• Published: 11 Oct 2019
  • Incident ID: 4274

Three-Way Valve Incident - ejected stem during changeout of Duplex Filter

Cause & Consequence

  • Moving, flying or falling object
  • Other
  • Uncontrolled release of a flammable gas or liquid

Contributing Factor

  • Change management
  • Control of work

Description of Process

Three way valve on the lube oil system is designed to permit change out of duplex filter whilst the system remains online.

Description of Incident

Operation technicians were attempting to change filter banks by operating a three way valve. In act of trying to “loosen” the valve, the pin through the shaft had sheared and the lifting jack nut backed out to the point where the threads were no longer sufficiently engaged. Pressure within overcame any remaining hold on the stem from the packing, and the stem and oil was ejected.

Good Practice Guidance

Immediate controls implemented to isolate equivalent valves.

Valve operating instructions shared among operations and maintenance teams to ensure valve is set up, operated and maintained in the correct manner.

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