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LTI no 46: 12/Nov/00

LTI no 46: 12/Nov/00.

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LTI no 46: 12/Nov/00

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  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. Auch!! 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?

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