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.
- 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.