1.1.2 Isolations Removed Too Soon: 1.1 Isolation

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1.

1 ISOLATION 7

The 1988 explosion and fire on the Piper Alpha oil platform in the
North Sea, which killed 163 people, was also caused by poor isolation.
A pump relief valve was removed for overhaul and the open end blanked.
Another shift, not knowing that the relief valve was missing, started up
the pump. The blank was probably not tight, and light oil leaked past it
and exploded in the confined processing area. The official report [18] con-
cluded “that the operating staff had no commitment to working to the
written procedure; and that the procedure was knowingly and flagrantly
disregarded.” The loss of life was greater on Piper Alpha than on the
other two incidents because oil platforms are very congested and escape
is difficult.
Section 18.1 describes similar incidents.

1.1.2 Isolations Removed Too Soon


An ethylene compressor was shut down for maintenance and correctly
isolated by slip-plates. When repairs were complete, the slip-plates were
removed before the machine was tried out. During the tryout, some eth-
ylene leaked through the closed isolation valves into the machine. The
ethylene/air mixture was ignited, either by a hot spot in the machine or
by copper acetylide on the copper valve gaskets. The compressor was
severely damaged.
Isolations should not be removed until maintenance is complete. It is
good practice to issue three work permits—one for inserting slip-plates
(or disconnecting pipework), one for the main job, and one for removing
slip-plates (or restoring disconnections).
A similar incident occurred on a solids drier. Before maintenance
started, the end cover was removed, and the inlet line was disconnected.
When maintenance was complete, the end cover was replaced, and at
the same time the inlet pipe was reconnected. The final job was to cut off
the guide pins on the cover with a cutting disc. The atmosphere outside
(but not inside) the drier was tested, and no flammable gas was detected.
While cutting was in progress, an explosion occurred in the drier. Some
solvent had leaked into the inlet pipe and then drained into the drier [19].
The inlet line should not have been reconnected before the guide pins
were cut off.

1.1.3 Inadequate Isolation


A reactor was prepared for maintenance and washed out. No welding
needed to be done, and no entry was required, so it was decided not to
slip-plate off the reactor but to rely on valve isolations. Some flammable
vapor leaked through the closed valves into the reactor and was ignited
by a high-speed abrasive wheel, which was being used to cut through

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