Gas Release Tripod Beta Analysis Final-2

Gas Release-7Mar08
Tripod Beta v3 Analysis
Report Version: Final

Gas Release-7Mar08: Tripod Beta v3 Analysis, Gas Release-7Mar08
1 Investigation Case
Case: Gas Release-7Mar08

Title: Gas Release-7Mar08 Incident Date: Mar 7 2008
Category: Severe Incident Time: 09:30:00
Status: Closed Incident Place: Bed-3, Export gas
Compressor_Train 1
Summary:
On Friday 7 March 2008 at about 09:10 hr am a gas leak occurred from train 1 pipeline compressor
in the BED3 plant.
The compressor tripped twice the previous night with no shut down signal. Excessive lube oil
consumption was noted which lead to an investigation into the mechanical seal the following
morning. At the same time an investigation took place into the shutdown system. Simulating zero
differential pressure over the suction ROV lead to actually opening of this valve which formed part of
the mechanical isolation of the area worked on.
A leak occurred but the gas cloud did not ignite. No people were injured and no damage to assets
occurred. A minor leak of gas into the environment and a small spill of lube oil occurred, estimated at
3500 scf and 20 liter, respectively
Chronology of the incident:

------------------------------
6 March 2008, 20:00 hr

Pipeline compressor K1120 of HP train 1 in BED3 facility trips with no shutdown signal. Following
investigation, the compressor was started up at 21:00 hr.
24:00 hr
The compressor trips again with no shutdown signal. Operator found low lube oil level alarm; the
actual tank was found at 30%. The tank was filled to 75% with 5 drums (1000 liter), thereby clearing
the alarm at 50%. The start up sequence was commenced with the lube oil system yet the level
dropped again giving low level alarm on the tank. The start up was interrupted and the tank level
returned to 55%.
7 March, 04:00 hr
As every morning, the production supervisor calls the night shift production supervisor enquiring
about problems during the night. The lube oil problem was discussed. The production supervisor
asked the night shift production supervisor to report this issue to the mechanical supervisor.
7 March 2008, 04:30 hr

The night shift supervisor calls the mechanical supervisor discussing the problem. Directly after this
phone call, the mechanical supervisor calls his senior supervisor.
04:50 hr
A meeting is held in the control room with the senior mechanical supervisor and the night shift
production supervisor to clearly understand the lube oil situation. Based on the senior mechanical
supervisors experience, a mechanical seal failure on the compressor is suspected judging by the
900 liter/day lube oil consumption. He prepares a Permit-To-Work (PTW) and prepares the resources
for the job.
7 March 2008, 06:00 hr

The mechanical PTW is signed off by the night shift production supervisor and the production
supervisor. Work commences by the permit holder and 4 assistants. The night shift production
supervisor isolates and depressurizes the compressor by closing the inlet and outlet ROV, closing a
manual outlet valve and opening the blow down ROV. The blow down ROV was closed once the
system was depressurized avoiding back flow from flare. The mechanical isolation commenced.
Document Version: Final Wednesday, Apr 16 2008 Page: 2 of 28
07:00 hr
The field manager gets notified by the production supervisor about the work related to the
compressor. The instrumentation PTW is acknowledged by the field manager sometime before 8 am.
system was depressurized avoiding back flow from flare. The mechanical isolation commenced.
07:00 hr
The field manager gets notified by the production supervisor about the work related to the
compressor. The instrumentation PTW is acknowledged by the field manager sometime before 8 am.
Meanwhile, a PTW for instruments is being prepared by the instruments supervisor. This permit is to
clear the area from instruments providing access to the compressor internals and to provide direct air
to the blow down ROV as requested by mechanical. The permit also includes work to simulate the
shutdown signals. It is signed off by the day shift production supervisor) and the production
supervisor.
7 March 2008, 07:30 hr

The E&I manager and the mechanical manager investigate alternative leak paths for the lube oil.
They check the sour seal drain recorder in the control room and find the mechanical seal in the
compressor working properly. The E&I manager, the mechanical manager and the senior mechanical
supervisor decided to check rundown system bladder prior to the mechanical seal.
08:00 hr
Work on the compressor had progressed in parallel to the point that the suction spool piece was
removed and a blind was installed on the upstream flange.
08:30 hr
Disassembly of the bladder started in order to investigate the internal float.
7 March 2008, 09:00 hr

