Cause & Consequence
- Uncontrolled release of a flammable gas or liquid
Specific Incident Equipment
Bleed valve on a pressure transmitter instrumentation line
Whilst the investigation team cannot be 100% certain they believe that the most probable cause was the valve was left open and uncapped because it failed to be identified this during start-up line walks. It is difficult to pinpoint a specific reason why line walkers missed this. There are a number of factors which could have contributed to the valve being open and the incident occurring; fading light and scaffolding obstructing certain areas making it difficult to clearly assess valve position. In addition, the incident occurred at a time of high workload for the individuals, coupled with elements of fatigue.
Learning from Incident alert raised and discussed at Safety meetings focusing the importance of line-walks including consideration of Human Factors risks during line-walking tasks