Thanks MJCronin to share this information,

Deepest condolences to the families of the victim.
Very unfortunate and disappointed that similar incidents had happened 5 times within 40 years.
Not really clear to me, but shouldn’t all parties (manufacturer, end user and contractor team leader/management) hold accountable for this incident? So, it can trigger constructive domino effect and action can be done for existing situation (I bet there are a lot of actuator’s brackets being mounted on a body/bonnet studs everywhere in the world).
No living souls should accept a risky job without proper procedure.

24July2021 (leaking found) to 27July2021 (incident): what has been done during risk assessment team for the last 3 days? If cannot found protocol, shouldn’t them at least decide which bolts are safe to be loosened?
All names are mentioned except one, the brand of the valve (only blurry casting on valve body)? Any specific reason? I can only guess Tu***

One can read the report with multiple interpretation, but without any influence towards valve design and API regulatory, then most of use might fall into the narration that there is no training for personnel on the ground (end user and contractor) is the contributing factor.
Quote:
LyondellBasell did not have a procedure detailing how to remove the actuator, and neither LyondellBasell nor Turn2 trained the Turn2 personnel on how to remove the actuator.
Unquote
No matter how expert we are, it is near impossible to be ON THE SPOT knowing everything about valve dismantling for hundreds of valve brands. However, it should be a standard for any valve mechanic to spot which studs are pressure containing parts and how to isolate actuator.

Color coding the nuts and paper (warning) tag is not a fool proof solution.

Cannot imagine how many incident could or would have happened, if ‘back-seat’ feature on gate/globe valve was not imposed in 1990.

Sorry, it is just a sad story and reality that this still happened in 21st century.

Regards,
Danlap

Tragic event, and sadly preventable. I wonder if it's not practical to add a set of nuts for pressure retention between the valve body and actuator mounting bracket?

Interesting that the report did not touch on the culture of turnarounds. I have no firsthand knowledge of turnarounds at Lyondell Basell in La Porte, but turnarounds are commonly rife with workers working dangerously long double- and triple-shifts, managing safety on the fly, and doing 'whatever it takes' to get it done now. For a contractor to specialize in turnaround support, implies a business environment that rewards a contractor for pushing ahead, meeting unreasonable schedules, and working for customers who are minimally present and don't want to be interrupted for any reason. And then to go to the very next jobsite and do the same thing again and again seems brutal, stressful, and risky. At least the regular plant workers get some normal operating time in between turnarounds.

Thanks for this information, with all symphaty to the victims and their families.

We can always improve products technically to prevent wrong operation or demounting. But, again, nothing can 100% protect against an operator with insufficient knowledge of the product.

For pressure retaining components, where released content can give damage to persons, environment and equipment there is a well known common known routine, often used by by top safety factories:

No visits, repair or operations to vessels (including all lines, valves and operational instruments and devices) without an exact, written documentation of what is planned to do. Plans approved by qualified people not directly doing or participating in the task. In this case a descrption would be : removing actuator by losing and removing nuts a,b,c,d (illustration), replacing by T on so on.

For this incident you have the unfortunate combination of an already ongoing leakage, nighttime, and probably a pressure to repair as qiuck as possible, resulting in lacking safety procedures. (And in addition perhaps no good written routine of whom to contact and how to handle such an incident? Report says nothing about the factory's dafety procedures status or certification level, just focusing on the valve and actuator)

Safety and qulification of procedures comes always in addition to product design and safety.