Presentation on theme: "DCP Mewbourn II Rupture Disc - Recordable Incident."— Presentation transcript:
DCP Mewbourn II Rupture Disc - Recordable Incident
Incident Description IE was installing a cap on a 1" by-pass line at the pig launcher outside of barricade (approximately 70' away) from the outlet side of the blow down piping / rupture disc process. At approximately 1:50am the 20' line reached the rupture disc blowout pressure and ruptured. IE was in direct line of fire with the outlet side of the pipe. When the disc ruptured the IE bent down and covered his head when he heard the "boom" from the blow down. IE then noticed that something had struck his left arm. IE was escorted to the safety trailer, then escorted to the ER in Greeley.
Site Sketch (NTS) –WSG
In- Line Close Up
In-Line 60 Ft
Rupture Disking (Simulation of Incident Blowdown)
Aftermath Pictures Caution The next few pictures are graphic.
Injury To Distal Left Arm
Root Cause Causal Factor
Root Cause – Causal Factor Tree
RCA Snap Chart – Time Line
Findings RCA discovered that a break down in communication was the ROOT CAUSE. – Turn Over from day shift to night shift – 2 turn overs took place verbally – 1 from day shift blow down GF to night shift blow down GF – 1 from day shift Hydro/Nitro test GF to night shift Hydro/Nitro test Lead Hand – Communication between night shift task were not shared between GF and Lead Hand – Communication of continuous rupture disking task was communicated verbally and via radio from night shift GF – No communication of 2 nd Hydro test preparation in affected rupture disk blow down area – IE entered direct line of fire from the rupture disk area, (outside barricaded area) to conduct bolt up for the hydro test preparation. – BJSA did not discuss SIMOPs of the 2 task working in close proximity BJSA did not cover details of task being conducted
Contributing Casual Factors Verbal turn over from day shift to night shift on both crews Inadequate barricade in place and tagged by day shift but not altered by night shift Barricade set differently than times prior – Less personnel to be affected – Not enough personnel to post perimeter watch – More adequate communication during day shift with assistance of additional personnel IE entered 2 nd hydro test area with out verifying blown down / rupture disk task was complete. – No communication with blow down crew or GF
Create a SWP for: Blow Down / Rupture Disking – Lead by Operations / Management – Assisted in completion by Safety Create a shift turnover information / verification form – Lead by Operations / Management – Assisted in completion by Safety Complete communication exercise with supervision – Completed by: Safety and Supervision Complete BJSA training with supervision and necessary personnel –Completed by: On Site Safety – Cheryl Zaleski Corrective actions
Communication is the key to a SAFE and successful job! Plan you work, Work your plan!