Cause & Consequence
- Failure of vessels or pipework
Lifting, crane, rigging, deck operations
Specific Incident Equipment
During an ESD process shutdown, the Production Header PSV 10032 lifted
- Insufficient procedures had been developed over the operating life of the installation to cover this eventuality.
- There were human factors involved as not all operations personnel were fully aware of the full procedure for alignment prior to well start-up.
- Mechanical failure of the choke valve. In conjunction with the procedural and knowledge shortfall, a coincidental failure of the mechanical choke valve exacerbated the incident
- An improved Wellheads/manifolds procedure has been developed to cover this shortfall.
-Additional training and knowledge sharing has been introduced to ensure better understanding of the alignment issues for well start-up.
-A revision to the Wellheads/manifold procedure to identify choke valve failure will be introduced.