Miscommunication and Trapped Pressure Causes Injury During Valve Maintenance

BSEE (the Bureau of Safety and Environmental Enforcement) has published Safety Alert 509. It describes an incident in which a worker was injured.

In our post BSEE Safety Alert No. 509 at we analyze this event using the elements of SEMS (Safety and Environmental Management System).

Following are the SEMS management elements. The ones that deserve attention with respect to this incident are highlighted.

1. General
2. Safety and Environmental Information
3. Hazards Analysis
4. Management of Change
5. Operating Procedures
6. Safe Work Practices
7. Training
8. Mechanical Integrity (Assurance of Quality and Mechanical Integrity of Critical Equipment)
9. Pre-startup Review
10. Emergency Response and Control
11. Investigation of Incidents
12. Auditing (Audit of Safety and Environmental Management Program Elements)
13. Recordkeeping (Records and Documentation) and additional BSEE requirements
14. Stop Work Authority (SWA)
15. Ultimate Work Authority (UWA)
16. Employee Participation Plan (EPP)
17. Reporting Unsafe Working Conditions