Line of Fire
Safety
Meeting
Learning
Session
Manufacturing Learning from Incidents
DSM-AC-201301
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Instructions for use of this Engagement pack
 This engagement pack is designed for leaders to use with
their staff.
 Sites must determine how best to conduct these engagements,
a few options include:
 A safety stand down
 A regular safety meeting or team meeting
 Special engagements
 All discussed in one session or sections discussed over time.
 This powerpoint is made to be used in any of these ways.
 Sites may even want to add some of their own incidents as
examples
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Objectives
This engagement pack is designed for leaders to use with their
staff.
The objectives of the engagement include:
 Provide a reminder about why stop work empowerment is
important.
 Review Line of Fire hazards.
 Review some examples of Line of Fire hazards and
potential barriers.
 Consider what actions you should take to address
potential Line of Fire hazards.
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What Happened – Some statistics from FIM
Line of Fire Situations have resulted in:
 Half of the 81 Recordable Cases in 2013
 40-50% of the Lost Time Incidents since January 2012
 BOTH of the fatalities in M since 2010
In 2013 – Line of Fire
 Injuries were often associated with Maintenance or
Construction Activities (75%)
 Involved hands or fingers in more than 50% of the
injuries, 25% were head injuries
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What Happened – Recent Fatalities in Other Shell Businesses
PTP
Malaysia
May 2013
A technician was fatally injured when he
attempted to open a water-tight door to a
pump room. The door violently opened and
struck the technician causing fatal injuries. It is
likely that differential pressure was caused by
an air leak from a control valve actuator.
UAU
Canada
Jul 2013
Contract worker was fatally injured after
being struck by a pipe during tie-in work. He
was inside a trench preparing for a pipe to
be welded when a separate section of pipe
fell into the trench and struck him.
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DZA
Australia
2013
A pedestrian walked through an operational
loading area (a pedestrian exclusion zone) and
was struck by a reversing forklift causing serious
injuries.
UI
May 2012
Contractor was fatally injured when
struck by a telescopic corrosion coupon
retraction tool.
UIN
Oman
Oct 2012
Incidents
involving Line
of Fire
A worker stepped onto the bed of a mobile
crane and entered the arc path of the
counterweight. He was crushed and fatally
injured when the counterweight was rotated.
UI
Malaysia
Aug 2011
UIN
Oman
Mar 2012
A worker was run over and fatally injured by a
reversing Heavy Goods Vehicle at a construction site
One fatality involving a contractor staff
when a wall collapsed at a site office
renovation job
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Identifying Hazards Helps Prevent Injuries
According to US Occupational Safety and Health
Administration (OSHA), hazards that represent 90% of all
workplace injuries or fatalities can be categorized in the
following four areas:
 Falls
 Electrical Shock
 Struck By
 Caught By / Caught Between
Which of these involve Line of Fire?
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What is Line of Fire?

The path an object travels or can potentially travel is the Line
of Fire.

When you place yourself or any part of your body in a
position where you are directly exposed to the path that the
object travels or may travel you are exposed to a Line of Fire
hazard.

Exposure to a Line of Fire hazard can potentially result in
injury or death.
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Line of Fire Awareness
 Stay aware of the work environment around you and of the
direction of movement of your body and equipment that is
around you.
 Always anticipate what could happen if unexpected
movement occurs. For example, before you bend over or
step back/forward, are you exposed to potential line of fire
hazards?
 Think about what could go wrong and how you can safely
react instead of reacting by impulse or instinct alone.
 Personal protective equipment (PPE) may be a last line of
defense from line of fire hazards and may not protect you
from injury.
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You are EMPOWERED to STOP WORK!
Why stop work?

