Cause & Consequence
- Moving, flying or falling object
Other Cause & ConsequenceLoose or missing primary securing method
- Change management
Description of Process
Movement of manual valve by operator
Description of Incident
During the movement of a manually operated valve the operator moved the valve handle from the horizontal to vertical position. At this point the handle slid from the valve stem and fell to the ground.
There was no injury or asset damage as a result of this event.
The handle is made of straight stainless tube and is usually secured within the valve stem by two grub screws.
It is believed that the grub screws either became loose from vibration or were never adequately secured on installation.
Good Practice Guidance
All valves of the same or a similar design were identified and grub screws were re-tightened or replaced.
All handles also had a bolt installed either side of the stem as a method of secondary securement to prevent the handle slipping through the stem in the event of the grub screws failing.