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.
Saturday, October 18, 2008
Hidden Hazard Accidents
Safety Lesson Learned: Hidden Hazard Accidents
Location of Incident : Office, Workshop or even House
Have you ever bumped into another person or ever been hit by falling or flying object? In 1979 a total of 1,883 lost time claims were filed with the Industrial Commission Of Ohio by Ohio hospital employees. Of these claims, 211 were for injuries that happened when people were struck by moving objects. Lost work days because of these accidents in 1979 numbered 5,472. A few precautions will reduce your chances of becoming one of these statistics.
A door is another moving object that often strikes people. Never stand in front of such a door for an extended period of time. We shouldn’t use a ladder where a door opens toward it unless you can be sure by locking the door or propping it open.
People too can be safely hazards if they do not watch where there are going if they don’t notice threats to his safety that are right in front of him. When approaching a corner there is another possibility to hazards where you cannot see or be seen by those traveling in other directions. Think about how this type of accident can be avoided. The next person you bump into could be carrying hot coffee or sharp objects.
These are some ‘Hidden Hazards’ example which discussed and summarized by team members. There are many more things to think of to avoid this type of accidents from happened.
When It Comes to Safety, Don't Delay It - Say It
Location of Incident : Office, Workshop or even House
Have you ever bumped into another person or ever been hit by falling or flying object? In 1979 a total of 1,883 lost time claims were filed with the Industrial Commission Of Ohio by Ohio hospital employees. Of these claims, 211 were for injuries that happened when people were struck by moving objects. Lost work days because of these accidents in 1979 numbered 5,472. A few precautions will reduce your chances of becoming one of these statistics.
A door is another moving object that often strikes people. Never stand in front of such a door for an extended period of time. We shouldn’t use a ladder where a door opens toward it unless you can be sure by locking the door or propping it open.
People too can be safely hazards if they do not watch where there are going if they don’t notice threats to his safety that are right in front of him. When approaching a corner there is another possibility to hazards where you cannot see or be seen by those traveling in other directions. Think about how this type of accident can be avoided. The next person you bump into could be carrying hot coffee or sharp objects.
These are some ‘Hidden Hazards’ example which discussed and summarized by team members. There are many more things to think of to avoid this type of accidents from happened.
When It Comes to Safety, Don't Delay It - Say It
Ethanol Released
Safety Lesson Learned : Ethanol Released
Location of Incident : Des Moines Terminal
A connector on ½’ flush line of the loading rack alcohol pump broke off, allowing alcohol to spray from the pump whenever trucks were loading. A driver who was preparing to deliver a load of denatured alcohol to the terminal discovered the leak. Approximately 6,800 gallons of alcohol were released. The spill was totally contained, and there were no injuries or fire.
Incident Causes
1. Corrosion caused the pump thrust bearing to fail, creating excessive vibration in the pump and associated piping.
2. The flush line piping was stretched during installation, putting excessive stress on the connections.
Lessons Learned
1. Additional training may be required to assist operators in detecting pump problems before a leak developed.
2. Regular maintenance of pumps is critical to avoid bearing of shaft problems.
3. Pumps must be installed properly and with piping that is capable of withstanding the pressure and stresses of operation.
Location of Incident : Des Moines Terminal
A connector on ½’ flush line of the loading rack alcohol pump broke off, allowing alcohol to spray from the pump whenever trucks were loading. A driver who was preparing to deliver a load of denatured alcohol to the terminal discovered the leak. Approximately 6,800 gallons of alcohol were released. The spill was totally contained, and there were no injuries or fire.
Incident Causes
1. Corrosion caused the pump thrust bearing to fail, creating excessive vibration in the pump and associated piping.
2. The flush line piping was stretched during installation, putting excessive stress on the connections.
Lessons Learned
1. Additional training may be required to assist operators in detecting pump problems before a leak developed.
2. Regular maintenance of pumps is critical to avoid bearing of shaft problems.
3. Pumps must be installed properly and with piping that is capable of withstanding the pressure and stresses of operation.
