GRACE

Group Risk Assessment Conversation & Experience transfer

Identify hazards within your own working areas!!
Isolation of pressurized system: 1of 3
Installation of flow line
Identify Potential Hazards!
1/3
Isolation of pressurized system: 2 of 3
Activity
Installation of flow line
Preparations
Work Permit
Personnel
Operation and maintenance team
Circumstances
Work was being carried out to install new flowline
The new flowline had been positively isolated from the production manifold by a blind
A hot work permit had also been issued for cutting with an open flame, the work site was adjacent to the
flowline work
Action
The new flowline was only isolated from the production manifold by a single remotely actuated isolation valve
which was not locked
2/3
Isolation of pressurized system: 3 of 3
Actual / potential consequence
Gas leakage / multiple fatalities
What happened
The remotely actuated isolation valve on the new flowline was opened by a mistake and a gas release triggered
two gas detectors, shutting down the installation
The gas release was identified to have come from the incompletely made up flowline connector
The work with the welding had stopped before the leak occured
Direct causes
5-7 Inadequate isolation of process or equipment
System causes
11-1 Inadequate work planning
13-1 Inadequate assessment of needs and risks (tools & equipment)
3/3
GRACE
Group Risk Assessment Conversation & Experience transfer
Identify hazards within your own working areas!!
Working on pressurized system: 1 of 3
Replacement of choke
1/3
Identify Potential Hazards!
Working on pressurized system: 2 of 3
2/3
Activity
Replacement of choke
Preparations
Work permit, isolation certificate
Personnel
One technician
Circumstances
Replacement of choke on flowline
On removal of the choke it was found that the upstream flange face was in need of repair
Both exposed faces of the flowline were capped with Teklok/Graylock type hubcaps until repairs could be
effected
Action
The following day the technician started to remove the hubcap again
Working on pressurized system: 3 of 3
3/3
Actual / potential consequence
Minor injury (DAFWC) / serious injury
What happened
As the technician was loosening the hub clamp the hubcap blew off with force, hitting him on the shoulder and
propelling him backwards off an access platform onto the floor grating below
Pressurized nitrogen had migrated into the flowline
Direct causes
1-10 Shortcuts
3-1 Lack of knowledge of hazards present
5-7 Inadequate isolation of process or equipment
System causes
5-4 Inadequate reinforcement of critical safe behavior
11-1 Inadequate work planning
13-1 Inadequate assessment of needs and risks (tools & equipment)
GRACE
Group Risk Assessment Conversation & Experience transfer
Identify hazards within your own working areas!!
Blinding of processing plant: 1 of 3
Installation of blinds
1/3
Identify Potential Hazards!
Blinding of processing plant: 2 of 3
2/3
Activity
Installation of blinds in preparation for planned shutdown
Preparations
Planned program for blinding
Work permit, isolation certificate
Personnel
Four mechanic
Circumstances
The blinding team were under pressure to complete the work prior to the scheduled start of the maintenance
work
The blind list and drawings had been prepared by a contractor rather than by the operations team
There was only one last blind to install on a flare line adjacent to a valve
Action
An operations representative was at the worksite along with the 3 man contractor crew as the work was started
on the final blind
Blinding of processing plant: 3 of 3
3/3
Actual / potential consequence
Four fatalities / multiple fatalities
What happened
Hydrocarbon gas was released as the flange by the valve was wedged open because the flange was split on the
wrong side of the valve on the live flare line
The gas was immediately ignited by the nearby crane causing a flash fire that killed all four people
Direct causes
1-2 Violation by group
7-4 Energized systems, other than electrical
System causes
8-2 Inadequate leadership
11-1 Inadequate work planning
13-1 Inadequate assessment of needs and risks (tools & equipment)
GRACE
Group Risk Assessment Conversation & Experience transfer
Identify hazards within your own working areas!!
Work on El-system: 1 of 3
Control of 440 V El-system
1/3
Identify Potential Hazards!
