• Published: 27 Sep 2012
  • Incident ID: 3450

Lube oil release from flange

Cause & Consequence

  • Uncontrolled release of a flammable gas or liquid
Incident Consequence
Hydrocarbon release

Incident Location

Fixed Installation

Incident Activity

Production operations

Specific Incident Equipment

Compressor lube oil pump pipework flange

Lessons Identified

  • Presence of supervision at the worksite at key times was limited due to their attendance at platform meetings.
  • Toolbox Talk by the Performing Authority role was insufficient for overall task awareness – additional work added to the job list was not fully addressed
  • A number of opportunities for intervention in the chain of events leading to the incident were missed
  • Day shift / Night shift handover process & work management during handover period insufficient

Incident Recommendations

  • Assess and revise daily meeting structures to allow supervisory face to face handovers
  • Review attendees at key planning meetings to ensure ownership of the work plan.
  • Emphasise the Roles & Responsibilities of the PA in accordance with the relevant procedures.
  • Ensure consistent approach to Area Authority role with clear demarcation of responsibility between day and nightshift.
  • Improve the effectiveness of team handovers for Production & Maintenance and monitor implementation.
  • Complete cross asset review of the progress of MJI training and competency.

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