Cause & Consequence
Onshore fabrication, repair
Incident Info Source
Specific Incident Equipment
Management of change and project handover not adequate.Training requirements not identified.
Install or confirm that correct specification retaining bolts have been fitted. Generate an operating instruction that contains all relevant information. Perform a risk assessment to cover removal and replacement of filters. Provide instruction, information and training to all maintenance and operations personnel in the correct isolation, depressurisation and closing tecniques for these filter. Obtain a PECO closure name plate and inatall on door to contain valuable correct information to aid understanding. Present incident findings to workforce at next safety meeting. All assets to check similar filters for retaining bolts if relevant to their area of operations.