High Pressure Jet Cleaning
Safety Lesson Learned : High Pressure Jet Cleaning
Location of Incident : BP Chemical, Pahang Malaysia
Brief Account of Incident
The incident occurred at about 3.22 p.m. on Tuesday 15th May 2001 during high pressure (HP) water jet cleaning inside rotary vacuum filter (RVF) B ,BM702B. The contractor worker was doing cleaning for final inspection. The equipment was being overhauled.
During cleaning, the worker who was working alone inside the restricted & confined working area suddenly slipped and sprayed his right foot with the 3000 psi HP water jet stream. The water jet passed through his rubber boot and cut his right big toe. He received a deep lacerated wound measuring about 3 cm long on the lateral side of his right big toe. 7 stitches were administered. On the following day after the incident, he returned to work on restricted to light duty work.
Critical Factors
1. Lack of knowledge and compliance to the plant safety regulation
2. Lack of appropriate PPE – using non-steel toe shoes and no metal leg protectors.
3. Restricted/confined cleaning working area.
4. Improper communication/decision making by staff and contract staff.
5. Slippery condition inside the RVF drum.
Location of Incident : BP Chemical, Pahang Malaysia
Brief Account of Incident
The incident occurred at about 3.22 p.m. on Tuesday 15th May 2001 during high pressure (HP) water jet cleaning inside rotary vacuum filter (RVF) B ,BM702B. The contractor worker was doing cleaning for final inspection. The equipment was being overhauled.
During cleaning, the worker who was working alone inside the restricted & confined working area suddenly slipped and sprayed his right foot with the 3000 psi HP water jet stream. The water jet passed through his rubber boot and cut his right big toe. He received a deep lacerated wound measuring about 3 cm long on the lateral side of his right big toe. 7 stitches were administered. On the following day after the incident, he returned to work on restricted to light duty work.
Critical Factors
1. Lack of knowledge and compliance to the plant safety regulation
2. Lack of appropriate PPE – using non-steel toe shoes and no metal leg protectors.
3. Restricted/confined cleaning working area.
4. Improper communication/decision making by staff and contract staff.
5. Slippery condition inside the RVF drum.
Thursday, October 16, 2008
Plastic Plant Explosion
Safety Lesson Learned: Plastic Plant Explosion
Location of Incident : Malaysia
Brief Account of Incident
The incident occurred during a maintenance operation. Workers were unbolting a five foot cover plate from a process vessel when the explosion occurred. The vessel was used to collect process wastes during process start ups and shutdowns. Preliminary evidence indicated the vessel may have contained process material from aborted start up that continued to react generating pressurized steam. Workers were unaware of the accumulated pressure when they began unbolting the cover plate. The incident resulted in 3 death.
Location of Incident : Malaysia
Brief Account of Incident
The incident occurred during a maintenance operation. Workers were unbolting a five foot cover plate from a process vessel when the explosion occurred. The vessel was used to collect process wastes during process start ups and shutdowns. Preliminary evidence indicated the vessel may have contained process material from aborted start up that continued to react generating pressurized steam. Workers were unaware of the accumulated pressure when they began unbolting the cover plate. The incident resulted in 3 death.
Fall From Height
Safety Lesson Learned: Fall From Height
Location of Incident : Tioxide, Malaysia
Brief Account of Incident
At approximately 07:30 hrs on 01 December 2000 a Tioxide process technician fell down 2.5 metres to ground whilst descending from a potable ladder. It happened during plant start-up. The technician used potable ladder to open manual valve fixed at height. Suddenly the ladder twist and the technician felt down and broke his leg. Luckily he has radio and shout control room personnel. Site first aid and medical personnel attended the technician and taken to the local hospital.
Location of Incident : Tioxide, Malaysia
Brief Account of Incident
At approximately 07:30 hrs on 01 December 2000 a Tioxide process technician fell down 2.5 metres to ground whilst descending from a potable ladder. It happened during plant start-up. The technician used potable ladder to open manual valve fixed at height. Suddenly the ladder twist and the technician felt down and broke his leg. Luckily he has radio and shout control room personnel. Site first aid and medical personnel attended the technician and taken to the local hospital.
