3 WHAT IS MORE IMPORTANT - THE PERMIT TO WORK OR THE EXECUTION OF THE PLAN? This incidentis used to illustrate and to discuss the significance of this question. Itlooks at the task, the execution and the potential consequences and then uses this to answer the question THE TASK The task way to replace 2 boiler drum level control valve bypass valve. ‘this valve was welded in. Unfortunately the tecd water munifuid isolation valve "7" was louking and, some other positive solation way required (See Figure 3.1) THE PLAN The plan, as devised, was (0 install an ice plug using a nitrogen bath in a VERTICAL section of pipe line. Asa back up the plug would be pressure tested by injecting water at "VY" se to achieve @ pressure equal to the fine rating After this the level control valve was to he removed and a stopple fitted in the line. With this arrangemeat there would be a double block with onc proven isolation EXECUTION 1 The exccution was ant tially according 10 plan, First the maip isolation valve wasleaking, Feed water manifold FIGURE31 so badly that no pressure test could be achieved, Second the stopplé could aot be josialied duc to difficulty with access Whatever the righis and weongs the task was. completed sucecssfully and the ice plug thawed out. The boiler was put on fine and sty af the lols were on site it was decided tudo the samic task cia an adjacent boiler dewm levei contcol salve bypass EXECUTION 2 The piping configuration on the adjacent boiler was different and che only suitable section of piping was oricated horizontally, Asa results difforeat nitrogen bath had to be fitted. Once again the pressure test could noi be achieved and the stopple could not be Fitted. The plan had now heen violated om three accounts but the tusk had started and no-one thought more shout it Euely in the execution of thistask the Nitrogen Dewar Flask evel indicator maltusctioned. however it was decided that the flask cwald he weighted and thereby the weight of the romaining nitrogen could be determined As cine task proceeded twas evident thats scvond Dower Flask of nitrogen would have tu he used bul the hose.ffor some reason. did noi fit (his possible the coupling on the second flask ad hocn damaged in transit) Level controt valve L__h - To boiler Srum Fauity valve The Plan SKETCH OF PIPING ISOMETRIC OF BOILER FEED SYSTEM 5 Loss Prevention Bulletin 104At this point the Work site was only protected by a singic isolation which is only effective as Jong 4s the low of aitrogen was maintained to the nitrogen bath and that flow is not guaranteed. ‘The inevitable occurred, whether it Was da te prematurcioss of nitrogen or low nitrogen flow matters tittle. The icc plug blew out and hot fed water sprayed ouc af this Lins, The levels nthe on-hine boilers started to fall and by aucaus of reduced theoughput and putting un exter feed pumps, maintained dur ler levels were a contegiled shutdown, ANALYSIS OF THIS INCIDENT ‘The analysis of this incident illustrates une of Ihe major misunderscandinus and appheation of the Permit in Work system, Too nfiee there is heated debate about the niectics of the layout! of the Permit and Shere the sigaatare should be lacated to the detriment of the objective of the It, The Permit 19 Work shoald be a cord of 1 The Work Pianaing (including calculations of loods, Ferces, stresses or other phys limitations) The preparation of the work itself (Isolation, draining, purgiiiy ete) ‘The preparation of the work site (sand bagging drains. isolation of local cquipment) 4 Limitation of Incompatible Practiess {such as, draining flammabies during hot work). ‘The exact scope aud limitations al the work to be carried out 6 The exact method and twols 10 he used to carry out that work ‘The monitoring and supervision of this work site 8. The physical protection tobe adopted by the man. 8 ‘Tae precautions tg be adopted by the map. 10. The possible process and physical hazardsassociatedwith theworksite Li, The contingency plans ta be adopted should anything untoward develop, iechising how and when the work shold si9p. . The agreement in the furor of signature, that alt parties visited 1b: work site, inspected iLand agree that the work Will be done as deserihed, without deviation and chat all possible precautions have been carried uutin ordes go muke the work aad the s fe sale far the operation Where appropriate this shoold wuclude testing the losis and associated Cguipmeal lo emare it willwork as required, when requized Far coo often, steps Lod, 7, 1b and particalarly Dare gmijied. In this case in question ’ The plan was not devised properly nor Was it followed Contingency pleas were not developed and the work should have been shorted om a number of 4 The equipment had not been tested What seould have happened if the {uids had heen wale os Jammable or currosive + the consequences could have been quite unthinkable What is more important the permél to workor the execution of the plan? Surely it 1s the execution of the detailed plan which is embodied in written format in the permit (o work