To stop an injury or incident before it happens

To address identified unsafe conditions or acts

To reinforce a positive safety culture and safe work practices

To promote safety awareness
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10 Situations to AVOID LINE of FIRE INJURIES
Line of Fire – the zone within work area where there is a risk of serious injury from machinery and equipment
1.Moving
Vehicles /
Heavy
Equipment
2.Lifting /
Hoisting
3. Working at
Height /
Dropped
Objects
4.Tensioned
Lines /
Spring
Loaded
Devices
5.Objects with
Roll or
Fall
Potential
6. Pressurized
Equipment
7.Machinery
& Tools
8. Electrical
Equipment
9. Projectiles
10. Pushing /
Pulling
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What Line of Fire Situations have you seen that involve
Moving Vehicles or Heavy Equipment?
1. MOVING VEHICLES/ HEAVY EQUIPMENT
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1. Moving Vehicles/ Heavy Equipment - examples
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
Stay out of the area when
vehicles or heavy
equipment are moving

Be aware of the potential for
movement when
loading and unloading vehicles
or equipment
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1. Moving Vehicles/ Heavy Equipment
 What steps should you take to avoid Line of Fire
Situations that involve Moving Vehicles or Heavy
Equipment?
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1. Moving Vehicles/ Heavy Equipment
Here are some examples of precautions to take when moving vehicles
and equipment at a job site:

Use parking brakes and wheel chocks for parked equipment.

Turn off the engine of the vehicle where possible.

Be aware of the potential for movement of the vehicle and the load
when loading and unloading.

When/where possible move and stay out of the area when vehicles
or heavy equipment are moving.

Use/establish defined vehicle/equipment travel routes that are
separate from pedestrian travel routes when possible.

When you must work near moving vehicles or heavy equipment
obtain operator’s attention prior to approaching vehicles/equipment.
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What Line of Fire Situations have you seen that involve
Lifting or Hoisting?
2. LIFTING / HOISTING
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2. Lifting/Hoisting – An Incident

Lowering basket with 15-ton cherry picker

Using tag line to guide basket

At 5 foot ( meter) level contractor employee
placed hands on basket to position it

Support bar failed & basket fell

Tip of finger pinched between shackle and
basket wall


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Avoid placing your hands on a
suspended load.
Use the proper tool, such as a tag line.
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2. Lifting
Lifting/Hoisting
/ Hoisting
 What steps should you take to avoid Line of Fire
Situations that involve Lifting or Hoisting?
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2. Lifting / Hoisting
Here are some examples of precautions to take when lifting or hoisting:

Never walk under a suspended load.

Avoid placing your hands on a suspended load. Use the proper tool, such
as a tag line.

Secure all loads before lifting, loading, unloading and transporting.

Obtain permission from the Lift Coordinator before entering a
lifting/hoisting zone to perform work, even if for a short period.

Verify that the lifting equipment is rated for the weight of the load and
choose the appropriate equipment for the material being lifted.

Verify rigging equipment is rated for the weight of the load and has been
properly inspected.
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What Line of Fire Situations have you seen that involve
Working at Height or Dropped Objects?
3. WORKING AT HEIGHT / DROPPED OBJECTS
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3. Working at Height / Dropped Objects

Working on elevated deck to remove
bolts

Using an impact driver with a 1 ¼
inch socket

Tool broke and the socket fell to the
ground where other contractors were
working.

No injuries

Netting was in place to prevent
dropped objects, but there was a hole
in the netting near the work.
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Near
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2. Working
3.
Lifting/Hoisting
at Height / Dropped Objects
 What steps should you take to avoid Line of Fire
Situations that involve Working at Height or the Potential
for Dropped Objects?
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3. Working at Height / Dropped Objects
Here are some examples of precautions to take when working at height and to
prevent dropped objects:

Secure equipment with roll/fall potential, such as tools, cylinders, pipes,
and poles.

Secure all loads before lifting, loading, unloading and transporting. Stay
out of the line of fire.

Secure Tools and equipment when climbing a ladder.

Always use tool lanyards & tool bags when working at height.

Survey work areas for any unsecured equipment before beginning the job.
Use netting where possible.

Barricade/limit access to the drop zone below any elevated work being
performed above.

