Description of Incident
Maintenance was planned on a defective valve inside an APV compressor room. Work had been completed, and the valve was changed out.
Personnel were in the process of returning the system back online – the isolation valve was opened, causing the valve/fitting to rupture, releasing 300 bar (4,351 psi) of airflow from 4 x 1665 litre accumulator bottles into the room.
At the time of the incident, two IPs were present near the opened valve.
IP-A was hit by airflow/debris and was thrown against the bulkhead, causing significant injury to the left leg and upper body.
IP-B managed to escape the area without injury and raised the alarm. IP-A was transported to the rig’s sick bay before medivac to ABZ hospital.
As a result, a Time Out For Safety (TOFS) was held.
Findings:
- Isolation was not suitable – single isolation achieved.
- Principles of HSG253 Safe Isolation and Reinstatement of Plant were not followed.
- Risk assessment did not suitably address "Stored Energy" Hazard.
- No isolation/de-isolation procedures in place.
- Lack of familiarisation on the equipment.
Good Practice Guidance
- Ensure HSG253 principles are adopted within Isolation procedures - ensuring suitable risk assessment is undertaken and level of isolation chosen is appropriate.
- Verify and confirm isolation procedures are being followed at site by supervision.
- Ensure personnel are familiar with the expectations of HSG253 and are trained in how to achieve the right standard of isolation.
- Ensure suitable rig-specific procedures are in place Toolbox Talk with all personnel involved in the task.
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