2Q QPR – Jun 2012

LLD – Bleeder Valve Assembly Hit on the face of Contractor Staff (IN-20211003-001)
)
Description: 8" Ball Valve was being installed on Separator; Pressure Indicator (PI) assembly was removed as it was obstructing the installation of
the ball valve. Later contractor pipe fitter (IP) was asked to re-install the PI assembly on the same 2" line at a different location, while dismantling
of vent valve for installing the PI, the assembly hit IP because the line was pressurized.
WHAT WENT RIGHT: LESSON LEARNT:
• IP put on PPEs in particular safety googles.  Unplanned activity without formal approval must not
• Immediate medical support was provided to IP. be done.
 Eleventh hour addition of jobs during shut down must
CRITICAL FACTORS:
be restricted.
• Activity on pressurized pipeline.
 Risk assessment to be carried out for all activities and
• Removal of whole valve assembly instead of plug. procedure compliance to be ensured and reinforced.
ROOT CAUSES ANALYSIS:
IMMEDIATE CAUSE:
• 1.2 DID NOT FOLLOW EXISTING PROCEDURES: The PTW, EI, Risk Management and MOC
procedures not followed during the installation of pressure gauge.
• 7.4 UNANTICIPATED EXPOSURE TO ENERGIZED SOURCE OTHER THAN ELECTRICAL: did not
anticipate the hazard of pressurized line and continued to remove the valve assembly.
SYSTEM CAUSE:
• 19.1 NO WORK PLANNING OR RISK ASSESSMENT PERFORMED: The pressure gauge installation &
removal of bleeder valve assembly was not part of the shutdown planning & no risk performed.
• 14.1 ASSESSMENT OF REQUIRED SKILLS OR COMPETENCY NOT EFFECTIVE: The removal of the
valve was not required & only Plug removal with isolation valve could have avoided gas release.

KEY RECOMMENDATIONS:
• Addition of activities in the shutdown job list need to be halted (72-hours) for job planning .
• Necessary approval of MOCs and job specific CRFs should be available prior to start of activity.
• Permit Issuer & Area Authority need to be engaged for not authorizing any activity without CoW.
• Process needs to be reviewed & re-enforced for continuous evaluation of competency of all
contractor staff prior to performing any shutdown / major activity. SIMILAR INCIDENTS:
IN-20160414-003 : Injury Incident at Maintenance
• Closure of open actions process revision (rocedures/Operation Assurance Framework) inclusive.
Workshop.