tag:blogger.com,1999:blog-279744432024-03-08T05:35:42.601-08:00SAFETY TOPIC INCIDENTGET INFO ON SAFETY INCIDENT TOPIC FOR YOUR SAFETY TALK TOPIC AND SAFETY LESSON LEARNEDUnknownnoreply@blogger.comBlogger40125tag:blogger.com,1999:blog-27974443.post-25015224000301103122007-09-14T03:55:00.000-07:002007-09-14T03:59:01.424-07:00Confined Space Entry Incident<strong>Safety Incident Topic: Confined Space Entry<br />Location of Incident: Blaine, USA</strong><br /><strong>Date of Incident: Unknown</strong> <br /><br /><strong><span style="color:#009900;">Brief Account Of Incident</span></strong><br />H2 Plant Caustic Scrubber was blinded and permitted for entry. After several hours of work in the tower by a contractor, an engineer came into the tower to take pictures. His personal LEL meter was set off. The tower entry permit was pulled. Safety checked the tower and found 100%+ of LEL at the top of the tower.<br /><br /><strong><span style="color:#009900;">Potential Outcome</span></strong><br />Potential for serious injury or fatality to individuals entering into the tower in an atmosphere which exceeded the LEL(lower explosive limit).<br /><br /><strong><span style="color:#009900;">Likely Causes</span></strong><br />Initial investigation indicates that the full thickness blind for the top of the tower, which was located near grade, had spreaders on the tower side to allow steam and condensate during tower cleanup. The spreaders were not removed for tower entry. A small hydrogen leak was seeping past a gasket on the process side of the blind. The hydrogen educted up the line to the top of the tower.<br /><br /><strong><span style="color:#009900;">Action Taken</span></strong><br />Entry permit pulled. Leaking plug valve upstream of blind pumped with grease. Speaders on blind pulled and gaskets replaced. Tower purged with blower air. A root cause investigation has been initiated.Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-27974443.post-89239067837259952562007-09-12T16:48:00.000-07:002007-09-12T16:55:10.292-07:00Electrical Shock Incident<strong>Safety Incident Topic: Electrical Shock Incident</strong><br /><strong>Location of Incident: Kuantan, Malaysia</strong><br /><strong>Date of Incident: 5 December, 2005</strong><br /><br /><strong><span style="color:#009900;">Brief Account of Incident</span></strong><br />On the 5th of December 2005 about 2 pm, an electrical technician felt a minor electrical shock by a 240 volts AC supply. During the incident, he was installing a small instrument roof and re-routing the pressure switch cable entrance and piping from top position to downward position. He stopped the job and noticed some water trapped inside the cable gland & terminal box. There is no injury to the technician. The incident was reported four days later.<br /><br /><span style="color:#009900;"><strong>Outcome<br /></strong></span>The technician could have been fatally electrocuted or seriously injury<br /><br /><strong><span style="color:#009900;">Critical Factors</span></strong><br />- Rain water trapped inside the switch terminal block<br />- Technician rotated the switch with bare hand while the switch was hooked up with 240 volts AC supply<br /><br /><strong><span style="color:#009900;">Immediate Root Causes</span></strong><br />- Ineffective protection from previous seal (old silicone sealant peeled off) to prevent water seepage into the switch<br />- Lack of knowledge of hazards present – not aware of trapped water hazard<br />- Routine activity without thought – normal practices that isolation was not required if work involves only the body of the switch<br />- Inadequate PPE – technician should protect both hand with glove before touching the switch casing<br />- Inadequate isolation of process or equipment – 240 volts was not isolated<br /><br /><strong><span style="color:#009900;">System Root Cause</span></strong><br />- 240 volts supply to the instrument is not favorable design for instrument supply<br />- Inadequate implementation of PSP, due to deficiencies – as per LOTO procedure, any electrical energy (24 – 240 volts) should be isolated but not in this case as work was carried out on the casing.<br /><br /><strong><span style="color:#009900;">Lesson Learned</span></strong><br />- No matter how small or insignificant an incident maybe, it should be reported timely so that appropriate measures can be taken.<br />- The proper power supply should be clearly identified/labeled at site.<br />- 240 volts AC supply should not be used for instrumentation (budgeted to be changed in 2006)<br />- All E/I technicians are reminded to be more vigilant about the hazard of any 240 volts AC supplied instrumentation.<br />- To review the existing LOTO procedure to address the hazards of working with 240 volts AC power supply and its isolation requirements.Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-27974443.post-32297312138198805452007-09-12T16:35:00.000-07:002007-09-12T16:48:04.129-07:00Boiler Fuel Oil Leakage<strong>Safety Incident Topic: Boiler Fuel Oil Leakage</strong><br /><strong>Location of Incident: Capco, Taiwan</strong><br /><strong>Date of Incident: 17 July, 2005</strong><br /><br /><span style="color:#009900;"><strong>Brief Account of Incident</strong></span><br />On July 17th 03:10, BU6 operator discovered oil from the Oil Separator was pumped to open ditch within the plant site. After checked the related pipeline, he found that one of boilers fuel oil pump, AG-602B, casing drain was not fully closed. It was estimated that a total of approximately 11 MT of fuel oil leaked since July 15th 17:30 when AG-602B was undergoing a testing run after repaired work by the maintenance team. The open ditch is a close system connected to the plant’s wastewater treatment system, and hence the oil did not flow outside of the plant site. Plant emergence response team was activated immediately and all oil was collected from the open ditch and Oil Separator and open ditch was cleaned on the same day. The collected oil was sent to Chinese Petroleum Corp. CPC for further treatment. There was no damage to the plant and the outside environment.<br /><br /><span style="color:#009900;"><strong>Potential Outcome</strong></span><br />Overload wastewater treatment system and increase waste water effluent fee from Union wastewater treatment plant of Industrial Zone.<br /><br /><strong><span style="color:#009900;">What Went Wrong</span></strong><br />1. One of boiler fuel oil pump, casing drain leaked<br />2. Oil separator was accumulated a lot of fuel oil<br />3. Inadequate enforcement of safety procedure<br /><br /><strong><span style="color:#009900;">SUMMARY OF IMMEDIATE CAUSES</span></strong><br />1. Defective equipment - Fuel oil pump’s casing drain was connected with dark plastic hose, and then to a collection pipe. Operator can not easily check leak status.<br />2. Improper decision making or lack of judgment - Operator started air pump to remove bottom water from oil separator but didn’t make sure pump discharge fluid was water or oil.<br />3. Inadequate or excessive illumination - Oil separator area is poorly illuminated.<br /><br /><strong><span style="color:#009900;">SUMMARY OF SYSTEM CAUSES</span></strong><br />Inadequate enforcement of PSP - Field operators was not properly enforced to patrol and detect equipment leakage.Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-27974443.post-87701774861598591832007-09-11T19:59:00.000-07:002007-09-11T20:04:36.447-07:00Fall From Scaffolding<strong>Safety Incident Topic: Fall From Scaffolding</strong><br /><strong>Location of Incident: TExas, USA</strong><br /><strong>Date of Incident: 29 august, 2007</strong><br /><br /><strong><span style="color:#009900;">Brief Account of Incident</span></strong><br />On August 29 at approximately 14:00, a worker fell headfirst over a scaffold rail from a height of 30 feet. He was in the process of pulling plastic sheeting for a sandblasting barrier over a 42” pipe. He was tied-off with a double lanyard to a scaffolding top rail. When he lost his balance and fell backwards, one end of the anchor rail became disconnected. There was potential for the lanyards to become disconnected from the anchor rail which could have allowed the worker to fall to ground level. Two coworkers on the platform were able to quickly pull him back onto the deck. The worker was evaluated at the clinic, released and returned to work.<br /><br />It is not known at this time if the scaffold rail pinning mechanism failed or if it was not installed properly.<br /><br /><a name="OLE_LINK1">Work planning did not consider alternate work positions which may have prevented the fall hazard. Hazard elimination and control was not discussed for working on top of the pipeline for this task. The worker did not inspect and verify the anchor rail connections before use.</a><br /><br />An incident investigation has been initiated and the lessons learned document will be available by September 30, 2007.Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-27974443.post-45444082317353250802007-09-09T07:24:00.000-07:002007-09-09T07:49:26.242-07:00Explotion Incident<strong>Safety Incident Topic: Explotion Incident</strong><br /><strong>Location of Incident: Texas, USA</strong><br /><strong>Date of Incident: Unknown</strong><br /><br /><strong><span style="color:#009900;">Brief Account Of Incident</span></strong><br />A trailer being towed by a forklift snagged and pulled a small drain valve out of a strainer in a liquid propylene system. Escaping propylene rapidly vaporized, forming a large flammable vapor cloud. Two minutes after the released the vapor ignited creating an explosion. The explosion knocked down several and burned two (one seriously) operators exiting the unit. Flames from the fire reached more than 500 feet in the air .Because of the size of the fire, Formosa initiated a site-wide evacuation. Fourteen workers sustained minor injuries including<br />scrapes and smoke inhalation. The extensive damage shut down Olefins II unit for 5 months<br /><span style="color:#009900;"><strong></strong></span><br /><span style="color:#009900;"><strong>Incident Analysis</strong></span><br /><br /><strong>1. Vehicle Impact Protection<br /></strong>The polypropylene involved in this incident protruded into an open space, yet had no impact protection. Formosa has administrative safeguards for vehicle operation in the unit but not specifically address the operating safe area. The plant design drawing are also not marked in the unit. Guidance about protecting control pipelines is stated that protective measure should be in place to prevent impact.<br /><br /><strong>2. Structual Steel Fire Protection</strong><br />During the fire , part of a stucture suppoting the relief valves and emergency piping to flare header collapsed. Passive fire protection was installed only on three of four support column rows and the column supported the pressure relief valves and emergency vent pipe had no firefroofing. The API “Fire froofing Practices In Petroleum And Petrochemical Processing Plants” publication was issued after Kellogs was contracted for the early design. If had the steel been firefroof as API recommend. The consequences of this incident would likely have been less severe.<br /><br /><strong>3. Remote Equipment Isolation</strong><br />A check valve and remote isolation valve located downstream of the leak prevented the backflow of propylene from storage product. Operator were unable to reach the manual valve to isolate the leak as well as local control station to turn off pump supplying propylene. Kellogg specified the remote operation of islotaion valves and equipment only at the local.<br /><br /><strong>4. Flame Resistance Clothing</strong><br />Neither of the two operators burned in this incident were wearing FRC. Had they been heir injury wolud likely have been less severe. Formosa point comfort evaluated requiring FRC following two incident where static electricity was suspected og igniting hydrocarbon releases but decided not require FRC for operator in the Olefin II Unit except for those involved in emergency response.<br /><br /><strong><span style="color:#009900;">Lesson Learned</span></strong><br /><br /><strong>Hazard Reviews</strong><br />While Formosa conducted a preliminary hazard analysis, a process hazard analysis, a siting analysis, and a PSSR prior to operating the Olefins II unit, these reviews did not fully address protection of specific process equipment from vehicle impact or the use of remotely actuated valves to control a catastrophic release.When performing a hazard analysis, facility siting analysis, or pre-startup safety review, vehicle impact and remote isolation of catastrophic releases should be investigated.<br /><br /><strong>Flame resistant clothing</strong><br />Formosa had prior incidents of flash fires from hydrocarbon leaks and evaluated the use of FRC. However, Formosa did not require FRC for operators working within the unit, even though the large flammable liquid and gas inventory may put operators at risk of injury from flash fires.In process plants with large flammable liquid and/or gas inventories, mechanical failures can result in flash fires that endanger workers. The use of FRC may limit the severity of injury to employees who work in plants with large inventories of flammable gases and liquids.<br /><br /><strong>Use of Current Standards<br /></strong>The the plant design used at Formosa multiple times between the mid-1980s and 2000. However, the design was not updated to incorporate improved recommended practices with respect to fireproofing structural steel that supports critical safety systems.<br />Evaluate the applicability and use of current consensus safety standards when designing and constructing a chemical or petrochemical process plant. This should include reviewing and updating earlier designs used for new facilities.Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-27974443.post-35561315744132108872007-09-07T09:09:00.000-07:002007-09-07T09:17:39.862-07:00Gas Leak Out of Broken Drain Pipe<strong>Safety Incident Topic: A Crack On the Weld of a Pump Drainage Pipe</strong><br /><strong>Location of Incident: Lingen, Germany</strong><br /><strong>Date of Incident: 10 May, 2005</strong><br /><br /><strong><span style="color:#009900;">Brief Account of Incident</span></strong><br />May, 10 2005, while a contract worker performed assembly work on the Feed pump he accidentally damaged a drain pipe of the pump housing. This causes a strong gas leakage out of the broken drain pipe.<br /><br />RESULT: Formation of light gasoline gas cloud at the downstream of the furnace reformer. The pump is stopped and changed over, while applying adequate PSA. The cloud is dispersed by steam with involvement of the fire brigade team.<br /><br /><strong><span style="color:#009900;">What Went Well</span></strong><br />· The contractor informed control room operators immediately.<br />· Quick identification of the problem on site<br />· Quick and safe change over the pump and using breathing mask as well as fire brigade support<br />· Fortunately the wind direction was turned away from the furnace.<br /><br /><strong><span style="color:#009900;">What Went Wrong </span></strong><br />As a general rule, it is prohibited to step onto piping regardless if assembly work is done or during operations. Unfortunately this cannot always be avoided due to the location of valves and piping. A weld failed at a location which was not fulfilling the required quality levels.<br /><br /><strong><span style="color:#009900;">Direct Causes</span></strong><br />1. Leakage due to stepping on the drain pipe.<br />2. Insufficient weld at the pump drainage.<br /><br /><strong><span style="color:#009900;">Causes In The System</span></strong><br />Reconsider of Integrity management for inspection and documentation of nozzles.<br /> <br /><strong><span style="color:#009900;">Direct Measurements<br /></span></strong>1. Immediate repair of the defect weld.<br />2. Inspection of neighbouring welds, also at the parallel feed pump GA-1804A via x-rays (without findings).<br />3. Clarifying discussion with the contractor, who can demonstrate long lasting experience in the Lingen refinery.<br /><br /><strong><span style="color:#009900;">Lessons Learned<br /></span></strong>1. Leakages even on small pipes could have serious consequences for people and equipment<br />2. Nozzle inspection programs must be completed and well documented<br />3. For limitation of damages process units have to be divided up into smaller, containable sections.Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-27974443.post-33372502005264700782007-09-07T08:57:00.000-07:002007-09-07T09:07:55.897-07:00Electrical Failure<strong>Safety Incident Topic: Electrical Failure</strong><br /><strong>Location of Incidetn: Coryton, UK</strong><br /><strong>Date of Incident: 15 September, 2005</strong><br /><br /><strong><span style="color:#009900;">Brief Account of Incident</span></strong><br />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.<br />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.<br />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.<br /><br /><strong><span style="color:#009900;">Outco</span><span style="color:#009900;">me</span></strong><br />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.<br /><br /><strong><span style="color:#009900;">Critical Factors</span></strong><br />1. Incorrect co-ordination between the external power supply network and Refinery network protection systems.<br />2. Failure of the CCR BFW pump-motor drive to auto-start.<br />3. Voltage fluctuations on the Uninterruptible Power Supply (UPS) system distribution network supplying the CCB.<br /><br /><strong><span style="color:#009900;">System Causes</span></strong><br />1. Inadequate technical design,input obsolote – Refinery and the external power supply protection system settings are not properly coordinated.<br />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.<br />3. Inadequate evaluation and/or documentation of change – the wiring mode were not adequately evaluated and technical query was not issued.<br /><br /><span style="color:#009900;"><strong>What Went Wrong</strong></span><br />- Poor operation/reliability of Production radio communications system.<br />- Delays in start-up due to piping failures in Product Movement Area.<br /><br /><span style="color:#009900;"><strong>What Went Well</strong></span><br />- There were no injuries or significant environmental incidents during the Refinery shutdown.<br />- The Refinery power load shedding system (SCADA) operated as per design.<br />- The Major Incident Team effectively managed the incident with tremendous team support from all Refinery Departments.<br />- Boiler House facilities including steam and power generation remained on-line.<br />- All units were made safe and abnormal start-up procedures instigated and followed.Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-27974443.post-83944715002397085482007-09-07T08:40:00.000-07:002007-09-07T08:45:19.416-07:00Falling Motor During Lifting<strong>Safety Incident Topic: Falling Motor During Lifting Work</strong><br /><strong>Location of Incident: Geel, Belgium</strong><br /><strong>Date of Incident: 10 April, 2002</strong><br /><br /><span style="color:#009900;"><strong>Brief Account of Incident<br /></strong></span>· Cover plate of the electrical connecting box was removed to enable motor removal from equipment.