Baker & O'Brien, Inc.

Case Studies

Case Studies details

Case Studies details

Inadvertent Valve Disassembly Results in Loss of Containment

Litigation, North America

August 1, 2021

During reinstatement of equipment following a refinery process unit turnaround, a pump suction valve had to be opened for flow alignment.  When the valve handwheel freely turned and failed to open the valve, the operator decided to remove the gearbox so he could manually turn the valve stem with a wrench.

However, the operator mistakenly removed the valve top cap bolts instead of the gearbox bracket bolts, which resulted in a loss of containment, explosion, and fire.

A few personnel present in the vicinity at the time of the release were injured from the explosion and fire and filed a claim for their injuries.  Baker & O’Brien was engaged to investigate a number of relevant issues:  1) the incident cause; 2) applicable plug valve standards; 3) gearbox bracket mounting and design changes; 4) operator training and competence; 5) industry practices for operator maintenance; 6) human factors and the error type; 7) potentially related incidents and OSHA notices; and 8) the likelihood of an incorrect gearbox removal.  We provided expert opinions and rebuttals in the following areas of expertise: operations, maintenance, process equipment design, process safety management, competence management, risk management, incident investigation, and human factors.