A facility representative observed pipe-fitters enter a containment tent around a riser with a tool bag that contained a mixture of steel and copper/beryllium tools. The top flange was loosened using a copper/beryllium socket and a steel torque wrench. When questioned, the pipe-fitters correctly stated that this was allowable for initial loosening and tightening of these bolts. A copper/beryllium ratchet was used to accomplish the bolt removal. The bonded riser was shifted to allow access for the IH technician. The standard hydrogen monitoring system (SHMS) cabinet and local sample showed no hydrogen/flammable gas was present.

While the continuous vapor sample was being taken, the pipe-fitters proceeded to put together the copper/beryllium ratchet and socket with a 10" steel socket extension to remove the bolts that were securing the spool piece at its base. These bolts were approximately 6" to 8" below grade and were only accessible through an 18" access hole. The facility representative questioned this practice, as the steel extension could bump against the steel rim of the access hole and cause a spark near the open riser, and brought this issue to the attention of the person in charge (PIC). The PIC agreed that they could not use the steel extension.

Since the pipe-fitters did not have the copper/beryllium socket extension, one pipefitter proceeded to use a copper/beryllium crescent wrench in combination with a large copper/beryllium wrench to loosen the spool piece bolts. The other pipefitter proceeded to use a large copper/beryllium channel lock pliers to assist in removing the bolts. On approximately every fifth turn of the crescent wrench combination, the pipefitter lost his grip of the bolt he was turning and would swing his wrench out of control nearly hitting the unsecured, steel flange riser cover. He also nearly hit his fellow worker with the wrench on several occasions. The facility representative felt this operation was unsafe due to the pipefitter causing potential injury to his coworker and the potential for spark if the bonding and flange cover were knocked off the riser. He instructed the pipe-fitters to stop work and secure the flange cover/spool piece assembly. The pipe-fitters complied, using the copper/beryllium tools to secure the work site. The PIC, who had moved approximately 20' away to make phone calls requesting the copper/beryllium extension, returned to the containment tent and was immediately notified by the facility representative of the stop work instruction. The PIC had already determined the extension was not immediately available and was returning back to the work site to shut down the job. The work site was secured at approximately 1200 hours.

The direct cause of the event was management problem/work organization/planning deficiency. The proper tools were not staged at the work site, causing the craft to improvise. At the critique, the pipe-fitters indicated that they were given very little time after the pre-job brief to gather the tools needed for the job and had a combination of copper/beryllium and steel tools. After correctly loosening the flange, they assembled tools to loosen the spool piece. They did not have a Cu/Be extension and substituted a steel extension. This was stopped by the PIC when noted by the facility representative. While the PIC tried to locate the correct tool, the craft took it upon themselves to improvise, using tools of the proper material but of the improper type.

Incident Date
Sep 24, 1996
  • Hand Tools
  • Crafts Tools
Damage and Injuries
When Incident Discovered
Lessons Learned

Thoroughly plan and schedule work such that the correct tools are at the job site. If activities take place that take the job supervisor away from the job location while critical steps are to be performed, the work should be temporarily stopped. A ferrous tool used in combination with spark-less tools is a potential spark producer.