Safety Incident Topic: Crane Overtuned
Location of Incident: Road Between Tank And Cooling Tower Area
Date of Incident: 15 January, 2007
Brief Account of Incident
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.
Potential Outcome
- Naptha leak / acid leak- single or multiple leakCritical Factors
- West side of stabilizers to the tank area was not fully extended due to narrow working space.
- Crane rotated in the direction of the not fully extended stabilizers.
Immediate Root Causes
1- Crane stabilizers not fully extended both sides.
2- Crane operator miscalculated weight load on un-extended stabilizer side.
3- Detailed work procedure was not prepared prior to crane operation specifically.
System Root Causes
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.
2- Crane operator’s decision to continue without change of location; but only adjusting boom angle while rotating the boom
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.
4- In summary:
- Work procedures insufficient to task
- Proper precautions had not taken
- The work procedure did not address specific crane issues.
- Lack of employee experience regarding crane operation and safety.
Key Actions
1- Another company contracted to bring 25 ton crane to complete remaining job and new safety procedures utilized during setup and completion of task.
2- Spread the narrow working place to extend all stabilizers fully according to newly revised work procedure
3- Specific safety protocols and procedures drawn up for use of heavy equipment within SSBP
4- All outside contractors to be monitored closely and to follow SSBP safety procedures while working within SSBP
5- Safety training plan for outside contractors to address safety issues while performing tasks for SSBP Lesson Learned
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.
7- In the event of difference or deviation against original plan, new safety analysis for the situation should be performed within all authorized people.
03 September 2007
29 August 2007
Partial Flare Line Blockage
Safety Incident Topic: Partial Flare Line Blockage
Location of Incident: Bulwer Island, Brisbane Australia
Date of Incident: 9 May, 2007
Brief Account of Incident
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.
Potential Outcome
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.
Likely Causes
Currently is under investigation.
Action Taken
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.
Location of Incident: Bulwer Island, Brisbane Australia
Date of Incident: 9 May, 2007
Brief Account of Incident
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.
Potential Outcome
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.
Likely Causes
Currently is under investigation.
Action Taken
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.
Crane Incident
Safety Incident Topic: Crane Incident
Location of Incident: Kwinana, Australia
Date of Location: 24 May, 2007
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.
Brief Account of Incident
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.
Potential Outcome
Investigation is underway and will identify the causes
Action Taken
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.
Location of Incident: Kwinana, Australia
Date of Location: 24 May, 2007
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.
Brief Account of Incident
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.
Potential Outcome
Investigation is underway and will identify the causes
Action Taken
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.
28 August 2007
Fall of Reinforcing Cage
Safety Incident Topic : Fall of Reinforcing Cage
Location Of Incident : Hull Site, United Kingdom
Date Of Incident : 09 May, 2007
Brief Account of Incident
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.
Potential Outcome
Fatality
Likely Causes
The reason for the lifting strop coming off the hook is not yet known
Actions Taken
All work has been stopped.The incident is reportable to the Health and Safety Executive under the RIDDOR Regulations
Location Of Incident : Hull Site, United Kingdom
Date Of Incident : 09 May, 2007
Brief Account of Incident
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.
Potential Outcome
Fatality
Likely Causes
The reason for the lifting strop coming off the hook is not yet known
Actions Taken
All work has been stopped.The incident is reportable to the Health and Safety Executive under the RIDDOR Regulations
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