At 11:00 a.m. on May 18, 2017, an employee was using a reaming tool to unplug a line. The employee attached the reaming tool to port to unplug line. When done, the employee relieved the pressure by using the bleeder on the tool. When employee removed the reaming tool, he discovered that he had not closed the valve and was splashed with hot oil on his right arm and lower back. The employee received second degree burns from the hot oil.
The Employee did not follow the proper procedures to ensure the valve was closed.
What Can We Learn?
Using a Peer Check would have confirmed that the valve was not closed and he shouldn’t have removed the reaming tool
Following Procedures would have ensured that the employee was following the proper protocol and taking the right steps to unplug the line.
Since unplugging a line is routine in pipeline construction, the employee was likely complacent and succumbed to Overconfidence.
Time Pressure was also likely at play as the employee may have experienced an urgency to complete his task due to the project schedule.
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