April 2026 PSMS Lesson Learned

Plan-Do-Check-Act (PDCA) applied in every decision and action in the field ensures a layers-of-protection approach to risk mitigation. The event shared in this Lessons Learned highlight an electrofusion failure due to contamination that on the surface could simply be excused as human error, however a deeper dive reveals that while procedures and training requirements existed, they were not consistently executed, monitored, or enforced, indicating a breakdown in the management system rather than an isolated human error.

A more robust application of PDCA cycle could have reduced the likelihood and impact of this event by clearly planning failure response expectations and tool control requirements, ensuring disciplined execution in the field, verifying compliance through inspection and audits, and acting promptly to correct deficiencies. Strengthening these elements, consistent with API 1173, reinforces accountability, improves contract performance assurance, and supports continuous improvement of the PSMS.

Description of Event:

A two-inch electrofusion tee leaked after being tapped by a Contractor Crew. The sample was sent to the lab for analysis, and the lab concluded that the leak was due to joint surface contamination.

Key Causal Factors/Root Causes:

• Root Cause: Management System – Standards, Policies, or Admin Controls (SPAC) Needs improvement - Accountability Needs improvement.
• Causal Factor: Electrofusion failure due to contamination between the main and tee caused a gas leak due to use of improperly maintained equipment.

Key Corrective Actions:

1. Contractor leadership will create and communicate a safety bulletin to inspectors and contractors, reminding them to halt all subsequent fusions post-failure and quarantine the electrofusion control box, peeler, alcohol, etc.
2. Contractor leadership and operations SME’s team will create a focused process to audit peelers for visible contamination.
3. The Contractor will retrain and requalify the fuser and peer inspector.

Key Lessons Learned:

1. Conduct a full stop of all fusion activity once a failure occurs and quarantine the fusion control box, peeler, clamp, alcohol, etc., in preparation for the following lab investigation.
2. Check all rotary peelers for signs of blade wear or contamination before utilizing them on fusion preparation.
3. Operator approved peelers must be the tool of choice to prepare the plastic pipe for joining when performing an electrofusion or saddle fusion.
4. Installers are not permitted to peel a second time. If the peel is not within the specified parameters, the tool and blade should be checked for defects, contamination and sent out for repair or change the blade.

Connecting the dots (Process, Pipeline and Personal Safety)

Process Safety

• Operational discipline and contractor oversight were weak; procedures and training existed but were not consistently followed or enforced.

• Verification and accountability failed to detect tool contamination and compliance gaps before the event.

Pipeline Safety

• Asset integrity and quality control were compromised when electrofusion contamination caused a loss of containment.
• Abnormal operations response was inadequate, as fusion work was not immediately stopped and equipment was not quarantined.

Personal Safety

• Hazard recognition and stop‑work authority were not effectively applied after the initial failure.
• The resulting gas leak increased worker and public safety risk, despite no reported injuries.