Severity
Incident
Was Hydrogen Released?
No
Was There Ignition?
No
Incident Date
Jun 29, 1999
Setting
Equipment
- Hand Tools
- Construction Tools
Damage and Injuries
Probable Cause
Contributing Factors
When Incident Was Discovered
Lessons Learned
Work documentation (work orders and baseline drawings) should reflect the current system configuration.
Recommendations
Develop procedures for temporary change configuration control of high-pressure systems. The overall work process should be included in one work authorization document.
Re-emphasis to all personnel that current procedures be followed. If the work order is not written to reflect the current system configuration, stop work, revise work order, and have the work order properly reviewed prior to continuing work.
Write a procedure for proper clamp removal and installation and train technicians to the procedure.