A small leak A small leak was found in was found in the freon gas the freon gas cooling circuits cooling circuits of this air-of this air-conditioning conditioning unit.unit.

A technician A technician was called out was called out to fix itto fix it

LTI no 43: Tightening bolt on AC 14/Sept/00LTI no 43: Tightening bolt on AC 14/Sept/00

Discuss in your team:Discuss in your team:

What should he do before What should he do before attending to this repair?attending to this repair?

What could go wrong?What could go wrong?

LTI no 43: Tightening bolt on AC 14/Sept/00LTI no 43: Tightening bolt on AC 14/Sept/00

The leak was The leak was minor: just a minor: just a small connection small connection in the HP end of in the HP end of the freon gas the freon gas system. system.

The technician The technician decide to tighten decide to tighten it without first it without first de- pressurising de- pressurising the system. the system.

LTI no 43: Tightening bolt on AC 14/Sept/00LTI no 43: Tightening bolt on AC 14/Sept/00

The leak increased. The leak increased. The very cold fluid The very cold fluid splashed over his splashed over his hands. His cotton hands. His cotton gloves did NOT gloves did NOT protect against the protect against the cold.cold.

The fingers of both The fingers of both hands suffered bad hands suffered bad “frost bite”. At first “frost bite”. At first only redness could only redness could be seen. be seen.

LTI no 43: Tightening bolt on AC 14/Sept/00LTI no 43: Tightening bolt on AC 14/Sept/00

Later blisters came. He went to the burns unit of Later blisters came. He went to the burns unit of Nizwa hospital. He will be off work for 3 to 4 weeks.Nizwa hospital. He will be off work for 3 to 4 weeks.

Ouch!!Ouch!!

What caused this LTI ??:What caused this LTI ??:

- Procedure to depressurise was not followed.- Procedure to depressurise was not followed.- Wrong PPE was used: cotton gloves instead of PVC as- Wrong PPE was used: cotton gloves instead of PVC as specified in the SHOC card for freon gas. specified in the SHOC card for freon gas.- Supervision could have been better. STOP techniques were- Supervision could have been better. STOP techniques were not practised not practised

Discuss in your team:Discuss in your team:

- How could this incident have been prevented?- How could this incident have been prevented?- What is a SHOC card? What is it for? - What is a SHOC card? What is it for? - Have you got SHOC cards for the chemicals you work with?- Have you got SHOC cards for the chemicals you work with?- Do you have procedures for working on pressurised- Do you have procedures for working on pressurised systems? systems? Are they known? Are they followed? How do you know? Are they known? Are they followed? How do you know?

LTI no 43: Tightening bolt on AC 14/Sept/00LTI no 43: Tightening bolt on AC 14/Sept/00