16 1.

PREPARATION FOR MAINTENANCE

look at the line. The line actually heat treated contained chlorine,
and the heat was sufficient for the iron and the chlorine to react and
“burn” a hole in the line; 350 kg of chlorine escaped. Afterward, the
lead operator said he thought it was obvious that the line to be heat
treated was the one that had been renewed the day before [24].
(d) An electrician was asked, in writing, to remove a fuse labeled FU-5.
He did so. Unfortunately, he removed a fuse labeled FU-5 from the
fuseboard that supplied the control room, not from the fuseboard
that supplied the equipment room [25]. Not only were his instruc-
tions ambiguous, but the labeling system was poor.
(e) An operator asked an electrician to disconnect the cable leading to a
piece of equipment that was to be modified. The operator checked the
disconnection and signed the permit-to-work for the modification.
A second operator certified that the preparation had been carried out
correctly.
The construction worker who was to carry out the modification
checked the cable with a current detector and found that the wrong
one had been disconnected. It was then found that the cable was
incorrectly described on the written instructions given to the opera-
tors. The description of the cable was not entirely clear, but instead
of querying it, the first operator decided what he thought was the
correct cable and asked the electrician to disconnect it. The second
operator, or checker, had not been trained to check cables [32].
This incident shows the weakness of checking procedures. The
first operator may assume that if anything is wrong the checker will
pick it up; the checker may become casual because he has never
known the first operator to make an error (see Sections 3.2.7b and
14.5c).

1.2.4 Identification of Relief Valves

Two relief valves, identical in appearance, were removed from a plant
during a shutdown and sent to the workshops for overhaul. One relief
valve was set to operate at a gauge pressure of 15 psi (1 bar) and the other
at 30 psi (2 bar). The set pressures were stamped on the flanges, but this
did not prevent the valves from being interchanged.
A number of similar incidents have occurred in other plants.
Such incidents can be prevented, or at least made much less likely, by
tying a numbered tag to the relief valve when it is removed and tying
another tag with the same number to the flange.

1.2.5 Make Sure You Find the Right Line

There was a leak on the line supplying steam to a plant. To avoid a
shutdown, a hot tap and stopple was carried out—that is, the line was