A badly damaged float was found. The work was stopped. The senior mechanical supervisor
informed his team that he needed 20 minutes minimum to get the spare part. Meanwhile the rest of
the team went to the control room standing by.
At the same time the weekly project/field operation coordination meeting with key field staff
commenced in the field managers office.
7 March 2008, 09:15 hr

In the auxiliary room behind the control room, the instrument supervisor simulates zero differential
pressure over the compressor inlet ROV as one of the shutdown signals. The suction and discharge
ROVs actually open as two other pre-conditions were already met (blow down valve position
indicator closed and shut down reset). Gas at 74 bar pressure flows through the suction ROV,
through the open anti surge valve into the compressor discharge line and the compressor itself. The
gas with traces of lube oil escapes into the atmosphere through the open flange connection where
the spool piece was removed.
The gas leak leads to low pressure and turbo-expander over-revving shut down signals on train 1.
This closes all train inlet and outlet ROVs, including the pipeline compressor ROVs and opens all
blow down ROVs except the blow down ROV on the pipeline compressor (due to direct air supply).
The leak stops after ~15 seconds.
The coordination meeting becomes the emergency control center (ECC). The production supervisor
runs to the plant to support the day shift production supervisor controlling the situation. The field
manager runs to the radio room and announces the emergency on the radio and pager.
09:17 hr
The ambulance, doctor and fire brigade are mobilized to the plant gate to stand by. However, 10
HSE staff (fire brigade) enter the plant without instruction. An evacuation of the plant was initiated
from the control room within minutes following the incident by the production supervisor as instructed
by the field manager. The alarm signal sounds and everyone leaves the plant. Production staff
inspect the site and confirm no injuries to staff and no further gas leak.
7 March 2008, 09:26 hr

Confirmation that all 47 staff inside the plant are accounted for by security staff. There are no injuries.
The E&I manager and the mechanical manager are requested to go into the plant by the field
manager to do a preliminary investigation and return back to the ECC reporting the findings.
Document
09:40 hr Version: Final Wednesday, Apr 16 2008 Page: 3 of 28
The operation manager in Cairo is informed by the field manager.
~10.10 hr
manager to do a preliminary investigation and return back to the ECC reporting the findings.
09:40 hr
The operation manager in Cairo is informed by the field manager.
~10.10 hr
The emergency is called off by the field manager. The plant gate remains closed. The field manager
with key technical staff enters the plant witnessing the site, confirms all is safe with no escalation or
damage. The recovery plan was discussed with the same staff on site. It was decided that train 1
was to remain shut in and depressurized until after the compressor was boxed up.
7 March 2008, ~11.00 hr

The mechanical PTW was signed by the field manager after inclusion of additional comments
(double block + bleed or risk analysis for combined jobs). The plant gate was re-opened.
13.30 hr
Work re-commenced on the bladder. The spool piece was reinstalled.
14.38 hr
The mechanical PTW is closed enabling preparation for start up of train 1 and the pipeline
compressor.
18:20 hr
The instrument PTW is closed.
7 March 2008, 18:30 hr

Train 1 and the pipeline compressor were started up. The lube oil consumption remained high and
therefore the pipeline compressor was shut down after approximately two hours. During this period,
the tank was filled with another 4 drums (800 liter) of lube oil.
8 March, am
The check valve on the compressor rundown system was replaced. During this operation the
compressor was depressurized and double block & bleed was ensured.
The pipeline compressor was restarted with normal lube oil consumption.
KEY FINDINGS:
1. Automatic shut down systems on train 1 performed flawlessly according to logic design.
2. Emergency response procedure was followed.
3. OPGs is in place and adhered to. This does not include the equipment isolation for
maintenance.
4. Written isolation procedure for pipeline compressor maintenance is not approved.
5. This unapproved procedure is not followed on this and previous occasions. Key deviations:
Train 1 is not shut down/depressurized prior to any work on the pipeline compressor.
Only suction spool piece is removed where one blind is installed upstream. No blind/spade is
installed on the discharge.
Purging with nitrogen and gas testing is not done.
6. Double block & bleed procedure was not followed.
7. Actuated valves were used for isolation without removing air supply.
8. Spurious shut down signals were investigated concurrently with the mechanical seal
investigation on opportunity basis to avoid deferment.
9. Instrumentation PTW combined isolation activity with troubleshooting shut down signals.
10. Simultaneous jobs (mechanical & instrumentation) were carried out.
11. There was limited awareness of potential interference between jobs, in particular effect of
simulating shutdown signals on the mechanical isolation.
12. Mechanical seal inspection/repair undertaken without full investigation of other possibilities of
high lube oil loss.
13. No gas test was performed prior to re-entry into the effected area.
14. No official delegation system is in place for field staff apart from the OF position.

