Safety Incident Topic: Confined Space Entry
Location of Incident: Blaine, USA
Date of Incident: Unknown
Brief Account Of Incident
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.
Potential Outcome
Potential for serious injury or fatality to individuals entering into the tower in an atmosphere which exceeded the LEL(lower explosive limit).
Likely Causes
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.
Action Taken
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.
14 September 2007
12 September 2007
Electrical Shock Incident
Safety Incident Topic: Electrical Shock Incident
Location of Incident: Kuantan, Malaysia
Date of Incident: 5 December, 2005
Brief Account of Incident
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.
Outcome
The technician could have been fatally electrocuted or seriously injury
Critical Factors
- Rain water trapped inside the switch terminal block
- Technician rotated the switch with bare hand while the switch was hooked up with 240 volts AC supply
Immediate Root Causes
- Ineffective protection from previous seal (old silicone sealant peeled off) to prevent water seepage into the switch
- Lack of knowledge of hazards present – not aware of trapped water hazard
- Routine activity without thought – normal practices that isolation was not required if work involves only the body of the switch
- Inadequate PPE – technician should protect both hand with glove before touching the switch casing
- Inadequate isolation of process or equipment – 240 volts was not isolated
System Root Cause
- 240 volts supply to the instrument is not favorable design for instrument supply
- 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.
Lesson Learned
- No matter how small or insignificant an incident maybe, it should be reported timely so that appropriate measures can be taken.
- The proper power supply should be clearly identified/labeled at site.
- 240 volts AC supply should not be used for instrumentation (budgeted to be changed in 2006)
- All E/I technicians are reminded to be more vigilant about the hazard of any 240 volts AC supplied instrumentation.
- To review the existing LOTO procedure to address the hazards of working with 240 volts AC power supply and its isolation requirements.
Location of Incident: Kuantan, Malaysia
Date of Incident: 5 December, 2005
Brief Account of Incident
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.
Outcome
The technician could have been fatally electrocuted or seriously injury
Critical Factors
- Rain water trapped inside the switch terminal block
- Technician rotated the switch with bare hand while the switch was hooked up with 240 volts AC supply
Immediate Root Causes
- Ineffective protection from previous seal (old silicone sealant peeled off) to prevent water seepage into the switch
- Lack of knowledge of hazards present – not aware of trapped water hazard
- Routine activity without thought – normal practices that isolation was not required if work involves only the body of the switch
- Inadequate PPE – technician should protect both hand with glove before touching the switch casing
- Inadequate isolation of process or equipment – 240 volts was not isolated
System Root Cause
- 240 volts supply to the instrument is not favorable design for instrument supply
- 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.
Lesson Learned
- No matter how small or insignificant an incident maybe, it should be reported timely so that appropriate measures can be taken.
- The proper power supply should be clearly identified/labeled at site.
- 240 volts AC supply should not be used for instrumentation (budgeted to be changed in 2006)
- All E/I technicians are reminded to be more vigilant about the hazard of any 240 volts AC supplied instrumentation.
- To review the existing LOTO procedure to address the hazards of working with 240 volts AC power supply and its isolation requirements.
Boiler Fuel Oil Leakage
Safety Incident Topic: Boiler Fuel Oil Leakage
Location of Incident: Capco, Taiwan
Date of Incident: 17 July, 2005
Brief Account of Incident
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.
Potential Outcome
Overload wastewater treatment system and increase waste water effluent fee from Union wastewater treatment plant of Industrial Zone.
What Went Wrong
1. One of boiler fuel oil pump, casing drain leaked
2. Oil separator was accumulated a lot of fuel oil
3. Inadequate enforcement of safety procedure
SUMMARY OF IMMEDIATE CAUSES
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.
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.
3. Inadequate or excessive illumination - Oil separator area is poorly illuminated.
SUMMARY OF SYSTEM CAUSES
Inadequate enforcement of PSP - Field operators was not properly enforced to patrol and detect equipment leakage.
Location of Incident: Capco, Taiwan
Date of Incident: 17 July, 2005
Brief Account of Incident
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.
Potential Outcome
Overload wastewater treatment system and increase waste water effluent fee from Union wastewater treatment plant of Industrial Zone.
What Went Wrong
1. One of boiler fuel oil pump, casing drain leaked
2. Oil separator was accumulated a lot of fuel oil
3. Inadequate enforcement of safety procedure
SUMMARY OF IMMEDIATE CAUSES
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.
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.
3. Inadequate or excessive illumination - Oil separator area is poorly illuminated.
SUMMARY OF SYSTEM CAUSES
Inadequate enforcement of PSP - Field operators was not properly enforced to patrol and detect equipment leakage.
11 September 2007
Fall From Scaffolding
Safety Incident Topic: Fall From Scaffolding
Location of Incident: TExas, USA
Date of Incident: 29 august, 2007
Brief Account of Incident
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.
It is not known at this time if the scaffold rail pinning mechanism failed or if it was not installed properly.
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.
An incident investigation has been initiated and the lessons learned document will be available by September 30, 2007.
Location of Incident: TExas, USA
Date of Incident: 29 august, 2007
Brief Account of Incident
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.
It is not known at this time if the scaffold rail pinning mechanism failed or if it was not installed properly.
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.
An incident investigation has been initiated and the lessons learned document will be available by September 30, 2007.
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