Never drop or throw tools/equipment when performing elevated work. Use
tool bags, hand lines and/or equipment to hoist or lower.
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What Line of Fire Situations have you seen that involve
Tensioned Lines or Spring Loaded Devices?
4. TENSIONED LINES / SPRING LOADED DEVICES
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4. Tensioned Lines / Spring Loaded Devices

Positioning a pre-fabricated steel
support to the base of a large tank

Chain block anchor hook failed when
winching the support into position

No injuries

The chain block hook failed. It was
attached to a securely braced piece of
angle-iron (instead of a shackle
connection).
Be aware and stay clear of tensioned
lines
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2. Tensioned
4.
Lifting/Hoisting
Lines / Spring Loaded Devices
 What steps should you take to avoid Line of Fire
Situations that involve Tensioned Lines or Spring Loaded
Devices?
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4. Tensioned Lines / Spring-Loaded Devices
Here are some examples of precautions to take when working around or
with tensioned lines or spring loaded devices

Be aware and stay clear of tensioned lines, strapping, and coiled &
spring-loaded devices such as cable, chain and rope. They can generate
tremendous energy when compression or tension is released.

Keep hands and your body away from rigging equipment such as
cables and shackles while loading, lifting, and unloading.

Be aware of hand and body placement
when applying tension to rigging. Use tag
lines whenever possible.

Anticipate pipe movement when cutting
pipe.
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What Line of Fire Situations have you seen that involve
Objects with the Potential to Roll or Fall?
5. OBJECTS WITH ROLL / FALL POTENTIAL
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5. Objects with Roll / Fall Potential

Machinist setting a 95 lb pump stuffing box head in a lathe

As loosened one of the chuck jaws to center the box, it fell onto the
lathe guides.

Machinist’s gloved hand was crushed, fracturing his finger
Do not use your body or hands to try to stop an unstable or shifting load
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5. Objects with Roll / Fall Potential

A golf cart was raised 4.5 feet from the floor for inspection of the
brakes

While the mechanic was checking his paperwork, the cart suddenly
tilted backwards and fell off of the jack.

Damage to the golf cart cab was minor.

The rear of the golf cart contained many items
Secure all loads,
especially top-heavy
items. Do not work
near or under
equipment that could
potentially fall.
Potential
Struck By
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5. Objects with Roll / Fall Potential

Loading two cylinders onto a flat bed truck with a fork lift

Cylinders began to roll towards the opposite side of the truck

A contractor worker attempted to stop the cylinders from falling off of
the truck.

The contractor worker was fatally injured.
Potential
Struck By
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2. Objects
5.
Lifting/Hoisting
with Roll / Fall Potential
 What steps should you take to avoid Line of Fire
Situations that involve Objects with either Roll or Fall
Potential?
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5. Objects with Roll / Fall Potential
Consider these precautions if objects have the potential to roll or fall:

If a load shifts, stay out of harm’s way (i.e., do not enter the line of fire). Do
not use your body or hands to try to stop an unstable or shifting load.

Secure equipment with roll/fall potential, such as tools, cylinders, pipes,
pumps, engines, poles, etc.

Secure all loads before lifting, loading, unloading and transporting.

Secure all loads, especially top-heavy items and items being transported by
forklift or flatbed.

Survey work areas for any unsecured equipment or items before beginning
the job.

When loading objects with a roll/fall potential on a vehicle, use truck bed
stakes and/or gates, as necessary.

Survey your work area for any equipment that could fall. Do not work near
or under equipment that could potentially fall.
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What Line of Fire Situations have you seen that involve
Pressurized Equipment?
6. PRESSURIZED EQUIPMENT
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6. Pressurized Equipment

Contractors were replacing a section of hot water piping by cutting it
out, welding on flanges and installing a new section of piping.

Plugs were placed in the open ends of the piping after it was cut.

Two hours later, while welding on a flange, the plug suddenly blew
out, followed by hot water and water vapor.

The hot water injured three of the four contractors, one fatally.
Keep your body out of the line of fire and think about the direction of the
line of fire if pressure releases unexpectedly.
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6. Pressurized Equipment

Two contract employees returned to their
worksite to remove plugs from an air fin
exchanger that they had blinded earlier in the
day.

One contractor mistakenly began to loosen a
plug that on an exchanger that was still in
service.

The plug blew out of the exchanger, and the
release pushed him back against the rail of
the deck.

His hard hat and the air tool fell 27 meters
(89 feet) to grade.

