문서: 근접사고 / 작업허가 검토 · Form 404
작업: 밀폐 진입 + 인접 핫워크(익명)
결과: 부상 없음. “격리” 개방 중 process fluid release.
형식: 양식 자체, markup. Policy sermon 아님.
SECTION A — 작업 설명(기재대로)
“개스킷 교체를 위해 XV-12 downstream flange 개방. 구역 gas-free.”
Markup: “Gas-free”는 hope verb. 필수: numbered isolation point + prove-dead method.
SECTION B — 격리(체크박스)
| Point | Claim | Field find | | --- | --- | --- | | XV-12 closed | ☑ | Local closed; no lock | | Bleed B-3 open | ☑ | Partially open; tape residue plugged | | Blind installed | ☐ N/A | N/A이면 안 됨 |
Markup: Blind N/A는 “isolated”가 vocabulary가 되는 경로.
Lock 없는 체크는 stationery.
SECTION C — Gas test
| Time | O₂ | LEL | Toxics | Tester | | --- | --- | --- | --- | --- | | 09:10 | 20.8 | 0 | ND | R.T. | | 09:40 | — | — | — | blank |
Work 09:35 start. Retest blank. Opening 후 09:52 release.
Markup: Single test ≠ continuous atmosphere.
SECTION D — Signatures
Issuer ______ Acceptor ______ Gas tester ______ Area authority ______
Walkdown photo 전 모두 서명. Photo timestamp 28분 후.
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(red 추가)
- Permit software가 lock photo 없이 isolation step complete 허용
- Production pressure metric이 “isolations proven”이 아니 “permits closed” count
- Hot-work + confined combo 별도 training; 이 job은 both
Second test는 wrench 첫 turn 전 mandatory였어야 함.
Corrective actions(owned)
| Action | Owner | Gate | | --- | --- | --- | | Isolation step close에 lock photo required | Work control | Soft → 14d hard | | Bleed prove-dead checkbox + method text | Operations | Immediate | | Combo-job template(entry + hot work) | Safety | 30d | | KPI: incomplete isolation open permits = red | Leadership | Next month |
Adjacent fences
Electronic permit/LOTO product brief는 workflow software. SIS lifecycle은 proof tests. Fixed gas-detection lifecycle은 head siting·bump cadence. Form 404는 single job authorization honesty. Blind skip하고 permit app 사지 마라.
Closing stamp
Near-miss 404 permit theater로 close. Lock evidence 없는 다음 identical form은 memory가 아니 software로 issuable하지 않아야 함.