High Pressure Incident
Safety Lesson Learned : High Pressure Incident
Location of Incident : USA
Brief Account of Incident
Contract personnel were installing a 3” flow line from a high pressure gas well to a compressor. Two roustabout crew, a backhoe operator and lease operator were present onsite. The flow line installation went uneventfully until the tie in to the compressor header. The flow line was laid in to the header, and a 90% connection was attached to the pipeline. The roustabouts began to thread the 3” pipe to make the connection. One employee went to the header and began to remove the victaulic clamp and blind so that the pipe line could be connected. He heard pressure, but assumed it would bleed off safely. He assured that his body position was not in front of the clamp and blind, and continued to release the bolts on the clamp one thread at a time, alternating between the left and right. Soon, the pressure inside the header trapped between the two valve caused the blind to exit the clamp forcefully, breaking two of the employees fingers and narrowly missing members of the roustabout crew who were in the line of fire.
Location of Incident : USA
Brief Account of Incident
Contract personnel were installing a 3” flow line from a high pressure gas well to a compressor. Two roustabout crew, a backhoe operator and lease operator were present onsite. The flow line installation went uneventfully until the tie in to the compressor header. The flow line was laid in to the header, and a 90% connection was attached to the pipeline. The roustabouts began to thread the 3” pipe to make the connection. One employee went to the header and began to remove the victaulic clamp and blind so that the pipe line could be connected. He heard pressure, but assumed it would bleed off safely. He assured that his body position was not in front of the clamp and blind, and continued to release the bolts on the clamp one thread at a time, alternating between the left and right. Soon, the pressure inside the header trapped between the two valve caused the blind to exit the clamp forcefully, breaking two of the employees fingers and narrowly missing members of the roustabout crew who were in the line of fire.
Saturday, October 13, 2007
Material Release
Safety Lesson learned: Material Release
Location of Incident: Chocolate Bayou, USA
Brief Account of Incident
During a cycle-ending turn around of 2003, a tie-in was made on the Olefins 1 flare header to enable a hydrogen line to be tied in during the 2005 DCP outage. When this line was placed in service after being tied in, the fitting (4” weld-o-let on 8” header) separated from the flare header, leaving an open hole in the header. Analysis of the failure indicated that fatigue failure was the reason the pipe failed. Investigation determined that the line had not been supported for vibration, only for weight.
Potential Outcome
Because this incident left a hole in the flare header as well as an open-ended hydrogen line, the potential outcome was fire.
What Went Wrong
The hydrogen piping that was tied in to the flare header during the 2005 DCP outage was not braced properly to provide adequate protection from fatigue failure of the weld area.
Immediate Causes
Routine activity without thought – Since the tie-in was routine, the designers did not think to analyze for vibration.
System Causes
- Inadequate technical design
- Inadequate assessment of potential failure
- Inadequate standards or specifications
What Went Well
Operator action and the Emergency Response.
Safety Lesson Learned
1. Add a checklist to the piping portion of the specifications dealing with flow-induced vibration.
2. Review the results of the investigation with the engineering departments.
3. Add the review of this incident to the Lessons Learned document for the DCP outage.
4. Review the Hot Tap procedure in the Process Safety Committee.
5. Survey all tie-ins to the flare at Olefins 1 and Olefins 2 to identify other potential issues.
6. Correct any deficiencies found during the audits.
Location of Incident: Chocolate Bayou, USA
Brief Account of Incident
During a cycle-ending turn around of 2003, a tie-in was made on the Olefins 1 flare header to enable a hydrogen line to be tied in during the 2005 DCP outage. When this line was placed in service after being tied in, the fitting (4” weld-o-let on 8” header) separated from the flare header, leaving an open hole in the header. Analysis of the failure indicated that fatigue failure was the reason the pipe failed. Investigation determined that the line had not been supported for vibration, only for weight.
Potential Outcome
Because this incident left a hole in the flare header as well as an open-ended hydrogen line, the potential outcome was fire.
What Went Wrong
The hydrogen piping that was tied in to the flare header during the 2005 DCP outage was not braced properly to provide adequate protection from fatigue failure of the weld area.
Immediate Causes
Routine activity without thought – Since the tie-in was routine, the designers did not think to analyze for vibration.
System Causes
- Inadequate technical design
- Inadequate assessment of potential failure
- Inadequate standards or specifications
What Went Well
Operator action and the Emergency Response.
