Incident Review in Gas Facility Operations: Gas Compressor Re-Initiation Procedure Error Case

Welcome to the Risk Management Tips newsletter. As a Senior Risk Management Specialist, I will provide insights and updates regarding safety culture, risk assessments, comprehensive procedures, learning environments, and performance monitoring. I'll also feature personal experiences, best practices, and professional development tips. In our field, the goal is to always stay informed, safe, and improve.

This time, I would like to open a section dedicated to Process Safety in which we can discuss issues related to staying safe when processing facilities are in operation.

In this incident, the human factor played a central role, manifesting as communication breakdowns, procedural gaps, and inexperienced decision-making. Multiple safeguards prevented severe consequences in this incident, demonstrating the importance of layering protection systems.

Incident Description:

●?????In a gas facility, a butane compressor underwent an extended two-shift maintenance job. The maintenance work permit spanned from the morning shift to the afternoon shift. Upon takeover by the second shift operator, they were directed by the control room operator to initiate the Vapor Recovery Unit (VRU) compressor cycle to lower the butane tank pressure. However, after two unsuccessful attempts, the compressor became unresponsive and "slaved."

●?????This necessitated the activation of an alternative mixed compressor to control the butane tank pressure. Notably, the compressor had been isolated using a Lockout-Tagout (LOTO) procedure prior to maintenance. Subsequent assessment of the compressor panel revealed that the oil system had been left shut off. All primary and auxiliary compressor systems were operational except for the oil system. The operator involved was undergoing training during this incident.

Root Cause Analysis:

●?????Procedural Gaps and Checklist Implementation

The absence of robust procedures and comprehensive checklists played a role in the incident. A lack of a structured checklist for post-maintenance reactivation allowed the operator to miss a critical step. Establishing standardized and foolproof checklists can minimize the likelihood of such errors.

●?????Inadequate Handover and Communication

A breakdown in communication and handover occurred between the control room operator, maintenance personnel, and the second shift operator. This lack of clear communication about the status of the equipment and any outstanding tasks led to the improper initiation of the VRU compressor cycle.

●?????Human Performance Under Stress

The operator's inexperience, combined with the pressure to reduce the butane tank pressure promptly, could have led to hasty actions. Under stress, the operator might have failed to conduct a comprehensive check of all systems, focusing solely on the task at hand.

Takeaways:

●?????Clear Handover Protocols

Establish well-defined protocols for shift handovers, ensuring that information is effectively communicated about ongoing tasks, equipment status, and any potential risks. This can prevent critical gaps in understanding during transitions.

●?????Enhanced Training and Mentorship

Provide comprehensive training to all personnel, especially those in training, and assign mentors or supervisors during complex tasks. Experienced guidance can significantly reduce the likelihood of errors.

●?????Stress Management and Decision-Making

Incorporate stress management and decision-making training into the curriculum for operators. Equipping operators with techniques to manage stress and make informed decisions under pressure can prevent hasty actions.

?Process Safety Management (PSM) Reflection:

●?????Layered Protection

The incident underscores the importance of layered protection systems. The low oil pressure system guard, the auxiliary mixed compressor, and facility operation flexibility acted as multiple layers of defense to prevent more severe consequences. Strengthening these layers enhances the facility's resilience.

●?????Human Factor Integration

PSM should integrate human factors into procedures, training, and equipment design. Recognizing the role of human behavior, cognitive biases, and decision-making in process safety can lead to more effective risk mitigation.

●?????Continuous Improvement and Lessons Learned

Regularly review incidents and near-misses to identify areas for improvement. Incorporate these lessons into training, procedures, and safety culture to continuously enhance process safety.

●?????Risk Assessment and Management

?Employ rigorous risk assessment methodologies to identify potential scenarios where human error might occur. Mitigation measures can then be designed to address these vulnerabilities.

Human Factor Role and Layer of Protection:

The human factor played a central role in this incident, manifesting in communication breakdowns, procedural gaps, and decision-making influenced by stress and inexperience. The importance of a layered protection system is evident in the incident's outcome; multiple safeguards prevented severe consequences. This highlights the significance of considering human factors alongside technical and operational elements to ensure a comprehensive approach to process safety management.