Our suite of Q1-themed resources includes Learning Event Bulletins that align with the theme ‘Preventing Major Accidents’.
Maintaining Process Equipment - Loss of Containment
What Happened?
While installing a temporary pig launcher for an inline inspection (ILI), workers identified the tie-in valve was passing and there was unexpected pressure in the pipeline. Attempts were made to depressurise the pipeline at the receiver end approximately 7 km downline. Pressure remained at the launcher location so the work was stopped, the pig launcher removed and the blind flange re-instated.
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Why did it Happen?
The following morning while reviewing isolations/depressurisation it was discovered that:
- An incorrect Permit to Work (PTW) was used for the work scope. The Permit printed was for a different Job Location and different work scope (hazards and controls not the same, Isolation Certificate incorrect). The Permit Authority, Permit Holder and Work Party members (up to 10 people in total) signed the incorrect permit and the work was commenced. A manual change was made to the Job Location number on the permit paperwork without revisiting electronically. A correct permit was issued electronically but not printed and issued to the Permit Holder and Work Party before the work commenced.
- Work was performed under a non-conformant Isolation. There was no locked isolation at the break containment flange and some upstream well isolations were not documented.
What did they Learn?
- Permit Holder did not hold an adequate pre-start meeting with the Work Party to review permit conditions before signing on.
- Permit Holder and Work Party did not walk and verify the isolation before work commenced (best practice). This may have identified the Permit error (Isolation Certificate number would not have matched permit).
- Isolation did not include bleeds for the double valve isolations against the Upstream Wells (thermal overpressure risk).
- Hazard controls section on electronic Permit was overflowing with text (therefore cut off from view on the paper copy), however the Permit Authority and Permit Holder did not follow procedure to print and attach the full controls.
- 4 of the 9 wells upstream of the pig launcher were listed on the Isolation Certificate as ‘well offline’ without evidence of well operational status.
- All three permits reviewed as part of the investigation did not have Work Packs attached, and one had no Work Order linked.
- The Isolation Plan / Permit developed attempted to combine both the mechanical works to install the temporary pig launcher, and launching the pig, in the one isolation plan.
- This potentially contributed to an incorrect application of “Operator in Attendance” criteria, which was used to allow flexibility in isolation when the pig would need to be launched through the pipeline isolation valve.
Learning Event Bulletins
Learning Event Bulletins are a tool to assist with learning from unwanted events and/or threats in order to minimise Fatalities and Permanent Impairment incidents (FPIs).
They focus on ‘unwanted events/threats’ as triggers to investigate and disseminate lessons learned. Encourage industry to approach unwanted events/threats with a positive learning mindset. Investigate, report and share the lessons from ‘High Value Learning Events’ triggered by unwanted events/threats occurring, regardless of whether it is classified as a HiPo or not.
Use Learning Event Bulletins to facilitate discussions that influence and reinforce behaviours focused on helping prevent harm to frontline workers.
How do HSERs get the most value from this Learning Event Bulletin?
- Print the Bulletin and post it to notice boards.
- Discuss the Learning Event and lessons learned AND use it as a chance to discuss “Could this happen to you?”
- Send your feedback to Safer Together: [email protected].
Frontline workers:
- Actively participate in discussions about this Bulletin.
- Ask your frontline leader to provide the opportunity to discuss the Bulletin and download and discuss it with your work crew.
- Help your frontline leader provide feedback to Safer Together.