Cause & Consequence
- Moving, flying or falling object
- Uncontrolled release of a flammable gas or liquid
- Change management
- Control of work
Description of Process
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
Valve operating instructions shared among operations and maintenance teams to ensure valve is set up, operated and maintained in the correct manner.