Safety Flash
Fatality: Stored pressure release
Fatality: Stored pressure release
- IMCA
- Safety Flash
- IMCA SF 08/16
- Control of WorkIsolationPermit to WorkPressure Systems
- Leadership and safety cultureLine of firePressure systems
- Inspection and maintenancePressure testing
- Valve
- Energy and process isolationManagement of changeOperating and work proceduresPermit to work
Summary
A crewman suffered fatal injuries when a Techlok clamp released under high pressure during leak repair. The flash identifies incorrect removal methods, conflicting permit requirements, deficient mechanical isolation, procedural deviations and absent change management. It also highlights inexperienced personnel, inadequate shift handover and poor enforcement of earlier incident actions.
Classifications: Leadership and safety culture; safety culture; safety leadership.
Classifications: Line of fire; struck-by hazards.
Classifications: Pressure systems; stored pressure; pressurised systems; pressurized systems.
Classifications: Inspection and maintenance; asset inspection; equipment maintenance.
Classifications: Pressure testing; hydrostatic testing; pneumatic testing.
Classifications: Valve; valves.
Classifications: Energy and process isolation; isolation; energy isolation.
Classifications: Management of change; MOC; change management.
Classifications: Operating and work procedures.
Classifications: Permit to work; PTW; work permit.
Summary
A pressurised clamp connector released during repair work, exposing failures in isolation, permits, procedures and change management.
IMCA SF 08/16. Themes: control of work, isolation, permit to work, pressure systems.