Failed Job Hazards Analysis
A true story about pinch points

The unit was 15 feet in diameter and the flange that shifted weighed 8900 pounds. The whole outer flange was separated about 5 inches which was enough for us to remove the existing gasket, clean the area and replace it with a new one. All the bolts were out of the flange and one side of the flange was suspended from a beam above with chain falls. The separated flanges were held in position with all thread bolts with 4 nuts on each bolt. There was all thread in between the gap and on the outside of the flange to keep it from moving in and out. After our JSA and tool box meeting I crawled in the lower half of the unit to start installing the gasket with one other coworker. The outside crew started putting in bolts to tighten the flange once the gasket was in place. To hold the gasket I was using temporary duct tape so it wouldn’t move until the bolts on the outside were snug. On the outside the crew that was installing the bolts was having trouble lining up the holes. They decided to take the all thread bolts out. Once the all thread bolts were out they crawled on top of the unit and pulled on one of the chain falls to help align holes. The bottom section of the flange closed so fast that I didn’t even know my finger was caught until I tried moving my hand. In my role, I had no idea what was going on outside other than I could hear the outside personnel working on getting bolts installed. I am not blaming anyone but myself for what went wrong that day but hope others can learn from it. I have been doing this type of work for 11 years and have been a foreman for 4 years.

Things that went wrong:
  • No communication from personnel outside the unit to personnel inside
  • People not paying attention in safety meeting
  • Getting complacent after so many years in the trade
  • Putting my fingers and hands where they don’t belong
I should have made sure everyone knew what their exact role. I also would have used a tool instead of my finger to install tape.

Something to think about:
  • A Job Hazard Analysis, Job Safety Analysis, Pre-task Plan or any other safety document is only as good as the employees who: writes it, reads it and makes a conscious decision to follow it.
  • Something that a co-worker does can affect you for the rest of your life, or cost you your life. 
  • Your daily actions can directly affect someone else's well being.
  • Lock Out Tag Out is not just for live systems (electrical, process piping and machinery) the program can be used to prevent operations, deny access and help to put a whole crew on the same page.