2 Investigation Team
Name Job Title Ref. Company

Marcel Braas Deputy Chief EPT/12 Company Bapetco
Production
Technologist
Notes:
Yehia Mokhtar Maintenance OG Company Bapetco
Manager
Notes:
Tarek Soliman HSE Consultant MSS/1 Company Bapetco
Notes:
Galal Habba Bed Fields General OF Company Bapetco
Manager
Notes:
Magdy Shalaby Bed Fields OFP Company Bapetco
Production
Manager
Notes:
Hassan Abbas Bed Fields OFME Company Bapetco
Elec&Inst
maintenance
Manager
Notes:

3 People Involved
<no injured persons entered for this case>

4 Assets Involved
Item: Bed-3 gas plant

Category: Pipe line Gas Compressor Damage: no damage
Reference: Severity: 0
Owner: OF Estimated Cost:
Additional information:
Sales Gas released to the environment for 15 sec with an estimated amount of 3500 Scf and 20 liters
lube oil spilled.
Total number of Assets 1

5 Events analysed as part of incident

The following event(s) are identified in this analysis:
Event Title Description
1 Decision to open up the gas

compressor to replace the mech. seal
2 lacking Mechanical/Process Isolation
3 Simulate Zero diffrentail Pressure
across ROV
4 ROV Opened and Gas flowed through
the broken isolated system
5 15 second Gas Release to the Gas release at Bed-3 gas train 1
atmosphere
Total number of event(s) analysed 5

6 Results of analysis
This section identifies the significant event(s), the hazard(s), the target(s) affected
EVENT: 1
EVENT INFORMATION:
Title: Decision to open up the gas compressor to replace the mech. seal
<no additional information added>
Description: Decision to open up the gas compressor to replace the mech. seal as a result of Need
to fix high lube oil consumption on P/L HC gas compressor acting on Pipeline Gas
Compressor
Location: Bed-3, Export gas Compressor_Train 1
Date: Mar 7 2008

HAZARD INFORMATION:
Title: Need to fix high lube oil consumption on P/L HC gas compressor
The barriers involved for this hazard are:

1. Manufacturer's operation and maintenance manual (a failed barrier)
This Barrier failed because:
- active failure: Operation and Maintenance manual not consulted because of haste
- precondition: Misperception by staff that production takes priority over safety
- latent failure: Leadership and comittment is not clearly demonstrated
TARGET INFORMATION:
Title: Pipeline Gas Compressor
The barriers involved for this target are:

<No barriers involved>
EVENT: 2
EVENT INFORMATION:
Title: lacking Mechanical/Process Isolation
Description: lacking Mechanical/Process Isolation as a result of Decision to open up the gas
compressor to replace the mech. seal acting on Isolation

Date: Mar 7 2008

HAZARD INFORMATION:
Title: Decision to open up the gas compressor to replace the mech. seal
Reported as EVENT 1 above

2. Mechanical/Process Isolation Certificate (a failed barrier)
- active failure: Certificate was not completed properly and not adhered to
- precondition: Unfamiliarity "they always do it this way and believed that was correct
- latent failure: Inadequate Competence Standards / training
- precondition: Lack of direction
- latent failure: Inadequate Competence Standards / training
3. PTW (a failed barrier)
- active failure: Operational precautions incorrectly prescribed
- precondition: insufficient knowledge and experience
- latent failure: Deficiencies in the system of providing necessary skills to individuals
4. Isolation Procedure for P/L Compressor Maint. (a failed barrier)
- active failure: Train-1 not S/D and depressurized as per procedure requirements
- precondition: Complacency of staff "know everything about it and always do it correctly"
- latent failure: Inherently deficient procedures
- precondition: Isolation procedure had not either been approved or enforced
- latent failure: Inherently deficient procedures
5. Double Block and Bleed procedure (a failed barrier)
- active failure: Double block and bleed procedure was not followed
- precondition: No reference to Double block and bleed in the PTW
- latent failure: inadequate competence "Training"
TARGET INFORMATION:
Title: Isolation