The contractor was treated for minor injuries.
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Keep your body out of
the line of fire and think
about the direction of
the line of fire if
pressure releases
unexpectedly.
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2. Pressurized
6.
Lifting/Hoisting
Equipment
 What steps should you take to avoid Line of Fire
Situations that involve Pressurized Equipment?
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6. Pressurized Equipment
The following are some precautions to consider when working with
pressurized equipment:

Verify zero energy state before cutting into or opening any equipment
such as flanges, lines, couplings, hose connections, pumps, vessels, etc.

Compressed cylinders must be secure and upright with caps installed at
all times.

Always assume that there is pressure on equipment before opening.
Keep your body out of the line of fire and think about the direction of the
line of fire if pressure releases unexpectedly.

Be aware of body positioning when working with pressurized tools.
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What Line of Fire Situations have you seen that involve
Machinery or Tools?
7. MACHINERY & TOOLS
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7. Machinery & Tools
.
Contractor was torquing
flanges with a pneumatic
wrench.

Reached to steady a socket
while the pneumatic tool
was energizing.

The ‘reaction bar’ rotated
and crushed his finger
against the adjacent nut.
Never use your hand to hold sockets in place on torquing equipment.
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7. Machinery & Tools

Contractor employee was grinding a tack weld on the bottom of a pipe.

He was positioned to obtain leverage for the task.

During grinding, the grinder suddenly kicked back, knocking off his face
shield and hard hat.

The grinder blade stopped and contacted the contractor employee’s chin.

The contractor employee sustained an abrasion to the chin.
Be prepared for the
movement of the tool when
it starts to rotate.
“Kickback” can occur when
using rotating tools.
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2. Machinery
7.
Lifting/Hoisting
& Tools
 What steps should you take to avoid Line of Fire
Situations that involve Machinery or Tools?
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7. Machinery & Tools
The following examples are precautions to take when working with
machinery and tools.

Be aware of torque stresses generated by rotating equipment.

Anticipate the unexpected rotation or movement of machinery.

Never operate a tool or equipment without proper safety devices such as
guards, keepers, etc.

Be aware of hand placement to avoid pinch points.

Never use your hand to hold sockets in place while torquing equipment.

Secure equipment before starting work and be prepared for the
movement of the tool or the equipment when it starts to rotate. “Kickback”
can occur when using rotating tools .

Be prepared for equipment rotation long after applied torque force has
stopped -“Coasting”.
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What Line of Fire Situations have you seen that involve
Electrical Equipment?
8. ELECTRICAL EQUIPMENT
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8. Electrical Equipment
Stay out of the line of fire in case
an arc flash occurs.
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8. Electrical Equipment
The following are examples of precautions for working around
electrical equipment:
 Avoid working on or near energized electrical equipment.
Make sure power is turned-off, and always follow lockout/ tagout procedures.
 When switching a breaker into position, stand out of the line of
fire in case of an arc flash
 Stand clear when breakers are being closed remotely.
 If an electrician is working in an opened panel, stay away.
 Electrical rooms are not a safe place to “hang out” or come in
from the weather.
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What Line of Fire Situations have you seen that involve
Projectiles?
9. PROJECTILES
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9. Projectiles

A contractor employee was assigned to
“hammer test” cast steel caps to verify
tightness.

When struck, a piece of the steel cap
broke, flew at high speed and struck the
worker chipping a tooth.

The contractor employee was wearing a
face shield.

Both the hammer and the cast steel cap
were hard steel which caused the cap to
break when impacted.

Be aware of tasks that
generate flying debris
The debris entered underneath the face
shield.
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2. Projectiles
9.
Lifting/Hoisting
 What steps should you take to avoid Line of Fire
Situations that involve Projectiles?
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9. Projectiles
Consider these precautions when there is a potential of projectiles:
 Be aware of tasks that generate flying debris such as grinding,
chipping, abrasive blasting, hydro-blasting, sawing, using
hammers, opening bleeders, equipment, etc.
 Contain projectiles and/or barricade the area and restrict
access.
 Position the tool to direct the projectiles in a safe direction, such
as directing sparks from grinding into the firebox.
 Stay aware of your body position and
think about the potential
path of the projectile.
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What Line of Fire Situations have you seen that involve
Pushing or Pulling?
10. PUSHING & PULLING
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10. Pushing & Pulling - Example

Contractor employee was in the process of
tightening the last nut on a flange.

He was pulling a combination wrench in the
direction of his face.

