One more example:
This from a colleague of mine:
I recall the incident vividly. It happened to the 3rd shift Fire Brigade in 1999, who were changing out a 400lb compressed air cylinder—that provided fire extinguishing air to an overhead dust collector--within the confines of the metal support structure for the dust collector. The steel framed enclosure was about a 12 ft by 12 ft square. There were four or five team members standing within the enclosure area during the change out.
The brigade had removed a spent cylinder and set it aside. They had rolled a filled cylinder into place, but had not yet locked it in place. It began to leak heavily at the head while one team member was attempting to attach the hose from the dust collector to the cylinder valve. As he grappled with the unit in an attempt to stop the leaking—he inadvertently pushed it over. The valve head was knocked off in the fall, resulting in the violent release of pressure, and causing the cylinder to rocket around the enclosure. (It DID NOT crash thru any kind of wall.)
The rocketing cylinder struck one member in the back—severely bruising him—and struck the Assistant Fire Captain on the right lower leg, entrapping it against a longitudinal steel brace of the enclosure, resulting in multiple fractures to both bones of the lower leg. A serious, serious injury.
The team had performed this same job task correctly many times—but on this occasion, they failed to secure the cylinder BEFORE beginning re-attachment of the cylinder valve.
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