An incident has been brought to IMCA’s attention in which a crewman died as a result of a stored pressure release. The incident occurred when a two man team was removing a Techlok (clamp hub connector) to conduct repair work on a leak found during testing. The leak was identified at the hub connector upstream of the manual valve on the top deck of the module. The clamp released under high pressure and struck one of the crewman, causing fatal injuries.
The following points were noted:
- The Techlok clamp removal was done using an incorrect method;
- The Permit to Work was issued with conflicting isolation requirements – there was substandard identification of conflicting work scopes;
- The compressor isolation certificate number was not included in the test log sheet within the procedure;
- The Permit to Work recognised the need for electrical Isolations but not mechanical Isolations;
- Permits to Work for leak testing and leak rectification covered multiple systems. They become generic by nature and reduced the ability to identify task specific hazards;
- No bleed point was identified between primary and secondary isolation valves;
- The team did not adequately follow existing leak test procedures. Valve line-out was not confirmed during second leak test;
- Some members of the crew were inexperienced in the task and were unaware of their individual roles and responsibilities;
- There was inadequate shift handover; electronic handovers were used rather than face to face or written handovers;
- The agreed procedure and Permit to Work were deviated from. The Project Manager was not aware of change and there was no Management of Change undertaken;
- Actions implemented following a previous incident were not enforced for any significant period;
- There was a poor incident reporting and investigation culture.
In conclusion, the following points were re-emphasised:
- Ensure that toolbox talks take place when appropriate;
- Ensure that all crew are fully familiar with Permits to Work and Isolations and Barriers;
- Ensure there is complete understanding of the job and all the risks involved before starting work;
- Stop The Job and inform a supervisor if conditions change;
- Always intervene when you see an unsafe act or condition;
- Never remove safety isolation/equipment/barriers;
- Never perform tasks for which you are not trained and competent.