(198e) Expect the Unexpected:Hydrogen Sulfide Exposure during Troubleshooting

During routine troubleshooting work involving multi-stage vacuum jets, an unexpected release of Hydrogen Sulfide (H₂S) at the indoor job site led to exposure of two people, one of whom later died. The worker who subsequently died was attending to his coworker, whom he believed was suffering from a heart attack. Several additional individuals were exposed when they rushed to the room without protective equipment; fortunately, all made a full recovery.

This paper discusses the circumstances that led to this tragic incident as well as the management system and cultural issues that contributed to the event and to the subsequent emergency response. Key learnings included:

• Troubleshooting and maintenance activities require robust pre-job planning and hazard recognition processes.
• Hazardous by-products can be generated in a facility, even from non-hazardous chemicals, and can result in exposures unless well understood. This facility was not subject to the OSHA 1910.119 PSM regulation, and the raw materials and products were non-hazardous.
• A strong Incident Command structure can reduce risk to personnel during emergency response.

Note that this incident did not occur at a facility owned by BP Americas, or by The Dow Chemical Company at the time of the incident. However, both authors were employed by the company that owned this facility at the time of the incident and Ms. Pearson was the lead investigator.