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Major incident

Final report

Near miss with potential for fatality involvingrisks of level fall and access the confined space.

ALUMAR - So Luis - 161Z

September, 3rd, 2003

INDEX


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1.0 - SUMMARY 3

2.0 - BACKGROUND 3

3.0 - INVESTIGATION PROCESS 4

3.1 - Investigation team 4

4.0 - EVENTS CRONOLOGY 5

5.0 - KNOWN FACTORS 6

5.1 - General Data 6

5.2 - Personal Data 6

5.3 - Equipment - Task necessity 75.3.1 Developed Activity - Reactor plenun cleanness 7

5.4 - Existent preventive measures for the execution of the task 7

6.0 - CONTRIBUTIVE FACTORS 8

7.0 - ROOT CAUSES 8

8.0 - TAKEN ACTIONS 8

9.0 - ATTACHMENTS 8

9.1- Event simulation 8

1.0- EXECUTIVE SUMMARY

In September, 3rd, 2003 at 4:30 p.m., the 162Z Alumina Distribution specialized

mechanical (Robisley Maia Aguiar), moving to the dressing room near the 141F

building, looked a person get into the 161-RE-009 reactor plenun in a wrong way.

The person was getting into the reactor plenun stepping in its structure beam,

without using the elevator platform neither accomplishing the confined space.

The reactor plenun is located at approximately 8 meters and its classified as

class Cconfined space. To execute a task in this environmental it is necessary to

accomplish the procedures of works in Confined Space and Prevention of fall. In

September 4th, 2003 it was identified that the person who was seen get into the

plenum reactor was the operator Jos Carlos Saraiva.


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2.0 - BACKGROUND

Consortium of Aluminum of Maranho - ALUMAR in So Luis, MA, Brazil - it

is a consortium formed by Alcoa Alumnio S.A., BHP-Billiton Metals S.A.,

Aluminum Alcan of Brazil Ltd. and Abalco, and Alcoa manages its operation. A

Port, an Alumina Refinery with production of 1.244 MTPY and a Smelter of

380.000 MTPY of aluminum compose the plant. There are 2050 direct

employees and 1500 contracted employees approximately at the plant.

The ABC area is located in the Smelter and it is responsible for the

distribution of Alumina and Bath for the Pot Rooms and for the generation and

distribution of air compressed for all the Smelter. In the Alumina Distribution area

are located the Reactors A-398 used in the treatment of the Gases generated in

the eletrolitics pots. We have a total of 55 reactors, distributed in the following

way: 18 reactors in the Line I, 22 reactors in the Line II and 15 reactors in the

Line III.

The reactor has the function of treating the gases generated in the eletrolitics

process. This treatment is done through the adsorption of the existent fluoride in

the gas to the Alumina that passes through the reactor. The Alumina that feeds

the reactor moves above the deviation perforated plates, through the ones the

gas originating from the eletrolitics pots is addressed, passing through the

eletrolitics layer. The holes of these plates in the course of time are obstructed

and it is necessary to substitute the plates for other clean ones, in other words,

other plates with cleared holes. When this activity of plates substitution is done,

also is done the cleaning of the reactor plenun. The plenun is the compartment of

the reactor that is below the deviation plates. This compartment has restricted

access and it is classified as confined space class C.

3.0 - INVESTIGATION PROCESS


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3.1 - Investigation team

Name Function

Nilson Frazo Ferraz Smelter Manager

Jos Maurcio Macedo EHS Manager

Oder Lima MSVIP Superintendent

Robson Cunha EHS Superintendent

Jos Carlos Viegas EHS Technical

Carlos Augusto Gervsio ABC Supervisor

Wilton de Jesus Sousa ABC Production Foreman

Paulo Rodrigues EHS Supervisor

Jos Carlos Saraiva Smelter Operator

4.0 - CHRONOLOGY OF THE EVENTS

Day 09/03/2003

1. At 3:30 p.m., beginning of the work day shift of the Plates

Maintenance Group in the Reactor 161 - RE-009;

