QSMS WARNING – FATAL ACCIDENT – Date: 03/11/2017
On 03 November 2017, a worker employed as a Hydrojet Painter was using a hydrojet at ultra-high pressure (40.000 PSI) on the outer wall of the pumping unit pipeline in Rio de Janeiro, Brazil, when accidental contact occurred between the pressurized jet of water and his body, perforating his neck (right side) and consequently rupturing arteries. The worker was using all the PPE necessary to the activity. Hydrojet services had started at 09:50, and the accident happened at 10:10. The injured worker was assisted by the subcontractor team and the contractor team, and immediately taken in a private vehicle to a local A&E Hospital. The injured worker received primary care at this hospital, and was put into an induced coma. He was later transferred to A&E Hospital in Rio de Janeiro state, where he died on 07 November 2017.
PHOTOGRAPHS and SIMULATIONS OF THE ACCIDENT:
Exact position of the worker at the moment of the accident. The worker is in a dangerous position for carrying out this task.
Exact moment at which the worker moves away from the place of the accident, having been hit by the jet of water, and the observer signals for equipment to be turned off.
Simulation of the position of the Hydrojet Painter, on his knees, assuming that he was indeed on his knees during the period when the camera was not pointing in his direction. Various attempts were made to bring the jet nozzle up to the worker’s neck, even inverting the position of the gun and the way the trigger was worked, with the hands and fingers reversed.
Simulation of the position of the injured person, lying down, which is the position shown on camera footage. Various attempts were made to bring the jet nozzle up to the worker’s neck, even inverting the position of the gun and the way the trigger was worked, with the hands and fingers reversed.
ANALYSIS OF PROBABLE CAUSES (STILL UNDER INVESTIGATION):
1) Failure in Task Planning (Failure to carry out prior risk assessment of activities and work environment).
2) Failure in awareness and training (Insufficient training).
3) Improper use of equipment (Unsafe position or posture).
4) Safety equipment became inoperative or inefficient (trigger tied back).
5) Unsafe act (Unnecessarily exposing himself to the reach of pressurized equipment).
6) Not following procedure (Observer did not pay attention during activities).
FINDINGS FOLLOWING INVESTIGATIONS AND SIMULATIONS:
Position regarding hydrojet painter and observer at the time of the accident, two hydrojet painters were working, and it has been verified that the two were at a safe distance, separated by the concrete wall, which makes it impossible that the jet of water could have been pointed at the injured man’s neck by the other hydrojet painter.
The observer was not paying proper attention when the high-pressure jet was being used, when filming took place, which may have added to the risk of the situation, with the hydrojet painter not being appropriately warned.
POSITION OF THE INJURED MAN DURING HYDROJET USE:
It has been established that for the jet to have been pointing at the neck of the injured man, the hydrojet painter would have had to have inverted the position of his hand, and to have used the trigger in an inappropriate manner, with his thumb on the first trigger, which would not have been sufficiently safe because any unexpected reaction from the gun, caused, for example, upon impact with the piping, could make it difficult to handle. It could also cause it to make a backward movement and point at his neck, due to the strength of the reaction of the rotating nozzle holder with the piping which was being pressure-painted.
Another possibility is that the injured man may have moved, changing his position, whilst holding the pressure gun. Another possibility which has not been discarded is that the trigger could have been locked, and this possibility, albeit only a possibility, must be taken seriously.
CONCLUSIONS FOLLOWING EQUIPMENT TESTING:
It was established that all the equipment and accessories were working perfectly and were in accordance with the minimum safety regulations regarding their use for hydrojetting. The water jet stopped immediately the hold on the trigger was released, both simultaneously and when alternated separately.The tests with the By-Pass also worked perfectly, with the gun losing operation once the valve was turned off.It was established that the hydrojet machine was fully operational, and the installations of rigid pipes and hoses was done in a safe way, following all hydrojet safety procedures.
CORRECTIVE ACTIONS PROPOSED:
ITEM RECOMMENDATIONS TO AVOID REPETITION WHO BY STATUS:
- Disclosure of the Accident on all Working Fronts, making employees aware by means of a QSMS Warning.
- Implement safety clothing made of high strength material for hydrojet users.
- Substitute short barrels and their covers for medium or large-sized ones.
- Only medium or large-barreled guns should be used, never short.
- Revise SMS Hydrojetting Procedure, including use of clothing.
Retrain all Hydrojetters regarding SMS Hydrojetting Procedure, emphasizing the risk of moving or changing position whilst holding the pressurized gun/risks in relation to safety position, and safe handling and wielding of equipment/risks, and that it is STRICTLY PROHIBITED to make inoperative or inefficient the safety device, i.e., to tie up the safety trigger.
Retrain all Hydrojetters, emphasizing that it is obligatory that observers pay close attention. They should never take their attention away from the activity, and should stop the hydrojet when they detect any abnormality or risk.
Prohibition Notice issued 01/12/2017: No Short Barreled versions of a A3000 Jet Lance can ever be used.
- Carry out an urgent site assessment to confirm whether there are short barreled (15″) in use.
- Any short barreled jet lances found must be immediately removed from service and their use PROHIBITED.
PHOTOS OF – A3000 JET LANCES:
This News Item was edited, translated and re-written from Portuguese – Dec 2017 The Water Jetting Association.