Preventing harm to frontline workers via sharing is central to Our Commitment.  Learning Event Bulletins (LEBs) focus on ‘unwanted events/threats’ as a trigger to investigate and disseminate lessons learned. We investigate, report, and share the lessons from these ‘High Value Learning Events’ occurring, and use these LEBs to facilitate discussions designed to influence and reinforce positive behaviours focused on helping prevent harm to frontline workers.

Process Safety LEB Image.png(Access LEB)

Aligning with our Quarter 1 Theme: Preventing Major Accidents, in this LEB - Maintaining Process Equipment – Loss of Containment, a maintenance worker was instructed to reduce bolt a flange join on a heat exchanger shell.  This was in the work scope and documented in the work permit. 

The worker set up their work area and then commenced work on the wrong heat exchanger shell, which was live.

An operator noticed that work was proceeding on the wrong exchanger shell and instructed the worker to stop.

Follow this link for the Learning Event Bulletin and the Toolbox related to this incident to use at your next Toolbox Talk with your team.

Our library of LEBs is available on the Safer Together website.

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