<br />· Removal of cover plate created sharp edge that made contact with the lifting strap.<br />· During reinstallation, the workers experienced problems to position the motor and had to man oeuvre it to enable reconnection.<br />· The lifting strap was cut over sharp edge of the connecting box.<br />· The motor fell down on the leg of one of the workers.<br />A second worker jumped away and experienced a slight cut.<br />· The lifting chain caught the motor and kept it hanging in the air and prevented the motor from falling on the next platform 2 m down.<br /><br /><span style="color:#009900;"><strong>What Went Wrong</strong></span><br />· The lifting works were not stopped to evaluate the situation at the moment the job was perceived to be more complex than initially anticipated.<br />· The sharp edge was not noticed (was covered with plastic bag) and so the risk was not seen.<br />· A lifting strap was used that was overdue on approval.<br />Potential Outcome: DAFW–case (more serious injury) or Fatality<br /><br /><span style="color:#009900;"><strong>What Went Well</strong></span><br />· Medical treatment and follow -up.<br />· Quick response from mechanics involved to safely position motor.<br /><br /><span style="color:#009900;"><strong>Lessons Learned</strong></span><br />· Lifting training is needed that covers how to deal with sharp edges.<br />· Evaluate who should be trained to do (manual) lifting works.<br />· Improve warehouse storage process to have sufficient approved safety material available.<br />· Evaluate what ideas can be copied from TAR’s during a smaller stop (eg container with safety material in unit).<br />· Evaluate need for a plant-wide procedure/checklist for doing (manual) lifting works.Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-27974443.post-32990531420942418122007-09-06T12:34:00.000-07:002007-09-07T08:49:52.536-07:00Check Valve Counterweight Failure<strong>Safety Incident Topic: Check Valve Counterweight Failure<br />Location of Incident: Compressor Building Cooper River, America<br />Date of Incident: 20 July, 2007<br /><br /></strong><span style="color:#009900;"><strong>Brief Account of Incident<br /></strong></span>While commissioning the gas expander, an operator was hit in the leg by a falling weighted lever from a check valve. The check valve was located approximately 20ft above the operator’s position at the time of failure. The weighted lever, weighing 15-20 pounds, hit the ground and then grazed the operator’s leg. There was no damage to equipment, no one was injured, and there was no harm to the environment.<br /><br /><span style="color:#009900;"><strong>What Went Wrong<br /></strong></span>1. The check valve counterweight assembly is held together with setscrews which can work loose over time and allow the weight to fall from the valve.<br />2. The check valve is installed high overhead in an area where there is operations activity.<br /><br /><span style="color:#009900;"><strong>Summary of Immediate Causes<br /></strong></span>Inadequate guards or protective devices – The swing check valve did not have a secondary means of securing the counterweight balance assembly from falling due to vibration or fatigue.<br /><br /><span style="color:#009900;"><strong>Summary of System Causes</strong></span><br />Inadequate preventative Maintenance – This check valve does not have a PM in SAP to check for functionality or proper operation of the counterbalance assembly.<br /><br /><span style="color:#009900;"><strong>Summary of Local Actions</strong></span><br />Upon investigation of this check valve, it was determined that the external counterweight assembly is an optional accessory that assists the operation of the valve. In this application, the counterweight was deemed not necessary and removed. The counterweight is primarily used in check valve applications where increased closing speed is necessary.<br /><br /><strong>The following actions were taken:</strong><br />1. All check valve installations were checked to identify any potential risk to personnel from falling object/counterweight.; Those check valves w/counterweights not in applications requiring increased closing speed will have the counterweights removed to prevent future incidents.<br />2. In areas where the counterweight assembly would not cause a danger; the assembly was left in place and verified to be secure (tack welded) and operating as designed.<br /><br /><span style="color:#009900;"><strong>Lesson Learned</strong></span><br />All check valves that have external counter weights that upon failure or fatigue could cause a potential falling object hazard will need a PM frequency that will mitigate the hazard. These same check valves will need an additional means of securing the counter weight to prevent a future failure (tack welding is an option).Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-27974443.post-82361100322154199092007-09-05T07:56:00.000-07:002007-09-07T08:51:20.249-07:00Fall From Height<span style="color:#000000;"><strong>Safety Incident Topic: Fall From Height</strong></span><br /><span style="color:#000000;"><strong>Location of Incident: Construction Site, Taichang China</strong></span><br /><span style="color:#000000;"><strong>Date of Incident: 27 January, 2007</strong></span><br /><br /><span style="color:#009900;"><strong>Brief Account of Incident</strong></span><br />A contract worker fell from a permanent work deck located 6m above the ground. The investigation revealed that on the morning of the incident, a wooden temporary platform was constructed and then positioned 1.2m./4 ft. (horizontally) from the edge of the steel permanent deck and 1m./3.3ft.(vertically) above it. The worker was standing on the wooden temporary platform in order to grind on an over head pipe. While repositioning himself, he stepped off the wooden temporary platform. The 1m fall caused the worker to lose his balance. When he landed on the steel permanent work deck, he rolled toward the edge, fell through an incomplete guardrail (top rail only), and landed on the concrete floor below. Immediately following the incident, the worker was taken to the hospital and released to work without restrictions. The extent of his injuries was a bruised torso.<br /><br /><span style="color:#009900;"><strong>Immediate Causes</strong></span><br />- Lack of knowledge of hazards present- Unprotected height<br />- Inadequate guards of protective measures<br /><br /><span style="color:#009900;"><strong>Root Causes</strong></span><br /><strong>1. Inadequate identification of critical safe behaviour</strong><br />Following the installation of the guard rail (top rail only) around the blend deck, the on-site contractor and BP personnel did not recognize the requirements for fall protection when a guardrail is missing a mid-rail and toe board. Once enhanced procedures are communicated to site personnel, extensive HSSE auditing would help to identify unsafe conditions or actions.<br /><strong>2. Inadequate identification of work hazards</strong><br />During the Jan. 27th daily pre-job tool box safety meeting, the pipe work on the steel permanent work deck was not recognized as “working at heights”. Contract supervisors and workers did not identify the increased risk of falling from the temporary work platform and its close proximity to the unprotected edge. They did not understand or recognize that approved fall protection is required when working on an elevated platform with guardrails that are missing mid-rails and toe boards.<br /><strong>3. Inadequate work planning</strong><br />For more than two weeks prior to the installation of mid-rails and toe boards on the guardrails, extensive construction activity was allowed to be performed on the steel permanent work deck without approved fall protection.<br /><strong>4. Inadequate implementation of 'Policies, Standard and Procedure'</strong><br />Standards for Working at Heights were in place but the applicability when working on a flat permanent work deck with an incomplete guardrail had not been addressed. Prior to the incident, the standard had been misapplied due to inadequate detail and implementation.<br /><br /><span style="color:#009900;"><strong>Actions Taken</strong></span><br />1- Revise/update written site safety procedures to enhance requirements for work on elevated walking and working surfaces. Procedures should include a requirement for guardrails to be constructed in full (top rail, middle rail, andtoe boards) at the time of initial installation. Communicate revisions to all site personnel.<br />2- Contractor and BP site personnel should attend additional formal instruction on Risk Assessments and Hazard Identification. The training will include the recognition of potential interactions of simultaneous activities.<br />3- Contract and BP site personnel should implement an enhanced HSSE audit process including HSSE audit checklists.<br />4- BP site construction coordinators should attend contractor planning meetings and ensure that work activities are strategically aligned with HSSE requirements.<br />5- BP site personnel should audit contactors to ensure that documented risk assessments for non-routine and routine permitted work activities are being completed and adequate for the work being performed.6- Communicate the following to all BP and contractor personnel on site. “Everyone must take personal accountability for themselves and for others. Any work viewed as being unsafe must be stopped.”<br /><br /><span style="color:#009900;"><strong>What Went Well</strong></span><br />A Permit to Work for the welding operations and the Daily Risk Assessments had been completed and signed by all contractor employees involved in the task. HSSE Training records for the contract employee were complete and readily available for review.