Document: Near-miss / Permit-to-work review · Form 404
Job: Confined entry + hot work adjacent (anonymized)
Outcome: No injury. Process fluid release during “isolated” opening.
Format: The form itself, marked up. Not a policy sermon.
SECTION A — Job description (as written)
“Open flange downstream of XV-12 for gasket replace. Area gas-free.”
Markup: “Gas-free” is a hope verb. Required: numbered isolation points + prove-dead method.
SECTION B — Isolations (checked boxes)
| Point | Claimed | Field find | | --- | --- | --- | | XV-12 closed | ☑ | Closed locally; no lock | | Bleed B-3 open | ☑ | Partially open; plugged with tape residue | | Blind installed | ☐ N/A | Should not have been N/A |
Markup: N/A on blinds is how “isolated” becomes vocabulary.
A checked box without a lock is stationery.
SECTION C — Gas test
| Time | O₂ | LEL | Toxics | Tester | | --- | --- | --- | --- | --- | | 09:10 | 20.8 | 0 | ND | R.T. | | 09:40 | — | — | — | blank |
Work started 09:35. Retest blank. Release at 09:52 after opening.
Markup: Single test ≠ continuous atmosphere.
SECTION D — Signatures
Issuer ______ Acceptor ______ Gas tester ______ Area authority ______
All signed before walkdown photos. Photo timestamp is 28 minutes later.
Markup: Signature time ≠ verification time.
SECTION E — Immediate causes (form language)
- Isolation not locked
- Bleed not proven
- No retest after break
SECTION F — Systemic causes (added in red)
- Permit software allows complete without lock photo
- Production pressure metric counts “permits closed,” not “isolations proven”
- Hot-work + confined combo trained separately; this job was both
The second test should have been mandatory before the first turn of the wrench.
Corrective actions (owned)
| Action | Owner | Gate | | --- | --- | --- | | Lock photo required to close isolation step | Work control | Soft → hard in 14d | | Bleed prove-dead checkbox with method text | Operations | Immediate | | Combo-job template (entry + hot work) | Safety | 30d | | KPI: open permits with incomplete isolation = red | Leadership | Next month |
Adjacent fences
Electronic permit/LOTO product briefs own workflow software. SIS lifecycle owns proof tests. Fixed gas-detection lifecycles own head siting and bump cadence. Form 404 owns authorization honesty on a single job. Do not buy a permit app and skip the blind.
Closing stamp
Near-miss 404 is closed as permit theater. The next identical form without lock evidence should not be issuable—by software, not by memory.