MSHA's "Best Practices" Related To This Incident Don't Make Sense.

State and federal safety agencies investigate all workplace fatalities in the U.S. On March 6, 2019 a mechanic was fatally injured when the pressure relief valve was ejected from a ram he was using.

I find it interesting that even though state and federal investigators allegedly have little or no training, knowledge or experience with hydraulic safety they are tasked to determine the root cause of incidents related to hydraulics. The "best practices" recommendations that accompanied the subject "fatality alert" serve to prove my point.

Here is a list of MSHA's best practices to prevent these types of incidents. I am going to write a comment below each of MSHA's best practice recommendation:

? Inspect, examine, maintain, and evaluate all materials and system components used in the installation, replacement, or repair of pressurized system to ensure they are suitable for use and meet minimum manufacturer's specifications.

Comment - MSHA looks the other way while 99% of the people that work on and around hydraulic systems have never received training in hydraulic safety. Accordingly, over 99% of the people that work on and around hydraulic systems in America's mines do not have the training, knowledge or experience to inspect, examine, maintain, and evaluate all materials and system components used in the installation, replacement, or repair of pressurized system to ensure they are suitable for use and meet minimum manufacturer's specifications.

? Test systems are lower pressures to verify connections and flow rates prior to full pressure use.

Comment - It's interesting that the pressure relief valve was reportedly ejected before the ram made contact with the frame, which means it would have been operating at a relatively low pressure. It is plausible that the worker (s) either did not connect the oil transmission line to the upper port (either at the cylinder or the power unit), or they failed to fully engage the screw-in type quick connect/disconnect valve. According to the manufacturer's literature the purpose of the safety pressure relief valve is to prevent pressure intensification from causing the cylinder to suffer a catastrophic failure if the user made this error. There was no such a thing as a "low pressure test." If all quick-connects were not fully engaged nothing the workers did would have prevented this incident once they activated the valve. If the pressure relief valve remained in place (as it should have) the oil would have discharged through the opening. Of course, there is a chance the oil would have struck the victim and caused the same regrettable outcome.

Besides, both OSHA's and MSHA's lockout standards states "the release of stored hydraulic energy must be controlled." Releasing oil that is pressurized to 10,000-PSI (590-BAR) to the atmosphere as a "safety precaution" is hardly "controlling" the release of that energy. It's downright asinine!

Based on what I have read about the incident, the root cause was poor design/equipment failure. The purpose of the pressure relief valve to prevent this type of inc incident from happening.

? Position yourself in a safe location, away from any potential source of failure, while pressurizing the system.

Comment - The failure could occur anywhere in the system (the weakest link). The control valve is usually on the power unit. It's impossible to be in a safe location "away from the potential source of failure." Moreover, the unit could explode and fragments could glance off structures and head toward its victim. This is advice is from an uniformed person.

Consult and follow the manufacturer's recommended safe work procedures.

Comment - Agreed! With one exception. The manufacturer did not warn about the possibility that oil could eject from a 10,000-PSI (690-bar) "safety" relief valve, or that the pressure relief valve could be ejected from the ram. In my opinion there should have been a warning label on the ram that warned users to rotate the pressure relief valve away from the operator. Also, the manufacturer should have installed some type of "diffuser" in front of the safety relief valve. No one in their right mind discharges oil at 10,000-PSI (690-bar) to the atmosphere.

? Establish and discuss safe work procedures that include hazard analysis before beginning work. Identify and control hazards associated with the work to be performed and use methods to properly protect person.

Comment - Over 99% of people working in mines have never received training in hydraulic safety. It's not mandated by MSHA therefore only a handful of mines offer it. While the investigators were on site investigating this preventable tragedy they ignored the fact that over 99% of the hydraulic systems on the mine site do not have the means for workers to control the release of stored hydraulic energy post-shutdown.

Note: I am proud to have worked with Freeport McMoRan for a decade. Freeport employs a team of dedicated instructors that teach hydraulic safety. Freeport can be proud to be in the 1% of mines in America that teach workers hydraulic safety.

Takeaway

1. Workers MUST NOT be permitted to work and around hydraulic systems without safety training.
2. If you own a high-pressure ram, or any hydraulic system/component that discharges high-pressure oil to the atmosphere in any way, shape or form, I strongly urge you to get a letter from the respective manufacturer guaranteeing that under no circumstances can the release of that energy cause workers (whether trained or untrained) to get injured or killed, nor can it cause property damage.
3. If you operate a ram with this type of safety device make sure ALL connection are secure before starting the unit. In fact I suggest you have a metal depth gauge made, which you attach to the unit with a cable. The gauge can be used to confirm the engagement depth is correct.
4. If you operate a ram with this type of safety device TURN IT AWAY FROM YOU AND OTHERS before you start the power unit. Also advise people around the unit to stand away when it starts up.
5. ALL personnel that operate these ultra high-pressure systems should receive specialized training before being permitted to operate them.

What I don't like about this alert is that it seems to imply that the victim was solely responsible for incident. I sincerely hope these are preliminary findings and that MSHA will publish a final report with accurate facts.

There are untold numbers of rams with the same or similar "safety" devices in workers hands across America. I suggest that MSHA and other investigators move swiftly to find the root cause of this incident. It may very well prevent another tragedy.

I have received two calls in the past to ask if I have developed safety training courses for these ultra high-pressure systems. In both cases a worker (s) had suffered injuries. Let's stop closing the barn door after the horse has bolted.

My opinions are based on my training, knowledge and experience in hydraulics. It is also based on my understanding of the incident and having read the manufacturer's literature. I reserve the right to correct my opinions should further evidence become available.