Vent valves were not identified as environmentally critical and therefore not controlled as such under the isolation certificate
Project managers role requires clarification – individuals assigned as Project Managers due to availability & role was not clearly defined
Key positions involved were not correctly following ISSOW and TBT Procedures
Area Authority aware that testing was occurring but was not aware of what was controlling the work
Line walking discipline requires improvement, as line walk checks on other plant had identified all hydrocarbon capped fittings but not captured auxiliary (lube oil) systems
Valves which may be environmentally sensitive to be tagged appropriately as Environmentally Critical
Decision point where a work pack based approach is needed for this type of project to be clearly documented. Where this is the case, the appointment and attributes of a Project Mgr are also to be defined and appropriately communicated.
Impact and consequence of this incident to be communicated to key involved parties
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