Gas Release Tripod Beta Analysis Final-2
Gas Release Tripod Beta Analysis Final-2
1 Investigation Case
Summary:
On Friday 7 March 2008 at about 09:10 hr am a gas leak occurred from train 1 pipeline compressor
in the BED3 plant.
The compressor tripped twice the previous night with no shut down signal. Excessive lube oil
consumption was noted which lead to an investigation into the mechanical seal the following
morning. At the same time an investigation took place into the shutdown system. Simulating zero
differential pressure over the suction ROV lead to actually opening of this valve which formed part of
the mechanical isolation of the area worked on.
A leak occurred but the gas cloud did not ignite. No people were injured and no damage to assets
occurred. A minor leak of gas into the environment and a small spill of lube oil occurred, estimated at
3500 scf and 20 liter, respectively
24:00 hr
The compressor trips again with no shutdown signal. Operator found low lube oil level alarm; the
actual tank was found at 30%. The tank was filled to 75% with 5 drums (1000 liter), thereby clearing
the alarm at 50%. The start up sequence was commenced with the lube oil system yet the level
dropped again giving low level alarm on the tank. The start up was interrupted and the tank level
returned to 55%.
7 March, 04:00 hr
As every morning, the production supervisor calls the night shift production supervisor enquiring
about problems during the night. The lube oil problem was discussed. The production supervisor
asked the night shift production supervisor to report this issue to the mechanical supervisor.
04:50 hr
A meeting is held in the control room with the senior mechanical supervisor and the night shift
production supervisor to clearly understand the lube oil situation. Based on the senior mechanical
supervisors experience, a mechanical seal failure on the compressor is suspected judging by the
900 liter/day lube oil consumption. He prepares a Permit-To-Work (PTW) and prepares the resources
for the job.
07:00 hr
The field manager gets notified by the production supervisor about the work related to the
compressor. The instrumentation PTW is acknowledged by the field manager sometime before 8 am.
Meanwhile, a PTW for instruments is being prepared by the instruments supervisor. This permit is to
clear the area from instruments providing access to the compressor internals and to provide direct air
to the blow down ROV as requested by mechanical. The permit also includes work to simulate the
shutdown signals. It is signed off by the day shift production supervisor) and the production
supervisor.
08:00 hr
Work on the compressor had progressed in parallel to the point that the suction spool piece was
removed and a blind was installed on the upstream flange.
08:30 hr
Disassembly of the bladder started in order to investigate the internal float.
At the same time the weekly project/field operation coordination meeting with key field staff
commenced in the field managers office.
The coordination meeting becomes the emergency control center (ECC). The production supervisor
runs to the plant to support the day shift production supervisor controlling the situation. The field
manager runs to the radio room and announces the emergency on the radio and pager.
09:17 hr
The ambulance, doctor and fire brigade are mobilized to the plant gate to stand by. However, 10
HSE staff (fire brigade) enter the plant without instruction. An evacuation of the plant was initiated
from the control room within minutes following the incident by the production supervisor as instructed
by the field manager. The alarm signal sounds and everyone leaves the plant. Production staff
inspect the site and confirm no injuries to staff and no further gas leak.
The E&I manager and the mechanical manager are requested to go into the plant by the field
manager to do a preliminary investigation and return back to the ECC reporting the findings.
Document
09:40 hr Version: Final Wednesday, Apr 16 2008 Page: 3 of 28
The operation manager in Cairo is informed by the field manager.
~10.10 hr
Gas Release-7Mar08: Tripod Beta v3 Analysis, Gas Release-7Mar08
manager to do a preliminary investigation and return back to the ECC reporting the findings.
09:40 hr
The operation manager in Cairo is informed by the field manager.
~10.10 hr
The emergency is called off by the field manager. The plant gate remains closed. The field manager
with key technical staff enters the plant witnessing the site, confirms all is safe with no escalation or
damage. The recovery plan was discussed with the same staff on site. It was decided that train 1
was to remain shut in and depressurized until after the compressor was boxed up.
13.30 hr
Work re-commenced on the bladder. The spool piece was reinstalled.
14.38 hr
The mechanical PTW is closed enabling preparation for start up of train 1 and the pipeline
compressor.
18:20 hr
The instrument PTW is closed.
