A lab technician was A lab technician was completing a completing a “High Pressure-High “High Pressure-High Temperature” test on a Temperature” test on a drilling mud sample.drilling mud sample.

He bled down the He bled down the pressure from the pressure from the hoses, disconnected hoses, disconnected them and removed the them and removed the sample container. sample container.

The container still had The container still had 6 bar pressure inside. 6 bar pressure inside.

LTI no 46: 12/Nov/00LTI no 46: 12/Nov/00

The procedure The procedure requires to first requires to first release the release the remaining pressure remaining pressure from the sample from the sample container and only container and only then to carefully then to carefully remove the cap.remove the cap.

This is how the This is how the pressure should pressure should have been released.have been released.

LTI 46: LTI 46: 12/Nov/00 12/Nov/00

The technician forgot to The technician forgot to release the pressure before release the pressure before starting to remove the cap. starting to remove the cap. He unscrewed the six He unscrewed the six retaining screws.retaining screws.

LTI 46: LTI 46: 12/Nov/00 12/Nov/00

6 bar presssure inside 6 bar presssure inside this container !!!this container !!!

The cap The cap shoots up!shoots up!

This is the valve he This is the valve he should have opened.!!!should have opened.!!!

The steel cap hit him just The steel cap hit him just above the eye making deep above the eye making deep cuts and braking his skull. cuts and braking his skull. He was lucky he could He was lucky he could have been killed!!! have been killed!!!

LTI 46: Technician hit by mud-cell 12/Nov/00LTI 46: Technician hit by mud-cell 12/Nov/00

Auch!!Auch!!

What caused this LTI ??:What caused this LTI ??:

- Technician did NOT FOLLOW THE PROCEDURE (why??).- Technician did NOT FOLLOW THE PROCEDURE (why??).- Container was opened without first releasing the pressure. - Container was opened without first releasing the pressure.

3 simple “rules” for procedures (do you know them?):3 simple “rules” for procedures (do you know them?):

- Must be “adequate” (needed? practical? logical? possible?)- Must be “adequate” (needed? practical? logical? possible?)- Must be known and understood (do you know its purpose?)- Must be known and understood (do you know its purpose?)- Must be followed (do you?) - Must be followed (do you?)

Discuss in your team:Discuss in your team:

- Do we comply with the “3 simple rules” for procedures?- Do we comply with the “3 simple rules” for procedures?- Do we know the purpose of these procedures?- Do we know the purpose of these procedures?- Do I realise what can happen if a procedure is not followed?- Do I realise what can happen if a procedure is not followed?- Why would you NOT follow a procedure? - Why would you NOT follow a procedure?

LTI 46: Technician hit by mud-cell 12/Nov/00LTI 46: Technician hit by mud-cell 12/Nov/00