QUALITY HEALTH, SAFETY & ENVIRONMENT

MANAGEMENT SYSTEM

HIGH LEARNING VALUE INCIDENT: HLVI

MEDICAL TREATMENT INJURY (HPWJ JOB)
 Contents
• INCIDENT DESCRIPTION
• IMMEDIATE ACTION
• ROOT CAUSE ANALYSIS (RCA)
• RECOMMENDATIONS AND CORRECTIVE ACTIONS
• INCIDENT PHOTO

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Incident Description
DATE: 27.05.2019 MEDICAL TREATMENT CLASS B
Detail description of incident ( How, When, Where & What Happened)
On 27 May 2019 around 08:15am a worker was doing hydro jetting cleaning on a
benzene heat exchanger using flexi lance with 10,000psi. While pulling the flexi
hose out is slips in his hands due to the slippery benzene material and hit his
right upper shoulder. When flexi got hit him he did not feel any pain and
continued his job (cleaned 2 more tubes). Afterwards he felt pain & reported
immediately to the safety officer & his supervisor. Right after he was sent to
nearest hospital at around 09:30am for further medical treatment of his injury.

Immediate Action:
• The issue was reported to operation and HSE department for investigation.
• Bring the injured person to the nearest hospital for further medication.

Root Cause:
• Slippery flexi hose due to hot chemical benzene.
• Poor supervision.
• Push back of lance hose was not controlled (no hose catcher/marker used).
• No full body protection.
• Miscalculation of flexi lance while performing the job.
• Personal Behavior (over confidence).
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Recommendations
FURTHERS
DETAILS REFERENCES
• Use proper Jetting suit (TST suit).
• Hose catcher must be provided. SHEM 8.7
• The flexi hose need to put indicator if the tip is Tools Handling
near. SHEM 05
• Refresher training. CMS
• Use slip resistance hand gloves for jetting. SHEM 8.8
• Frequent monitoring and supervision on the PPE
job. AIC-HYDJ-104
(HPWJ Training
and Assessment
Manual)
INCIDENT PHOTO AIC-HYDJ-100
(Hydro Jetting
Operations
Manual)

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