8 March, am
The check valve on the compressor rundown system was replaced. During this operation the
compressor was depressurized and double block & bleed was ensured.
The pipeline compressor was restarted with normal lube oil consumption.
KEY FINDINGS:
1. Automatic shut down systems on train 1 performed flawlessly according to logic design.
2. Emergency response procedure was followed.
3. OPGs is in place and adhered to. This does not include the equipment isolation for
maintenance.
4. Written isolation procedure for pipeline compressor maintenance is not approved.
5. This unapproved procedure is not followed on this and previous occasions. Key deviations:
Train 1 is not shut down/depressurized prior to any work on the pipeline compressor.
Only suction spool piece is removed where one blind is installed upstream. No blind/spade is
installed on the discharge.
Purging with nitrogen and gas testing is not done.
6. Double block & bleed procedure was not followed.
7. Actuated valves were used for isolation without removing air supply.
8. Spurious shut down signals were investigated concurrently with the mechanical seal
investigation on opportunity basis to avoid deferment.
9. Instrumentation PTW combined isolation activity with troubleshooting shut down signals.
10. Simultaneous jobs (mechanical & instrumentation) were carried out.
11. There was limited awareness of potential interference between jobs, in particular effect of
simulating shutdown signals on the mechanical isolation.
12. Mechanical seal inspection/repair undertaken without full investigation of other possibilities of
high lube oil loss.
13. No gas test was performed prior to re-entry into the effected area.
14. No official delegation system is in place for field staff apart from the OF position.
2 Investigation Team
3 People Involved
<no injured persons entered for this case>
4 Assets Involved
Additional information:
Sales Gas released to the environment for 15 sec with an estimated amount of 3500 Scf and 20 liters
lube oil spilled.
6 Results of analysis
This section identifies the significant event(s), the hazard(s), the target(s) affected
EVENT: 1
EVENT INFORMATION:
Title: Decision to open up the gas compressor to replace the mech. seal
<no additional information added>
Description: Decision to open up the gas compressor to replace the mech. seal as a result of Need
to fix high lube oil consumption on P/L HC gas compressor acting on Pipeline Gas
Compressor
EVENT INFORMATION:
Title: lacking Mechanical/Process Isolation
<no additional information added>
Description: lacking Mechanical/Process Isolation as a result of Decision to open up the gas
compressor to replace the mech. seal acting on Isolation
EVENT INFORMATION:
Title: Simulate Zero diffrentail Pressure across ROV
<no additional information added>
Description: Simulate Zero diffrentail Pressure across ROV as a result of Need to investigate
Spurious S/D signals acting on Suction ROV
EVENT INFORMATION:
Title: ROV Opened and Gas flowed through the broken isolated system
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Gas Release-7Mar08: Tripod Beta v3 Analysis, Gas Release-7Mar08
Title: ROV Opened and Gas flowed through the broken isolated system
<no additional information added>
Description: ROV Opened and Gas flowed through the broken isolated system as a result of
Simulate Zero diffrentail Pressure across ROV acting on Isolation integrity
EVENT INFORMATION:
Title: 15 second Gas Release to the atmosphere
Gas release at Bed-3 gas train 1
Description: 15 second Gas Release to the atmosphere as a result of ROV Opened and Gas
flowed through the broken isolated system acting on lacking Mechanical/Process
Isolation
Priority: 1
Assignee: BO
Priority: 1
Assignee: MS
Description: Conduct refresher training sessions on PTW to all those having input in the PTW
system.
Barrier: 3 PTW (is a failed barrier)
Category: Organisational
Priority: 1
Assignee: MS
Description: Review, update and rollout Bapetco PTW procedure to ensure no overlap in
Document Version: responsibilities
Final Wednesday, andApr
no ambiguity
16 2008 as to what each signatory is signing for and
Page: 14 of 28
each person is expected to do. also include the need for JHA to be conducted
for secific activities before work commence.
Gas Release-7Mar08: Tripod Beta v3 Analysis, Gas Release-7Mar08
Description: Review, update and rollout Bapetco PTW procedure to ensure no overlap in
responsibilities and no ambiguity as to what each signatory is signing for and
each person is expected to do. also include the need for JHA to be conducted
for secific activities before work commence.
