dcp mewbourn ii rupture disc - recordable incident

DCP Mewbourn IIRupture 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

Rupture Disking(Simulation of Incident Blowdown)

Aftermath Pictures

Caution

The next few pictures are graphic.

Injury To Distal Left Arm

Stitches

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 over’s 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 2nd 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 2nd 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!

Questions?

Discussion