Contractor Safety Share

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Near Miss - LOTO

An insulator was performing routine work in a process manufacturing room. The employee was installing PVC covering over existing fiberglass insulation on an active chemical line with associated heat trace (110v). The employee cut a slit to set the end cap and cut the line heat trace line.  He encountered smoke/spark and noticed his knife was damaged with discoloration and notches were broken/ melted out of the blade. The line was not labeled with its contents, or for the presence of heat trace as required by NEC/ NFPA 70 code, but electrical components were visibly connected to the pipe near the work area.

Other lines in the room were labeled with heat trace but they were not easily seen. The line was located indoors, so it was not anticipated to have heat trace. During the investigation it was discovered that heat trace is always on this particular chemical line whether indoors or outdoors. 

Health and Safety pre-planning was conducted but no one was aware that the heat trace line was present; and the presence of an unlabeled line was not discovered or discussed. It was also discovered that HSE items are not typically discussed at the bid estimate phase. Once work began, the field team did not recognize the potential hazards of the unlabeled line and the adjacent electrical component within their scope of work (SOW). The field team completed two daily safety forms at the beginning of the day, which was the first day of the project.

After the incident, an investigation team was assembled and a subsequent RCA was conducted. The unlabeled line for contents and heat trace, the team being unaware of the heat trace, and the unrecognized hazard of adjacent electrical components were the causal factors identified during the investigation.

Other significant events alongside the causal factors included the HSE pre-plan team did not visit the work site and did not include any representatives from the subcontractor team during the meeting; and the HSE pre-plan checklist is general in nature and does not address specific work practices. The facility procedure did not require the job site to be visited or the subcontractor to be present at the HSE pre-planning meeting; and the checklist is geared to be more general and not specific.

Factors to consider at your site or on your project include, but are not limited to, the following:

1.    Conduct a thorough HSE walk-through of the project prior to commencing field activities using a checklist to identify hazards, including unknowns, that are associated with the SOW.

2.    Review specific work practices that include small demo and cutting activities on operable systems.

3.    Train employees to recognize the hazard of unlabeled systems; and the presence of live electrical components within their SOW.

4.    Include representatives from all contract firms if feasible; and visit the work site if possible.

5.    Expand HSE pre-plan checklists to include small demo/ cutting and unknowns.


Consider this example as you complete today‚Äôs work activities. 

Think about the hazards associated with your particular work, and the steps that can be taken to increase safety on your job.

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