"KINDER MORGAN LIQUID TERMINALS, LLC"

Incident Narrative

"ON MAY 11, 2020 AT 7:00 PM, AN OPERATOR DISCOVERED A STAIN NEAR THE COLONIAL MANIFOLD AND AN INVESTIGATION TO IDENTIFY THE SOURCE BEGAN. ON MAY 12, 2020 AT 1:30 PM, IT WAS DETERMINED THAT THE SOURCE WAS A BLOCK AND BLEED VALVE. THE BLOCK AND BLEED WAS ISOLATED AND THE PRODUCT WAS CLEANED UP. THE CAVITY DRAIN VALVE WAS INADVERTENTLY IN AN OPEN POSITION DUE TO IT BEING INSTALLED IN THE WRONG ORIENTATION. THE VALVE WAS INSTALLED IN AN INCORRECT ORIENTATION (UPSIDE DOWN) PREVENTING THE LOCKING MECHANISM FROM ENGAGING AND MAKING IT SUSCEPTIBLE TO BEING UNKNOWINGLY OPENED. KM HAS A SIGNIFICANT NUMBER OF CONTRACTORS WORKING IN THE AREA OF THE VALVE, MAKING THIS A TEMPORARILY HIGH TRAFFICKED AREA DUE TO A CURRENT PROJECT. THE LAST WORK PERFORMED ON THE VALVE WAS ROUTINE MAINTENANCE TO REPLACE AN ACTUATOR. THE ACTUATOR REPLACEMENT DOES NOT REQUIRE THE VALVE TO BE OPENED, HOWEVER, TO WORK ON THE ACTUATOR SCAFFOLDING HAD TO BE INSTALLED. KMLT HAS AN OQ COVERED TASK FOR OPENING AND CLOSING VALVES, HOWEVER, DUE TO THE ACTUATOR REPLACEMENT NOT REQUIRING THE VALVE TO BE OPENED OR CLOSED THIS TASKS WAS NOT PART OF THE WORK. THE EMPLOYEE WAS OQ QUALIFIED TO REPLACE THE ACTUATOR. IT IS LIKELY THAT THE CAVITY DRAIN VALVE WAS INADVERTENTLY BRUSHED OPENED DURING THE INSTALLATION/DISASSEMBLY OF THE SCAFFOLDING AROUND THE VALVE. PLAN FOR PREVENTION: THESE VALVES ARE BEING REPLACED WITH SPRING LOADED VALVES TO AVOID THIS TYPE OF INCIDENT FROM OCCURRING AGAIN."