21 May 2006

Blind Rolled By Mistake

Safety Incident Topic: Blind Rolled By Mistake
Location Of Incident: Texas City
Date Of Incident: 9 May, 2006

Brief Account of Incident
FCCU-3 Operations, with the help of a representative from the turn around group, prepared an authorization to work (ATW) for the overall task of installing blinds and making modifications to the slurry pump suction system. The ATW identified the need for fresh air equipment to mitigate the risk of exposure to a nitrogen rich atmosphere. A representative from operations accompanied the contract pipe fitter foreman to the work site and identified the appropriate location for the installation of a blind flange. The pipe fitter foreman walked two contract employees (pipe fitters) that had been loaned to him from another crew, to the site of the work and identified the flange to be blinded by shining a flashlight on the flange. A job safety analysis (“A.S.A.P. card) was completed by the foreman and the pipe fitters. The pipe fitters set up the fresh air equipment and their foreman acquired two gaskets to use when bolting up the flange. The blind was brought to the job site and left on a pallet at this time. After overcoming some issues with the fresh air system the fitters proceeded to unbolt the flange between vessel 401-E and the valve. By breaking containment on the vessel a large quantity of nitrogen was released into the surrounding atmosphere and the vessel was depressurized. A low pressure alarm in the control room was activated and a board operator responded by alerting an outside operator. The outside operator stopped work.

Potential Outcomes
- Oxygen Deficient Environment possibly resulting in serious injury or fatality.
- What Went Wrong (Critical Factors): Pipe fitters opened the wrong Flange.

Immediate Causes
Ineffective Communication between Supervisor and Employees. The Altair Strickland foreman’s direction to his employees did not accomplish the goal of getting the two pipe fitters to install a 20 inch blind flange in the correct location, downstream of the 401E block valve.

System Causes
1. Inadequate Vertical communication between supervisor and person: The employees and the foreman had different understandings of the task to be completed.
2. Verification/repeat back techniques not used There was no method in place to ensure the fitters understood what they were being asked to do
3. Inadequate Leadership – Inadequate work site walk-through: The fitters reported not seeing the foreman at the job site from the time they were left to do their work until the incident occurred

Corrective Actions/Lessons Learned
- Have a person from operations present at every line break.
- Ensure the employees doing the work understand the risks of the process and area they are working and the task they are to perform explained to them

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