NEAR MISS report EVENT DESCRIPTION: KEY LEARNINGS: KEY TAKEAWAYS:

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Jack Julius Warren
5 years ago
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1 A CPC contractor noticed municipal contractors working nearby who were digging without approval on Line 18 ROW. Work was stopped without incident but the excavator had gotten within 2-feet of the pipeline. SR Operator covering ROW met with crew multiple times to discuss their project and our line Line 18 was properly marked Crew had a one-call but not to dig in the area they were in Our contractors helped look out for our line safety Trust but verify - agreed-to plans can be changed without our knowledge 3 rd party excavation damage remains a high risk potential Unauthorized encroachment documented

Test logic was inputted into a station PLC to record data needed for troubleshooting without completing an MOC. All changes to programming require MOC in accordance with Procedure 10.

2 Test logic was inputted into a station PLC to record data needed for troubleshooting without completing an MOC. All changes to programming require MOC in accordance with Procedure 10. An MOC was considered but was thought to not be required since station nor PLC functionality would be affected by the change Test logic (aka PLC traps ) are often used for troubleshooting Procedures can be written to cover changes like this (done routinely and with controls in-place) Changes made under such procedures do not require MOC MOCs are required for all changes to equipment, process or technology that are not like-in-kind replacements or not covered by approved procedures Get with your Safety Specialist or any member of the SMS Team for more info

3 The total gasoline batch was changed from 205k bbls to 210k bbls Operators were informed (verbally) of the change but a new schedule was not issued Gasoline batch was cut short and kerosene started too early after a schedule change was updated in the batch queue but not in the automated recipe system. No product was contaminated but it was close. DRA (contaminated kero) injected during the gasoline batch had only been down for 1 hour instead of the required 2 hour buffer. Schedule updates should be issued even when small changes are made Small changes are often easier to miss than big changes HMI tools and systems are designed to help ensure accurate operations but depend on accurate inputs Double-check your numbers and the numbers of those you relieve

4 While removing a smart pig from an origin station trap on Line 2, the station operation was changed causing a change in pressure at the trap. As a result, a small amount of product leaked by the trap inlet valve slab and into the trap. <5 gals of distillate contained in catch pan at trap opening Gate valves, when closed, need pressure on the back side to keep the valve slab in a sealed ( seated ) position Trap operations are considered line separation activities that should be completed under double-block and bleed if operationally feasible Work with Scheduling and Control Center to see if trap operations can be done with station isolated If not, work with CC to ensure steady state conditions during trap activities Always anticipate the unexpected things like air monitors and catch pans aren t needed until you need them

The hitch ball broke off on a contractor s trailer while backing an air compressor into position. It was a factory-welded 3 ball hitch. No other damage.

5 The hitch ball broke off on a contractor s trailer while backing an air compressor into position. It was a factory-welded 3 ball hitch. No other damage. Fortunately, the hitch chains were fastened so the compressor dropped but was not able to "run away Safety devices like hitch chains work use them! Inspect vehicles and equipment often even things like trailer hitches Repair or replace items with signs of cracked or damaged welds

Symptom Diagnostics - Hard Start/No Start April Hard Start/No Start - Two-Filter Fuel System (This Test Must Be Done First)

04 10-17 1 04 10-17 SUBJECT DATE Symptom Diagnostics - Hard Start/No Start April 2017 Additions, Revisions, or Updates Publication Number / Title Platform Section Title Change Hard Start/No Start - Two-Filter