Cause & Consequence
- Uncontrolled release of a flammable gas or liquid
Specific Incident Equipment
Bleed point/pig launcher
Human factors were involved and concluded to be the mis-application of a bad rule based on a successful outcome in the past. A conscious ‘deliberate’ action which seems to be appropriate given historical evidence to substantiate the decision. This is based on evidence gathered that the dedicated 2” purge connection has never been used and the alternative tie-in point has been the normal purge point.
The temporary hose was not isolated or disconnected prior to introducing hydrocarbons into the launcher. This had become normal practice and the omission of a step in a sequence of actions brought about by miscommunication and mis-understanding when it came to isolating and disconnecting the temporary hose.
At each step in the task there was the opportunity to intervene, to challenge, to make a change, to peer check. As each of these opportunities were lost the incident became more inevitable
Increase the level of challenge and verification via the line and via third parties to improve and ensure operational Integrity
Operations Leadership to change tolerance of Operators not following procedures, processes, work instructions etc