“The Natural Gas facility lacked a formal PSV testing procedure that included a QA/QC process to ensure that PSV’s are properly returned to service after testing with isolation valves car–sealed in their correct positions. At the time of the Incident, operators were trained to assist with PSV testing by observing another more experienced operator and then expected to be able to perform oversight of contractor led PSV testing with no further training and without the aid of a written procedure or process. In addition, there was no formal car–seal procedure, no car–seal inventory, and no formal requirement to audit required car–seals in use throughout the units.”
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