Vent valve hits worker, leading to fall from height

A water injection filter was leaking from the filter outlet flange.

Workers tightened the flange and stopped the leak.

They noticed that a drainage valve was in bad condition, so they replaced it. They used the old drainage valve to replace a vent valve which was also corroded.

The water injection well was reopened, and a worker remained onsite to monitor the valves.

A few hours later, the vent valve started to leak.

The worker climbed the top of the water filter (2 metres / 6.5 feet) to install a plug.

The vent valve came away from the water filter because of pressure in the line and hit the worker in the face, knocking him to the ground.

The worker was standing on the filter 2 metres (6.5. feet) from the ground without any fall protection or personal protective equipment (PPE).

Worker put himself in the ‘line of fire’.

Worker was not contractually entitled (allowed) to carry out the work.

The workers carried out extra work (using the old valve to replace a vent valve) without a technical evaluation of internal and external conditions. They did not follow a management of change (MOC) procedure.

Poor permit to work (PTW) management – it was not opened for the activity, and field personnel assumed that it had been opened by office personnel.

Isolation and lockout/tagout procedure must be applied before starting maintenance activities.

Implement appropriate fall prevention measures when working at height.

Do not work over equipment in the potential line of fire.

Apply PTW and MOC procedures where appropriate.

Ensure that safety critical jobs are not carried out by individual workers.

How do you ensure that energy is isolated before you start work?

What fall protection do you use when working at height? What should you do if it’s unavailable before you start the job?

What is your management of change procedure?

Have you ever been asked to carry out work by yourself when the task requires more workers? What happened?