit and inspect the management arrangements in place. A number of locations were seen featuring both scaffolding and rope access. However, the ever changing nature of work at height locations during outage (and general) activities mean that the inspection was a sampling one that enabled insight into EDF’s management of working at height.

Regulatory judgement was based on determining compliance with sections 2 & 3 of the Health & Safety at Work etc  Act 1974. A number of key relevant statutory provisions were referred to during the visit, including: The Work at Height Regulations 2005 (as amended).

Explanation of Judgement if Safety System Not Judged to be Adequate

N/A

Key Findings, Inspector's Opinions and Reasons for Judgements Made

A number of areas of good or best practice were seen during the proactive inspection in addition to areas for improvement. These were summarised during feedback provided at the conclusion of the visit, as were the visit outcomes/actions required by EDF HPB.

Areas of good or best practice seen during the inspection included: The integrated safety team meetings, appropriate use of scaffolding to facilitate work at height activity in the turbine hall and the practical implementation of EDF COP24A procedures (covering temporary grating removals). 

Areas requiring improvement during the inspection included: improved supervision of scaffolding modification work activities. 

Conclusion of Intervention

The investigation explored the circumstances of the RIDDOR reportable accident event in the XXXXX building. The investigation concluded that the EDF HPB SACI report was an accurate reflection of the event and effectively captured the key causes and broader learning issues arising. A number of corrective actions were identified within the SACI as event learning. Two additional recommendations were made during the visit and these were accepted by the Quality Management Group Head. The EMM was considered and no further regulatory action was deemed appropriate in relation to the accident event. EDF HPB will provide ONR with an update in due course with regard to progress made in implementing the identified corrective actions.

An issue will be added to the ONR Regulatory Issues database for tracking purposes.

The overall impression gained from the proactive inspection of work at height was generally a positive one. A CHS topic rating of ‘3 – adequate’ will be applied to the visit. This rating is based on an intervention assessment that ‘there were one or more minor shortcomings - since these shortcomings are not serious they can be dealt with informally.