Barrier: 4 Isolation Procedure for P/L Compressor Maint. (is a failed barrier)
Category: Physical
Priority: 1
Assignee: BO
Description: Responsible supervisor shall require risk assessment to be conducted for every
job till the completion of the development of the new approved OGP and
isolation procedures.
Barrier: 5 Double Block and Bleed procedure (is a failed barrier)
Category: Physical
Priority: 1
Assignee: BO
Description: Double blook and bleed procedure shall be updated and enforced.
Barrier: 6 MOPO (is a failed barrier)
Category: Physical
Priority: 1
Assignee: BO
Description: No permit shall be issued without consulting MOPO sheet by permit applicant
and responsible supervisor and referred to in the PTW. this shall be discussed
during the TBT.
Document Version: Final Wednesday, Apr 16 2008 Page: 15 of 28
Gas Release-7Mar08: Tripod Beta v3 Analysis, Gas Release-7Mar08
Description:
and responsible supervisor and referred to in the PTW. this shall be discussed
during the TBT.
Barrier: 7 PTW (is a failed barrier)
Category: Physical
Priority: 1
Assignee: MS, BO
Description: Link PTW procedure to the relevant HSE Case and Manual of Permitted
Operations and mandate the requirement for attaching the MOPO sheet to PTW.
Barrier: 8 LOTO Procedure (is a missing barrier)
Category: Physical
Priority: 2
Assignee: OF
Description: Enforce the implementation of Lock Out & Tag Out Procedure and Procure
LOTO tags and locks.
Barrier: 9 Isolation Procedure (is a failed barrier)
Category: Physical
Priority: 2
Assignee: BO
Failure: 1
Underlying causes:
Priority: 1
Description: Management team shall visit company operational areas in accordance with the
annual schedule and clearly emphasize and demonstrate in all occasions that
safety is first over work urgency
Failure: 2
Underlying causes:
Priority: 1
Assignee: MS
Description: Review, update and simplify Bapetco PTW procedure with clear identification of
responsibilities and then roll out the new procedure to ensure full understanding
by those having input to the PTW system
Failure: 4
Underlying causes:
Priority: 1
Assignee: MS, BO
Description: Develop competence profile defining the knowledge and skill requirements for
PTW Signatories and Others having an Active Role in the PTW System.
Failure: 5
Underlying causes:
Priority: 1
Assignee: BO, MS
Description: Review, Update, Roll out and Enforce Bapetco Isolation procedures and
mandate the requirement of attaching the relevant isolation procedure to the
PTW.
Failure: 7
Underlying causes:
Priority: 1
Assignee: BO
Description: Update, issue and roll out the OPG to all relevant staff
Failure: 8
Title: HSE case not user friendly & not written for easy reference by operations
Underlying causes:
Priority: 2
Assignee: BO, MS
Description: Review and update Bed-3 HSE Case so as to be a simple and user friendly live
document.
Failure: 9
Underlying causes:
Priority: 1
Assignee: MS
Description: Conduct refresher training course on PTW for Permit Signatories and Others
Having an Active Role in the PTW.
Failure: 10
Underlying causes:
Priority: 2
Assignee: MS
Description: Develop and rollout Lock Out & Tag Out Procedure (LOTO) and link it to
Bapetco PTW system.
Failure: 11
Underlying causes:
Priority: 1
Description: Senior Management shall send a clear message to all staff that Safety takes
priority over work urgency.
BRF Profile
BRF Chart
BRF Scores
BRF Description Score
DE Design 0
HW Hardware 0
MM Maintenance 0
HK Housekeeping 0
EC Error Enforcing Conditions 1
PR Procedures 6
TR Training 3
CO Communication 0
IG Incompatible Goals 1
OR Organisation 0
DF Defences 0
= The most implicated BRF
9 Conclusion
Based on the findings of facts by the investigation team, the follwoing are concluded to be the
underlying causes of the gas release incident:
1. Procedures
* Inadequate procedures
2. Competence
* Inadequate competence standards and training
* HSE case not referenced by operators (not user friendly & not written for ease of reference
by operators)
3. Training
* Deficiencies in the system of providing necessary skills to individuals
Therefore and in order to prevent recurrence of such high risk incidents, the investigation team
suggests three areas for improvement and recommends:
Category: People
Category: Assets
Category: Environment
Category: Reputation