April, 2019

201901AprAll DayUnplanned plant modification resulting in hydrocarbon releasePSF Safety Alert 013 Origin: PSF Lessons:Asset integrity,Competency,Control of Work,Management of ChangeLanguage:EN TagsWorksite Checks

Summary

High pressure gas released (circa 560kg) when a small-bore tubing fitting assembly
ruptured as a result of vibration fatigue after 11 days in service.

Root cause
• Non-application of the Management of Change (MOC) procedure
• Inadequate work control (safe isolation and reinstatement of plant, e.g. no flange break
controls).
• Lack of appreciation of the effect of vibration on unsupported small-bore tubing assemblies

Origin

PSFProcess Safety Forum

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