What happened?
Hot
Tap technicians failed to complete a small bore hot tap on 150 PSI / 370 oF /
steam project.
What
went wrong?
The technicians failed to
inspect the dogs on the IP100 when mounting the cutter assembly on the boring
bar thus the 4” hot tap on a 6” pipe 150# flanged system the entire shell cutter / driver /
pilot bit & coupon fail into pipe when backing out of the cut.
Investigation
Results
Technician did not stop after making the connection with the “D”
ring into the boring bar noticing there was good bit of rocking and twisting
movement between the bar and cutter
driver.
Pre-job planning did not
address how to proceed if there was slop in the final connection of boring bar
and cutter.
Two bad boring
bar photos
Two good boring bar photos
How
do we prevent it from happening again?
Always follow the written procedures. If something does
not look right or requires any deviations all Furmanite have the responsibility
to utilize their “STOP WORK AUTHORITY”. Any
planned activity or job can be rescheduled so the issues can be addressed with
the customer. Do NOT continue until all changes and concerns have been
addressed and resolved.
What actions do I take?
Furmanite’s Pipe Line Intervention Engineers
need to modify the IP100 procedures so as to put a go no go step in the form
that states what is acceptable gapping in the dogs on the boring bar. This will
allow technicians to have a more complete procedure to follow.
Review this Shared Learning with all employees
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