Cause & Consequence
- Uncontrolled release of a flammable gas or liquid
Specific Incident Equipment
Compressor lube oil pump pipework flange
- 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
- 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.