Learning points:

• Enforce Strict compliance to Management of Change (MoC) process.
• Supervisor(s) are to supervise the job and stay away from getting manually involved.
• Immediately update procedures after a change has been approved for implementation.
• Refer to and Use the procedure / JSP / JHA during planning every job.
• Identify all associated hazards, assess their risks and put in effective mitigations prior to starting any job.

Recommended Actions:

Discuss this alert in toolbox talks and HSE meetings and

• Distribute to all contractors
• Post on HSE notice boards
• Include in site HSE induction