The Weekly Reflektion 25/2022
Making the effort to tell others about the incidents that you have had may prevent similar incidents in other companies. While there is no guarantee that anyone else will learn from your incident you can certainly guarantee that they will notlearn if they know nothing about it.
Do you make the effort to tell others about your incidents?
The incident with over-pressuring a nitrogen cylinder on Heimdal on 28th November 2019 has been the subject of two Reflektions. We also discussed the incident in our ‘Listen and Reflekt’ 1st June. Thank you for the feedback we have received on our focus on this incident. One of our subscribers contacted us earlier this week and told us about an incident in 2018 on another platform in the Norwegian sector with another operator.
Personnel were pressuring a nitrogen cylinder using a positive displacement gas pump. The gas pump did not have a pressure relief device and the pressure gauge that was being used to monitor the pressure was faulty, although this was not known at the time. During the operation the high-pressure hose burst and narrowly missed the person operating the gas pump. The similarities with the Heimdal incident are striking, luckily this time no one was hurt.
Following the incident our subscriber was keen to investigate thoroughly and send out an immediate safety alert. Incidents related to working with pressure are worth sharing sinceworking with pressure, in particular gas under pressure, is a hazardous activity and justifies that extra effort to let others know. The management however considered the consequences of the incident and were not particularly keen to publicize the incident and attract undue attention from the Petroleum Safety Authority. The management view was based on the actual consequences not the potential consequences as required by the Management Regulations § 29 Notification and reporting of hazard and accident situations to the supervisory authorities’ states.
The operator shall ensure coordinated and immediate notification via telephone to the Petroleum Safety Authority Norway in the event of hazard and accident situations that have led to, or under slightly altered circumstances could have led toa) death,b) serious and acute injury,c) acute life-threatening illness,d) serious impairment or discontinuance of safety related functions or barriers, so that the integrity of the offshore or onshore facility is threatened,e) acute pollution.
Slightly altered circumstances is of course open to interpretation, however when working with gas under pressure it is not difficult to imagine a serious and acute injury or even death if an incident occurs. Could a safety alert on this incident, less than 2 years before the incident on Heimdal have helped to prevent the incident or reduce its consequences? Is it possible that a safety alert would have led to more focus on the use of gas pumps for cylinder filling and the importance of pressure monitoring and protection against overpressure? If the potential for personal injury had been communicated with a safety alert would the people involved in the incident on Heimdal been standing so close to the gas cylinder when it exploded? We can speculate but we cannot know for certain. We don’t however need to speculate that the learning potential from any incident will not be realised if the incident is not communicated to others that carry out the same activities.