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What happened?
A duplex filter cartridge is designed to permit maintenance of one filter, while the other remains in operation on a lube oil system, allowing the machinery to stay online.
During maintenance, a worker mistakenly removed the in-service filter cartridge.
Two gallons of oil were released.
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Why did it happen?
The worker was not familiar with the equipment.
Inadequate/not visible labelling on the dual cartridge filter.
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What did they learn?
‘Stop work’ procedure should be initiated when:
- performing the task for the first time
- there is no procedure for an infrequent task
- work scope is not fully understood
- something does not look or feel right.
Handle positions should be labeled relative to energy isolation and details included in procedures and training.
Add drain valves to duplex filters to assist in energy isolation and verification.
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Ask yourself or your crew
How can something like this happen here?
Why do you think the worker continued the activity, although he was not familiar with the equipment? What would you do differently?
What would you do before starting work if you were in a similar situation or if the work scope was unclear?
What actions can we take to prevent this?
- Can we label the equipment?
- Can we add a drain valve?
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Published on 15/07/19
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During lube oil system filters maintenance on an online machinery, a worker mistakenly removed the in-service filter cartridge. 2 gallons of oil were released