Safety Lesson Learned
1. Add a checklist to the piping portion of the specifications dealing with flow-induced vibration.
2. Review the results of the investigation with the engineering departments.
3. Add the review of this incident to the Lessons Learned document for the DCP outage.
4. Review the Hot Tap procedure in the Process Safety Committee.
5. Survey all tie-ins to the flare at Olefins 1 and Olefins 2 to identify other potential issues.
6. Correct any deficiencies found during the audits.
Electrical Failure
Safety Lesson Learned: Electrical Failure
Location of Incident: Coryton Refinery, UK
Brief Account of Incident
On 15th September at 08:45hrs local time, a fault developed on the external electrical distribution network that ultimately resulted in all Refinery Units apart from the crude unit and the Boiler House shutting down. The Refinery HV protection system sensed the fault and disconnected the Refinery from the external grid. This resulted in the automatic operation of the Refinery power load shedding system. Prior to the incident the refinery was operating normally.
As a result of the initial disturbance some electrical drives tripped, but either re-accelerated or auto-started. However, on the Continuous Catalytic Reformer (CCR) the Waste Heat Boiler Feed Water Pump (BFW) did not auto-start, resulting in a controlled shutdown of the CCR Unit. The CCR is the only hydrogen producing unit for the Refinery and the loss of a hydrogen supply resulted in a domino shutdown of other hydrogen dependent units.
At approx. 08:55hrs, critical control equipment on the Cracking Complex control console in the Central Control Building (CCB) started to fail due to a fluctuating supply voltage. In response to the lack of unit displays and with the knowledge that the majority of Refinery units were shutting down, the decision was made to shutdown the Cracking Complex whilst control was still available.
Outcome
There were no injuries or any significant environmental emissions during the Refinery shutdown. The lost opportunity cost of the shutdown has been estimated at $10.5MM.
Critical Factors
1. Incorrect co-ordination between the external power supply network and Refinery network protection systems.
2. Failure of the CCR BFW pump-motor drive to auto-start.
3. Voltage fluctuations on the Uninterruptible Power Supply (UPS) system distribution network supplying the CCB.
System Causes
1. Inadequate technical design, input obsolote – Refinery and the external power supply protection system settings are not properly coordinated.
2. Insufficient knowldege transfer – there was a lack of understanding around the full functionality of the auto-start facility when only the duty pump/motor was available.
3. Inadequate evaluation and/or documentation of change – the wiring mode were not adequately evaluated and technical query was not issued.
What Went Wrong
- Poor operation/reliability of Production radio communications system.
- Delays in start-up due to piping failures in Product Movement Area.
What Went Well
- there were no injuries or significant environmental incidents during the Refinery shutdown.
- the Refinery power load shedding system (SCADA) operated as per design.
- the Major Incident Team effectively managed the incident with tremendous team support from all Refinery Department.
- Boiler House facilities including steam and power generation remained on-line.
- All units were made safe and abnormal start-up procedures instigated and followed.
Safety Lesson Learned
1. Need to periodically conduct System Studies and Interconnection Studies to ensure correct settings on electrical protection systems.
2. Need to understand the full functionality of pump auto-start facilities. Realize they can be different in design and functionality.
3. Equipment installations especially on UPS and Safety Critical systems must be thoroughly tested before commissioning.
Location of Incident: Coryton Refinery, UK
Brief Account of Incident
On 15th September at 08:45hrs local time, a fault developed on the external electrical distribution network that ultimately resulted in all Refinery Units apart from the crude unit and the Boiler House shutting down. The Refinery HV protection system sensed the fault and disconnected the Refinery from the external grid. This resulted in the automatic operation of the Refinery power load shedding system. Prior to the incident the refinery was operating normally.
As a result of the initial disturbance some electrical drives tripped, but either re-accelerated or auto-started. However, on the Continuous Catalytic Reformer (CCR) the Waste Heat Boiler Feed Water Pump (BFW) did not auto-start, resulting in a controlled shutdown of the CCR Unit. The CCR is the only hydrogen producing unit for the Refinery and the loss of a hydrogen supply resulted in a domino shutdown of other hydrogen dependent units.
