Safety Lesson Learned: Nitrogen Nearmiss
Location of Incident: Bataan Polyethylene, Filipina
Brief Account of Incident
As part of preservation of plant equipment, the Closed Cooling Water System of the extruder barrel was placed under nitrogen. On April 28 the moisture and oxygen levels in the system were monitored to be higher than the acceptable level. The Night Shift Team handed over its recommendation to address the problem to the incoming April 29 Day Shift Team. The day Shift Operations Team decided to do nitrogen pressure swing to bring the down the level of contaminants.
Two Technicians were assigned to the task. During the purging nitrogen was being discharged inside the Additive and Pelletizing building with all access doors open (natural ventilation) but exhaust fans in a shut off condition (no forced ventilation). The point of nitrogen release was less than 2 feet away from the Technicians. The Technicians were using a gas tester. The activity area was not barricaded. The activity was observed during an Advanced Safety Audit tour and was stopped immediately. A Team was immediately formed to conduct the investigation.
What Went Wrong
1. No comprehensive Job Safety Analysis and/or Risk Assessment was performed by the Team prior to the start of the activity.
2. Non-compliance with existing Operating Instructions covering (temporary) preservation related activities.
3. Inadequate communication of established Operating Instructions.
4. Established Instructions and guidelines for nitrogen purging activities do not adequately address all related HSE concerns.
5. Insufficient awareness of people performing the tasks on the imminent danger of nitrogen.
What Went Well
1. The activity was observed and assessed during a regular Advance Safety Audit (ASA).
2. The activity was immediately stopped. As a result, there were no cases of fatality nor injury.
3. Investigation Team was immediately formed.
Safey Lesson Learned
1. Review Procedures and Guidelines to ensure individuals and working teams do perform the appropriate risk assessment prior to starting a new or revised activity.
2. Ensure everyone's compliance to established Work Standing and Operating Instructions (WSI/WOI).
3. Ensure that all established Operating standing Instructions, including temporary equipment preservation instructions, adequately address Safety requirements and concerns.
4. Ensure an approved HSE Plan is available for activities like extended plant preservation.
5. Ensure sufficient knowledge and total awareness of each individual and working teams to different hazards in the workplace especially when handling hazardous materials (N2).
6. Risk management assurance processes need to recognise the degree of competency within the operating team / supervisory staff and also recognise organisational change (for example resignations).
Friday, October 24, 2008
Dropped Object through Open Hatch
Safety Lesson Learned: Dropped Object through Open Hatch
Location of Incident: Forties Delta platform, UK
Brief Account of Incident
Persons were working immediately adjacent to and underneath an open BOP deck hatch. The operation involved changing a Xmas Tree top flange as part of a wire-line rig up. The riser lifting cap, weighing 31.5kgs, was removed to the BOP deck, while an operator remained on location at the Xmas Tree below. When moving the lifting cap the operator on the BOP deck slipped, allowing the cap to fall through the open BOP deck hatch, striking the Injured Person.
Actual or Potential Outcome
Actual: Minor Injury
Potential: Fatality
What Went Wrong
1. Failed to identify the hazard in moving the lifting cap in the risk assessment
2. Did not recognize that changing the Xmas Tree flange was an unusual task compared to a normal rig-up
What Went Well
1. Injured person treated immediately on site for soft tissue injury and bruising to shoulder
2. Work stopped immediately and work permits withdrawn
3. Area was cordoned off immediately
4. Detailed photo set taken to help Investigation Team
Lessons Learned
1. Work practices around open hatches were inadequate
2. The hatch cover that is used whilst working through a hatch did not fit adequately for all circumstances
Location of Incident: Forties Delta platform, UK
Brief Account of Incident
Persons were working immediately adjacent to and underneath an open BOP deck hatch. The operation involved changing a Xmas Tree top flange as part of a wire-line rig up. The riser lifting cap, weighing 31.5kgs, was removed to the BOP deck, while an operator remained on location at the Xmas Tree below. When moving the lifting cap the operator on the BOP deck slipped, allowing the cap to fall through the open BOP deck hatch, striking the Injured Person.
Actual or Potential Outcome
Actual: Minor Injury
Potential: Fatality
What Went Wrong
1. Failed to identify the hazard in moving the lifting cap in the risk assessment
2. Did not recognize that changing the Xmas Tree flange was an unusual task compared to a normal rig-up
What Went Well
1. Injured person treated immediately on site for soft tissue injury and bruising to shoulder
2. Work stopped immediately and work permits withdrawn
3. Area was cordoned off immediately
4. Detailed photo set taken to help Investigation Team
Lessons Learned
1. Work practices around open hatches were inadequate
2. The hatch cover that is used whilst working through a hatch did not fit adequately for all circumstances
Thursday, October 23, 2008
Chemical Enter Waste Oil Treatment
Safety Lesson Learned: Chemical Enter Waste Oil Treatment
Location of Incident: Bataan Polyethylene, Luzon
Brief Account of Incident
59 full drums of waste materials believed to contain waste oil and 26 empty waste oil drums were removed from site and transported to Globecare. The drum contents were inspected at the Globecare treatment facility prior to transferring the waste oil to the stock tank. 19 drums were suspected to contain waste chemicals and not waste oil. Globecare segregated the 19 drums and immediately informed BPC of the incident. BPC completed a site visit to Globecare to assess the incident and formulate solutions and actions jointly with the treatment company. The drums were returned to BPC for containment and investigation. Further tests confirmed that the content of the 19 drums was PVC binder/resin.
