Gas release in turbine enclosure

Cause & Consequence

• Other

Incident Location

Fixed Installation

Incident Activity

Production operations

Specific Incident Equipment

High Pressure Train

Lessons Identified

The isolation was initially set up correctly. The isolation then had to be retagged and in doing this one vent valve was left in an open state.

Some valves required for isolation of train 2 were not uniquely identified to enable correct cross referencing with P&IDs

There was no record that the initial isolation had been checked by a second Isolating Authority (IA).

Incident Recommendations

Uniquely Number all valves associated with the isolation and update the P&ID’s.

Implement a rolling programme for isolation integrity checks, checking drawings and valve numbering.

All isolation must be checked by a second person to ensure their integrity is secure.