Industry-Submitted Notification

What Was the Impact?

The contract worker sustained minor burns to the face that required first aid treatment.

The event was reported to Alberta Occupational Health & Safety under the requirements of a workplace incident – unplanned fire with potential to cause serious injury (Report serious injuries, illnesses or incidents | Alberta.ca).

Incident Learnings:

Self applied pressures impacted decision-making and work execution, resulting in errors being made with respect to the Life Saving Actions, procedures and practices.

• Inadequate job planning, energy isolation, hazard assessment and failure to follow procedures resulted in an unplanned flash fire that injured a worker.
• The work scope was unclear and not documented, which led to a safe work permit being issued for multiple work tasks and communication breakdown between multiple workers.
• The energy isolation process of blinding was not fully completed.
• A flammable atmosphere was detected when breaking system integrity, which eventually dissipated. As work progressed, intermittent flammable atmosphere was detected and was not properly reported or investigated.

Corrective Actions:

• Provide additional coaching to ensure adequate oversight:
  • Ensure work scope is clearly identified on work permits
  • Ensure hazards and controls are identified and implemented
  • Ensure adequate supervision of work – based on risks and hazards
  • Ensure proper job plans are developed with appropriate subject matter experts (SMEs)