On March 6, 2018, a pipefitter (49) was hit in the chest by a pressurized 12-inch diameter polyvinyl chloride (PVC) pipe during a hydrostatic pressure test of a fire suppression system. The sudden pipe movement was attributed to a pipe joint connection failure in a buried section of the pipeline. The failure was due to torque shear bolts at the joint connection that were not tightened, which was missed during the utility installation process and the work inspection before the incident.
CONTRIBUTING FACTORS
Key contributing factors identified in this investigation include:
- A schedule delay due to design change, and schedule pressure
- Lack of task checklists for key testing and inspection processes
- Deviation from planned procedures
- Inadequate safety communication
- Inadequate training
RECOMMENDATIONS
To help prevent similar occurrences, employers should:
- Employers should ensure employees do not work on pressurized water systems.
- Pipe systems should be pressure-tested and inspected before pipes are backfilled. Use checklists during tasks and the inspection process to reduce risk of overlooking critical steps that could endanger workers.
- Prime contractors should establish a realistic project schedule in collaboration with subcontractors.
- Prime contractors should develop and follow a communication plan so that subcontractors are made aware of project design modifications in a timely manner and to work out how design changes will impact project schedule, so as not to compromise workplace safety.
- Employers should provide written procedures to employees prior to performing the work, and ensure employees receive adequate training so they understand the hazards and how to execute procedures safely.
Source: Oregon Fatality Assessment and Control Evaluation Program