PUBLIC SERVICE CO OF NORTH CAROLINA

Incident Narrative

PSNC EMPLOYEES ARRIVE AT CONSTRUCTION SITE TO TAP/STOP 2-INCH SHORT STOP H-17190 MUELLER FITTING. EMPLOYEES MADE THE TAP AND STOP OFF SO CONTRACTORS COULD TIE IN THE NEW MAIN EXTENSION. THE FITTING WAS AIR TESTED BEFORE THE TAP WAS MADE. AFTER THE TIE-IN WAS COMPLETED, EMPLOYEES STARTED THE COMPLETION PROCESS TO PUT THE PLUG BACK IN THE FITTING. BOTH EMPLOYEES CHANGED OUT TOOLS ON THE D-5 MACHINE TO COMPLETE TAP/STOP AND INSTALLING COMPLETION PLUG. WHILE INSTALLING THE COMPLETION PLUG EMPLOYEE 1 WAS OPERATING THE MACHINE, BOTH EMPLOYEES HEARD A LOUD POP. ONCE THE POP WAS HEARD, EMPLOYEE 1 BEGAN TURNING THE MACHINE COUNTERCLOCKWISE IN ORDER TO BRING THE PLUG BACK OUT TO REMOVE THE MACHINE AND FIGURE OUT WHAT WENT WRONG. WHEN THE MACHINE WAS REMOVED, THEY OPENED THE VALVE TO LOOK AT THE PLUG AND NOTICED IT WAS NOT PROPERLY SEATED IN THE FITTING. THE VALVE WAS REMOVED FROM THE FITTING AND EMPLOYEES BOTH NOTICED THE PLUG WAS NOT TIGHT IN THE FITTING BECAUSE THE RUBBER O-RING WAS STICKING OUT OF THE TOP OF THE FITTING. EMPLOYEE 1 ATTEMPTED TO TIGHTEN THE PLUG INTO THE FITTING BUT THE PLUG BLEW FROM THE FITTING AND METAL SHAVINGS BLEW INTO EMPLOYEES ARM. EMPLOYEE REQUIRED 3 NIGHTS OF HOSPITALIZATION TO MONITOR INFECTION. SUBSEQUENT INVESTIGATION DETERMINED THAT INADEQUATE JOB PLANNING, NOT FOLLOWING PROCEDURES, AND USING THE INCORRECT EQUIPMENT/TOOLS FOR THE JOB ALL CONTRIBUTED TO THE TAPPING AND STOPPING OPERATION FAILING AND THE SUBSEQUENT INJURY.