I want to encourage you to ask around and maybe even go as far as auditing around this learning opportunity to assess if this is going on at your facility. If your process involves doing preventive maintenance on flame arrestors and/or conservation vents, what controls are in place for this “routine work”? What kind of controls are they utilizing to prevent their exposure to a form of hazardous energy? Here is the scenario…
For years maintenance workers got their Work Order to do the PM on the flame arrestors and conservation vents on the process vessels (and storage tanks). There has never been a maintenance procedure for this task. Personnel claimed to have used the manufacturer’s Operations & Maintenance Manual, which loosely mentions “safety” in a very general manner. There is no energy isolation procedure in place for any of these vessels/tanks. So what we have is a group of workers who “check-in” with the operator(s) to get permission to perform these PM(s). The maintenance personnel has to go to the roof of the process building in order to access the vents and flame arrestors; out of sight of the operators who are working inside the process building down below. The vents are labeled at the process vessel, but they are NOT labeled on the roof. The vents are not uniformly arranged on the roof and one (1) vent does not go through the roof, but instead vents out the side of the process building. The “newer” mechanic goes on the roof (not his/her first time to do this W.O.) and proceeds to count the vents in order to identify the vent that he/she was granted permission to work on. Not knowing that one of the vents does not go through the roof, he/she miss-counts and begins pulling the conservation vent and flame arrestor on the WRONG vessel. About this time the operator below begins setting up the reactor to receive the 4,850 pounds of Toluene. It was a “hot day” in August and the roof was “incorrectly assumed” by all involved to be a non-rated area (i.e. not a Class I Div. 1 area) so the maintenance tech had removed their Flame Retardant Clothing (FRC) to do this task; after all, they believed they were in a non-HAZ location and the vessel they were working on was “out of service” (but knowing that it was NOT locked out by him/her)!
Luckily this scenario did not result in serious injury or incident. But the discussions around the failures were quite shocking, as management originally had chalked this incident up to “worker error” and “worker inexperience”. Let’s be clear here, this maintenance technician was set up to fail and we are lucky we did not kill him or seriously burn him. Yes, it was a “newer” employee but it was NOT the first time he had done this tasks. In fact, he had been “approved” by supervision to do this task on their own. This incident was a Management System FAILURE plain and simple. Here are the failures that I identified. Can you identify others?
1) No Maintenance Procedure for such a critical task. Had there been a procedure AND had the procedure been written properly we would have covered LOTO, PPE, etc.
2) No LOTO performed for the task. This one was hotly contested as many felt it was an open-ended pipe so there was no LOTO needed. My position is that the fill pump(s) and valve(s) to the vessel should have been locked out; however, I do have to concede that LOTO of the vessel would NOT have prevented this accident as the maintenance tech was working on the WRONG vessel.
3) The vent lines on the roof were not labeled. In fact, when the Division EHS Director was at the facility months later, he wanted to walk down the incident and view all the corrective actions were done properly. We labeled the vents on the roof with the following label… “Vent”. We did NOT label the vents with the Vessel number so in essence, yes we closed out the action item to “label the vents on the roof”; however, our vent labels did NOTHING to ensure the workers are working on the PROPER VENT. We relabeled the vent lines with the vessel numbers!!!
4) No one, except the engineering manager and me, realized the roof where these flammable vapors vent to was a hazardous location; in fact, the area directly around the vent discharge (where the worker was actually working) is a Class 1 Division 1, Group D HAZLOC! So we had to update the Electrical Classification documentation to include rooftops and retrain ~800 personnel. The site PPE rule regarding the use of FRC was that FRC was required to enter an HAZLOC; so not having the roof identified as an HAZLOC allowed the maintenance tech to feel comfortable enough to remove his FRC in a very dangerous area.
5) Operations and Maintenance personnel did not see this task as one that needed a Safe Work Permit since this work was done under a Work Order, which some also viewed as a “procedure” as some work orders did contain some procedural steps. However, this work order contained NO procedural steps and maintenance used the O&M manual from the manufacturer. An SWP should have been issued which would have required an operator to go onto the roof with the mechanic to inspect the work area and identify the equipment.
6) Operations and Maintenance personnel did not see this task as one that needed a Line Break Permit since the process was “already open”. The Line Break and Process Opening Safe Work Practice were updated to ensure that personnel knew/understood that anytime a pipe/vessel connection is opened/broken that a permit is required (except when the break/opening is covered under an operating/maintenance procedure). Does your facility require a line break permit to remove a conservation vent/flame arrestor from an open-ended vent?
So without an operating/maintenance procedure, no safe work permit, and no line break permit we had NO administrative control over this very critical and hazardous task. Coupled with NO line labeling and NO PPE we aligned all our dominoes for a failure to occur!
Do your maintenance personnel lockout the vessel and obtain a work permit BEFORE they begin work on a process vent open to the atmosphere? You may be surprised at what you find out! I know I was.