<br /><br /><span style="color:#009900;"><strong>Lesson Learned</strong></span><br />1. Training on Hazard Identification, considering the interactions of location and tasks, needs to be further enhanced.<br />2. Personal accountability of others to stop work that they viewed as unsafe is critical to safe operations.Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-27974443.post-77187101693178402712007-09-05T07:46:00.000-07:002007-09-07T08:51:55.418-07:00Carbon Dioxide Asphyxiation<span style="color:#000000;"><strong>Safety Incident Topic: Carbon Dioxide Asphyxiation Due To Exposure To Carbon Dioxide<br />Location of Incident: 33kV Switchgear Room, Malaysia<br />Date of Incident: 17 April, 2007</strong></span><br /><br /><span style="color:#009900;"><strong>Brief Account of Incident</strong></span><br />A contractor personnel was unconscious due to asphyxiation when a CO2 fire protection system activated inside an electrical switchgear room. The incident occurred during functional testing of a fixed CO2 fire protection system, which had earlier been relocated and isolated, when another CO2 system inside the same area activated. The victim was evacuated from the room by the plant’s emergency response team and regained consciousness after given first-aid treatment.<br /><br /><span style="color:#009900;"><strong>Outcome</strong></span><br />1. One contractor personnel was asphyxiated due to CO2 exposure<br />2. The entire fixed CO2 fire protection system for the 33kV switchgear room was out of service due to loss of CO2 from the cylinders bank.<br /><br /><span style="color:#009900;"><strong>Active Failures</strong></span><br />Unauthorized testing of the CO2 fire protection system by an incompetent personnel.<br /><br /><span style="color:#009900;"><strong>Lesson Learned</strong></span><br />1- All work including functional testing of electrical/instrument system should be approved by authorized personnel of the OPUs. The work should be supervised and performed by competent personnel.<br />2- The effect of a stop-work-order should be made understood to all personnel and necessary actions e.g. cancellation/withdrawal of PTW, evacuation of personnel from the work area etc. should be taken as soon as possible.<br />3- Relevant parties such as Operation, Maintenance Project Team and HSE etc. should be involved in the review of method statements, Job Safety Analysis and other work procedures to ensure all hazards are identified and control measures e.g. isolation requirements are taken.<br />4- Method statement for each task should be documented in detail e.g. the steps to be taken, the specific switch(es) to be isolated etc. The method statement should be discussed with all relevant parties involved including the contractor and subcontractors prior to the job.<br />5- Access into rooms which are protected by fixed fire protection systems e.g. CO2, FM200 etc should be controlled especially during testing of the system.6- Updated drawings to be made available in the plant.Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-27974443.post-10097760796462421772007-09-05T07:12:00.000-07:002007-09-07T08:52:43.328-07:00Warm Diesel Spill<span style="color:#000000;"><strong>Safety Incident Topic: Warm Diesel Spill When Loosening Plug</strong></span><br /><span style="color:#000000;"><strong>Location of Incident: Refinery, Australia</strong></span><br /><span style="color:#000000;"><strong>Date of Incident: 12 June, 2007</strong></span><br /><br /><span style="color:#009900;"><strong>Brief Account of Incident</strong></span><br />The Distillate Ultrafiner was being shut down for maintenance. Part of the procedure called for soda ash washing of a heat exchanger bank. Temporary fittings were required to enable the soda ash wash. Work to prepare for blinding was being conducted by fitters while operators progressed the draining and depressuring of the unit. A plug on a heat exchanger was loosened to check if the heat exchanger was empty and depressured in preparation to installing a soda ash wash fitting. Upon the initial loosening some diesel came out of the tapered plug, but this stopped. Upon further loosening, the plug came out of the socket and ~400L of warm diesel flowed out of the exchanger under pressure. The diesel stream hit a concrete pillar, forming fine droplets. The diesel pooled and ran towards the vacuum distillation charge furnace. The diesel did not ignite. With an operator directing, the fitters responded in running out and manning fire hoses. The supervising operator isolated the heat exchanger bank from the source of pressure. The control room was contacted and instructed to sound the active aid alarm. Emergency responders arrived at the incident scene, relieved the fitters and mitigated escalation. The supervising operator installed the soda ash wash fitting when the system was depressured to re-establish containment. After securing the site, the diesel spill was removed by vacum truck.<br /><br /><strong><span style="color:#009900;">Investigation Findings</span></strong><br />The work was being done following an operations procedure with a blind list under the supervision of an operator. The supervising operator asked the fitters to second bolt a number of heat exchanger flanges to prepare for blinding. The operator and the fitters talked about the step of pulling a plug to install the soda ash wash fitting. The operator thought that he clearly communicated that the step of pulling the plug was not to be done until the blind was in place, after completely draining the heat exchanger bank and isolating it from the stabiliser.The fitters’ understanding was that the operator had instructed them to pull the plug and install the soda ash wash fitting. It was believed that the heat exchanger bank was open to drain to the pump out system. After initially loosening the plug, the fitters checked and confirmed that the figure 8 blind had been swung to the open position and the valves were lined up to the pump out drum. Subsequent checks confirmed that the pump out line was not blocked. The level in the pump out drum remained constant while the heat exchanger was thought to be draining (this is the subject of ongoing investigation). The fitters had conducted a personal job safety analysis (PJSA). The hazard of breaking containment on live equipment was not raised on the PJSA. The procedure had not been progressed to the stage where breaking containment was called for.<br /><br /><span style="color:#009900;"><strong>What Went Wrong (critical factors)</strong></span><br /><strong>1. Containment was broken when it was not safe to do so. </strong>The plug was loosened based on the fitter’s understanding of the operator’s verbal instruction. The operator and the fitter did not have a common understanding of how far the procedure had progressed and whether or not it was safe to break containment.<br /><strong>2. Containment was broken by loosening a plug. </strong>Once the plug came out of the socket, it was impossible to control the outflow of diesel until the system could be isolated from fuel gas pressure.<br /><strong>3. There was no valve or flange on the plug hole to allow a safer means of checking the pressure and liquid level. </strong>Verification that the system was drained and depressured was by loosening the plug. This method was not appropriate.<br /><br /><span style="color:#009900;"><strong>Immediate Causes</strong></span><br /><strong>1. Servicing of energised equipment.</strong> The heat exchanger bank was at stabiliser pressure using fuel gas, let down to flare. The heat exchanger bank had not completely drained when the plug was loosened.<br /><strong>2. Inadequate isolation of process or equipment.</strong> The plug was not a suitable form of isolation from the process to break containment because once the plug was removed from the socket the plug could not be replaced until the system had depressurised.<br /><strong>3. Inadequate equipment.</strong> The heat exchanger bank did not have an adequate or obvious means of determining that the shell side of the heat exchanger was fully drained and depressurised<br /><br /><span style="color:#009900;"><strong>System Causes</strong></span><br /><strong>1. Human factors consideration.</strong> Verbal communications in the plant are susceptible to misunderstanding.<br /><strong>2. Inadequate implementation of policy / standards / procedures.</strong> In the procedure the step for isolating the heat exchangers from the stabilizer appears after the step to install the temporary fittings.The operating procedure was ambiguous on when to install the isolating blind on the shell side inlet of the heat exchanger. The step to install the blind appeared twice in steps K11 and L21. Step L21 appeared after the step (L13) calling for the installation of the soda ash wash fitting.<br /><strong>3. Inadequate assessment of needs and risks the plug</strong> was loosened without positive confirmation that the shell side of the exchanger was drained of liquid and depressurised.<br /><strong>4. Inadequate technical design.</strong> The heat exchanger bank requires periodic repair and maintenance. To prepare for this maintenance, the heat exchanger must be drained, gas freed and opened. The lack of an appropriate facility for checking that the heat exchanger is empty and depressurized represents and inadequate design.<br /><strong>5. Inadequate correction of prior hazard /incident.</strong> The hazard of the plug without an isolation valve was recognised and had been raised at previous turnarounds, but had not been corrected.