A facility manager was notified that an authorization basis requirement, associated with roofing contractor work, had not been met. The requirement was that an unused hydrogen gas cylinder adjacent to the building and not connected to a manifold be removed prior to the use of propane tanks for the hot tar portion of the work.

The project manager failed to remove the extra gas bottle as required because he did not recognize from the bottle color and lack of stencil that the bottle contained hydrogen.

An explicit checklist containing all the administrative controls and requiring careful inspection was not available at the time of the inspection. The checklist preparation also would have made obvious the fact that administrative controls had been established. The project manager paid insufficient attention to his inspection and did not notice that the extra gas bottle had a tag attached identifying its contents. Unlike the adjacent bottle that was connected to the manifold and therefore acceptable, the extra bottle was painted red only at the top and lacked the identifying stencil "HYDROGEN".

The root cause was that management did not require a consolidated checklist based on the controls identified by the facility as a part of the work planning and organization process and assure that the controls were in place prior to commencing the work.

Incident Date
May 01, 2001
Damage and Injuries
Probable Cause
Contributing Factors
When Incident Discovered
Lessons Learned

This occurrence points to the importance of gathering and organizing all applicable administrative controls and other commitments prior to commencing work. It also re-emphasizes the importance of attention to detail, not only by the person responsible, but also by anyone confirming compliance.