Critical Factors
1. Failure to identify and segregate drum waste
2. Failure to positively identify contents of each drum prior to dispatch
3. Inadequate implementation of new waste management procedure
Corrective Actions
1. When implementing new procedures ensure that all employees involved in the task receive training and that their understanding is formally assessed.
2. Positive identification of drums and contents:
3. Durable and weatherproof identification label must be affixed to individual drums
4. Positive identification of waste contents verified against drum label prior to dispatch from site must be done
5. Waste storage area to be purposely designed and suitable for site waste (type & volume).
6. To remove waste from site in a timely manner to prevent unmanageable build up.
Location of Incident: Bataan Polyethylene, Luzon
Brief Account of Incident
59 full drums of waste materials believed to contain waste oil and 26 empty waste oil drums were removed from site and transported to Globecare. The drum contents were inspected at the Globecare treatment facility prior to transferring the waste oil to the stock tank. 19 drums were suspected to contain waste chemicals and not waste oil. Globecare segregated the 19 drums and immediately informed BPC of the incident. BPC completed a site visit to Globecare to assess the incident and formulate solutions and actions jointly with the treatment company. The drums were returned to BPC for containment and investigation. Further tests confirmed that the content of the 19 drums was PVC binder/resin.
Critical Factors
1. Failure to identify and segregate drum waste
2. Failure to positively identify contents of each drum prior to dispatch
3. Inadequate implementation of new waste management procedure
Corrective Actions
1. When implementing new procedures ensure that all employees involved in the task receive training and that their understanding is formally assessed.
2. Positive identification of drums and contents:
3. Durable and weatherproof identification label must be affixed to individual drums
4. Positive identification of waste contents verified against drum label prior to dispatch from site must be done
5. Waste storage area to be purposely designed and suitable for site waste (type & volume).
6. To remove waste from site in a timely manner to prevent unmanageable build up.
Texas City Refinery
safety Lesson Learned: Texas City Refinery
Location of Incident: Texas City
Brief Account of Incident
Oxygen deficient environment while working on a Resid Hydrotreater Reactor Ebulating Pump Motor overcame a BP Instrument/Electrical Technician. The RHU 200 Ebulated Bed Reactor train was shut down on 12/4/01 to replace an Eb Pump/Motor, which was damaged during a power failure. As part of the work process for replacing an Eb Pump/Motor, a nitrogen purge is maintained on the reactor train while the work is taking place. The replacement Eb Pump/Motor was in place and the I&E Technician was in the process of checking the electrical continuity on the motor when an Oxygen Deficient Environment temporarily overcame him.
The I&E Technician was evaluated by the BP Medical Staff and released to return to work with no restrictions. A Level 3 Investigation team has been formed due to the serious nature of the event. Additional findings from the investigation will be communicated when the investigation is complete.
Potential Outcome
Fatality
Location of Incident: Texas City
Brief Account of Incident
Oxygen deficient environment while working on a Resid Hydrotreater Reactor Ebulating Pump Motor overcame a BP Instrument/Electrical Technician. The RHU 200 Ebulated Bed Reactor train was shut down on 12/4/01 to replace an Eb Pump/Motor, which was damaged during a power failure. As part of the work process for replacing an Eb Pump/Motor, a nitrogen purge is maintained on the reactor train while the work is taking place. The replacement Eb Pump/Motor was in place and the I&E Technician was in the process of checking the electrical continuity on the motor when an Oxygen Deficient Environment temporarily overcame him.
The I&E Technician was evaluated by the BP Medical Staff and released to return to work with no restrictions. A Level 3 Investigation team has been formed due to the serious nature of the event. Additional findings from the investigation will be communicated when the investigation is complete.
Potential Outcome
Fatality
Golfo Fatality
Safety Lesson Learned: Golfo Fatality
Location of Incident: Golfo San Jorge
Brief Account of Incident
Contractor (WellTech) Work over Rig No.5 had been rigged-down and was in the process of being prepared for transporting to another well site, piece by piece. Whilst loading-up the substructure onto the back of a lorry, with another lorry positioned close by to assist the loading, the substructure became unstable and struck a WellTech employee on the head, fatally injuring him & subsequently throwing him off the lorry. Employee was reported to have adjusted the slings of the load prior to it becoming unstable and striking him.
Action Taken
Incident scene secured. Santa Cruz Province Police contacted. Field PAE HSE and operations personnel attending incident site. PAE Chief Operating Officer & HSE Manager flying to area this afternoon to assist in preparations for Fatal Incident Investigation. Upstream HSE Director contacted to initiate Fatal Incident Investigation.