At approx. 08:55hrs, critical control equipment on the Cracking Complex control console in the Central Control Building (CCB) started to fail due to a fluctuating supply voltage. In response to the lack of unit displays and with the knowledge that the majority of Refinery units were shutting down, the decision was made to shutdown the Cracking Complex whilst control was still available.
Outcome
There were no injuries or any significant environmental emissions during the Refinery shutdown. The lost opportunity cost of the shutdown has been estimated at $10.5MM.
Critical Factors
1. Incorrect co-ordination between the external power supply network and Refinery network protection systems.
2. Failure of the CCR BFW pump-motor drive to auto-start.
3. Voltage fluctuations on the Uninterruptible Power Supply (UPS) system distribution network supplying the CCB.
System Causes
1. Inadequate technical design, input obsolote – Refinery and the external power supply protection system settings are not properly coordinated.
2. Insufficient knowldege transfer – there was a lack of understanding around the full functionality of the auto-start facility when only the duty pump/motor was available.
3. Inadequate evaluation and/or documentation of change – the wiring mode were not adequately evaluated and technical query was not issued.
What Went Wrong
- Poor operation/reliability of Production radio communications system.
- Delays in start-up due to piping failures in Product Movement Area.
What Went Well
- there were no injuries or significant environmental incidents during the Refinery shutdown.
- the Refinery power load shedding system (SCADA) operated as per design.
- the Major Incident Team effectively managed the incident with tremendous team support from all Refinery Department.
- Boiler House facilities including steam and power generation remained on-line.
- All units were made safe and abnormal start-up procedures instigated and followed.
Safety Lesson Learned
1. Need to periodically conduct System Studies and Interconnection Studies to ensure correct settings on electrical protection systems.
2. Need to understand the full functionality of pump auto-start facilities. Realize they can be different in design and functionality.
3. Equipment installations especially on UPS and Safety Critical systems must be thoroughly tested before commissioning.
Friday, October 12, 2007
Left Eye Injury From Blending Repair Weld
Safety Lesson Learned: Left Eye Injury From Blending Repair Weld
Location of Incident: Dragline 28
Brief Account of Incident
At approximately 1300HRS on the 14th Jan 2003, a boilermaker (not a Fluor project) suffered a serious eye injury from a fragment of shattered grinding disc penetrating the inner lens of his welding helmet and subsequently his eye. The employee was grinding a repair weld on the lower stabiliser link of the RHS propel of the dragline with a 5 inch electric grinder when it is believed
that the tool jammed. It then appears that upon releasing the grinder, the disc shattered and penetrated his eye protection.
The injured person was transported and treated by an eye specialist upon arrival. He has suffered a permanent loss of vision in his left eye.
Contibuting Factors
Pending outcomes of the final investigation, preliminary findings indicate that the below factors may have contributed to the injury:
- Restricted work environment necessitating close proximity to the area being ground.
- Jamming/stalling of the grinder and subsequent failure of the disc wheel.
- The inner lens of the welding helmet, which should be impact resistant, may inadvertently have been replaced with an anti-splatter cover lens, offering little impact resistance.
As the inner lens of welding helmets are interchangeable, it is possible to replace the inner polycarbonate lens with an anti-splatter cover lens, the latter offering minimal impact resistance
Improvement Measurement
The following preventive actions are being adressed:
- Check of welding helmets on site to ensure the correct lens plates are installed in the correct position.
- Discussion of the incident possible causes and interim preventative measures with mine site personnel.
- Interim measure of mandating a face shield and safety glasses be worn whilst performing grinding as opposed to welding helmets
- Further investigation into equipment and tooling capability / protection levels
Location of Incident: Dragline 28
Brief Account of Incident
At approximately 1300HRS on the 14th Jan 2003, a boilermaker (not a Fluor project) suffered a serious eye injury from a fragment of shattered grinding disc penetrating the inner lens of his welding helmet and subsequently his eye. The employee was grinding a repair weld on the lower stabiliser link of the RHS propel of the dragline with a 5 inch electric grinder when it is believed
that the tool jammed. It then appears that upon releasing the grinder, the disc shattered and penetrated his eye protection.
The injured person was transported and treated by an eye specialist upon arrival. He has suffered a permanent loss of vision in his left eye.
