1. Near Miss Incident Pipe Movement

2. 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

3. 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

4. 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