WORKING ON THE WRONG LINE INCIDENT

How do you address human factors of lookalikes when handing over lines/ equipment for maintenance?

 At approximately 9:00 a.m. on March 15, 2022, an employee disconnected nuts to a line for service and repair work. The employee was working to depressurize lines of ammonia for service work. The team had isolated, performed proper lockout/tagout, and bled the line assigned for work off. The employee began disconnecting nuts on the wrong line with pressure still on it. Pressurized ammonia began to leak from the pipe; the employee reacted to protect the plan and other personnel on-site, grabbed the nut, and manually screwed a few turns of the threads to stop the leaking. This action caused burns to the employee's hands that needed medical attention. The employee was not wearing his protective gloves because he was supposed to be working in the bled offline, which would have eliminated the hazard of glove use. 

Source:OSHA.gov