Near Miss Incident Pipe Movement

Failure to control the work area Background High Potential Near Miss occurred on a project site in Bulgaria PIH Engineer completing maintenance activities during a period of downtime Failure to control the work area

Investigation Mainline production was stopped due to inclement weather All Subcontractors and client staff followed different agendas during period of down time Permit to work procedure in place but not followed Reversing of pipe was an “Out of Scope” activity and should have been carried out under a Permit to Work Maintenance activities on mainline machinery was a permitted activity PIH Engineer was new to site covering as part of a rotation plan Permit to Work training and awareness had not been delivered to PIH Engineer No audible/visual alarm during pipe reversing Pipe movement was covered as part of project start up but never refreshed or re-communicated

Lessons Learned There were many contribution factors to the incident and it was apparent that the lack of control during a period of down time was the root cause of the incident. The following actions are in the process of implementation following the incident: Raise awareness of Permits to Work for all CRC/PIH Supervisors and Engineers Develop process for completing Job Safety Analysis Work with Client on all projects to ensure stop work procedures are understood and followed by all parties Include CRC/PIH Project inductions and ensure client HSE requirements are fully communicated on all future projects