Document e12NVEVVajxR23Xb4BYEEeX2E

^conoco; interoffice Communication R. A. Conrad J. B. Bello y-ai-W-l-ic -IF -JLfi oie May 1, 1982 Subject Near-Miss Accident - G 305 Pump April 27, 1982 An investigation was held on April 28, 1982. Team members were: Joe Bello - Immediate Supervisor/Team Leader Donny Jesse - No. 2 Operator Richard Dungan - No. 2 Operator Chris Turner - Process Superintendent 1. Circumstances Leading To The Accident On April 27, 1982 Maintenance had reinstalled G-305, a VCM charge pump, after repairing the seals around 1530 Maintenance stated their work was completed and G-305 could be used. Removal of the blinds had been witnessed by Joe Bello, however, he did not notice that an unplugged valve had been left open. About 1610 it was decided that the pump would be used on the next charge. The pump's suction valve was then opened to fill the pump with VC. Immediately after opening the suction valve the VC leak alarm sounded`and the deluge system came on. The suction valve was closed off immediately. Lee Steward and Donny Jesse were in the V-40 area and could see VC escaping around the F 301/G 305 area. They directed the fire water cannons at the area of the leak. It was determined that the leak was coming from an open valve, the valve was closed off and has since been plugged. 2. Basic Cause of Accident A. The equipment was not inspected and prepared for use by Operations prior to being put into service. B. No one was standing by when the equipment was being pressured up. C. The bleeder valve was not plugged or capped. DTH 000098982 May 1, 1982 Page 2 3. Recommendations and Conclusions ML Adequate procedures are established for putting equipment into service. Equipment must be inspected to insure that it has been properly prepared for use and a qualified person must be standing-by in the event some unforseen failure occurs. The operations shift supervisor must insure these procedures are followed. /S JL& J. B. Bello Shift Supervisor/Team Leader C. W. Turner Process Superintendent/Coojrdinator R. E. Dungan No. 2 Operator Q.R. --/ D. R. Jesse No. 2 Operator DTH 000098983