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Scaffolding - Incidents

  • Scaffolding collapse at Chinese construction site kills dozens - November 24, 2016     Scaffolding at a construction site in eastern China collapsed into a deadly heap on Thursday, sending iron pipes, steel bars and wooden planks tumbling down on about 70 workers in the country’s worst work-safety accident in over two years. At least 67 people were killed by the collapse of the work platform at a power plant cooling tower that was under construction, state media reported. Two others were injured, and one worker was missing 

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Line Opening - Incidents

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Field Review of Permits - Incidents

The following losses occurred due to inadequate Permit to Work system management or control.  In all cases there were other factors also involved.   

  • Refinery Fire – Hot work was being conducted in a packed column by a sub-contractor under the supervision of the equipment vendor/contractor. The site hot work permit procedure was not followed, and a fire occurred causing major damage and subsequent collapse of equipment.  

– Lloyd’s Market Association Oil, Gas and Petroleum Loss Analysis 

  • Fire and Explosion - The tragic explosion at the DuPont facility exposed weaknesses in how process hazards were analyzed and controlled. The result was the death of a welder in a preventable hot work accident. The CSB investigation found the hot work ignited the vapor as a result of the increased temperature of the metal tank, sparks falling into the tank, or vapor wafting from the tank into the hot work area. The welder died instantly from blunt force trauma, and a foreman received first-degree burns and minor injuries.  The CSB Investigator stated that the contractors did obtain hot work permits for welding, but those permits were authorized by DuPont employees who were unfamiliar with the specific hazards of the process and did not require testing the atmosphere inside the tanks. 

https://www.csb.gov/csb-releases-new-safety-video-on-fatal-hot-work-explosion-at-dupont-facility-in-buffalo-hot-work-hidden-hazards-shows-danger-of-inadequate-gas-monitoring-safety-video-follows-release-of-the-csb-s-investigative-report/ 

  • Refinery Fire - The refinery fire occurred on February 23, 1999, in the crude unit at the Tosco Corporation Avon refinery in Martinez, California. Four workers were killed, and one was critically injured. 
    • Tosco Avon management did not recognize the hazards presented by sources of ignition, valve leakage, line plugging, and inability to drain the naphtha piping. Management did not conduct a hazard evaluation of the piping repair during the job planning stage. This allowed the execution of the job without proper control of hazards.  
    • Management did not have a planning and authorization process to ensure that the job received appropriate management and safety personnel review and approval.  
    • Tosco did not ensure that supervisory and safety personnel maintained a sufficient presence in the unit during the execution of this job. Tosco’s reliance on individual workers to detect and stop unsafe work was an ineffective substitute for management oversight of hazardous work activities 

https://www.csb.gov/tosco-avon-refinery-petroleum-naphtha-fire/ 

  • Refinery Asphyxiation Incident - Two contract employees were overcome and fatally injured by nitrogen as they performed maintenance work near a 24-inch opening on the top of a reactor.  Recommendations from the investigation included the following: 
    • Conduct safe work permit refresher training for all permit-preparers and approvers and affected refinery personnel and contractors.  Emphasize that all proposed work requires a jobsite visit by the requestor and a unit operator to identify special precautions, equipment status, and personal safety equipment requirements. 

https://www.csb.gov/valero-refinery-asphyxiation-incident/ 

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Equipment Identification - Incidents
  1. Toxic gas cloud affecting nearby community due to a mixed connection at MGPI processing facility, Kansas.  

    https://www.csb.gov/mgpi-processing-inc-toxic-chemical-release-/ 

     
  2. VCM vapor cloud ignited and exploded when the operator opened the bottom valve of D310 (in line at 70psig) instead of opening bottom valve of D306 for cleaning operation at Formosa Plastics. 

     https://www.csb.gov/formosa-plastics-vinyl-chloride-explosion/ 

     
  3. Multiple Incidents of chlorine toxic cloud formations due to improper tagging and materials mixing – CCPS Process Safety Beacon February 2017.   

    https://www.aiche.org/ccps/resources/process-safety-beacon/archives/2017/february/english 

 

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Hot Tapping - Incidents

The US Chemical Safety Board site has documented several incidents involving hot work activities.  However, none of these appear to be from “hot tapping”.  The incidents in the US CSB site are all related to hot work (welding and line opening) in or around tanks that contained flammable vapors.  The hot work ignited the vapors causing a fire and/or explosion in these cases.  While these incidents are not 100% analogous to “hot tapping”, they are included here as they clearly illustrate the inherent dangers and potential consequences of “Hot Tapping”. 

