LEARNING FROM INCIDENTS ACTION ALERT GRP-AC-201203 CUT Deed Retrieval of Corrosion Coupons from Pressurised Lines Target audience for this alert t= Personnel responsible for and managing corrosion inspection work = Maintenance and Inspection Managers = Assot Managers What happened On May 3" 2012, in a non-Shell operated joint venture, a team was removing @ corrosion monitoring instrument (corrosion coupon installed at the bottom of « {905 pipeline ("6 o'clock" positon). At the time of this operation the line was pressurised and operating at 74 ber. The corrosion coupon retrieval operation was nearing completion when a sudden a unbalanced release of pressure resulted in an uncontrolled outward movement of _Piue 1: Siveton before the incident the outer barrel (piston) with the rotation handles cttached. Person 3 was hit on the helmet/head by one of handles and fall injured Why it happened The investigation ofthis incident is not yet complete. Lessons learned Insight gained to date: tis understood that for botiom-oF ine applications ("6.0'¢ock') the assembly con be vlnerable to fouling due to corrosion product seiling in low poins/ the botom- Fine and can drop down int the corrosion coupon balancing path. This cn lood fo pressure imbalance within the rival tool rosutng in an uncoirlled outward movement ofthe over bere (piston) upon disengagement of he coupon threads Fae ME sos cer he nile Adas Cel ede pr ‘While the incident investigetion is ongoing, itis recommended hat the following ‘Bun yar ce ccion be considered os precautionary measures: 1. Stop all corrosion coupon relrivel operations on pressurised lines. When the investigation of this incident is complete, subsequen' LF Alert [expected end May) wll communicate the learnings andl advise if his type of work Prior tothe start of werk Contract Holders, with he support of Shell maintenance and inspection personne, are fo assess ‘whether contactors wh perform corosion coupon retrieval operajions on pressurised ines have a Competence ‘Assurance process for thar personnel and essure they are competent. This type of work sa specait operaion normally corrected ou fo Orginal Equipment Mangfactrer (OEM approved contractors with cerified personnal (Refer Shell HSSE & SP Control Framework Contractor HSSE Management Manval (requirement 3.3)}.