Safety Flash
ATSB: Undocumented modification contributed to steam burns
ATSB: Undocumented modification contributed to steam burns
- IMCA
- Safety Flash
- IMCA SF 20/25
- IsolationManagement of ChangePressure Systems
- Loss of containmentPressure systems
- Inspection and maintenance
- Process pipework and pipelinesValve
- Energy and process isolationManagement of changeRisk assessment
- Marine industry
- Vessel
Summary
An oil tanker maintenance team suffered burns when hot condensate escaped during steam valve bonnet removal. The ATSB found insufficient cooling time and an undocumented drain-line modification that likely weakened isolation. The flash highlights formal management of change, recording and assessing changes, adequate cooling and visual confirmation of isolation.
Classifications: Loss of containment; containment loss.
Classifications: Pressure systems; stored pressure; pressurised systems; pressurized systems.
Classifications: Inspection and maintenance; asset inspection; equipment maintenance.
Classifications: Process pipework and pipelines; process piping.
Classifications: Valve; valves.
Classifications: Energy and process isolation; isolation; energy isolation.
Classifications: Management of change; MOC; change management.
Classifications: Risk assessment; hazard assessment.
Classifications: Marine industry; shipping industry; maritime sector.
Classifications: Vessel; aboard ship; onboard vessel.
Summary
An unplanned pressure release resulted in burn injuries to three crew members.
IMCA SF 20/25. Themes: isolation, management of change, pressure systems.