Failure of pipework on Gross Overload Protection (GOP)

Cause & Consequence

• Fire or explosion

Incident Location

Any Location Type

Incident Activity

Maintenance

Incident Info Source

Step change in safety

Specific Incident Equipment

A gas accumulator system linked to the crane GOP hydraulic system.

Lessons Identified

The deck crew did not identify that the gas cylinders selected contained Oxygen instead of Nitrogen.The crane op did not check the content of the gas cylinder being used to charge the accumulator.The crane op did not plan the recharge operation in advance had not obtain a work control certificate.

Incident Recommendations

A Step Change Alert # 1025 contains information regarding the correct identification and selection of gases. http://stepchangeinsafety.net/stepchange/SingleItem_Incident.aspx?AlertNo=1025

Step Change ask the industry body/suppliers if there is anything they can do to minimise the likelihood of confusing the colour codes.