Contibuting Factors
Pending outcomes of the final investigation, preliminary findings indicate that the below factors may have contributed to the injury:
- Restricted work environment necessitating close proximity to the area being ground.
- Jamming/stalling of the grinder and subsequent failure of the disc wheel.
- The inner lens of the welding helmet, which should be impact resistant, may inadvertently have been replaced with an anti-splatter cover lens, offering little impact resistance.
As the inner lens of welding helmets are interchangeable, it is possible to replace the inner polycarbonate lens with an anti-splatter cover lens, the latter offering minimal impact resistance
Improvement Measurement
The following preventive actions are being adressed:
- Check of welding helmets on site to ensure the correct lens plates are installed in the correct position.
- Discussion of the incident possible causes and interim preventative measures with mine site personnel.
- Interim measure of mandating a face shield and safety glasses be worn whilst performing grinding as opposed to welding helmets
- Further investigation into equipment and tooling capability / protection levels
Acetylene Cylinder Fire
Safety Lesson Learned: Acetylene Cylinder Fire
Location of Incident: Kuantan, Pahang
Brief Account of Incident
A contractor was performing gas cutting of handrail modification work on the platform above a sacrificial heater. A flashback occurred of the acetylene supply, back to the cylinder. The firewatcher under the working area noticed the acetylene cylinder had caught a fire. He put out the fire by extinguisher at once with the help of one operator on site. After the fire was extinguished, they found the drain plug of the cylinder was leaking, so they took it to a safe place to let it vent to atmosphere.
An investigation team was organized at once. Later analysis found the probably cause was the acetylene hose at the connection with the flammable arrester was cracked. Simultaneously the drain plug was leaking, which was ignited by flashback.
Potential Outcome
- Cylinder gas explosion
- injury and/or fatality
What Went Well
- The flashback arrester was used and the cylinder explosion was avoided.
- The extinguiser was well prepared and both firewatcher and operator reacted rapidly to deal with the emergency situation
What Went wrong
- The worker did not check gas cylinder for leakage prior to the work commencement.
- The gas hose was aging and has no securing clip.
Immediate Causes
- Following Procedure: The worker didn’t check the tools and equipment properly.
- Use of Tools or Equipment: The hose connection was cracked and without securing clip.
- Inattention/Lack of Awareness: The workers were unaware of leakage and flashback.
- Tools, Equipment and Vehicle: The cylinder had a drain plug leakage and the hose was defective
Location of Incident: Kuantan, Pahang
Brief Account of Incident
A contractor was performing gas cutting of handrail modification work on the platform above a sacrificial heater. A flashback occurred of the acetylene supply, back to the cylinder. The firewatcher under the working area noticed the acetylene cylinder had caught a fire. He put out the fire by extinguisher at once with the help of one operator on site. After the fire was extinguished, they found the drain plug of the cylinder was leaking, so they took it to a safe place to let it vent to atmosphere.
An investigation team was organized at once. Later analysis found the probably cause was the acetylene hose at the connection with the flammable arrester was cracked. Simultaneously the drain plug was leaking, which was ignited by flashback.
Potential Outcome
- Cylinder gas explosion
- injury and/or fatality
What Went Well
- The flashback arrester was used and the cylinder explosion was avoided.
- The extinguiser was well prepared and both firewatcher and operator reacted rapidly to deal with the emergency situation
What Went wrong
- The worker did not check gas cylinder for leakage prior to the work commencement.
- The gas hose was aging and has no securing clip.
Immediate Causes
- Following Procedure: The worker didn’t check the tools and equipment properly.
- Use of Tools or Equipment: The hose connection was cracked and without securing clip.
- Inattention/Lack of Awareness: The workers were unaware of leakage and flashback.
- Tools, Equipment and Vehicle: The cylinder had a drain plug leakage and the hose was defective
Monday, October 1, 2007
Failure of Fire Hose
Safety Lesson Learned: Failure of Fire Hose
Location of Incident: Kerteh, Malaysia
Brief Account of Incident
At approximately 23:45hrs on Sunday 24th February 2003 PEMSB Operation ‘A’ shift started their monthly fire drill. The drill was basically a practice of handling a fire hose. They completed setting up the hoses to the breach and hydrant then started to line up the firewater. After about 5 minutes the Team Leader realized that the water pressure was not very high. He therefore proceeded to the hydrant to increase the opening of the firewater valve. On his way back towards the breach the 2½” hose started snaking for about 10 secs before it separated from the coupling. The hose swung around a radius of approx 10ft for about 15 secs before the firewater isolated by the Team Leader. He was about 5 to 6 meters away from the breach when the hose burst. Upon checking it was found that only the hose was separated while the coupling was still intact to the breach. The binding of the hose was found 10 meters away from the breach. The drill was immediately stopped.