EVENT: 3
EVENT INFORMATION:
Title: Simulate Zero diffrentail Pressure across ROV
Description: Simulate Zero diffrentail Pressure across ROV as a result of Need to investigate
Spurious S/D signals acting on Suction ROV
Date: Mar 7 2008

HAZARD INFORMATION:
Title: Need to investigate Spurious S/D signals

6. MOPO (a failed barrier)
- active failure: MOPO not followed
- precondition: Bed-3 HSE case not referenced
- latent failure: HSE case not user friendly & not written for easy reference by operations
7. PTW (a failed barrier)
- active failure: PTW has been issued for concurrent instrument job
- precondition: lack of knowledge
- latent failure: Insufficient training, job coaching by mentors & supervisors
TARGET INFORMATION:
Title: Suction ROV

EVENT: 4
EVENT INFORMATION:
Title: ROV Opened and Gas flowed through the broken isolated system
Description: ROV Opened and Gas flowed through the broken isolated system as a result of
Simulate Zero diffrentail Pressure across ROV acting on Isolation integrity
Date: Mar 7 2008

HAZARD INFORMATION:
Title: Simulate Zero diffrentail Pressure across ROV

8. LOTO Procedure (a missing barrier)
- latent failure: Inadequate competence standard
9. Isolation Procedure (a failed barrier)
- active failure: Air supply to ROV's actuators not removed
- precondition: This was not a requirement in the isolation Certificate
- latent failure: time pressure & avoidance of deferment
TARGET INFORMATION:
Title: Isolation integrity

EVENT: 5
EVENT INFORMATION:
Title: 15 second Gas Release to the atmosphere
Gas release at Bed-3 gas train 1
Description: 15 second Gas Release to the atmosphere as a result of ROV Opened and Gas
flowed through the broken isolated system acting on lacking Mechanical/Process
Isolation
Date: Mar 7 2008

Date: Mar 7 2008
HAZARD INFORMATION:

10. Automatic S/D system on Train-1 (an effective barrier)
<There are no items for this barrier>

TARGET INFORMATION:
Title: lacking Mechanical/Process Isolation


7 Barriers involved and Task List
Barrier: 1 Manufacturer's operation and maintenance manual (is a failed barrier)

Category: Organisational
Human Error Type: Violation, Exceptional

Action(s) for this defence:
Priority: 1
Assignee: BO
Due: Tuesday, Apr 1 2008
Description: Mandate the requirement of consulting manufacturer's operation and

maintenance manual and follow the logic of trouble shooting in order to reduce
the repeated unnecessary exposure to high risk activities.
Barrier: 2 Mechanical/Process Isolation Certificate (is a failed barrier)
Category: Physical
Human Error Type: Violation, Situational

Priority: 1
Assignee: MS
Due: Monday, Jun 2 2008
Description: Conduct refresher training sessions on PTW to all those having input in the PTW
system.
Barrier: 3 PTW (is a failed barrier)
Category: Organisational
Human Error Type: Mistake, Knowledge based

Priority: 1
Assignee: MS
Due: Sunday, Jun 1 2008
Description: Review, update and rollout Bapetco PTW procedure to ensure no overlap in
Document Version: responsibilities
Final Wednesday, andApr
no ambiguity
16 2008 as to what each signatory is signing for and
Page: 14 of 28
each person is expected to do. also include the need for JHA to be conducted
for secific activities before work commence.
Description: Review, update and rollout Bapetco PTW procedure to ensure no overlap in
responsibilities and no ambiguity as to what each signatory is signing for and
each person is expected to do. also include the need for JHA to be conducted
for secific activities before work commence.
Barrier: 4 Isolation Procedure for P/L Compressor Maint. (is a failed barrier)
Category: Physical
Human Error Type: Violation, Optimizing

