Case report: #2018OR030
Issued by: Oregon State Fatality Assessment and Control Evaluation (FACE) Program
Date of incident: March 6, 2018

A 49-year-old subcontracting pipefitter was hit in the chest and knocked backward by a pressurized 12-inch PVC pipe during a hydrostatic pressure test of a fire suppression system. The pipe came loose under pressure because the torque shear bolts on the mechanical joint restraining gland hadn’t been tightened. Emergency medical services pronounced the pipefitter dead at the scene. The failed pipe connection had been backfilled before the hydrostatic pressure test. Although a visual inspection by qualified persons was performed before backfilling, documentation wasn’t available. Workers reported mid-project design changes that led to schedule pressure from the primary contractor as a reason for backfilling the work before the pressure test was performed. Investigators found no record that the victim had received training on how to perform the hydrostatic pressure test safely, and no record that the employer’s test procedure and checklists were followed on the day of the incident.

To help prevent similar incidents, employers should:

• Employers should ensure employees don’t work on pressurized water systems.

• Pipe systems should be pressure-tested and inspected before pipes are backfilled. Use checklists to reduce the risk of overlooking critical steps.

• Prime contractors should establish a realistic project schedule in collaboration with subcontractors.

• Prime contractors should develop and follow a communication plan so subcontractors are made aware of project design modifications in a timely manner and to work out how design changes will impact the project schedule.

• Employers should provide written procedures to employees before performing the work, and ensure employees receive adequate training.