This post is part of a series on Lessons Shared…
This incident is about a common problem in PSM plants: Some people don’t think the rules apply to them.
This story is from a friend who works as a refrigeration contractor. Many smaller facilities lack their own qualified and experience maintenance staff and they hire contractors to do basic maintenance on their systems such as changing oil filters and equipment inspections. My friend had a contract with a company to stop by twice a week and walk through their mechanical room; taking readings and doing basic preventative maintenance.
One day, after he was finished with his work in the mechanical room, he walked out into a hallway and saw a young man on a ladder with a sawzall. The young man was in the process of cutting into a 2” Ammonia High Pressure Liquid line. My contractor friend quickly stopped him – thankfully before he managed to cut through the pipe wall. The young man had no idea what was in the pipe and was not aware how close he came to dying.
How did this situation happen?
It turns out that the Plant Manager had hired the young man (a golfing buddy’s son who was home on break from college) to do some little projects around the plant. The Maintenance Manager had been bugging him about his backlog of work so the Plant Manager took it upon himself to get rid of some of the projects, including a project that involved removing some abandoned water piping. He had told one of the maintenance workers to “tag the pipes you want removed with some fluorescent orange spray paint,” and that’s exactly what happened.
The only work instruction given to the young man was “Go cut out all the old piping. It’s been marked orange so it’s easy to see.” It shouldn’t be surprising that the young man saw the orange High Pressure Liquid Ammonia piping and thought that this was some of the piping to be removed. There was no safety briefing concerning the hazards in the area. There was no training on the location of safety showers, plant alarms or evacuation routes. There was no contractor paperwork.
Why? The plant manager didn’t go through the usual procedure because he thought this was just a little project that would only take a few days. He also explained that the young man wasn’t supposed to be working on the Ammonia system so he didn’t think that PSM applied to him. After all, he reasoned, this is just a college kid making a couple bucks while on break! He also said that he was the Plant Manager – and “those rules were put there to control hourly people, not management!”
It’s not uncommon to find these situations where management thinks that they are above the system and not part of it. It usually happens in elements such as Training, Operating Procedures, Contractors and Management of Change. On the other hand, there are a lot of experienced operators who think the same thing about SOPs: “They are there for the new guy, not for me!”
PSM policies and procedures are put there for EVERYONE who could affect, or be affected by, the process. While it’s possible to have different rules for different people, these different rules must be analyzed in the Process Hazard Analysis.
Please use this story to talk to your maintenance staff about the VERY REAL hazards of acting outside of the PSM program. Hopefully this story hits home and if they find themselves in similar situations, they may take some time to consider their actions before their well-intentioned efforts inadvertently results in another of these stories.
Note: How should this young man have been handled by the PSM system? The young man should have been viewed as a contractor under their PSM guidelines which should have required, at a minimum:
- An evaluation of the hazards presented by the contractors work. This should have included fairly obvious questions such as “What if he misidentifies the piping?” This should have led to a clear marking scheme that would not have been confused with existing piping that wasn’t being decommissioned.
- Training on the hazards present in, and around, the process.
- Training on the alarm and evacuation procedures.
- An evaluation of the contractor’s safety training. (Since he wouldn’t have had his own safety programs, his understanding of the facility’s programs would be evaluated)
- An evaluation of the contractor’s adherence to safety programs.