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Near Miss - LOTO

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 requires.

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.


      1.    Provide to, and ask for, written SOW, drawings/markings as necessary to fully clarify SOW.

2.    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.

3.    Provide to, and ask for, site specific work permits.

4.    Be aware of your own company H&S requirements submitted to your client.

5.    Always walk down the LOTO with an informed owner and/or supervisor.

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