https://www.csb.gov/packaging-corporation-of-america-hot-work-explosion-/ 

https://www.csb.gov/e-i-dupont-de-nemours-co-fatal-hotwork-explosion/ 

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Energy Isolation - Incidents

Have at least one incident for each unique “failure mode” of the Lock-Out/Tag-Out SWP?  For example, failure to:

  • Properly de-energize equipment
  • Identify potential source of stored energy
  • Execute properly the Lock-Out/Tag-Out procedure
  • Recognize hazard 

Incidents:

At approximately 1:30 p.m. on September 6, 2016, an employee was servicing the scissor lift table to fix a leak in the hydraulic hose. The hose fitting broke and the lift table lowered pinning the employee between the table and the floor. The employee received crushing injuries, such as fractured clavicle and ribs with hemorrhaging and was killed.

– United States Department of Labor, OSHA

https://www.osha.gov/pls/imis/accidentsearch.accident_detail?id=88370.015

 

On April 8, 2004, four workers were seriously injured when highly flammable gasoline components were released and ignited at the Giant Industries Ciniza refinery, east of Gallup, New Mexico. The release occurred as maintenance workers were removing a malfunctioning pump from the refinery’s hydrofluoric acid (HF) alkylation unit. Unknown to personnel, a shut-off valve connecting the pump to a distillation column was apparently in the open position, leading to the release and subsequent explosions.

– U.S. Chemical Safety Board

https://www.csb.gov/giant-industries-refinery-explosions-and-fire/

 

Workers were attempting to clear a plugged line. The LOTO permit was authorized and locks placed per procedure. Unfortunately, the workers did not verify that all hazardous energy was removed. The residual pressure from blowing out the line remained. As workers opened a flange just below the plug, material was blown out, burning personnel in the immediate area.

– CCPS Safety Alert February 23, 2005

https://www.aiche.org/sites/default/files/docs/pages/CCPSAlertLOTO.pdf

 

A maintenance technician was investigating a bag-feeding machine because bags were not feeding properly through the roller. He reached into the machine with his left hand while the machine was still running to clear a jam, without locking out first. He put his right hand down next to rollers that were running. His right hand slipped into the moving rollers. Investigation showed that all of the operators and maintenance workers routinely reached into the machinery without proper LOTO. He was the one who got unlucky.

– CCPS Safety Alert February 23, 2005

https://www.aiche.org/sites/default/files/docs/pages/CCPSAlertLOTO.pdf

 

I am convinced that one of the most likely ways to severely injure workers is through not using, or not correctly following, safe work practices, including LOTO, Line Opening, Confined Space Entry and Hot Work. This is one of the topics that I stress the most in audits, and I make particular mention of in Process Hazard Analyses. We read about such incidents all the time. For such practices to not be in place is (unacceptable).

– CCPS Safety Alert February 23, 2005

https://www.aiche.org/sites/default/files/docs/pages/CCPSAlertLOTO.pdf

 

Our company standards, including LOTO are REQUIRED for all our sites worldwide. LOTO is one of a few inviolable safety rules that will prompt immediate dismissal from the company if violated.

– CCPS Safety Alert February 23, 2005

https://www.aiche.org/sites/default/files/docs/pages/CCPSAlertLOTO.pdf

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Excavation - Incidents

•Manslaughter verdict after trench collapse death | Construction Enquirer www.constructionenquirer.com/.../building-boss-guilty-of-manslaughter-af...

•Sentence following multiple deaths on excavation site – Norfolk ...press.hse.gov.uk › News › Media centre, Sentence following multiple deaths on excavation site – Norfolk. Date: 25 May 2017. Two companies have been fined a total of £700,000

•OSHA: Excavation Company Could Have Prevented Workers' Deaths ..https://www.naxsa.org/.../OSHA-Excavation-Company-Could-Have-Prevented-W... Oct 2016 - BOISE –... A third man, Jorge Soto, suffered multiple injuries

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Equipment Filling and Mixing - Incidents
  1. Inadvertent mixing of sulfuric acid and sodium hypochlorite produced a cloud containing chlorine and other compounds. The cloud impacted workers onsite and members of the public in the surrounding community. The incident occurred during a routine chemical delivery of sulfuric acid from a chemicals cargo tank vehicle (CTMV) at the MGPI facility tank farm.                           

