Lesson Learnt Analysis

[ben]

I picked up the incident happened in Bloomfield Compressor Station, New Mexico.
The lessons which I could capture from the share report was "Bolt tightening procedures are critical for process safety. Training in the use of bolt tightening and flange closure procedures is necessary."
And now I have started thinking about the training part of bolt tightening. Procedures is also concerning.
The controls I can think of in our operations vary from the experienced technicians and the supervisors to having stipulated values of bolt torquing wherever mandatory especially in hydrocarbon services. That still requires to be audited at a certain frequency. And after all this, what about the competency assessment of new staff, contractors involved, training part.
Share what should be maintained here to ensure this critical process safety issue is under adequate layers of checks.

[neo]

ben, I could get a document on the incident from National Transportation Safety Board.
Attaching here.

I picked up the incident happened in Bloomfield Compressor Station, New Mexico.
The lessons which I could capture from the share report was "Bolt tightening procedures are critical for process safety. Training in the use of bolt tightening and flange closure procedures is necessary."
And now I have started thinking about the training part of bolt tightening. Procedures is also concerning.
The controls I can think of in our operations vary from the experienced technicians and the supervisors to having stipulated values of bolt torquing wherever mandatory especially in hydrocarbon services. That still requires to be audited at a certain frequency. And after all this, what about the competency assessment of new staff, contractors involved, training part.
Share what should be maintained here to ensure this critical process safety issue is under adequate layers of checks.

[ben]

neo, thanks, need some one to move to the next lesson learnt analysis.

ben, I could get a document on the incident from National Transportation Safety Board.
Attaching here.

I picked up the incident happened in Bloomfield Compressor Station, New Mexico.
The lessons which I could capture from the share report was "Bolt tightening procedures are critical for process safety. Training in the use of bolt tightening and flange closure procedures is necessary."
And now I have started thinking about the training part of bolt tightening. Procedures is also concerning.
The controls I can think of in our operations vary from the experienced technicians and the supervisors to having stipulated values of bolt torquing wherever mandatory especially in hydrocarbon services. That still requires to be audited at a certain frequency. And after all this, what about the competency assessment of new staff, contractors involved, training part.
Share what should be maintained here to ensure this critical process safety issue is under adequate layers of checks.

[neo]

The next one is the incident happened in Vila Soco, Brazil.
More than 800 deaths and the cause I could see was the failure of the pipeline, loosing pressure and operators pumped even more fluid to maintain the pressure.
1984 that was.
Got some more details as the pipelines were poorly maintained.

[tuan]

Vila Soco, attached an analysis published in Journal of Environmental Protection, 2024.

[neo]

Thanks tuan, a lot many things assessed within this analysis.
Thoughtful writing to describe everything including the background, the place, the pipeline setup.

Vila Soco, attached an analysis published in Journal of Environmental Protection, 2024.

[octane]

Incident No. 7: BP Oil Grangemouth (1987)
Detailed report available at the below link:
https://www.icheme.org/media/13700/the- ... ry-ltd.pdf