Lesson Learned
1. No adjustment should be made to the slings while load is hanging.
2. Employee must stay at the safe position during loading the substructure.
3. JSA must be clear and followed before attend any job.
Location of Incident: Golfo San Jorge
Brief Account of Incident
Contractor (WellTech) Work over Rig No.5 had been rigged-down and was in the process of being prepared for transporting to another well site, piece by piece. Whilst loading-up the substructure onto the back of a lorry, with another lorry positioned close by to assist the loading, the substructure became unstable and struck a WellTech employee on the head, fatally injuring him & subsequently throwing him off the lorry. Employee was reported to have adjusted the slings of the load prior to it becoming unstable and striking him.
Action Taken
Incident scene secured. Santa Cruz Province Police contacted. Field PAE HSE and operations personnel attending incident site. PAE Chief Operating Officer & HSE Manager flying to area this afternoon to assist in preparations for Fatal Incident Investigation. Upstream HSE Director contacted to initiate Fatal Incident Investigation.
Lesson Learned
1. No adjustment should be made to the slings while load is hanging.
2. Employee must stay at the safe position during loading the substructure.
3. JSA must be clear and followed before attend any job.
Sunday, October 19, 2008
Fire Explosion in Thai Oil
Safety Lesson Learned: Fire Explosion in Thai Oil
Location of Incident: Thailand
Brief Account of Incident
Basically one of their gasoline tanks overflowed. A security guard detected a strong smell and notified shift control who sent two operators to investigate. They don’t walk but they drive. Say no more, the bang was so big and shook the apartment building in Pattaya about 20kms away.
The fire spread from one tank to 4 others before it was contained and eventually put out by allowing the fuel to completely burn out, over 100,000 litres. There was 8 fatalities and 13 hospitalized with serious injuries. Fortunately it had occurred during silence hours and save over 100 people as admin building, maintenance workshop store and medical center were either completely gutted or severely damaged by the blast.
Lesson Learned
1. If you see a release of flammable material: Turn in the plant alarm, identify the wind direction.
2. If you hear any plant alarm: Stop work, extinguish cigarettes, if you’re in a vehicle immediately stop and turn off the engine.
3. If the plant alarm for toxic gas: Assembly point is in control room.
4. There should a rules for taking vehicles anywhere inside a plant. For such situation confine all vehicles to the main roads and designated parking areas.
5. Never forget that we handle very dangerous chemicals. Be careful and follow the HSE procedures, operating procedures and maintenance procedures so horrible accidents such as this can be avoided.
Location of Incident: Thailand
Brief Account of Incident
Basically one of their gasoline tanks overflowed. A security guard detected a strong smell and notified shift control who sent two operators to investigate. They don’t walk but they drive. Say no more, the bang was so big and shook the apartment building in Pattaya about 20kms away.
The fire spread from one tank to 4 others before it was contained and eventually put out by allowing the fuel to completely burn out, over 100,000 litres. There was 8 fatalities and 13 hospitalized with serious injuries. Fortunately it had occurred during silence hours and save over 100 people as admin building, maintenance workshop store and medical center were either completely gutted or severely damaged by the blast.
Lesson Learned
1. If you see a release of flammable material: Turn in the plant alarm, identify the wind direction.
2. If you hear any plant alarm: Stop work, extinguish cigarettes, if you’re in a vehicle immediately stop and turn off the engine.
3. If the plant alarm for toxic gas: Assembly point is in control room.
4. There should a rules for taking vehicles anywhere inside a plant. For such situation confine all vehicles to the main roads and designated parking areas.
5. Never forget that we handle very dangerous chemicals. Be careful and follow the HSE procedures, operating procedures and maintenance procedures so horrible accidents such as this can be avoided.
Fall From Height
Safety Topic Incident: Fall From Height
Location of Incident: Venezuela
Brief Account of Incident
During an Acid job a Halliburton operator climbed to the top of a tank truck to check the fluid level in the tank. He leaned against handrail and the handrail failed causing him to fall to the ground approximately 3 meters. He suffered a sprained ankle.
Lesson Learned
1. Pre job equipment checklist should be thorough and should cover all safety equipment to protect personnel when working at height.
2. JSA (Job Safety Analysis) should cover all at risk tasks when working at heights.
3. Handrail design can be changed to make it more stable and fool proof.
4. Review and inspect all safety equipment when working at height with pre job checklist and JSA’s.
Location of Incident: Venezuela
Brief Account of Incident
During an Acid job a Halliburton operator climbed to the top of a tank truck to check the fluid level in the tank. He leaned against handrail and the handrail failed causing him to fall to the ground approximately 3 meters. He suffered a sprained ankle.
Lesson Learned
1. Pre job equipment checklist should be thorough and should cover all safety equipment to protect personnel when working at height.
2. JSA (Job Safety Analysis) should cover all at risk tasks when working at heights.
3. Handrail design can be changed to make it more stable and fool proof.
4. Review and inspect all safety equipment when working at height with pre job checklist and JSA’s.
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