Check the situation before issuing a work permit: Blinding while system still in service

A furnace was taken out of service for maintenance due to a leak. After decoking, it was cooled down to  300C/570F.

Product blinds were installed in two batches a few days apart. Second batch was to be installed after the contractor received the permit to work from the operator.

The contractors did not wait for the operator’s assistant to hold the start-work discussion (as per standard procedure), but held the talk themselves and started the job.

When installing the last blind on the fuel gas system, it was discovered that the fuel gas header was still in service and burners still lit.

The line was closed immediately. Control room was contacted.

No one was injured. This could have resulted in burns to personnel and even a fire.

The furnace was kept at 300C/570F, rather than allowed to cool down completely.

• Daily instructions for welding activities preparation were misinterpreted by different shift teams.

Work authorisation procedure was not followed, partially due to stress:

• Operator signed the work permit without having read the shift report first (due to time constraints).
• As the blind-list had been partially filled in, he assumed the furnace was cooled down completely. He signed the permit and gave it to the contractor without full awareness of the situation.

Start-work discussion procedure not followed:

• They crew did not wait for the operator’s assistant.
• Assistant didn’t arrive because he had another task to do first.

Remember your responsibility in the work-permit process: works should be permitted only after ensuring the work can be done safely.

Ensure adequate procedures are in place for stopping and taking out of service hazardous systems, equipment and machinery.

Ensure preparation, verification, isolation and lock-out are implemented before maintenance/construction intervention.

Reinforce the importance of critical procedures (e.g. energy isolation procedures, permit procedures etc.) by frequently referring to them.

Remind all personnel (organisation-wide) of the importance of strictly following the permit procedure.

Re-evaluate the complete maintenance work procedure process, including the role of the different persons involved.  Make an inventory of all missing procedures on furnace operations.

Hold a toolbox meeting about the importance of blinding and tagging.

How can something like this happen here?

How do you think time pressure might affect our work today?  What can we do about it?

Who is responsible for verifying the work permit conditions?

Have the work permit conditions been met?  How do we know it is safe to start work?

Before starting work, how can you check if the equipment has been taken out of service?

What else can we learn from this incident?