Safety Learning: Could This Happen in Your OC? Hugoton, Little Finger R.I… May 15, 09

1. Safety Learning: Could This Happen in Your OC?Hugoton, Little Finger R.I… May 15, 09 Brief Account of Incident: IP was responding to an air compressor alarm, found primary air compressor locked up. Secondary air compressor was out of service due to a pinhole air leak on the drip pot, and was not useable in the current state. IP proceeded to replace the drip pot on the secondary air compressor with the drip pot from the primary air compressor. While connecting the last fitting the drip pot fell from its housing onto the IP's right hand little finger. Following notifications and initial first aid, IP was taken in to the Gertsberger Medical Clinic and had 5 stitches on his right hand little finger. IP was released to duty same day 1 Key Learnings: • Critical Factors: • Drip Locking Device failed • Inadequate Hazard Recognition Employee should recognize when a task changes from routine to non routine and stop work and re-evaluate the hazards associated with the changes, update JSEA or write a new JSEA as needed. Understanding equipment safety devices and there operation. 2 Safety device was detached from side of drip pot and drip pot did not hold in place as it was being re-installed. Immediate Causes: 5.2 Defective Protective Device: Drip pot locking device missing . 7.4 Energized sources other than electrical: Failure to relieve pressure on the drip pot. 3 5 System Causes: 18.8 Other /Engineering Design: Locking device is attached with glue. The glue degenerates over time causing the locking device to detach. 19.1 No work planning or risk assessment performed: JSEA not completed. 19.4 Specified controls not followed: LO/TO not fully implemented. 21.3 No inspection: Replacement part was defective. When drip pot comes apart finger gets caught Between air compressor Base and elbow Connection below drip pot. 4