Hydrocarbon release - Failure to Follow Safe Systems of Work PTW

Cause & Consequence

• Release of a harmful substance

Incident Location

Fixed Installation

Incident Activity

Maintenance

Incident Info Source

alerts@nopsa.gov.au

Specific Incident Equipment

Piping manifold, production pipeli

Lessons Identified

What went wrong ?Investigation found that the review conducted to bring the valve back into service was inadequate and did not identify the need to replace the bleed plug. A previous incident involving corrosion of a bleed plug prompted the replacement a number of plugs on operating valves. However, as this particular valve was mothballed at the time, the plug was not replaced.Following the initial release, the permit to work was not reviewed to ensure that:

1. fitting of a new valve plug was addressed;

2; isolation and venting of gas trapped in the system carried out;

3. new or changed hazards were identified;

4. adequate controls were in place for the work; and

5. there were clearly defined and communicated process steps. There was a lack of communication between the control room and personnel in the field such that people were not made aware of what actions had been taken or were about to be taken.Fortunately, there were no injuries or ignition of the gas. The valve bleed port was then plugged and residual pressure vented to atmosphere via the fixed vent system.What went wrong ?

Investigation found that the review conducted to bring the valve back into service was inadequate and did not identify the need to replace the bleed plug. A previous incident involving corrosion of a bleed plug prompted the replacement a number of plugs on operating valves. However, as this particular valve was mothballed at the time, the plug was not replaced.Following the initial release, the permit to work was not reviewed to ensure that: fitting of a new valve plug was addressed; isolation and venting of gas trapped in the system; new or changed hazards were identified; adequate controls were in place for the work; and there were clearly defined and communicated process steps. There was a lack of communication between the control room and personnel in the field such that people were not made aware of what actions had been taken or were about to be taken

Incident Recommendations

1. Mothballed equipment should be thoroughly inspected and, where necessary, should be tested and verified prior to bringing it back into service. Review processes should be robust enough to ensure lessons from previous incidents are considered

2..After any accident or dangerous occurrance, work should stop to allow for a thorough investigation of the causes prior to continuing.

3. If work activities change as a result of an event, it is important to ensure that any new or changed hazards are identified at the these changes are considered in a PTW (including hazard identification and risk assessement) before proceeding