An insulator was
removing insulation from an inoperable water line with associated heat trace
(208v-AC). He began removing insulation from the wrong line that was not
de-energized (the heat trace); he thought it was LOTO as performed by others. He
did not encounter any noise, spark or other indicator that an energized line
was struck with his knife, but he had a notch broken/melted out of the blade.
No written Scope of
Work (SOW) or field drawings or markings were provided to the contractor; and
the long and changing route and crossing of lines made identification of the
pipe difficult. A basic hand sketch was provided to the insulators, but this
was for estimating purposes only and not to convey the SOW.
No Health and
Safety pre-planning was conducted and the insulating contractor did not verify
the LOTO. It was also discovered the
contractor was not following their own LOTO policy as submitted to their
client; and the client did not complete a work permit as their own policy
After the incident,
an investigation team was assembled and a subsequent RCA was conducted. The identified
causal factor was the work was released but no field drawings or markings were
provided to clearly communicate the SOW. Other contributing factors listed
above were noted as significant events alongside the causal factor.
Provide to, and ask for, written SOW,
drawings/markings as necessary to fully clarify SOW.
Conduct an effective H&S pre-plan
meeting and include all necessary groups (owner, prime, subs, HSE, etc.) to
fully understand and convey the planned work, the associated risks and the
controls needed to for the hazards.
Provide to, and ask for, site specific
Be aware of your own company H&S
requirements submitted to your client.
Always walk down the LOTO with an
informed owner and/or supervisor.