HSE LEARNINGS INCIDENT SRDC K5440 Meter Insulating Gasket

HSE LEARNINGS INCIDENT: SRDC K-5440 Meter Insulating Gasket Failure (ID# 518779) • A loss of containment occurred on K-5440 compressor discharge line. The compressor automatically shut down and blew down. There was damage to the flow meter. • The loss of containment was the result of the failure and ejection from the flow meter joint of insulating gaskets that were of incorrect material and temperature rating. • The operating temperature during commissioning tests was in excess of 140 C for approximately two hours, which exceeded the maximum rated continuous operating temperature of 79 C for the installed insulating gaskets. • After two hours the two insulating gaskets in the flow meter joint failed catastrophically and were blown out of the joint. CAUSES: • Vendor misinterpreted original PO quantity. • Step out procedure not followed for procurement of insulating gaskets from non-approved vendor • Contractor purchasing procedures were not followed for additional insulating gaskets (‘rush order’). • Supplied additional insulating gaskets were issued directly to site bypassing warehouse QA/QC. LEARNINGS: • Develop and implement processes for improving QA/QC of bulk equipment orders, ‘rush orders’ and re-supply to meet order shortages in EPC/ODC/EMC contracts. Recommended Actions: • Discuss this alert in toolbox talks and HSE meetings and Ø Distribute to all contractors Ø Post on HSE notice boards Ø Include in site HSE induction Contact MSE 511 for further information or visit HSE website • Close management attention and verification on procurement process & QA/QC for • “rush orders” and re-supply of “bulk materials” to assure design integrity. AI-PSM -Incident Alert No 16 SEP 2010