Cause & Consequence
- Uncontrolled release of a flammable gas or liquid
Specific Incident Equipment
Small bore instrument tubing
- Management of change – During installation in 2007 management of change failed to identify a requirement for more frequent maintenance routines.
- Maintenance and inspection requirements within the Management of Change procedure should be considered to determine whether further clarification is required when changing small bore tubing
- The installation of additional clamps/supports to the replacement instrument tubing should be considered when installing small bore tubing
- To reduce the risk of instrument tubing failures due to pitting and stress corrosion cracking, consideration should be given to the use of 6Mo stainless steel instead when replacing small bore tubing
- The management of small bore tubing integrity at facilities should be reviewed
- Facilities should give due consideration of the development of a comprehensive vibration/fatigue management strategy that includes: small bore tubing
- periodic comprehensive review/update to address addition/ modification/removal of equipment, changes to the asset condition, changes to process fluids, operating conditions, etc.