Investigation Report
Hot Pressurised Crude Oil Released During Heater-Treater Controller Replacement
06-23-2014 10:30 G10638 EC 328 B Required Evacuation / Pollution / Human Error
- BSEE
- Investigation Report
- Unknown
- Environmental protectionHuman factorsHydrocarbon releasePressure systems
- Inspection and maintenance
- Pressure vessel
- Energy and process isolationJob safety analysis
- Upstream oil and gas
- Offshore installation
Summary
An offshore heater-treater controller replacement released hot, pressurised crude oil, burning an operator and polluting surrounding waters. The investigation found that the controller lacked a thermowell and was removed before depressurisation and oil-level reduction. Task hazard analysis missed this installation hazard and the necessary mitigations, including cooling.
Classifications: Environmental protection; environmental safety; pollution prevention.
Classifications: Human factors; human performance; ergonomics.
Classifications: Hydrocarbon release; hydrocarbon leak; oil and gas release.
Classifications: Pressure systems; stored pressure; pressurised systems; pressurized systems.
Classifications: Inspection and maintenance; asset inspection; equipment maintenance.
Classifications: Pressure vessel; pressure vessels.
Classifications: Energy and process isolation; isolation; energy isolation.
Classifications: Job safety analysis; JSA; job hazard analysis; JHA.
Classifications: Upstream oil and gas; oil and gas extraction; upstream petroleum.
Classifications: Offshore installation; offshore platform; offshore rig.