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Lincoln Fernandes
Graduate Risk Engineer, Transfield-Worley WEL (ISC)
North Rankin A
Timeline to Inception
Analysis of uncontrolled releases
Review of incident investigation
Review of immediate fixes
Global organisational improvement
Transfield Worley Services 2008
What happened?
Weld at reducer cracked approx 180 degrees
around the weld, resulting in a gas release
Failure noticed by personnel and the
compressor was shutdown
Failure due to fatigue caused by
acoustically induced vibration
< 2 hours to full failure:
What happened?
Immediate Investigation
Numerous co-incident contributing causes:
- Management
- Team Leaders
- Client
Finding:
Global step-change is required
=
Integrity Management Initiative
Transfield Worley Services 2008
Plan of Action
Global deficiencies to be addressed
Workshops aimed at organisational
improvement of:
- Internal / Workshares
- 3rd Party Contractors
Competencies Workshop
Actions:
More communication!
- Enhance inductions
- Communications Sessions
- Process Safety Moments
- Empowerment through
Promotes accountability
Lagging
Leading
Engineering Measurements
In progress
And
Sound familiar ?
Fatality
Environmental Damage
Community Impact
Asset Loss
The power of
Photoshop!
43%
Human Performance
Deficiencies
57%
www.nopsa.gov.au
01/2005 - 10/2007
Transfield Worley Services 2008
Equipment Difficulties