On October 21, 2015, two mechanical technicians were involved in an incident while attempting to remove a Victaulic blind flange from supply piping on a Magnet Cooling Water System. The mechanical technicians were assisting a welder to obtain final measurements to make final connections from the system to a new Cell 14 cryostat as part of the Series Connected Hybrid magnet project. When loosening the nuts on the Victaulic flange collar, an explosion occurred. The flange, the water behind the flange, or some combination of both, struck and propelled one mechanical technician backward and into the metal support structure for the cryostat, resulting in his death. A second technician, who was approximately 10 feet away at the time of the explosion, sustained minor injuries.
Lessons Learned: A pneumatic butterfly valve believed to be in a CLOSED position, may not have been positively seated, resulting in leakage and pressure buildup in a high pressure water system. An adequate lock/tag/verify process, including lockout and tagout of all necessary isolation points and comprehensive zero energy verification, is absolutely critical prior to any work on the system.
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