On March 6, 2018, a 49-year-old pipefitter 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 were missed during the utility installation process and the work inspection prior to 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.