Questions
1.Was a pre-excavation checklist filed out from the safety manual and was a member of Lemoine there
to start the excavation
2. was there a meeting requested of plumber on 4/9 to review the line and verify line was ready to work
on?
3.Did a meeting take place with the person responsible for the line?
4.If modifying line (removing thrust block), should the person responsible for line be there while we
modify his line
Thrust removal is not mentioned in report
5.Where was signage on line? Did we know about signage? was line-locked out with signage
6.Is the email from the owner proof that the line is ready to go
What are we going to do to prevent this from happening again?
1-6
If this resulted in a SIF, did we do everything in our procedure to ensure everyone went home at the end
of the day?
Root cause-keep asking “why” until you can no longer ask why
what does that tell you
Report
Blake D Hines and IOC had a scheduled date with Palma, which had, in turn, subcontracted plumbers
from Porsche plumbing. The plumber was to start adding and removing pressure from the waterline as
well as bleeding the line out. Palma later sent an email to IOC verifying the pipe was bled out, who
afterward gave the go-ahead to continue with the work. BDH was digging a bore pit to connect to the
out-of-scope work waterline then removed the thrust block. Unfortunately, Palma did not double-check
the plumbers' work, causing an accident when BDH was proceeding with the work. When BDH started to
dig so they could connect the pipe to the 4'deep, the pipe pushed away from the connection line, then
the cement slab launched into the air and fell back to the ground and shattered. Luckily no one was in
the vicinity as dirt flew everywhere; therefore, there were no casualties. At the incident, the line still had
100PSI of pressure which couldn't be identified.BDH says the 100 PSI shouldn't have been inserted into
the pipeline if Palma had not thoroughly inspected the waterline. IOC gave authorization as it received
verification from Palma, which in this case, it is safe to say Palma did not fully inspect the area properly.
1.Was a pre-excavation checklist filed out from the safety manual and was a member of Lemoine there
to start the excavation
2. was there a meeting requested of plumber on 4/9 to review the line and verify line was ready to work
on?
3.Did a meeting take place with the person responsible for the line?
4.If modifying line (removing thrust block), should the person responsible for line be there while we
modify his line
Thrust removal is not mentioned in report
5.Where was signage on line? Did we know about signage? was line-locked out with signage
6.Is the email from the owner proof that the line is ready to go
What are we going to do to prevent this from happening again?
1-6
If this resulted in a SIF, did we do everything in our procedure to ensure everyone went home at the end
of the day?
Root cause-keep asking “why” until you can no longer ask why
what does that tell you
Report
Blake D Hines and IOC had a scheduled date with Palma, which had, in turn, subcontracted plumbers
from Porsche plumbing. The plumber was to start adding and removing pressure from the waterline as
well as bleeding the line out. Palma later sent an email to IOC verifying the pipe was bled out, who
afterward gave the go-ahead to continue with the work. BDH was digging a bore pit to connect to the
out-of-scope work waterline then removed the thrust block. Unfortunately, Palma did not double-check
the plumbers' work, causing an accident when BDH was proceeding with the work. When BDH started to
dig so they could connect the pipe to the 4'deep, the pipe pushed away from the connection line, then
the cement slab launched into the air and fell back to the ground and shattered. Luckily no one was in
the vicinity as dirt flew everywhere; therefore, there were no casualties. At the incident, the line still had
100PSI of pressure which couldn't be identified.BDH says the 100 PSI shouldn't have been inserted into
the pipeline if Palma had not thoroughly inspected the waterline. IOC gave authorization as it received
verification from Palma, which in this case, it is safe to say Palma did not fully inspect the area properly.
