Tool Box Talk: Near Miss Lesson, Fuel Discharge

A Near Miss Lesson

A tradesman was nearly sprayed with heavy fuel oil while attempting to change the suction strainer on a pump. He was removing the securing bolts from the strainer when the incident occurred. Initial findings indicated that the suction and discharge valves were not isolated and the system contained a tank header pressure of 80-100Kpa at a temperature of 35º-40ºC. Approximately 10,000 litres were discharged into the bunded area before an operator could isolate the system.

Isolation procedures had not been followed. There were demands to complete the job due to a backlog of tasks.

Contributing Factors:

• The Scope of Work on the Clearance did not match the isolation that was in place.
• Authorized Person did not complete the workplace inspection with the Recipient.
• Recipient did not identify that valves were not isolated and drained.
• Pressure to clear clearances due to 20 minute backlog.
• Congestion due to limited space in CTW area as well as multiple shutdowns in addition to normal workload.

The primary lesson from this experience is that all parties compromised safety in executing a task by failing to follow safe operating procedures and “justified” the actions by focusing on the “urgency” of the job.

And a bonus quote from William A. Foster:

 “Quality is never an accident: It is always the result of high intention, sincere effort, intelligent direction and skilful execution. It represents the wise choice of many alternatives.”

Thanks for the share, TO!