Dangerous Goods Significant Incident Report No. 01-18 and
Petroleum Safety Significant Incident Report No. 01/2018
Gasket rupture at processing facility results in gas leak
Summary of incident
On 6 December 2016, an operator at a liquefied petroleum gas (LPG) processing
facility heard a loud noise coming from an area of the plant during start-up, following
major maintenance works. The operator identified that high pressure, flammable
natural gas was being released to the atmosphere from a localised point beneath the
insulation of process equipment.
The Department of Fire and Emergency Services (DFES) responded to the incident. No
evacuation of personnel was required, although local traffic on adjacent roads was
redirected as a precautionary measure.
Once the incident was contained, the area was secured and closely inspected for
damage. The cause of the incident was identified as the sudden failure of a newly
installed gasket within a bolted flange joint assembly. It is estimated that around
20,000 m3 of gas was released to the atmosphere during the incident. There were no
injuries or damage to the plant.
Direct factors
? Failure of a newly installed gasket within a bolted flange joint assembly.
Contributory factors
? Improper installation of the flange joint assembly.
? The inadequate detail provided in the procedural (quality) checks for workers to verify
the bolted flange joint assembly was installed fit-for-service prior to plant start-up.
Actions required
The following actions are recommended to operators of major hazard facilities to
reduce the potential for failure of safety critical plant components following
maintenance work.
? Prepare clear and adequate work instructions prior to authorising work to
commence within processing facilities.
? Develop or review manuals for critical parts of the plant and confirm they outline
operational parameters and quality checks required for maintenance activities.
? Prior to commencing the maintenance operation, confirm that all members of the
maintenance team fully understand the steps required, and any uncertainty or
ambiguity is clarified before work commences.
? Undertake quality assurance inspections (e.g. “GO/NO GO”) throughout the
maintenance operation to confirm the work is satisfactory and may continue.
Note: Reliance only on functional testing and job paperwork review, and post-completion
quality inspections, to confirm that safety critical maintenance was
completed correctly, may be insufficient.
? Undertake a thorough inspection and testing of works in critical areas of the plant
prior to start-up following maintenance and shutdowns.
Further information
Visit www.dmirs.wa.gov.au/ResourcesSafety for information on dangerous goods and
petroleum safety.
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