Priority: 1
Assignee: BO
Description: Responsible supervisor shall require risk assessment to be conducted for every
job till the completion of the development of the new approved OGP and
isolation procedures.
Barrier: 5 Double Block and Bleed procedure (is a failed barrier)
Category: Physical
Human Error Type: Violation, Situational

Priority: 1
Assignee: BO
Due: Thursday, May 1 2008
Description: Double blook and bleed procedure shall be updated and enforced.
Barrier: 6 MOPO (is a failed barrier)
Category: Physical
Human Error Type: Violation, Unintended

Priority: 1
Assignee: BO
Description: No permit shall be issued without consulting MOPO sheet by permit applicant
and responsible supervisor and referred to in the PTW. this shall be discussed
during the TBT.
Description:
and responsible supervisor and referred to in the PTW. this shall be discussed
during the TBT.
Barrier: 7 PTW (is a failed barrier)
Category: Physical

Priority: 1
Assignee: MS, BO
Description: Link PTW procedure to the relevant HSE Case and Manual of Permitted
Operations and mandate the requirement for attaching the MOPO sheet to PTW.
Barrier: 8 LOTO Procedure (is a missing barrier)
Category: Physical
Priority: 2
Assignee: OF
Description: Enforce the implementation of Lock Out & Tag Out Procedure and Procure
LOTO tags and locks.
Barrier: 9 Isolation Procedure (is a failed barrier)
Category: Physical

Priority: 2
Assignee: BO
Description: Provide on job training as well as formal courses on process safety

Barrier: 10 Automatic S/D system on Train-1 (is an effective barrier)
Category: Physical
Category: Physical

8 Latent Failures and Actions (Task list)
Failure: 1
Title: Leadership and comittment is not clearly demonstrated
Underlying causes:
BRF: IG - (Incompatible Goals) CCS:
Action(s) for this failure:
Priority: 1
Assignee: BG, BC, BO, BO/1, BP, BX, BE, MM, MS
Due: Sunday, Mar 30 2008
Description: Management team shall visit company operational areas in accordance with the
annual schedule and clearly emphasize and demonstrate in all occasions that
safety is first over work urgency
Failure: 2
Title: Inadequate Competence Standards / training
Underlying causes:
BRF: PR - (Procedures) CCS:
Priority: 1
Assignee: MS
Due: Wednesday, Jul 30 2008
Description: Review, update and simplify Bapetco PTW procedure with clear identification of
responsibilities and then roll out the new procedure to ensure full understanding
by those having input to the PTW system

Failure: 4
Title: Deficiencies in the system of providing necessary skills to individuals
Underlying causes:
BRF: TR - (Training) CCS:
Priority: 1
Assignee: MS, BO
Due: Friday, May 30 2008
Description: Develop competence profile defining the knowledge and skill requirements for
PTW Signatories and Others having an Active Role in the PTW System.
Failure: 5
Title: Inherently deficient procedures
Underlying causes:
Priority: 1
Assignee: BO, MS
Description: Review, Update, Roll out and Enforce Bapetco Isolation procedures and
mandate the requirement of attaching the relevant isolation procedure to the
PTW.

Failure: 7
Title: inadequate competence "Training"
Underlying causes:
Priority: 1
Assignee: BO
Due: Tuesday, Jul 1 2008
Description: Update, issue and roll out the OPG to all relevant staff
Failure: 8
Title: HSE case not user friendly & not written for easy reference by operations
Underlying causes:
Priority: 2
Assignee: BO, MS
Due: Saturday, May 31 2008
Description: Review and update Bed-3 HSE Case so as to be a simple and user friendly live
document.

Failure: 9
Title: Insufficient training, job coaching by mentors & supervisors
Underlying causes:
Priority: 1
Assignee: MS
Description: Conduct refresher training course on PTW for Permit Signatories and Others
Having an Active Role in the PTW.
Failure: 10
Title: Inadequate competence standard
Underlying causes:
Priority: 2
Assignee: MS
Description: Develop and rollout Lock Out & Tag Out Procedure (LOTO) and link it to
Bapetco PTW system.

Failure: 11
Title: time pressure & avoidance of deferment
Underlying causes:
BRF: EC - (Error Enforcing Conditions) CCS:
Priority: 1
Assignee: BC, BG, BO, BO/1
Description: Senior Management shall send a clear message to all staff that Safety takes
priority over work urgency.

