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.
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
Factors to consider
at your site or on your project include, but are not limited to, the following:
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.
Review specific work practices that
include small demo and cutting activities on operable systems.
Train employees to recognize the
hazard of unlabeled systems; and the presence of live electrical components
within their SOW.
Include representatives from all
contract firms if feasible; and visit the work site if possible.
Expand HSE pre-plan checklists to
include small demo/ cutting and unknowns.
this example as you complete today’s work activities.
Think about the hazards
associated with your particular
work, and the steps that can be taken to increase safety on your job.