IOGP SAFETY ALERT

INCORRECT PRESSURE GAUGE ON HIGH PRESSURE SUPPLY LINE

What Went Wrong?:

• Operations inspected the pressure gauge and found it to be a 0-100% gauge, where a 0-100 Bar pressure gauge should have been installed.
• The 0-100% gauge had been ordered in error for a prior boiler shutdown and had been subsequently stored in the utilities equipment room, rather than returned to the warehouse for disposal.
• Technicians had established a culture of storing some small items in equipment rooms to allow easy access for small maintenance tasks.
• On the day of installation, the 0-100% gauge was mistaken for a 0-100 Bar pressure gauge (due to the near identical appearance) and was taken from the utilities equipment room and installed on the steam turbine high pressure steam supply line. A human error mode of “miss-perception” was recorded following a Human Factors investigation.

Figure 1 – Correct pressure gauge (Bar)

Figure 2 – Incorrect Pressure Gauge (%)

Corrective Actions and Recommendations:

• Check all stores stock to ensure that all pressure gauges are stored in the correct place and in the correct boxes.
• Ensure that all un-used equipment is returned to the place of issue at the end of each day. This ensures that only the correct equipment for a specific work order can be withdrawn.
• Ensure that all pressure gauges are function checked and fit for purpose before installation.
• Review stores stock items and material numbers to establish those that are no longer used or required. Block all numbers that are not required in to prevent re-ordering by accident.
• For legacy assets, review and rationalize all local pressure gauges across each facility with a view to removing those that are no longer used or required.