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What happened?
4 locked blinds under hazardous energy control (HEC) were removed from the transfer line under the coke drums.
The blinds should have been left in place for a confined space entry isolation to the heater.
3 of the blinds were found hanging from the cables with the locks and tags attached. A cable had been cut to remove the 4th blind.
The product could have leaked through the valves, entering the tubes inside of the heater. Depending on the type of material (hot, flammable, etc.) and the potential for a tube rupture (due to thin piping, accidental disturbance by workers, etc.) within the heater, personnel could be injured.
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Why did it happen?
The permitted scope was too broad. It covered 2 jobs and 11 different blinds, which were generically referred to as ‘blinds’.
Unclear job plan.
Lack of communication.
Ambiguity around removing locked blinds. A workaround allowed the same crew to remove locked blinds when a hydro blind was leaking.
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What did they learn?
Define the field coordinator’s and operator’s roles and responsibilities clearly to ensure blind verification is effective.
Ensure that the task description includes a specific blind count and blind locations.
Update onboarding to ensure new staff know that locked blinds should not be removed.
Develop and implement a procedure for hydro blind management.
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Ask yourself or your crew
How can something like this happen here?
What other actions could have been taken?
What would we have done differently in this situation?
How do we ensure that blinds or other safeguards are in place?
How can we improve our procedures to ensure this does not happen on our site?
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What happened?
4 locked blinds under hazardous energy control (HEC) were removed from the transfer line under the coke drums.
The blinds should have been left in place for a confined space entry isolation to the heater.
3 of the blinds were found hanging from the cables with the locks and tags attached. A cable had been cut to remove the 4th blind.
The product could have leaked through the valves, entering the tubes inside of the heater. Depending on the type of material (hot, flammable, etc.) and the potential for a tube rupture (due to thin piping, accidental disturbance by workers, etc.) within the heater, personnel could be injured.
Why did it happen?
The permitted scope was too broad. It covered 2 jobs and 11 different blinds, which were generically referred to as ‘blinds’.
Unclear job plan.
Lack of communication.
Ambiguity around removing locked blinds. A workaround allowed the same crew to remove locked blinds when a hydro blind was leaking.
What did they learn?
Define the field coordinator’s and operator’s roles and responsibilities clearly to ensure blind verification is effective.
Ensure that the task description includes a specific blind count and blind locations.
Update onboarding to ensure new staff know that locked blinds should not be removed.
Develop and implement a procedure for hydro blind management.
Ask yourself or your crew
How can something like this happen here?
What other actions could have been taken?
What would we have done differently in this situation?
How do we ensure that blinds or other safeguards are in place?
How can we improve our procedures to ensure this does not happen on our site?
An unclear job plan, lack of communication and ambiguity around removing specific locked blinds led to a hazardous energy control (HEC) violation.
