Lockout tagout handover case
Lockout tagout handover case
In the process of maintenance of petrochemical equipment, due to not according to the requirements of the "management regulations on equipment safety maintenance", do well in the maintenance preparation work such as handover safety confirmation before equipment maintenance, risk identification of dangerous operation, Lockout tagout of equipment maintenance and unclear equipment fault handover, all kinds of safety accidents are often caused in the maintenance process.
The external operation personnel found that the pump vibration was big and there was abnormal sound. The next command was to stop the pump for maintenance and switch the standby pump. The shift leader shall arrange external operators to conduct cooling and isolation of pump body before maintenance. The external operator informed the monitor that the pump at the bottom of the tower had been isolated and discharged. The next morning, before the shift shift, when the shift leader met the shift leader in the central control room, he simply told the tower bottom pump p-100a about troubleshooting, and told the tower bottom pump had discharged oil last night. When the shift team takes over the shift, the shift leader will carry out the handover without the trouble of the bottom pump of the handover tower again. After the completion of the shift, the operator surnamed li came to the device for patrol inspection and found oil at the root of the outlet pipe of p-1004a blowdown vent valve. If it was found that the vent valve was not closed, the vent valve should be closed. Upon inspection, the operator also found that the pump p-1004a inlet valve was closed. Therefore, he considered that the spare pump should be in a normal standby state and be put into use as soon as possible. In addition, he also opened the inlet valve of the pump. When the shift monitor issued the permit maintenance work notice, the machine maintenance monitor received the maintenance work notice, arrange maintenance personnel for maintenance. Maintenance personnel to the device site maintenance, before the maintenance of no further check the isolation of the pump, open the pump cover, hot oil flow out of the fire caused by fire.
The root causes of fire accidents mainly include the following aspects:
1. Accident investigation shows that the inlet valve of the pump is open, while the vent valve is closed. The pump shell is full of medium.
2. When the machine pump is reported for fault repair and waiting for repair, it fails to carry out Lockout tagout warning in strict accordance with the "Lockout tagout management regulations for equipment maintenance", which causes the operator to open the inlet valve by mistake without knowing that the equipment is in need of repair, which is also one of the indirect reasons for this accident.
3. The equipment troubleshooting handover is not standard, not clear, when to handover equipment failure, not carried out in accordance with the company "team succession management system", shift supervisor not in transition team meeting and handover bottom hot oil pump failure, but privately and succession team, after completion of succession, succession monitor without and transition of operating personnel on duty, lead to the operator is also one of the indirect cause of the accident.
4. According to the previous operation experience, the operator opened the inlet valve of the spare pump illegally for the convenience of operation, which also caused the operator to be one of the indirect causes of the accident.
5. In the process of this overhaul, the import and export of the pump "isolation" measures are improper, the choice of isolation with the valve, cut off the machine pump and pipeline process media, is a non-standard "isolation" measures. If the valve leaks, it will cause the pipeline medium to leak into the pump body.
6. The maintenance safety management system and procedures are not perfect, and the operating staff's safety awareness is not strong. In the process of transition, the shift leader issued the permit inspection notice without the confirmation of on-site safety inspection. During the maintenance operation, the maintenance personnel did not carry out the risk identification before the operation and the maintenance operation permit in class.
1. According to the Lockout tagout management regulations for equipment maintenance, for equipment in trouble, maintenance and repair, a warning sign shall be put on the board to warn the equipment in trouble, maintenance and repair; Valves of blocking equipment, including those that must be closed after the installation of blind plates (or the disconnection of pipelines), must be locked with padlocks and chains or similar devices. Warning boards are not allowed only on valves.
2. During equipment maintenance, it is strictly prohibited to isolate equipment and pipeline materials with valves, which is a non-standard "isolation" measure. According to the safety management regulation of energy isolation, the equipment in the maintenance state must be separated by blind plate or completely disconnected. In particular, if the hot fluid may flow out or the personnel need to enter the equipment, the requirements of installing blind plate or disconnecting the pipeline must be implemented.
3. When the fluid pressure exceeds 600psi or the temperature is close to and above its spontaneous ignition point, a block valve and a vent valve shall be installed, not for isolation but for the safe installation of blind plates.
4. Strengthen the management group of succession, do "make" clearly, "pick up" understand, for equipment specification, troubleshooting handover to make sure that the, it is strictly prohibited to privately verbal handover, problems of equipment must be in clear shift team meeting, and written handover, delivery personnel everyone clearly understand, prevent omissions and later traced, form a closed-loop management.
5. To improve and implement the equipment maintenance safety management system, do a good job of risk identification and safety measures inspection and confirmation before the maintenance operation, is strictly prohibited in the maintenance operation without the maintenance operation permit.
6. Improve employees' safety awareness, work responsibility and enhance their safety business skills. Before the maintenance operation, strictly in accordance with the "equipment maintenance safety management system", do a good job before the maintenance of equipment transfer maintenance safety confirmation, do a good job before the operation of the hazard risk identification, according to the maintenance operation permit to fill in, and carefully on-site inspection to confirm the safety measures, layer upon layer to implement the point, the implementation of special responsibility.