<br /><br /><span style="color:#009900;"><strong>Summary of The Local Actions</strong></span><br />1. As an additional safeguard, fitters are requested to only loosen and remove plugs,which do not have an isolating valve, in the immediate presence of the supervising operator.<br />2. Implement site measures/procedures on verifying depressurization / isolation prior to breaking containment, checking that they are in line with the new group isolation standard.<br />3. Consider implementing a process for unit shutdown where the state of each section between isolations is shown as they progress (e.g. on the process flow diagram).<br />4. Revise the Ultrafiner shutdown procedures, including; nitrogen purging and closure of valve to stabiliser to occur prior to breaking containment and connections of the soda ash wash fitting; and remove ambiguity about when to install blinds on heat exchangers.<br />5. Revise the breaking of containment procedure to include the hazards of pressure (hydraulic / pneumatic) and how to verify that something is depressurized. Develop a breaking of containment training module.<br />6. Assess the need, develop a plan and implement the plan for fitting isolation valves to plugs in the older units. Alternatively, replace them with nozzles and blank flanges. Back weld plugs that do not need to be removed.<br />7. Address the training of fitters in the appropriate level of emergency response, considering the possibility of them being first responders.<br />8. Communicate the findings of this incident refinery wide to raise awareness.<br /><br /><span style="color:#009900;"><strong>What Went Well</strong></span><br />1. The fitters assisted the operators with the first response.<br />2. The emergency responders reacted quickly, providing more than the required resources to avert escalation of the incident.<br />3. The fitters and operators openly contributed to the investigation.Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-27974443.post-34645088455826332342007-09-03T22:01:00.000-07:002007-09-07T08:55:06.989-07:00Crane Overturned<span style="color:#000000;"><strong>Safety Incident Topic: Crane Overtuned</strong></span><br /><span style="color:#000000;"><strong>Location of Incident: Road Between Tank And Cooling Tower Area</strong></span><br /><span style="color:#000000;"><strong>Date of Incident: 15 January, 2007</strong></span><br /><br /><span style="color:#009900;"><strong>Brief Account of Incident</strong></span><br />A 50 tonnes crane being employed to lift pipes from ground level to a pipe rack 8 meters high located at the west side of the cooling tower. Prior to setting the pipes in place, it was required to blow out (clean) the pipe pieces. There was not enough space on the road between the cooling tower and tank area to extend both sides of the stabilizer fully so one side of crane stabilizer was not fully extended. When the crane operator lifted the pipes and rotated the crane, it overturned in the direction of the shortly extended stabilizer. The crane fell towards the tank area. The crane hook hit the vent pipe on top of the naphtha tank (at a height of 14m) then came to rest on top of the tank. The crane boom was jackknifed and rested on an acetic acid product line which was bent slightly. Fortunately, as the crane overturned slowly, there were no injuries or environmental problems.<br /><br /><span style="color:#009900;"><strong>Potential Outcome</strong></span><br />- Naptha leak / acid leak- single or multiple leakCritical Factors<br />- West side of stabilizers to the tank area was not fully extended due to narrow working space.<br />- Crane rotated in the direction of the not fully extended stabilizers.<br /><br /><span style="color:#009900;"><strong>Immediate Root Causes</strong></span><br />1- Crane stabilizers not fully extended both sides.<br />2- Crane operator miscalculated weight load on un-extended stabilizer side.<br />3- Detailed work procedure was not prepared prior to crane operation specifically.<br /><br /><span style="color:#009900;"><strong>System Root Causes</strong></span><br />1- The crane company supplied 50 ton crane where 25 ton crane was requested-Last minute plan change required the crane to reset and change location to blow out the pipes.<br />2- Crane operator’s decision to continue without change of location; but only adjusting boom angle while rotating the boom<br />3- Employee observed first movement; boom was raised to a high angle and then rotated to prevent overturn.- Crane operator began to lift and commenced his turn simultaneously on return of pipe.- At this position on return run; crane stabilizers on the west side could not support the load causing the crane to overturn.<br />4- In summary:<br />- Work procedures insufficient to task<br />- Proper precautions had not taken<br />- The work procedure did not address specific crane issues.<br />- Lack of employee experience regarding crane operation and safety.<br /><br /><span style="color:#009900;"><strong>Key Actions</strong></span><br />1- Another company contracted to bring 25 ton crane to complete remaining job and new safety procedures utilized during setup and completion of task.<br />2- Spread the narrow working place to extend all stabilizers fully according to newly revised work procedure<br />3- Specific safety protocols and procedures drawn up for use of heavy equipment within SSBP<br />4- All outside contractors to be monitored closely and to follow SSBP safety procedures while working within SSBP<br />5- Safety training plan for outside contractors to address safety issues while performing tasks for SSBP Lesson Learned<br />6- This incident is directly related with lack of sufficient safety procedures in place compared with other major big project. Therefore it is required to increase safety standards even if small project.<br />7- In the event of difference or deviation against original plan, new safety analysis for the situation should be performed within all authorized people.Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-27974443.post-24920550116176231422007-08-29T05:04:00.000-07:002007-09-07T08:53:55.154-07:00Partial Flare Line Blockage<span style="color:#000000;"><strong>Safety Incident Topic: Partial Flare Line Blockage</strong></span><br /><span style="color:#000000;"><strong>Location of Incident: Bulwer Island, Brisbane Australia</strong></span><br /><span style="color:#000000;"><strong>Date of Incident: 9 May, 2007</strong></span><br /><br /><span style="color:#009900;"><strong>Brief Account of Incident</strong></span><br />A back pressure observed at the Vacuum Tower was investigated by Operations and Technical personnel who found that the flare line was behaving as if it was partially blocked. Following a risk assessment, work was commenced to flush the line with steam and high temperature diesel. A relief valve in Crude Residue service was found to be passing. The relief valve and associated equipment was isolated and taken out of service. Flushing, steaming and external heating of the flare line was carried out until the line was cleared.<br /><br /><span style="color:#009900;"><strong>Potential Outcome</strong></span><br />In the event of a large flare loading through unplanned shutdown of major process units, if the flare line had not been cleared, a back pressure in the flare system may have resulted in hydrocarbon venting to atmosphere through Vacuum Tower atmospheric relief valves.<br /><br /><span style="color:#009900;"><strong>Likely Causes</strong></span><br />Currently is under investigation.<br /><br /><span style="color:#009900;"><strong>Action Taken</strong></span><br />Risk assessment had undertaken to establish the basis of continued operation. An exclusion zone was established in affected areas. Line clearing was commenced. Monitoring of progress and for completion was undertaken.Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-27974443.post-64989446480802264592007-08-29T04:52:00.000-07:002007-09-07T08:56:12.940-07:00Crane Incident<strong>Safety Incident Topic: Crane Incident<br />Location of Incident: Kwinana, Australia<br />Date of Location: 24 May, 2007</strong><br /><br />Please detailing an incident at Kwinana a jetties where a crane overbalanced with the boom and load landing on a sampling shed and a pipe rack. The crane driver suffered minor bruising to his right knee in the incident. The crane has been fully secured in place pending the incident investigation and an expert study to determine the appropriate recovery plan. A minor quantity or diesel leaked from the fuel tank but this was captured in a drip tray and recovered. There was no loss of containment from any of the lines impacted. At this time, a full investigation is underway with the findings and the lessons learned to be shared when available.<br /><br /><span style="color:#009900;"><strong>Brief Account of Incident</strong></span><br />At about 1050 on the 24th May a 25 tonne all terrain crane being used to locate scaffold planks on number three jetty overbalanced and the boom came to rest across a sample shed and the pipe rack to the Jetty “T” head. Number three jetty “T” head is the primary Crude unloading jetty.<br /><br /><span style="color:#009900;"><strong>Potential Outcome</strong></span><br />Investigation is underway and will identify the causes<br /><br /><span style="color:#009900;"><strong>Action Taken</strong></span><br />The crane has been stabilized and locked in position preventing any further movement, the area barricaded. Lines to and from the jetty have been valve isolated. Spill trays are in place to prevent any spillage of fuel from the crane fuel tank. Inspection of pipe work and cabling show no damage which could result in a spill.Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-27974443.post-73063802197717820602007-08-28T02:49:00.000-07:002007-09-07T08:57:18.136-07:00Fall of Reinforcing Cage<strong>Safety Incident Topic : Fall of Reinforcing Cage</strong><br /><strong>Location Of Incident : Hull Site, United Kingdom</strong><br /><strong>Date Of Incident : 09 May, 2007</strong><br /><br /><span style="color:#009900;"><strong>Brief Account of Incident</strong></span><br />The incident occurred during installation of piles for the base of a new tank. A 24 metre hole had been drilled and filled with concrete, then an 8 metre long cage of reinforcing bar was to be lowered into the concrete. The first cage became stuck with 2 metres still above ground so it was removed. An attempt was made to lower in a second cage, but it also stuck at the same position, so it was lifted out. Whilst this cage was being moved to a laydown area, with the cage suspended vertically, and with the bottom very close to the ground, the lifting strop appears to have come off the hook which had been suspending it. The cage therefore tipped over, and as it fell, the end of the cage hit one of the workers on the back.The injured man was taken by ambulance to the local hospital and discharged later in the evening. He was cut and bruised, but thankfully suffered no broken bones or internal injuries.<br /><br /><span style="color:#009900;"><strong>Potential Outcome</strong></span><br />Fatality<br /><br /><strong><span style="color:#009900;">Likely Causes</span></strong><br />The reason for the lifting strop coming off the hook is not yet known<br /><br /><span style="color:#009900;"><strong>Actions Taken</strong></span><br />All work has been stopped.The incident is reportable to the Health and Safety Executive under the RIDDOR RegulationsUnknownnoreply@blogger.com0tag:blogger.com,1999:blog-27974443.post-1151167108912468522006-06-24T09:19:00.000-07:002007-09-06T08:23:03.744-07:00Vacum Truck Thermal Burns<span style="font-family:arial;"><strong><span style="font-size:130%;">Safety Incident Topic : Thermal Burns To Operator</span></strong><br /><strong><span style="font-size:130%;">Location Of Incident : Toledo Refinery, United States</span></strong><br /><strong><span style="font-size:130%;">Date Of Incident : 25 May, 2006</span></strong><br /><br /><span style="font-size:130%;color:#009900;"><strong>Brief Account Of Incident</strong></span><br />A Vacuum Truck Operator at Toledo Refinery received significant second degree burns while preparing to offload hot water to a sump. The employee was transported by Life Flight to a hospital for treatment.The investigation team was not able to interview the injured employee. OSHA opened a formal investigation related to the incident that remains on-going at the time of this report.<br /><br /><strong><span style="font-size:130%;color:#009900;">Investigation</span></strong><br />Onyx Industrial Services provides routine vacuum truck and pressure washing services to the refinery. The vacuum tank is fitted with an intake (vacuum valve) and discharge valve. Valves are four-inch, 1/4 turn ball valves with four inch camlock tailpieces. The operator was using a three inch hose for vacuuming (filling the tank) and another three-inch hose at the discharge sump. The intake valve on this truck fitted with a four-to-three inch reducer on the tail-piece to allow connection of a three-inch hose with camlock coupling.<br /><br />After the incident, BP and Onyx inspected the vacuum truck. The vacuum truck was approximately ¾ full and the discharge valve was not leaking. The first person to arrive on-scene after the incident observed the discharge valve wide open, and a four-inch dust cap on the ground. The vacuum valve was closed, with the reducer, and dust cap installed. Manufacturer literature advises dust caps are not intended to contain hazardous materials or pressure.The injured had completed a Job Safety Analysis the day of the incident. He was wearing fire retardant clothing, safety glasses, hard hat, work boots and gloves.<br /><br /><span style="font-size:130%;color:#009900;"><strong>What Went Wrong (Critical factors)</strong></span><br />The injured either failed to notice the discharge valve was open during inspection, or opened the discharge valve before removing the four inch dust cap. The employee was positioned immediately behind the truck. As he removed the four-inch dust cap, he was exposed to the released contents of the vacuum truck.<br /><br /><strong>Critical factors:</strong><br />CF1: the technician removed cap from the discharge tailpiece of the vacuum truck while the discharge valve was in an open position<br />CF2: an inadequately protected technician burned from contact with hot water (estimated at 150 degrees or greater)<br /><br /><span style="font-size:130%;color:#009900;"><strong>Possible Immediate Causes</strong></span><br />- Unintentional error, improperly prepared equipment·<br />- Inadequate protective equipmentPossible System Causes·<br />- Inappropriate course of action (steps to offload truck)· Identification of worksite hazard (hot fluid, dust cap use, PPE)·<br />- Identifation of critical safe behaviours·<br />- Method of verifying absence of hot water behind cap<br /><br /><span style="font-size:130%;color:#009900;"><strong>Key Learnings (addressed by actions)</strong></span><br />1· Do you positively verify absence of thermal hazards before removing caps, plugs or valves from fixed andmobile equipment?<br />2· What safeguards are in place to manage fluids at temperatures >120degree F? (second degree burns occurwith exposure to hot fluids in five seconds at 140 degress F and one second at temperatures of 158 degrees F)<br />3· Is your equipment and that of your contactors designed to minimize the consequences of human error?<br />4· What PPE is required when transferring hot fluids?<br />5· How do you verify that contractors are conforming to their written HSE Plans (e.g equipment inspection, training, procedures, assesment)?</span>Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-27974443.post-1150478038213499882006-06-16T09:55:00.000-07:002007-09-06T07:34:23.282-07:00Electrical Flash Over<strong><span style="font-size:130%;">Safety Incident Topic : Electrical Flash Over</span></strong><br /><strong><span style="font-size:130%;">Location Of Incident : Kuantan, Malaysia</span></strong><br /><strong><span style="font-size:130%;">Date Of Incident : 24th July, 2005</span></strong><br /><br /><span style="font-size:130%;color:#009900;"><strong>Brief Account Of Incident</strong></span><br />A lost time injury incident occurred when a contractor worker was exposed to a severe electrical flash-over while servicing the 11KV cable connection bar in a substation during a turnaround.<br /><br /><span style="font-size:130%;color:#009900;"><strong>Outcome</strong></span><br />First degree burn due to severe electrical flash-over.<br /><br /><span style="font-size:130%;color:#009900;"><strong>Active Failures</strong></span><br />The Active Failure leading to the incident was the 11KV cable connection bar was still energized when the contractor worker applied the earth bonding clamps resulting in a severe electrical flash-over.<br /><br /><span style="font-size:130%;color:#009900;"><strong>Lessons Learned</strong></span><br />1. Two separate PTWs were issued for the same activity:<br />i) servicing of front and back portion of switchboard and<br />ii) switching for isolation of front portion of the switchboard. A single PTW shall be issued for one activity and the switching for isolation shall be recorded in the Electrical Isolation Certificate.<br /><br />2. The following shortcomings were observed in permitting processi) PTW – electrical hazard not identified, inadequate precautions & electrical PPEs not specified and contractorworker did not signed andii) Electrical Isolation Certificate – Lock-out and tag-out section not filled, Competent Person signing is not qualifiedBO and inadequate briefing/communication between issuer and receiver. The established PTW procedure shall bestrictly enforced and audited regularly to ensure full compliance.<br /><br />3. The practice of radio-called a competent person to ask for approval for permit/certificate and then signed by anotherparty shall be stopped.<br /><br />4. Inadequate communication and coordination between different turnaround teams and contractors during execution of works could result in miscommunication and different understanding of an intent.<br /><br />5. Established lock-out and tag-out procedure shall be strictly enforced including use of tag, dedicated locks and key box for control of issuance of locks & keys.<br /><br />6. Correct method of applying earth bonding clamps shall be used.<br /><br />7. If you are working on an electrical equipment, never assume it is de-energised unless tested and confirmed byyourself.Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-27974443.post-1150394936804733792006-06-15T10:55:00.000-07:002007-09-06T07:53:18.244-07:00Cutting Work Incident<strong><span style="font-size:130%;">Safety Incident Topic : Cutting Work </span></strong><br /><strong><span style="font-size:130%;">Location Of Incident : Lingen, Germany</span></strong><br /><strong><span style="font-size:130%;">Date Of Incident : 19th August, 2005</span></strong><br /><br /><span style="font-size:130%;color:#009900;"><strong>Brief Account Of Incident</strong></span><br />A worker from an outside contracting company (a repair company for steam boilers) was given the task of separating some steel pipes from a bundle of superheater pipes (1a) in Steam Boiler 2. To cut the pipes he used an angle grinder (P=2.2KW) with a cutting disk (D=230mm). When he was cutting out his third pipe, he put the angle grinder to the pipe at a height of about 1.8 m from the work platform. He switched the angle grinder to continuous operation mode. The pipe began to work loose whilst he was cutting through it and the cutting disk got stuck. The angle grinder recoiled and hit the workman on the left side of his chest. The angle grinder lodged in his work clothing. A colleague who was present prevented any further injury by switching the power off. The injured man was able to climb down from the scaffolding and leave the enclosed space unaided. The security guards called the ambulance men, who carried out first aid on him before taking him to the local hospital.The man was discharged after receiving treatment in the outpatients department, and the following day he was given lighter work to do (RWI).