Work on El-system: 2 of 3
2/3
Activity
Control of 440 V El-system
Preparations
None
Personnel
One electrician
Circumstances
An electrician had been working with a 440 El-system
The following day he detected a strange smell from the same system
Action
The electrician proceeded to investigate without informing the CCR, applying for a work permit or seeking
assistance
The electrician was not wearing safety glasses or gloves despite this being required in this area
Work on El-system: 3 of 3
3/3
Actual / potential consequence
Serious injury (DAFWC) / fatality
What happened
A flash over occurred and the electrician was burned on the face and hands, hospitalized for 12 days
The immediate cause of the incident was the introduction of a foreign body which caused the sudden short-
circuit, rather than the escalation of a long-standing fault
Direct causes
1-1 Violation by individual
4-1 Improper decision making or lack of judgment
5-3 Inadequate personal protective equipment
7-3 Energized electrical systems
System causes
5-4 Inadequate reinforcement of critical safe behaviors
11-1 Inadequate work planning
13-1 Inadequate assessment of needs and risks
14-4 Inadequate enforcement of PSP
GRACE
Group Risk Assessment Conversation & Experience transfer
Identify hazards within your own working areas!!
Depressurization: 1 of 3
Commissioning of a gas lift system
1/3
Identify Potential Hazards!
Depressurization: 2 of 3
2/3
Activity
Commissioning of a gas lift system
Preparations
Work Permit
Personnel
Operator
Circumstances
Lift gas at 85 bar was supplied to a wellhead platform by a 4 pipeline
The pipeline ESDV on arrival at the wellhead platform was stuck in an open position and required to be
repaired
In preparation for this it was decided to depressurized the flowline to the host platform cold vent
Action
An operator opened a control valve to route high pressure (HP) lift gas from the pipeline to vent
Operator suspects no flow due to noise and no indication of flaring
Depressurization: 3 of 3
3/3
Actual / potential consequence
Near miss
What happened
There was no flow in the line and the operator identified that the line was blocked by the closed valve and the
section had been over pressurized
The operator followed the depressurization line and found the tie-in valve to the cold flare closed
Central control room was alarmed and the exposed area roped off
Direct causes
3-1 Lack of knowledge of hazards present
4-1 Improper decision making or lack of judgment
5-1 Inadequate guards or protective devices
System causes
7-3 Inadequate training effort
10-1 Inadequate technical design
11-1 Inadequate work planning
14-1 Lack of PSP for the task
15-5 Inadequate communication between work groups
GRACE
Group Risk Assessment Conversation & Experience transfer
Identify hazards within your own working areas!!
Work on FPSO deck: 1 of 3
Replacement of passing butterfly valve
1/3
Identify Potential Hazards!
Work on FPSO deck: 2 of 3
2/3
Activity
Replacement of passing butterfly valve
Preparations
Work permit, Toolbox talk meeting, no risk assessment
Personnel
Two deck operators and crane driver
Circumstances
During a maintenance shutdown it was planned to change out a passing butterfly valve on the tank vent line
The tanks had been hydrocarbon gas freed, cleaned, inspected then inerted with a nitrogen/CO2 mixture
The butterfly valve was in closed position
Action
The bolts between the valve and the tank were removed in order to replace the butterfly valve
Work on FPSO deck: 3 of 3
3/3
Actual / potential consequence
Unconsciousness (DAFWC) / multiple fatalities
What happened
One of the operators collapsed and the supervisor although groggy managed to radio for help and drag his unconscious
colleague into a safe position
The crane driver observed the incident and also radioed for assistance
The butterfly valve was in the closed position before the bolts were removed. This prevented free venting of the system
immediately prior to valve removal
Direct causes
3-1 Lack of knowledge of hazards present
4-1 Improper decision making or lack of judgment
5-5 Inadequate warning system
System causes
6-1 Inadequate assessment of required skills
7-4 No training provided
11-1 Inadequate work planning
13-1 Inadequate assessment of needs and risks
GRACE
Group Risk Assessment Conversation & Experience transfer
Identify hazards within your own working areas!!
Process Isolation: 1 of 3
Replacement of a bursting disc
1/3
Identify Potential Hazards!
Process Isolation: 2 of 3
2/3
Activity
Replacement of a bursting disc
Preparations
Work permit but no isolation certificate
Personnel
One mechanic
Circumstances
Trouble with the compressor seal system
Replacing bursting discs was a common occurrence. The mechanic was used to getting cooling water spilling out
of the piping when replacing the discs
Action
The mechanic started to slacken the bolts on the bursting disc holder
Process Isolation: 3 of 3
3/3
Actual / potential consequence
HC gas leakage / escalation (fire, explosion)
What happened
As the mechanic slackened the bolts he heard a valve operate in the flare system and gas started to emit from
loose bolted flange
The bursting disc had not been isolated and there was no valid mechanical isolation certificate
Direct causes
1-2 Violation by groups
4-8 Routine activity without thought
5-7 Inadequate isolation of process or equipment
System causes
7-3 Inadequate training effort
11-1 Inadequate work planning
13-1 Inadequate assessment of needs and risks
15-4 Inadequate communication between work groups
GRACE
Group Risk Assessment Conversation & Experience transfer
Identify hazards within your own working areas!!
