Two craftsmen were replacing a valve on Tank 1 and they thought the next work task was to replace a different type of valve on Tank 2, but this tank was not part of the planned work for the day and not Locked/Tagged out or ready for work. It was pressurized and operating. The craftsmen asked the owner if Tank 2 was ready, but the owner thought they were talking about Tank 1. The craftsmen did not verify the LOTO and the presence of incoming energized sources to Tank 2, they thought it was part of the LOTO for Tank 1 and began work by unbolting the bottom flange which released approximately 200 L of an acetic liquid.
There was confusion among the ground crew at the beginning of the day about what parts were slated for what tanks. Extra parts were put on the work cart that were not ready for installation. Additionally, the owner representative given the responsibility of overseeing the work was not aware of the work until the day before and was not made aware of other project details. The owner Project Manager had been coordinating directly with the contract firm and did not involve the person coordinating the construction activities. The work was part of a larger project involving many tanks with similar work being conducted during an annual shutdown.
When the crew completed the LOTO walk through with the owner, another contract firm was present for different work at another tank (Tank 3) and the walk down began for both projects without the craft people present for Tank 1, which resulted in them not viewing the top page of the paperwork that identified the specific tanks included in the planned work. The group did back up to the beginning of the physical disconnects/isolation points, but Tank 2 was not visited or discussed during the walk down. The ground crew’s Supervisor was not present and did not sign the paperwork during the walk through as the policy stated. The contract firm did not have the authority to conduct the line break at Tank 2 per the policy in place.
No injury or property damage beyond the loss of the acetic liquid was incurred. The quantity was near a reporting environmental limit and was reported as such.
Factors to consider at your site or on your project include, but are not limited to, the following:
- Consider potential releases from active lines during the planning stage.
- Consider providing tradesmen with a copy of pertinent project paperwork that provides clear information on scope of work.
- Consider always having Supervisors lead and participate in all planning activities involving high risk work, and ensure the crew members understand their responsibilities.
- Consider communication improvements across work groups involving high risk work in high risk areas.
Consider 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.