1. A small leak was found in the freon gas cooling circuits of this air- conditioning unit. A technician was called out to fix it LTI no 43: Tightening bolt on AC 14/Sept/00

2. Discuss in your team: What should he do before attending to this repair? What could go wrong? LTI no 43: Tightening bolt on AC 14/Sept/00

3. The leak was minor: just a small connection in the HP end of the freon gas system. The technician decide to tighten it without first de- pressurising the system. LTI no 43: Tightening bolt on AC 14/Sept/00

4. The leak increased. The very cold fluid splashed over his hands. His cotton gloves did NOT protect against the cold. The fingers of both hands suffered bad “frost bite”. At first only redness could be seen. LTI no 43: Tightening bolt on AC 14/Sept/00 Later blisters came. He went to the burns unit of Nizwa hospital. He will be off work for 3 to 4 weeks. Ouch!!

5. What caused this LTI ??: - Procedure to depressurise was not followed. - Wrong PPE was used: cotton gloves instead of PVC as specified in the SHOC card for freon gas. - Supervision could have been better. STOP techniques were not practised Discuss in your team: - How could this incident have been prevented? - What is a SHOC card? What is it for? - Have you got SHOC cards for the chemicals you work with? - Do you have procedures for working on pressurised systems? Are they known? Are they followed? How do you know? LTI no 43: Tightening bolt on AC 14/Sept/00