PHILLIPS 66 PIPELINE LLC

Incident Narrative

IN PREPARATION FOR MAINTENANCE WORK ON THE BORGER DENVER PIPELINE, AN OPERATOR EMPLOYEE WAS REMOVING A CAP ON A 2"" THREADED O-RING (TOR) FITTING ON THE UPSTREAM SIDE OF THE MP-205 VALVE. TOR FITTINGS ARE INSTALLED WITH A PLUG IN THE FITTING TO HOLD LINE PRESSURE AND THEN A CAP IS INSTALLED OVER THE PLUG. AS THE EMPLOYEE STARTED REMOVING THE CAP, HE NOTICED PRESSURE UNDER THE CAP AND WHEN HE ATTEMPTED TO RE-TIGHTEN THE CAP, IT GAVE WAY. FULL FLOW OF GASOLINE WAS RELEASED FROM THE 2"" FITTING AS THERE WAS NO PLUG INSTALLED IN THE FITTING. THE EMPLOYEE BACKED AWAY FROM THE RELEASE AND IMMEDIATELY CALLED THE CONTROL CENTER. THE CONTROL CENTER SHUTDOWN THE PIPELINE. PRODUCT FLOWED FOR APPROX. 3 MINUTES UNTIL PRESSURE WAS REDUCED ON THE PIPELINE AND THE TOR FITTING CAP WAS REINSTALLED. THIS SECTION OF PIPE WAS NEWLY INSTALLED AS PART OF A 7 MILE REPLACEMENT PROJECT WHICH WAS TIED IN AND STARTED UP IN MARCH 2016. FOLLOWING THE INCIDENT, AND SUBSEQUENT SHUTDOWN OF THE BORGER DENVER PIPELINE, PHILLIPS 66 X-RAYED ALL THE NEW TOR FITTINGS INSTALLED WITH THE REPLACEMENT PROJECT AND FOUND 4 FITTINGS DID NOT HAVE PLUGS INSTALLED. P66 IMPLEMENTED AN IMMEDIATE INTERIM COMPANY WIDE POLICY THAT TOR FITTING CAPS COULD NOT BE REMOVED WITHOUT APPROVAL FROM THE HSE MANAGER AND PIPELINES MANAGER. PRIOR TO RESTARTING THE PIPELINE, PHILLIPS 66 SEAL WELDED THE CAPS ON THE 4 TOR FITTINGS IDENTIFIED WITHOUT PLUGS INSTALLED. THE INVESTIGATION OF THE INCIDENT FOUND THE ROOT CAUSE TO BE THAT (DURING THE INSTALLATION OF THE TOR FITTING), A PLUG WAS NOT INSTALLED (UNDER THE CAP) AS CALLED FOR BY PROCEDURE. THE CORRECTIVE ACTION IDENTIFIED WAS TO MODIFY THE PROCEDURE ON THE USE OF A TOR FITTING TO INCLUDE A STEP TO VERIFY PLUG INSTALLATION ON THE FITTING BY X-RAY PRIOR TO REMOVAL OF THE CAP. ONCE THE MODIFICATION IS MADE AND ALL AFFECTED EMPLOYEES TRAINED, PHILLIPS 66 WILL REMOVE THE INTERIM POLICY OF HSE AND PIPELINES MANAGER APPROVAL BEFORE USING A TOR FITTING.