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What happened?
An operator was opening a chain wheel valve for unit start up.
The chain wheel detached from the valve stem and fell to the pump basin.
The operator was not injured and there was no damage to the equipment.
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Why did it happen?
The wheel fell off after the bolt and nut came loose.
The valve was installed without a tether.
6 valves were installed without a tether, using the manufacturer’s bolt and nut.
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What did they learn?
After the incident, the manufacturer recommended using a locking nut when installing chain wheels.
Include field verification in the maintenance procedure to ensure that handwheels are installed using a locking nut and a safety tether/lanyard.
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Ask yourself or your crew
How can this happen here?
How do we know that chain wheels are secured at our site?
Do our current procedures include field verification? How can we improve them?
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What happened?
An operator was opening a chain wheel valve for unit start up.
The chain wheel detached from the valve stem and fell to the pump basin.
The operator was not injured and there was no damage to the equipment.
Why did it happen?
The wheel fell off after the bolt and nut came loose.
The valve was installed without a tether.
6 valves were installed without a tether, using the manufacturer’s bolt and nut.
What did they learn?
After the incident, the manufacturer recommended using a locking nut when installing chain wheels.
Include field verification in the maintenance procedure to ensure that handwheels are installed using a locking nut and a safety tether/lanyard.
Ask yourself or your crew
How can this happen here?
How do we know that chain wheels are secured at our site?
Do our current procedures include field verification? How can we improve them?
An operator was opening a chain wheel valve for unit start up. The chain wheel detached from the valve stem and fell to the pump basin.