As he pulled on the wrench, it came off the
nut striking him in the mouth.

Contractor employee’s front tooth was
knocked out.
When pulling or pushing with wrenches, remain
focused and anticipate the possibility of the
fastener suddenly loosening or wrench
slipping
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10. Pushing & Pulling - Example

Contractor employee removing bolts from a gate
valve using a combination wrench.

Box end of the wrench could not fit completely on
the nut due to its position, so tried to reposition the
nut with the open end of the wrench.

The wrench slipped off the nut and struck the
employee on the lip.

Congested area which limited body position.
Anticipate the possibility of sudden release during pulling or pushing and keep your
body, face, and hands out of the line of fire
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2. Lifting/Hoisting
10.
Pushing & Pulling
 What steps should you take to avoid Line of Fire
Situations that involve Pushing or Pulling?
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10. Pushing / Pulling
Consider these precautions when pushing or pulling is
involved:
 Be aware of your body position when conducting work
activities that involve pushing or pulling, such as using a
wrench or pushing/pulling a cart.
 When pulling or pushing with wrenches, remain focused
and anticipate the possibility of the fastener suddenly
loosening or wrench slipping.
 Anticipate the possibility of sudden release during pulling or
pushing and keep your body, face, and hands out of the
line of fire.
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10 Situations to AVOID LINE of FIRE INJURIES
Line of Fire – the zone within work area where there is a risk of serious injury from machinery and equipment
1.Moving
Vehicles /
Heavy
Equipment
2.Lifting /
Hoisting
3. Working at
Height /
Dropped
Objects
4.Tensioned
Lines /
Spring
Loaded
Devices
5.Objects with
Roll or
Fall
Potential
6. Pressurized
Equipment
7.Machinery
& Tools
8. Electrical
Equipment
9. Projectiles
10. Pushing /
Pulling
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CONCLUSIONS
Exposure to line of fire hazards can result in injury or death.

You are empowered to Stop Work (intervene) anytime a task cannot be completed
safely.

Stay out of the line of fire. Do not use your hands or body to stop a shifting load,
projectile, etc.

Personal protective equipment (PPE) is a last line of defense. Do not assume PPE will
protect you from a line of fire hazard.

If you find yourself in a line of fire situation, remove yourself from the line of fire
immediately.

Anticipate line of fire hazards and take steps to eliminate, mitigate or protect yourself
from the hazard.

Stay aware of the work environment around you and of the direction of movement of
your body and equipment that is around you.

Always anticipate what could happen if unexpected movement occurs. For example,
before you bend over or step back/forward, are you exposed to potential line of fire
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hazards?
Closing
 What other insights do you have based on these
incidents and your discussions today?
 What will you do differently as a result of learning from
these incidents and examples?
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Do the Right Thing!
Achieve Goal Zero!
Legal Disclaimer
This document is made available for information only and on the condition that (i) it may not be relied upon by anyone,
in the conduct of their own operations or otherwise; (ii) neither the Shell company issuing this document nor any
other person or company concerned with furnishing information or data use herein (A) is liable for its accuracy or
completeness, or for any recommendations or advice given in or any omission from this document, or for any
consequences whatsoever resulting directly or indirectly from any use made of this document by any person, even if
there was a failure to exercise reasonable care on the part of the Shell company or any other person or company as
aforesaid: or (B) make any claim, representation or warranty, express or implied, that acting in accordance with this
document will produce any particular results with regard to the subject matter contained herein, or satisfy the
requirements of any applicable federal, state or local laws and regulations; and (iii) nothing in this document
constitutes technical advice. If such advice is required it should be sought from a qualified professional adviser.
The content of this document may (i) be based on, but not identical to facts relating to a third party incident about which
Shell has become aware; (ii) contain Recommendations that are one, but not necessarily the only way, of addressing
incident learnings.
The companies in which Royal Dutch Shell plc directly and indirectly owns investments are separate entities. In this
Learning From Incident Alert, the expression “Shell” is sometimes use for convenience where references are made to
companies within the Shell group or to the group in general. Likewise, the words “we” and “our” are also used to
refer to Shell companies in general or those who work for them. These expressions are also used where no useful
purpose is served by identifying specific companies.
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