Safety Flash
High potential near-miss: Incompatible pillar valve assembly
High potential near-miss: Incompatible pillar valve assembly
- IMCA
- Safety Flash
- IMCA SF 18/13
- DivingManagement of ChangePressure Systems
- Mechanical failurePressure systems
- Diving operations
- Breathing apparatusGas cylinderValve
- Competence and trainingManagement of change
Summary
This flash describes a pillar-valve failure while charging a diver’s twin bailout set. The investigation identified mixed imperial and metric cylinders, absent management of change and forced valve insertion without investigating resistance. Corrective actions included metric-only components, thread measurement, parts marking and training in management of change.
Classifications: Mechanical failure; equipment failure.
Classifications: Pressure systems; stored pressure; pressurised systems; pressurized systems.
Classifications: Diving operations; diving; commercial diving.
Classifications: Breathing apparatus; SCBA; self-contained breathing apparatus.
Classifications: Gas cylinder; compressed gas bottle; gas cylinders.
Classifications: Valve; valves.
Classifications: Competence and training; competency assurance; safety training.
Classifications: Management of change; MOC; change management.
Summary
A member has reported a high potential near miss incident, in which there was a failure of a pillar valve in a diver’s bailout set.
IMCA SF 18/13. Themes: diving, management of change, pressure systems.