2. At 4:20 p.m., the employee Jos Carlos Saraiva receives a private

phone call informing that his mother was badly sick;

3. At 4:30 p.m. the elevator platform (zealous) that is used for access

to the plenun of the reactors, it presented operational problems;

4. At 4:35 p.m. the electric corrective maintenance group of the Shift

was called to correct the problem of the platform;

5. At 4:40 p.m. the Mechanic Robisley Aguiar observes a person

accessing the plenun of the Reactor 161-RE-009;

6. At 4:41 p.m. the electrician of the corrective maintenance group

begins tests to solve platform problem, without success cause it

was not an electric problem;


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7. At 4:45 p.m. the operator Luis Sergio Freitas got to adjust the

controlling valves of pressure allowing the operation of the

platform;

8. At 4:47 p.m. the group begins the ascent of the platform. When

they arrived to plenun access door, the group observed that the

operator Jos Carlos Saraiva was already inside of the plenun;

9. At 4:49 p.m. in spite of the situation to be atypical, the group

continued the task of cleaning the plenun;

Day 09/04/2003

1. At 08:30 a.m. the mechanic Robisley Aguiar communicates the fact

witnessed to the operation foreman of the area 161Z, Mr. Wilton de

Jesus Sousa;

2. The operation foreman waits for the arrival of the referred group,

foreseen for the 3:30 p.m. to get an explanation of the situation;

3. At 3:30 p.m. after the arrival of the shift, the operation Foreman, Mr.

Wilton de Jesus Sousa identifies that person seen getting into the

reactor plenun was the operator Jos Carlos Saraiva;

5.0 - Known Factors5.1 - General Data

Date: 09/03/2003

Time: 4:50 p.m.

Local: 161Z Alumina Distribution - Reactors Bank

Department: MSVIP/ABC

Locality: So Luis - Alumar - Brazil

5.2 - Personal Data

Name: Jos Carlos Saraiva Junior

Identification number: 203312

Experience at the function: 3 years and 6 months

The employee had been recycled in all of the mandatory norms (fall control,

lockout, tagout and verification procedures, confined space) in the second

semester of 2002.


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5.3 Equipment - Task Necessity

5.3.1- Developed Activity - Cleaning of the Reactor plenun

Whenever it is made the Maintenance of Plates of the Reactor, it is also

made the cleaning of the plenun. The frequency of the cleaning of the

plenun is two years, however due of the total number of reactors in the

Smelter (55 reactors) every two weeks it is made a plenun cleaning.

5.4 Existent preventive measures for the execution of the task

As the referred task (cleaning of the plenun of the reactor) is executed in an

environmental classified as confined space class C, the task is done

following all safety countermeasures included in the mandatory standards for

works in confined space. We can mention among the measures:

Measurement of levels of oxygen and carbon monoxide, before the

people get into the space;

Continuous Monitoring of the levels of oxygen and carbon

monoxide in the space confined during the execution of the task;

Continuous Presence of the confined space observer during theexecution of the task;

The reactor plenun is located approximately to 8 meters above the soil. To

access its entrance door the person has to use the people's elevation equipment,

once access stairway doesn't exist. This way, during the execution of this task all

the safety countermeasures foreseen in the mandatory standards for fall control

must be followed. We can mention the obligation of use the elevator platform.

6.0 - CONTRIBUTIVE FACTORS

6.1 - Phone call received by the operator Jose Carlos Saraiva before the

beginning of the works.

7.0 - ROOT CAUSE

Violation of task execution procedure and mandatory norms of fallsprevention and confined space.


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8.0 - TAKEN ACTIONS

8.5 - Communication of the occurrence to the leaderships

8.6 - Application of discipline measure to the employee Jose Carlos

Saraiva

7.3- Instructions to the others that execute the task

7.4- Deployment of the occurrence for all plant employees

9.0 - ATTACHMENTS9.1 - Simulation of the event

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