1.

4 PROCEDURES NOT FOLLOWED 29

The main message is clear: read permits carefully; don’t just glance
at them.
When a maintenance worker signs a permit to show that the job
is complete, he means he has completed the job he thought he had to
do. This may not be the same as the job he was expected to do. The
process team should therefore always inspect the job to make sure
that the one completed is the one wanted.
When handing over or handing back a permit, the maintenance
and process people should speak to each other. It is not good practice
to leave a permit on the table for someone to sign when he or she
comes in.
(b) When a work permit is issued to excavate the ground, it is normal
practice for an electrician to certify that there are no buried cables.
What, however, is an excavation? A contractor asked for and received
a work permit to “level and scrape the ground.” No excavation was
requested, so the process foreman did not consult the electricians.
The contractor used a mechanical shovel, removed several feet of
dirt from the ground, and cut through a live electric cable. The word
excavation needs careful definition.
(c) A construction worker was wearing a plastic protective suit, supplied
by breathing air, when the air supply suddenly stopped. Fortunately,
he was rescued without injury. A mechanic had isolated the breath-
ing air supply to change a filter.
The plant had what everyone involved thought was a good system:
before anyone used breathing air or did any work on the air system,
that person was supposed to tell the control room. Unfortunately, the
supervisor and the standby operator both thought that the other was
going to do so. The mechanic did contact the control room before
starting work, but the control room staff told him that no one was
using breathing air. To make sure, both the mechanic and someone
from the control room had a look around, but the check was rather
casual as neither of them expected to find anyone. The air was in use
in an out-of-the-way part of the site, and neither of them noticed the
job [29].
This system of working was not really very good. No work should
be allowed on the breathing air system (or any other system) without
a permit-to-work, as people will say okay with less thought than
they will sign a form. Users of breathing air should sign a book in
the control room or collect a tag, not just tell someone they are going
to use the air.
(d) Electricity supplies to a boiler and a water treatment unit were isolated
for replacement of electrical equipment. The supervisor in charge of
the work kept in touch with the two units by radio. After the replace-
ment work had been carried out, he received a message that testing