BRF Profile
BRF Chart
BRF Scores
BRF Description Score
DE Design 0
HW Hardware 0
MM Maintenance 0
HK Housekeeping 0
EC Error Enforcing Conditions 1
PR Procedures 6
TR Training 3
CO Communication 0
IG Incompatible Goals 1
OR Organisation 0
DF Defences 0
= The most implicated BRF

9 Conclusion
Based on the findings of facts by the investigation team, the follwoing are concluded to be the
underlying causes of the gas release incident:
1. Procedures
* Inadequate procedures
2. Competence
* Inadequate competence standards and training
* HSE case not referenced by operators (not user friendly & not written for ease of reference
by operators)
3. Training
* Deficiencies in the system of providing necessary skills to individuals
* Insufficient training & job coaching by mentors & supervisors
4. Leadership and commitment

* Perception of staff that production takes priority over safety
Therefore and in order to prevent recurrence of such high risk incidents, the investigation team
suggests three areas for improvement and recommends:
* Relentless demonstration of HSE committement by Bapetco Management and emphasis on the

principle that Safety takes priority over work urgency.
* Establish a robust training and competence assurance programme.
* Simplify HSE documentations and procedures to obtain compliance.

Tripod Beta Tree

Risk Assessment Matrices
Category: People
Category: Assets

Category: Environment
Category: Reputation

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Gas Release-7Mar08

Tripod Beta v3 Analysis

Report Version: Final

Case: Gas Release-7Mar08

Chronology of the incident:

6 March 2008, 20:00 hr

7 March 2008, 04:30 hr

7 March 2008, 06:00 hr

7 March 2008, 07:30 hr

7 March 2008, 09:00 hr

7 March 2008, 09:15 hr

7 March 2008, 09:26 hr

7 March 2008, ~11.00 hr

7 March 2008, 18:30 hr

Document Version: Final Wednesday, Apr 16 2008 Page: 4 of 28

Name Job Title Ref. Company

Document Version: Final Wednesday, Apr 16 2008 Page: 5 of 28

Document Version: Final Wednesday, Apr 16 2008 Page: 6 of 28

Item: Bed-3 gas plant

Total number of Assets 1

Document Version: Final Wednesday, Apr 16 2008 Page: 7 of 28

5 Events analysed as part of incident

1 Decision to open up the gas

Total number of event(s) analysed 5

Document Version: Final Wednesday, Apr 16 2008 Page: 8 of 28

Location: Bed-3, Export gas Compressor_Train 1

Date: Mar 7 2008

The barriers involved for this hazard are:

The barriers involved for this target are:

Location: Bed-3, Export gas Compressor_Train 1

Date: Mar 7 2008

The barriers involved for this hazard are:

Document Version: Final Wednesday, Apr 16 2008 Page: 10 of 28

The barriers involved for this target are:

Location: Bed-3, Export gas Compressor_Train 1

Date: Mar 7 2008

The barriers involved for this hazard are:

The barriers involved for this target are:

Location: Bed-3, Export gas Compressor_Train 1

Date: Mar 7 2008

The barriers involved for this hazard are:

The barriers involved for this target are:

Location: Bed-3, Export gas Compressor_Train 1

Date: Mar 7 2008

Document Version: Final Wednesday, Apr 16 2008 Page: 12 of 28

The barriers involved for this hazard are:

<There are no items for this barrier>

The barriers involved for this target are:

Document Version: Final Wednesday, Apr 16 2008 Page: 13 of 28

7 Barriers involved and Task List

Barrier: 1 Manufacturer's operation and maintenance manual (is a failed barrier)

Human Error Type: Violation, Exceptional

Due: Tuesday, Apr 1 2008

Description: Mandate the requirement of consulting manufacturer's operation and

Human Error Type: Violation, Situational

Due: Monday, Jun 2 2008

Human Error Type: Mistake, Knowledge based

Due: Sunday, Jun 1 2008

Human Error Type: Violation, Optimizing

Due: Tuesday, Apr 1 2008

Human Error Type: Violation, Situational

Due: Thursday, May 1 2008

Human Error Type: Violation, Unintended

Due: Tuesday, Apr 1 2008