1.

2 IDENTIFICATION 13

(e) Six slip-plates were inserted to isolate a tank for entry. When the
work inside the tank was complete, six slip-plates were removed.
Unfortunately, one of those removed was a permanent slip-plate
left in position to prevent contamination. One of the temporary slip-
plates was left behind.
(f) A mechanic was asked to repair autoclave No. 3. He removed the
top manhole cover and then went down to the floor below to remove
a manhole cover there. Instead of removing the cover from the man-
hole on autoclave No. 3, he removed the cover from No. 4, which
contained vinyl chloride and nitrogen at a gauge pressure of 70 psi
(5 bar). Polymer had formed around the inside of the manhole,
so when he removed the bolts, there was no immediate evidence of
pressure inside the vessel. Almost immediately afterward, the pres-
sure blew off the cover. The mechanic and two other men were blown
to the ground and killed, and the vinyl chloride was ignited [23].
(g) When a man tried to start the building ventilation fans, he found that
the control and power panels had been removed. Contractors were
removing surplus equipment and thought that these panels were
supposed to be removed. The surplus equipment should have been
clearly marked [44].
(h) A section of a chlorine gas line had been renewed and had to be heat
treated. The operator who was asked to prepare the line and issue
the permit-to-work misunderstood his instructions and thought a
vent line had to be treated. There would be no need to gas-free this
line, and he allowed the work to go ahead. It went ahead, on the cor-
rect line; the chlorine reacted with the iron, a 0.5-m length burned
away, and 350 kg of chlorine escaped. To quote from the report, “at
no stage on the day of the incident was the job thoroughly inspected
by the issuer [of the permit-to-work] or the plant manager [supervi-
sor in most U.S. companies].” The plant manager had inspected the
permit and the heat treatment equipment but did not visit the site.
He saw no reason to doubt the operator’s belief that the line to be
treated was the vent line [45]. Tagging would have prevented heat
treatment of a line full of chlorine.

Incidents like these and many more could be prevented by fitting a

numbered tag to the joint or valve and putting that number on the work
permit. In incident (c), the foreman would have had to go up onto the
scaffold to fix the tag. Accidents have occurred, however, despite tagging
systems.
In one plant, a mechanic did not check the tag number and broke a joint
that had been tagged for an earlier job; the tag had been left in position.
Tags should be removed when jobs are complete.