Cause & Consequence
- Uncontrolled release of a flammable gas or liquid
Incident Location
Fixed Installation
Incident Activity
Production operations
Specific Incident Equipment
½” Manual Drain Valve ball type
Lessons Identified
The hazard of potentially knocking open drain line valves and causing a gas release has been missed by risk assessments focusing too much on the task and not the surrounding environment.
Incident Recommendations
Consideration should be given to locking open/locking close single valve isolation and updating P&ID’s accordingly Generic Risk assessment to be updated to include valve awareness and controls
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