Potential Outcome
Injury to personnel from flying hose or binding
Critical Factors
· Failure of the fire water hose binding
· No checking of the condition of the firewater hose prior to use.
Location of Incident: Kerteh, Malaysia
Brief Account of Incident
At approximately 23:45hrs on Sunday 24th February 2003 PEMSB Operation ‘A’ shift started their monthly fire drill. The drill was basically a practice of handling a fire hose. They completed setting up the hoses to the breach and hydrant then started to line up the firewater. After about 5 minutes the Team Leader realized that the water pressure was not very high. He therefore proceeded to the hydrant to increase the opening of the firewater valve. On his way back towards the breach the 2½” hose started snaking for about 10 secs before it separated from the coupling. The hose swung around a radius of approx 10ft for about 15 secs before the firewater isolated by the Team Leader. He was about 5 to 6 meters away from the breach when the hose burst. Upon checking it was found that only the hose was separated while the coupling was still intact to the breach. The binding of the hose was found 10 meters away from the breach. The drill was immediately stopped.
Potential Outcome
Injury to personnel from flying hose or binding
Critical Factors
· Failure of the fire water hose binding
· No checking of the condition of the firewater hose prior to use.
PTA Forklift Incident
Safety Lesson Learned: PTA Forklift Incident
Location: Kuantan, Malaysia
Brief Account of Incident
After carrying out re-bagging of a damaged PTA bag (1.1 tone) using two forklift trucks, one of the forklift trucks driver got out of the cab to remove the empty bag, as he was standing in front of his forklift and leaning forward to remove the empty bag from the forks of the truck, the second forklift truck (which was now transporting the full bag) made contact with him as the truck driving forward and turning to get out of the gate. This contact knocked the person on to the stationary forklift. The Injured person was sent to local hospital by the emergency response team and given a comprehensive medical check. He was discharged later that morning, suffering only localized bruising.
Possible Immediate Cases
1. Improper use of equipment
The re-bagging operation should use the fixed hoist rather than using two Forklifts.
2. Improper decision-making or lack of judgment
The Injured Person stand at a very dangerous position but he did not pay much attention on it.
3. Routine activity without thought
The Forklift Driver just reverse the Forklift and drive forward, turn without noticing that the person is just in front of his Forklift.
4. Congestion or restricted motion
The Packaging area is too small and there is another Forklift parking there to limit the space for the Forklift movement
Location: Kuantan, Malaysia
Brief Account of Incident
After carrying out re-bagging of a damaged PTA bag (1.1 tone) using two forklift trucks, one of the forklift trucks driver got out of the cab to remove the empty bag, as he was standing in front of his forklift and leaning forward to remove the empty bag from the forks of the truck, the second forklift truck (which was now transporting the full bag) made contact with him as the truck driving forward and turning to get out of the gate. This contact knocked the person on to the stationary forklift. The Injured person was sent to local hospital by the emergency response team and given a comprehensive medical check. He was discharged later that morning, suffering only localized bruising.
Possible Immediate Cases
1. Improper use of equipment
The re-bagging operation should use the fixed hoist rather than using two Forklifts.
2. Improper decision-making or lack of judgment
The Injured Person stand at a very dangerous position but he did not pay much attention on it.
3. Routine activity without thought
The Forklift Driver just reverse the Forklift and drive forward, turn without noticing that the person is just in front of his Forklift.
4. Congestion or restricted motion
The Packaging area is too small and there is another Forklift parking there to limit the space for the Forklift movement
Fire Explosion In Refinery
Safety Lesson Learned: Fire Explosion In Refinery
Location: Thai Oil
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.
Safety 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: Thai Oil
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.
Safety 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.
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