<br /><br /><strong><span style="font-size:130%;color:#009900;">Outcome</span></strong><br />- Lacerations in the left chest area which responded to medical treatment in hospital (MTC).<br />- If the injury had been to his neck, the accident would have to have been classified as a major incident (MIA).<br /><br /><span style="font-size:130%;color:#009900;"><strong>Possible Immediate Causes</strong></span><br />- Unfavourable working position.<br />- The man was overtaxing his body at the time.<br />- Incorrect cutting sequence. (The first cut should have been in the lower section).<br />- The decision to start cutting at the top was the wrong one.<br />- It was a seemingly easy routing task and the man had not thought it through properly).<br />- Noise was a hazard. The pipe was under tension. The tools / working environment presented a mechanical hazard.<br />- The working position and ambient temperature were ergonomically unfavorable.<br /><br /><span style="font-size:130%;color:#009900;"><strong>Possible Causes in the System</strong></span><br />- Exhaustion as a result of the work load.<br />- Reduced performance as a result of the high room temperature.<br />- The man felt he had to finish the job quickly.<br />- The contracting company’s system for informing employees about work-related incidents is capable of improvement.<br /><br /><span style="font-size:130%;color:#009900;"><strong>What Went Wrong</strong></span><br />- The pipe which was to be cut out was under tension.<br />- In the position where it was, the angle grinder could not be operated safely.<br />- The angle grinder had been switched over to continuous mode.<br /><br /><span style="font-size:130%;color:#009900;"><strong>What Went Well</strong></span><br />- His colleague was on the spot to offer immediate help.<br />- The security guard had the workmen in view and was able to alarm the emergency services at the refinery immediately.<br />- The rescue team worked quickly and professionally.<br /><br /><strong><span style="font-size:130%;color:#009900;">Lessons learned</span></strong><br />- It is important not to underestimate potential hazards from routine jobs.<br /><br /><span style="font-size:130%;color:#009900;"><strong>Recommendations</strong></span><br />- Select prudently when choosing which tools to work with.<br />- Angle grinders should not be switched to continuous mode when working in an unusual position.<br />- Before each separate stage in the work, the workmen must assess the possible dangers, independently of the ambient conditions, and should take the necessary preventive steps.Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-27974443.post-1150391749603012342006-06-15T09:59:00.000-07:002007-09-06T07:54:25.220-07:00Release Of Hydrocarbon<span style="font-size:130%;color:#000000;"><strong>Safety Incident Topic : Release Of Hydrocarbon</strong></span><br /><span style="font-size:130%;color:#000000;"><strong>Location Of Incident : Hull, UK</strong></span><br /><span style="font-size:130%;color:#000000;"><strong>Date Of Incident : 20th April, 2006</strong></span><br /><br /><br /><span style="font-size:130%;color:#006600;"><strong>Brief Account Of Incident</strong></span><br />During the start-up of the dehydration section of the DF2 plant, approximately 30tes of DIPE (Di-isopropylether) and 53tes of Acetic Acid were released in to the plant’s open channel trade effluent system from the base of steam stripper C205. This release began when C205 was started up with valve ‘A’ in the open position. This valve is normally closed during start-up and normal operation of the unit as referenced in the local procedures. With this valve open, C205 was gradually over-loaded with hydrocarbons and experienced high operating pressures. To maintain the start-up and prevent C205 tripping on high-pressure, the control temperature was deliberately kept low, leading to the loss of hydrocarbons from C205 base to effluent. Short duration pressure spikes had been experienced during start-ups on C205 in the past and the duty shift team felt that the column would recover (as previously) if left operating in this manner. Limited plant reviews took place to determine the cause of this sustained poor control.<br />DIPE is used in this part of the process to break the Acetic Acid/water azeotrope. Normally, with valve ‘A’ closed, water (with residual hydrocarbons) flows from the base of liquid-liquid separator C213 to the E204 condensers before undergoing further separation in decanter D204. With valve ‘A’ open the system hydraulics allow back-flow of condensed hydrocarbons from the overheads of the Azeotrope column C204, directly in to C205. This was initially DIPE, but later became rich in Acetic Acid when the reflux back to C204 was lost.<br />High TOC levels were first recorded by a local effluent on-line analyser at 19:55hrs on the 20th April and were further confirmed by spot sample effluent results (that were being taken every four hours) and continued until the unit was shutdown and isolated at 08:09hrs on the 21st April. Effluent had already been diverted to on-site storage before this event, so operating teams were confident there would be no breaches of consent.<br /><br /><span style="font-size:130%;color:#006600;"><strong>Potential Outcome</strong></span><br />DIPE is a highly flammable immiscible hydrocarbon solvent with a low specific gravity, so readily floats on water. C205 base drops in to an open channel that passes through the plant before reaching the local effluent pit. With such a large quantity of highly flammable material in an open channel, there was the potential for combustion with resulting escalation.<br /><br /><span style="font-size:130%;color:#006600;"><strong>What Went Wrong (Critical Factors)</strong></span><br />· Engineering/Design. Valve ‘A’ should not have been open at start-up. The valve was not part of a locked closed valve register. Potential back-flow from E204 had not been recognised in any previous process safety studies.<br />· Inattention/Lack of Awareness. Failure to adequately respond to high TOC levels from both on-line analysis and spot sample results and failure to appreciate volumes of hydrocarbons involved. Limited plant investigation took place.<br />· Communication. Local Shift Site Manager (SSM) was not informed. Duty shift teams did not use local procedures for guidance on the actions to take on activation of high TOC alarm.<br />· Poor judgement. Mistrust of local TOC analyser. Persistent operation of C205 at low temperatures to avoid high pressure spikes/trips, believing column control would recover naturally.<br /><br /><span style="font-size:130%;color:#006600;"><strong>What Went Well</strong></span><br />· There were no breaches of consent, as effluent was already diverted to on-site storage as part of the plant re-start.<br />· The DIPE was recovered in the DF2 local effluent system and removed for off-site disposal.<br /><br /><span style="font-size:130%;color:#006600;"><strong>Lessons Learned</strong></span><br />· To immediately investigate and respond to any unexpected sustained rises in local effluent TOC results from on-line or spot sample analysis.<br />· To ensure process bypass valves are included in the plant’s locked valve register<br />· To improve communication between shift operating teams and the local SSM.<br /><br /><strong><span style="font-size:130%;color:#006600;">Key Messages</span></strong><br />· To actively investigate any abnormal effluent condition and seek further support as necessary.<br />· Reinforce the expectation that operating teams shut the plant down rather than trying to recover from a persistent process upset condition.Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-27974443.post-1150280997345386782006-06-14T03:02:00.000-07:002007-09-06T08:10:58.003-07:00Forklift Incident<strong><span style="font-size:130%;"><span style="font-family:arial;"><span style="color:#000000;">Safety Incident Topic : PTA Forklift Incident</span><br /><span style="color:#000000;">Location Of Incident : Kuantan, Malaysia</span><br /><span style="color:#000000;">Date Of Incident : Not Known</span></span></span></strong><br /><br /><span style="font-size:130%;color:#009900;"><strong>Brief Account Of Incident</strong></span><br />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.<br /><br /><span style="font-size:130%;color:#009900;"><strong>Possible Immediate Cases</strong></span><br /><strong>Improper use of equipment</strong><br />The re-bagging operation should use the fixed hoist rather than using two Forklifts.<br /><strong></strong><br /><strong>Improper decision-making or lack of judgment</strong><br />The Injured Person stand at a very dangerous position but he did not pay much attention on it.<br /><br /><strong>Routine activity without thought</strong><br />The Forklift Driver just reverse the Forklift and drive forward, turn without noticing that the person is just in front of his Forklift.