Description of Event:
| A contractor was engaged to upgrade station unwatering pumps. Our clearance process requires a company employee to hold clearances for outside entities. The contractors were given orientation and trained in our clearance and lock out tag out program January 4th. As part of the pump upgrade work, company crane crews were scheduled to assist with rigging and crane support for the contractor including removal of equipment from the powerhouse.
Tuesday January 5, 2021- 13:20 — Contractor’s crew foreman asked for company crew assistance removing some piping from the powerhouse for the station unwatering pumps. Company crew went to look over the pipes with Contractor’s foreman and noticed they were a ways off from needing assistance with crane work. The contractor’s foreman told company crew it would be ready to pick at 07:00 Wednesday morning January 6. Evening of January 5, during operator rounds an operator noticed a clearance violation in the contractor’s work. The pumps were disabled and tagged. However, the Operators noticed the clearance tags and the energy restraining devices on the discharge valves to the pumps had been removed but they were still on the clearance. Prior to shift change at 05:00 January 6, the Chief Operator recommended a stop work to resolve the clearance issue. A stop work was issued the morning of January 6th to investigate the situation when the contractor returned for work. Wednesday January 6 at 07:30 — Company crew went to see what progress was made. Contractor’s crew had the piping free and ”open to air”. It was noticed the tags had been removed from isolation point and had gravity slid down the pipe resting on the pipe flange. Company crew waited for the contractor’s crew to show up. 08:30 — Company crew decided to fly piping up under hatch. 09:00 — Company crew noticed asbestos gaskets we 09:30 — Company crew called the company liaison for the contractor to find out if contractor’s crew needed anymore assistance. In this conversation it was learned that contractor had a stop work for a clearance violation. Company crew work Various issues occurred during this time: 1) Contractor removed restraining devices in order to open the discharge valves to drain the discharge lines for removal, without clearing the tags first. 2) The asbestos gaskets were improperly handled when the pipe and valves were removed. 3) The company crew was unaware of the stop work when they went to remove the piping from the powerhouse.
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Actions Taken:
Once plant operations was aware of the situation, the stop work was verbally communicated to all parties, contractor and company.
An investigation into the events that led to work not stopping was performed.
Method & Findings:
Contractor signed off the tags after the restraint mechanisms had been removed and the valves opened in violation of the Company safety program. Examination of the workman’s copy of the clearance sheet showed the clearance holder signed the contractor crew members off of the clearance on January 6 at 1:45 pm. The tags and restraints were removed sometime January 5 near the end of the shift.
Pumps were presumably disabled at the main header. Pump discharge valves were opened after the numbered safety tags and lockout mechanisms loosened.
The stop work authority lacks a formal communication protocol. The contractor was directed to stop work but this was not communicated to company employees working on the same project.
Supporting Materials:
Corrective Actions:
Revisions are being made to the stop work to include a communication plan and define the processes and procedures to restart work.
Sequence & Completion Dates for Actions Listed:
Stop work communicated to all parties on January 7th. Stop work included refreshing of proper procedure to contractor.
Investigation begun January 11.
Stop work procedure being amended to include communication plan and return to work requirements in progress
Lessons Learned:
Contract crews may not follow proper clearance procedures even when they think they are making proper safety precautions.
Stop work is a useful authority and process.
Where more than one entity is involved, communication must be made to all parties working with the equipment/systems under the authority.
Recommendations:
Review stop-work processes and procedures to ensure that necessary communication is done in the event of a stop work.
Ensure the contractors are properly trained on the importance of following lock-out tag-out procedures.
was ceased at this point in time.