6VDU Incident Barrier Analysis

Contractor Planning /
Maintenance Selection / Work Request Scheduling of JSA / Work
Scoping of job SWP Tool Box Talk SWA
WR process Competency raising stage job / WO Handover
Test processing

Pull-up Gland of Hot

isolation valve on HVGO
shell side of release,
70E7001 2 LTIs

 Maintenance Contractor Supervisor Work Request Scoping Planning and Scheduling JSA Approving Authority – Head Tool Box Talk Use of SWA
procedure (EMPAC  JSA is not at done at Operator
WR process)  No process for PMD  No provision in EAM  No SME (OPD) input  Work Request not scoping stage by the  JSA and controls are not  TBT not specific  Metal Trade Workers
alignment with Risk related Live system mentioned if the job reviewed person who scoped reviewed and verified to the job were not aware of
Assessment Standard trade testing. is on live or dead line  No hazard the Job. SWA.
identification at JSA /  WR approved Issuing Authority – Area Outside
 Most JSA / RAMS are  Not interviewed by  No concern. RAMS without any Hazard Operator  Not used by Job
prepared only after PMD. No Situational identification  Communication failure  SWP - JSA controls were not Supervisor against
issuing WO. Awareness. Work between Bapco discussed. Job not explained Issuing Authority.
and Contractor
Receiving Authority – Contractor
Supervisor
 SWP Process not followed