Presentation on theme: "DCP Mewbourn II Rupture Disc - Recordable Incident"— Presentation transcript:
1DCP Mewbourn II Rupture Disc - Recordable Incident
2Incident DescriptionIE 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.
18FindingsRCA discovered that a break down in communication was the ROOT CAUSE.Turn Over from day shift to night shift2 turn over’s took place verbally1 from day shift blow down GF to night shift blow down GF1 from day shift Hydro/Nitro test GF to night shift Hydro/Nitro test Lead HandCommunication between night shift task were not shared between GF and Lead HandCommunication of continuous rupture disking task was communicated verbally and via radio from night shift GFNo communication of 2nd Hydro test preparation in affected rupture disk blow down areaIE 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 proximityBJSA did not cover details of task being conducted
19Contributing Casual Factors Verbal turn over from day shift to night shift on both crewsInadequate barricade in place and tagged by day shift but not altered by night shiftBarricade set differently than times priorLess personnel to be affectedNot enough personnel to post perimeter watchMore adequate communication during day shift with assistance of additional personnelIE entered 2nd hydro test area with out verifying blown down / rupture disk task was complete.No communication with blow down crew or GF
20Corrective actions Create a SWP for: Blow Down / Rupture Disking Lead by Operations / ManagementAssisted in completion by SafetyCreate a shift turnover information / verification formComplete communication exercise with supervisionCompleted by: Safety and SupervisionComplete BJSA training with supervision and necessary personnelCompleted by: On Site Safety – Cheryl Zaleski
21Communication is the key to a SAFE and successful job! Plan you work, Work your plan!