One morning a saltwell pump was placed in operation. Operation of this equipment requires that the Standard Hydrogen Monitoring System (SHMS) cabinet be in operation. Later that morning, during the morning surveillance rounds, the Standard Hydrogen Monitoring System (SHMS) cabinet was found not to be in the operational mode.

On the previous day, the night shift saltwell operator assigned to run the saltwell pump had placed the SHMS monitor in operational mode; however, the saltwell system was not started at this time. Shift turnover was conducted and the condition of the SHMS was turned over to the appropriate saltwell operator and shift manager. During the day shift the day shift operator assigned to the complex received approval from the operations engineer to place the SHMS in "dry out" non-operational mode. Shift turnover was conducted and the saltwell operators did not know the condition of the SHMS had changed. The routine operators turned over the change in status among themselves. The shift managers, however, did not effectively communicate the status of the SHMS during their turnover activity.

The direct cause was attributed to the failure to use and follow available procedures. The night shift saltwell operator assigned to run the saltwell pump had placed the SHMS monitor in operational mode in accordance with appropriate procedure documentation. The next evening, the same night shift saltwell operator was again assigned to saltwell pumping activities. This operator "listened to the unit", concluded that the unit was running, and made the assumption that the SHMS was in operational mode. The operator did not use an available procedure which required him to confirm through physical verification the operational status of the SHMS. The pump was then started, without the SHMS monitor configured in the proper operational mode.

Incident Date
Mar 22, 1999
  • Safety Systems
  • Measurement / Sensing Device
Damage and Injuries
When Incident Discovered
Lessons Learned

The lessons learned in this situation center around basic conduct of operations principles. Policies and procedures related to operations performance, safety performance, and management oversight were in place. They were not employed appropriately.

There were approved operations procedures in place to provide direction to personnel to ensure that the SHMS would be operated within its design basis. Those approved and available procedures provided the needed operational direction to accomplish safety, process quality, and control activities. Had the operator made use of the available procedures, the incident very likely would not have occurred.

When operational direction is available (procedures, turnover logs, etc), compliance with that operational direction is required. Communications and shift turnover protocols in this situation were wholly inadequate. Accurate communication is essential for the safe and efficient operation of facilities, systems, and equipment; highly reliable communication provides accurate transmission of information within a facility. That transmission of communication did not occur in this situation. The facility operations personnel should have known the status of all equipment and systems, and should have been able to maintain control at all times. The saltwell pumping activities require interface and coordination between roving operators, specific evolution-related operators, and shift supervisors. That integrative communication did not take place. From the shift supervisor on down, shift personnel should have been aware of operations planned or in progress; status of facility systems and equipment; and any abnormal conditions which may have existed. That information was not effectively documented or transmitted. In addition, the authorization, communication, and documentation of status changes was not thoroughly executed.

Startup and shutdown of systems and equipment require assessing status on a continuing basis. Notification of changes in system status by operators and shift supervisors must be comprehensive and complete to ensure an understanding of and adherence to precautions and prerequisites for safe shift evolutions.