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What happened?
A pig trap was not depressurised before attempting to remove it from a pipe.
When the trap door was opened, a sudden release of high pressure gas caused the door to be blown 30 feet/10 meters across the deck, through two handrails and overboard.
A worker was injured and treated for facial lacerations.
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Why did it happen?
Key steps in the procedure were missed. The injured worker did NOT:
- open depressurisation valves to confirm ‘zero energy’.
- check the local pressure indicator.
The worker was relying on years of experience, and not following a safety critical procedure.
The worker was not positioned sufficiently outside of the line of fire and got injured, but avoided fatality.
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What did they learn?
Check the pressure indicator and ensure ‘zero energy’ before opening a pig trap door. Breaking containment is a high risk activity.
When opening a pig trap door, ensure that staff members are positioned outside of the direct ‘line of fire’ in order to prevent fatality.
It is vital to understand and follow safety critical procedures.
Compliance with the work management system is mandatory.
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Ask yourself or your crew
What other actions could have been taken?
Are the permit-to-work assessments of high quality? Why do you think that?
Who is checking that the permit-to-work conditions are being met in the field?
How do you ensure that every step of a critical procedure is followed as intended?
How would you intervene when someone is working in an unsafe manner?
What should be the disciplinary action for non-compliance with the work management system?
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What happened?
A pig trap was not depressurised before attempting to remove it from a pipe.
When the trap door was opened, a sudden release of high pressure gas caused the door to be blown 30 feet/10 meters across the deck, through two handrails and overboard.
A worker was injured and treated for facial lacerations.
Why did it happen?
Key steps in the procedure were missed. The injured worker did NOT:
- open depressurisation valves to confirm ‘zero energy’.
- check the local pressure indicator.
The worker was relying on years of experience, and not following a safety critical procedure.
The worker was not positioned sufficiently outside of the line of fire and got injured, but avoided fatality.
What did they learn?
Check the pressure indicator and ensure ‘zero energy’ before opening a pig trap door. Breaking containment is a high risk activity.
When opening a pig trap door, ensure that staff members are positioned outside of the direct ‘line of fire’ in order to prevent fatality.
It is vital to understand and follow safety critical procedures.
Compliance with the work management system is mandatory.
Ask yourself or your crew
What other actions could have been taken?
Are the permit-to-work assessments of high quality? Why do you think that?
Who is checking that the permit-to-work conditions are being met in the field?
How do you ensure that every step of a critical procedure is followed as intended?
How would you intervene when someone is working in an unsafe manner?
What should be the disciplinary action for non-compliance with the work management system?
A pig trap was not depressurised before attempting to remove it from a pipe. When the trap door was opened, a sudden release of high pressure gas caused the door to be blown 30 feet/15 meters across the deck...
