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LSR#1/#2/#4 Safety Moment – Fatal incident

during CSE activity


What happened:
On 23/8/09, a welder crawled alone inside a 24” dia pipe to inspect
his own work but subsequently found suffocated. Helper wisely did
not enter but called for help. Emergency team safely pulled from
the pipe – found unconscious & unresponsive; CPR was attempted
but was unsuccessful. This happened at TR7 of QGC.
Key findings (based on draft LFI):
- Atmosphere in pipe: 10.2% O2 (safe entry 20%): Argon was
24” Stainless
introduced & not shut off prior entry. Steel Pipe
- No evidence of CSE training. (Line No.
NR5306212-
- CSE permit & company RA compliance not specified. 24”)
- Compliance of standby attendant at entry point not specified.
Key lessons learnt for us:
- CSE is HIGH RISK activity. NEVER, EVER enter a CS without having
the atmosphere Gas/O2 tested first, CSE permit approved, rescue
plan / tag in place, attendant on s/by & equip is safe for use!
- Sticking your head inside pipe/vessel/vessel skirt for quick look
is hazardous!
- CSE training is mandatory for all CSE workers / attendant. No
CSE ID means No entry.

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