Investigation Report
Gas Ignition During Compressor Starter Troubleshooting Burned Mechanic
10-14-2009 09:45 00205 VR/38 Required Evacuation - LTA (>3 days) - Fire
- BSEE
- Investigation Report
- Unknown
- FireHand and finger injuriesMechanical failure
- Inspection and maintenance
- Job safety analysisStop-work authority
Summary
A mechanic sustained facial and hand burns when gas from disconnected compressor starter exhaust piping ignited during troubleshooting. Investigators identified a possible spark from starter engagement and documented worn components. The report highlights failure to reassess the changed task, exercise stop-work authority and prepare a task-specific job safety analysis.
Classifications: Fire; fire safety.
Classifications: Hand and finger injuries; finger injury; hand injury.
Classifications: Mechanical failure; equipment failure.
Classifications: Inspection and maintenance; asset inspection; equipment maintenance.
Classifications: Job safety analysis; JSA; job hazard analysis; JHA.
Classifications: Stop-work authority; stop work; stop-work intervention.