28 1.

PREPARATION FOR MAINTENANCE

The first lesson from the incident is that welding should not be allowed
over large pools of water. Spillages some distance away might be ignited.
In 1970, 35 tons of gasoline were spilled on the Manchester Ship Canal,
England; 1 km (0.6 mile) away, 2 1⁄2 hours later, the gasoline caught fire,
killing six men [8].
The second lesson is that when large joints have to be broken regularly, a
proper means of draining the line should be provided. The contents should not
be allowed to spill onto the ground when the joint is broken.
Why was a permit issued to remove a slip-plate 20 m away from a
welding job? Although vapor should not normally spread this far, the
two jobs were rather close together.
The foremen who issued the two permits were primarily responsible
for operating a unit some distance away. As they were busy with the
running plant, they did not visit the pipe trench as often as they might.
Had they visited it immediately before allowing the de-slip-plating job
to start, they would have realized that the two jobs were close together.
They might have realized that oil would spread across the water in the
trench.
After the incident, special day foremen were appointed to supervise
construction jobs and interface with the construction teams. The con-
struction teams like this system because they deal with only one process
foreman instead of four shift foremen.
For another incident involving a construction team, see Section 5.4.2b.

1.4.5 Misunderstandings
Many incidents have occurred because of misunderstandings of the
meanings of words and phrases. The following incidents are typical:
(a) A permit was issued to remove a pump for overhaul. The pump was
defused, removed, and the open ends blanked. The next morning,
the maintenance foreman signed the permit to show that the job—
removing the pump—was complete. The morning shift lead opera-
tor glanced at the permit. Seeing that the job was complete, he asked
the electrician to replace the fuses. The electrician replaced them and
signed the permit to show that he had done so. By this time the after-
noon shift lead operator had come on duty. He went out to check the
pump and found that it was not there.
The job on the permit was to remove the pump for overhaul.
Permits are sometimes issued to remove a pump, overhaul it, and
replace it. But in this case, the permit was just for removal (see
Section 1.1.2). When the maintenance foreman signed the permit
to show that the job was complete, he meant that the job of removal
was complete. The lead operator, however, did not read the permit
thoroughly. He assumed that the overhaul was complete.