LTI no 46: 12Nov00

1
LTI no 46
12/Nov/00
A lab technician was completing a High
Pressure-High Temperature test on a drilling mud
sample.He bled down the pressure from the
hoses, disconnected them and removed the sample
container. The container still had 6 bar
pressure inside.
2
LTI 46 12/Nov/00
The procedure requires to first release the
remaining pressure from the sample container and
only then to carefully remove the cap.This is
how the pressure should have been released.
3
LTI 46 12/Nov/00
The cap shoots up!
This is the valve he should have opened.!!!
The technician forgot to release the pressure
before starting to remove the cap. He unscrewed
the six retaining screws.
6 bar presssure inside this container !!!
4
LTI 46 Technician hit by mud-cell 12/Nov/00
The steel cap hit him just above the eye making
deep cuts and braking his skull. He was lucky he
could have been killed!!!
5
LTI 46 Technician hit by mud-cell 12/Nov/00
What caused this LTI ??- Technician did NOT
FOLLOW THE PROCEDURE (why??).- Container was
opened without first releasing the pressure. 3
simple rules for procedures (do you know
them?)- Must be adequate (needed? practical?
logical? possible?)- Must be known and
understood (do you know its purpose?)- Must be
followed (do you?) Discuss in your team- Do
we comply with the 3 simple rules for
procedures?- Do we know the purpose of these
procedures?- Do I realise what can happen if a
procedure is not followed?- Why would you NOT
follow a procedure?