LOOP LLC

Incident Narrative

ON MAY 12, 2013, A SHIP WAS UNLOADING CRUDE OIL THROUGH THE MAIN OIL LINE TO THE CLOVELLY TANK FACILITY AT A RATE OF 60,000 BARRELS/HOUR. AFTER FILLING TANK 6401, THE FLOW WAS DIVERTED TO TANK 6416. SIMULTANEOUSLY, A 2-PERSON FIELD CREW WAS PERFORMING A FUNCTION TEST ON THE TANK 6416 42-INCH TANK INLET VALVE. THE FLOW WAS ERRONEOUSLY BLOCKED 8 MINUTES AFTER THE SWITCH TO TANK 6416 RESULTING IN AN OVERPRESSURE OF THE PIPELINE AND LOSS OF INTEGRITY OF MECHANICAL COMPONENTS. THE LOSS OF INTEGRITY OF THE MECHANICAL COMPONENTS WAS THE SOURCE OF THE RELEASE OF THE CRUDE OIL. AN INVESTIGATION OF THE INCIDENT WAS CONDUCTED. BY CONDUCTING A CAUSE AND EFFECT ANALYSIS, THE TEAM IDENTIFIED SEVERAL CAUSES WHICH CONTRIBUTED TO THE EVENT. THESE ARE LISTED AS FOLLOWS: 1. THE INSTRUCTION IN THE PREVENTATIVE MAINTENANCE PROCEDURE (TFRHYDVLV) TO ""VERIFY WITH OMC THAT THE VALVE CAN BE OPENED AND CLOSED PRIOR TO BEGINNING PM"" WAS NOT PERFORMED PRIOR TO OPERATING THE INLET VALVE FOR TANK 6416. 2. THE TRUNK LINE TO TANK 6416 WAS FLOWING WHEN THE ISOLATION VALVE WAS ACTUATED. 3. THE COMMUNICATION BETWEEN FIELD PERSONNEL AND OMC WAS INCOMPLETE AND/OR INACCURATE. 4. THE FIELD PERSONNEL WERE UNAWARE THAT THE SCHEDULING WORK ORDER TO FILL TANK 6416 WAS BEING EXECUTED. CORRECTIVE ACTIONS HAVE BEEN INITIATED TO ADDRESS THE CAUSES AND RECOMMENDATIONS AS LISTED. THESE RECOMMENDATIONS INCLUDE: PREVENTIVE MAINTENANCE PROCEDURES 1. UPDATE THE CURRENT TANK INLET VALVE PREVENTIVE MAINTENANCE PROCEDURE TO CLARIFY EACH STEP AND INSTRUCT EMPLOYEES IN THE USE AND EXECUTION OF THE UPDATED PREVENTIVE MAINTENANCE PROCEDURE. LOCKOUT/TAGOUT: 2. UPDATE THE CURRENT TANK INLET VALVE PREVENTIVE MAINTENANCE PROCEDURE TO INCLUDE A SPECIFIC STEP FOR LOCKOUT/TAGOUT TO ASSURE NO-FLOW CONDITIONS THRU THE INLET VALVE TO THE TANK. COMMUNICATIONS: 3. DEVELOP A DOCUMENT THAT DESCRIBES A VERBAL COMMUNICATION PROTOCOL FOR RADIO USE. CONDUCT TRAINING FOR AFFECTED EMPLOYEES. 4. IMPROVE THE SCHEDULING WORK ORDER DISTRIBUTION TO IMPROVE COMMUNICATION INVOLVING DAILY OPERATIONS. ALL CORRECTIVE ACTIONS INITIATED HAVE BEEN ADDRESSED.