Working on valves: 1 of 3
Working in the well bay area
1/3
Identify Potential Hazards!
Working on valves: 2 of 3
2/3
Activity
Working in the well bay area
Preparations
Considered as a routine work
Personnel
Operator
Circumstances
A number of body plugs had been replaced
The valves were of exotic material and some of the plugs that had been installed were of carbon steel
Action
Ongoing work in the well bay area
Working on valves: 3 of 3
3/3
Actual / potential consequence
HC gas leakage / fatality
What happened
A CS plug blew out of a valve body, narrowly missing the operator and causing a minor hydrocarbon leak
The direct cause was related to galvanic corrosion as a consequence of different materials in valve and body plugs
Direct causes
3-1 Lack of knowledge of hazards present
System causes
11-3 Inadequate repair
11-6 Inadequate inspection
13-1 Inadequate assessment of needs and risks
14-4 Inadequate enforcement of PSP
GRACE
Group Risk Assessment Conversation & Experience transfer
Identify hazards within your own working areas!!
Isolation of export pipeline: 1 of 3
Boundary isolation against a pressurized gas export
1/3
Identify Potential Hazards!
Isolation of export pipeline: 2 of 3
2/3
Activity
Boundary isolation against a pressurized gas export
Preparations
Maintenance shutdown, working plan and isolation plan
Personnel
Maintenance team
Circumstances
The 24 pipeline was not fitted with a subsea checkvalve. The pressure in the pipeline was 180 barg
The isolation comprised a double block and bleed comprised of two hydraulically operated 24 sealine valves and a 2
bleed left open to atmosphere between them
Action
Towards the end of the shutdown the hydraulic actuator on the outboard valve was to be fitted with a spring return
actuator instead and thus the control facilities for the valve had been dismantled
Work was being carried out locally on the hydraulic supply to the outboard valve, the system was disconnected from
the platform shutdown and safety systems
Isolation of export pipeline: 3 of 3
3/3
Actual / potential consequence
HC gas leakage / multiple fatalities
What happened
The outboard valve was opened resulting in a 2 full bore flow of gas at 180 barg at the platform cellar deck
level
The area was immediately evacuated but the gas leak continued unstopped. The leak was only brought under
controlwhen an operator approached the open 2 valve with breathing apparatus on and manually closed the
valve
Direct causes
1-3 Violation by supervisor
4-1 Improper decision making or lack of judgment
5-7 Inadequate isolation of process or equipment
System causes
6-1 Inadequate assessment of required skills
11-1 Inadequate work planning
13-1 Inadequate assessment of needs and risks
14-1 Lack of PSP for the task
GRACE
Group Risk Assessment Conversation & Experience transfer
Identify hazards within your own working areas!!
Working on pressurized system: 1 of 3
Replacement of grease nipple
1/3
Identify Potential Hazards!
Working on pressurized system: 2 of 3
2/3
Activity
Replacement of grease nipple
Preparations
Work Permit
Personnel
One mechanic
Circumstances
Plan for nipple replacement established
The mechanic were in the process of performing corrective maintenance on the valve
Action
Mechanic started to unscrew the cap
He ensured that no leak occurred
After a while he continued to unscrew the cap completely
Working on pressurized system: 3 of 3
3/3
Actual / potential consequence
HC gas leakage / escalation (fire or explosion)
What happened
A gas leakage occurred after the cap was fully removed
Attempt to screw cap back on failed and the gas leakage increased
The leak was detected by gas detector
Manual blow down
Direct causes
3-1 Lack of knowledge of hazards present
5-7 Inadequate isolation of process or equipment
6-1 Defective equipment
6-3 Defective tools
System causes
10-3 Inadequate assessment of potential failure
11-2 Inadequate preventive maintenance
13-3 Inadequate standards or specifications
13-7 Inadequate removal / replacement of unsuitable items
14-2 Inadequate development of PSP