<br /><br /><strong>Congestion or restricted motion</strong><br />The Packaging area is too small and there is another Forklift parking there to limit the space for the Forklift movementUnknownnoreply@blogger.com0tag:blogger.com,1999:blog-27974443.post-1150242263049057652006-06-13T16:28:00.000-07:002007-09-06T08:17:07.190-07:00Falling Nearmiss<strong><span style="font-size:130%;">Safety Incident Topic: Screen From Shroud On Roof Ventilation Fan Falls</span></strong><br /><strong><span style="font-size:130%;">Location Of Incident: Canada</span></strong><br /><strong><span style="font-size:130%;">Date Of Incident: 21th June 2003</span></strong><br /><br /><span style="font-size:130%;color:#009900;"><strong>Brief Account Of Incident</strong></span><br />While using the overhead crane to move a barrel of lube oil, the screen from a fan shroud on one of the roof ventilation fans became dislodged possibly by the passing crane and fell approximately 40 ft. to the compressor deck below. The screen, measuring approx. 5 ft in diameter and weighing 40 lbs (see Photo #1 below) missed the person operating the crane by a distance of 15 to 20 ft. Fortunately; he was the only person in the Compressor Building at the time.<br /><br /><span style="font-size:130%;color:#009900;"><strong>What Went Wrong</strong></span><br />A self-taping screw and tab holding the screen in place failed (possibly due to fatigue caused by vibration) allowing the screen to hang lower, and into the path of the overhead crane where it was caught and pulled loose.<br /><br /><span style="font-size:130%;color:#009900;"><strong>What Went Well</strong></span><br />- No injuries or property damage occurred as a result of this incident<br />- The fan was immediately locked out and tagged to prevent further use until inspected.<br />- An investigation was conducted and follow-up action promptly implemented.<br /><br /><span style="font-size:130%;color:#009900;"><strong>System Root Causes</strong></span><br />Inadequate technical design: The screens are held in place by only 4 small tabs welded to the screen material and secured to the fan shroud with self-taping screws. This design for securing the screens is evidently prone to failure, as other broken tabs and screws were also found on other fan screens.<br /><br /><span style="font-size:130%;color:#009900;"><strong>Actions</strong></span><br />- A Management of Change was initiated and the remaining screens have been temporarily removed.<br />- The manufacturer of the fan assembly has been made aware of problem and asked to design a better means of securing the fan screens to the shrouds. All screens will then be reinstalledUnknownnoreply@blogger.com0tag:blogger.com,1999:blog-27974443.post-1150193267674475692006-06-13T02:54:00.000-07:002007-09-06T08:02:08.267-07:00Workforce Fatality<span style="font-size:130%;color:#000000;"><strong>Safety Incident Topic : Fatality As A result From Fall</strong></span><br /><span style="font-size:130%;color:#000000;"><strong>Location Of Incident : Krasnogorsk Rayon, Russia</strong></span><br /><span style="font-size:130%;color:#000000;"><strong>Date Of Incident : Not Known</strong></span><br /><br /><br /><span style="font-size:130%;color:#006600;"><strong>Brief Account Of Incident</strong></span><br />Leonid Novokovski a 46 year employee of General Contractor Acis was blown off a 5 m (approximately) high canopy roof during construction of a new Service Station. Tragically, he died as a result of the fall.<br /><br />Leonid together with 2 fellow employees started to complete the roof by fixing the last row of sheet metal to a steel carcass. All 3 were wearing safety harnesses. Leonid removed his harness for reasons not yet known. A gust of wind blew the 4mx1m sheet and Leonid and his 2 co-workers off the roof. Leonid fell to the ground breaking his spinal chord in the region of his neck. His 2 co-workers, wearing safety harnesses, were uninjured. An ambulance was immediately summoned and arrived after 12 minutes. Leonid was pronounced dead by the ambulance doctor. The police arrived at 3 pm. Experienced contractor management was on site at the time of the accident as was a permanently stationed BP representative.<br /><br />Acis informed the BP office of the incident at approximately 3 pm. An immediate attempt was made to contact the PUL and he was contacted within an hour. Within 3 hours the BUL, the GVP and R&M CEO’s Chief of staff had been briefed. An incident team was dispatched to the site and the contractor’s senior management was also summoned to the site. Work was halted on the site and another construction site. resumption of work will be preceded by a Safety Time Out.<br /><br />Leonid’s twin brother and nephew were working on the site. (The nephew was on the roof with Leonid.) They are in a state of shock and every effort is being made to address their emotional needs. Leonid had worked with Acis since 9/8/03. He had received full safety training. He was Ukrainian from the town of Ordgenikidze in Dniepropetrovsk region.<br /><br />An investigation team is being formed and working close with TNK/BP organizationUnknownnoreply@blogger.com0tag:blogger.com,1999:blog-27974443.post-1150179472010649862006-06-12T23:10:00.000-07:002007-09-06T08:20:43.615-07:00Toxic Vapor Released<strong><span style="font-size:130%;color:#000000;">Safety Incident Topic : Vent of styrene vapors</span></strong><br /><strong><span style="font-size:130%;color:#000000;">Location Of Incident : Wingles, france</span></strong><br /><strong><span style="font-size:130%;color:#000000;">Date Of Incident : 28th, April 2006</span></strong><br /><br /><br /><span style="font-size:130%;color:#006600;"><strong>Brief Account Of Incident</strong></span><br />the reactor was vented for 10 minutes while full cooling At 8h00 pm , April 28, 2005 , an operational problem due to too a high polymer melt viscosity led to a an emergency shut-down of crystal line n° 2 in Wingles site. As per the emergency procedure, rarely used, was applied . The estimated vapor release is 1.3 t . Under weak windy conditions, styrene odors were detected by neighborhood community. Fire brigade has been called for enquiry. The odor disappeared within 30 minutes and the operations were successfully and safely stopped. The French Regulations Authorities have been informed. To date, no contact from the media.<br /><br /><span style="font-size:130%;color:#006600;"><strong>Potential Outcome</strong></span><br />Environmental and health nuisances; damage to BP image .<br /><br /><span style="font-size:130%;color:#006600;"><strong>What Went Wrong (Critical Factors)<br /></strong></span>- Lack of judgment : The control room operator increased the contents of one reactor which led to the process upset.<br />- No use of fire water gyromonitors which would have decreased partially the consequences of the vent via condensation of the vapors .<br />- Inadequate safety devices No means to catch or condense the vapors during an emergency reactor vent .<br />- Equipment - Other: The contents of the reactors were fairly high and possibly outside the operating window.<br />- Inadequate Recall of Training Material: There was no evidence that the operator was aware of the consequences of increasing the contents of the reactor .<br />- <strong>Inadequate correction of prior incident</strong>: a similar incident occurred in June 2001 .No adequate corrective action was taken.<br />- <strong>Inadequate technical design</strong>: The design input was obsolete.<br />- Procedures: - This critical factor refers to the operating window of the process. Potential situation not covered: the emergency procedure does not call for fire water use in case of venting .<br /><br /><span style="font-size:130%;color:#006600;"><strong>What Went Well</strong></span><br />1· The duration of venting was properly managed and reduced to the minimum<br />2· The plant fire brigade was responding well<br />3· Good internal and external communication<br /><br /><span style="font-size:130%;color:#006600;"><strong>Lessons Learned<br /></strong></span>- Operators should be remembered / trained regarding the hazards of running the process close to the operating window.<br />- Although venting of the reactor is part of the emergency procedure, the potential consequences were not sufficiently assessed. Adequate safety devices will be provided .<br /><br /><strong><span style="color:#006600;"><span style="font-size:130%;">Key Messages</span><br /></span></strong>Emergency VOC vent to the atmosphere is no longer tolerated .Risk assessment should be conducted to avoid the consequences of such incidentsUnknownnoreply@blogger.com0tag:blogger.com,1999:blog-27974443.post-1149588675239534482006-06-06T03:03:00.000-07:002007-09-06T08:25:56.909-07:00Fire Hose Failure<span style="font-family:arial;"><span style="font-size:130%;"><span style="color:#000000;"><strong>Safety Incident Topic : Fire Hose Failure</strong></span><br /><span style="color:#000000;"><strong>Location Of Incident : Polyethylene Malaysia</strong></span><br /><span style="color:#000000;"><strong>Date Of Incident : 24th February 2003</strong></span></span><br /><br /><br /><strong><span style="font-size:130%;color:#006600;">Brief Account Of Incident</span></strong><br />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.<br /><br /></span><span style="font-family:arial;"><strong><span style="font-size:130%;color:#006600;">Potential Outcome<br /></span></strong>Injury to personnel from flying hose or binding<br /><br /><strong><span style="font-size:130%;color:#006600;">Critical Factors</span></strong><br />· Failure of the fire water hose binding<br />· No checking of the condition of the firewater hose prior to use.</span>Unknownnoreply@blogger.com0