Three operators were trying to unplug a 7.5cm (3in) hose plugged with catalyst.
To dislodge the plug, the hose was pressurised with 200 pounds per square inch (psi) gauge nitrogen.
One operator braced the open end with his right foot.
When the plug pushed out, the hose moved from under his foot, striking his left ankle and breaking his shin bone.
Why did it happen?
The stored pneumatic energy in the plugged hose caused it to recoil when the pressure was released.
The working method was unsafe - the worker was in the line of fire of the hose.
The workers did not think the stored pneumatic energy in the plugged hose was a hazard.
What did they learn?
Recognise the danger posed by stored pneumatic energy.
Modify hose working practices and procedures to address stored pneumatic energy hazards.
Provide clear guidance on how to trouble-shoot and unplug hoses
Ask yourself or your crew
What other actions could have been taken?
How could something like this happen here?
What can we do differently to unplug hoses?
What changes do we need to make to working procedures and practices?
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While unplugging a 7.5cm (3in) pressurised hose, a worker was bracing the open end of the hose under his right foot. When the plug pushed out, the hose hit his left leg, breaking his shin.