  1. Several construction employees working near a collection pit were overcome with hydrogen sulfide gas. The gas was released nearby when sodium hydrosulfide was accidentally mixed with sulfuric acid. Three workers collapsed almost immediately and three others tried to rescue them. Two of those rescuers also collapsed. In all, ten workers were exposed to the toxic gas. Two died and eight others were injured.                                                                             
  2. (April 25, 2002)  An explosion and fire occurred in a 10-story mixed-occupancy building in the Chelsea district of Manhattan, New York City. Employees had just finished consolidating hazardous waste from smaller containers into two larger drums. The wastes, nitric acid and lacquer thinner, were incompatible, and an explosion occurred. Thirty-six people were injured, including six firefighters and 14 members of the public. The building was extensively damaged.

  1. (August 12, 2015)  A series of explosions killed 173 people and injured hundreds of others at a container storage station at the Port of Tianjin. The first two explosions occurred within 30 seconds of each other at the facility. The second explosion was far larger and involved the detonation of about 800 tons of ammonium nitrate. Fires caused by the initial explosions continued to burn uncontrolled throughout the weekend, resulting in eight additional explosions three days later. In addition to vast quantities of sodium cyanide and calcium carbide, paperwork was discovered showing that 800 tons of ammonium nitrate and 500 tons of potassium nitrate were at the blast site.

  1. (May 2013, Portland, Oregon)  A supplier truck driver pumped a mixture of nitric and phosphoric acids into a tank containing sodium hypochlorite at a dairy.

  1. (October 2007, Frankfurt, Germany)  Hydrochloric acid was accidently transferred into a sodium hypochlorite tank. Approximately 200 kg of chlorine were released, and more than 60 people were injured. The operator who finally stopped the transfer was fatally injured from exposure to chlorine.

  1. (August 2001, Coatbridge, UK)  A tanker driver transferred sodium hypochlorite solution and hydrochloric acid into the same tank at a swimming pool. 30 people required medical treatment.

  1. (August, 1993, Stockholm, Sweden)  A truck driver pumped phosphoric acid into a storage tank containing sodium hypochlorite at a swimming pool.

  1. (March 1985, Westmalle, Belgium)  Hydrochloric acid was pumped into a tank containing residual sodium hypochlorite.

  1. (November 1984, Slaithwaite, UK)  A plant expected a delivery of sodium hypochlorite, but received ferric chloride solution (an acidic solution) instead. The ferric chloride was unloaded into the sodium hypochlorite tank.

  1. (September 1984, Hinckley, UK)  Hydrochloric acid was unloaded into a tank containing sodium hypochlorite.
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Temporary Instrumentation and Controls Bypass - Incidents
  • Improper start-up bypass use
    • CSB. 2017. Investigation report – Airgas. Report 2016-04-I-FL. Washington, D.C.: U.S. Chemical Safety Board.
  • Insufficient access control of safeguard bypass and lack of timely response to prior audit findings and near-miss incidents involving bypass
    • CSB. 2007. Investigation report - vinyl chloride monomer explosion at Formosa Plas-tics Corporation. Report 2004-10-I-IL. Washington, D.C.: U.S. Chemical Safety Board.
  • Inadvertent bypass of safety interlock due to insufficient maintenance training and proce-dure updates after safeguard device change
    • HSE. 2007. Buncefield Standards Task Group (BSTG) Final Report. UK: Health and Safety Executive.
  • Insufficient training of bypass approver and lack of compensating measures
    • CSB. 2006. Investigation report - Sterigenics. Report 2004-11-I-CA. Washington, D.C.: U.S. Chemical Safety Board.
  • Systematic failure of bypass management program
    • CSB. 2008. Investigation report - Pesticide Chemical Runaway Reaction and Pressure Vessel Explosion at Bayer Crop Science. Report 2008-08-I-WV. Washington, D.C.: U.S. Chemical Safety Board.
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Confined Space Entry - Incidents

  • Test atmosphere

Surface Nonmetal Plant Kaolin Clay, Fatal Other Accident July 2015

 
 

  • Provide rescue plan and equipment

Surface Nonmetal Plant Kaolin Clay, Fatal Other Accident July 2015

Surface Nonmetal Mine (Limestone CB), Fatal Sliding Material Accident March 11, 2005

 
 

  • Provide confined space entry observer

Surface Nonmetal Plant Kaolin Clay, Fatal Other Accident July 2015

Surface Nonmetal Mine (Limestone CB), Fatal Sliding Material Accident March 11, 2005

Tesoro sulfuric acid injury 6/2010 - CSB

 
 

  • Recognize hazard

Surface Nonmetal Plant Kaolin Clay, Fatal Other Accident July 2015

Surface Nonmetal Mine (Limestone CB), Fatal Sliding Material Accident March 11, 2005

 
 

  • Improper isolation

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Hot Work - Incidents



 

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