Employee #1, a millwright, was standing near a 100 ft long by 5 ft diameter vacuum fat-splitter vessel that was undergoing a hydrostatic test. He was by the M-1 flange joint when the gasket experienced a catastrophic failure. Employee #1 was struck in the face by air and water released at the maximum allowable working pressure of 1,275 psig. He was killed.
Source:OSHA.gov
On October 6, 1994, an employee, working in the surgical wing at the Hospital, was exposed to ethylene oxide gas from the sterilizer room. The monitor in the sterilizer room read 77 ppm. The solenoid from the boiler had failed, and a bad gasket released the gas throughout the surgical wing. Three nurses and one maintenance employee who was performing daily routine maintenance were also exposed. Hospital employees participated in an emergency response until the fire department arrived on site. None of the exposed employees required hospitalization.
(EO is used as a sterilizing agent in hospitals)
Source: OSHA.gov
On April 30, 1985, at approximately 6 am, an alarm sounded in the control room. The chemical technican on duty checked the pressure in the control room. It was all right. He then went downstairs to check the alarm system. It was functioning properly. As he went back up the stairs he saw the fire on the line from the ethylene oxide storage tank. The fire department was notified. The fire department had three rail cars moved because of their proximity to the fire. The outlet from the ethylene oxide tank was turned off. The fire burned down and was extinguished. The leak was caused by a ruptured flange gasket in the ethylene oxide line. When the ethylene oxide came into contact with the plastic insulating cover on the line it may have ignited. Rust on the line way also have been a catalyst in igniting the ethylene oxide.
Source:OSHA.gov
On April 6, 1994, a unit operator with ARCO Products was conducting rounds of the coker unit when he observed a leak coming from the mechanical seal of the heavy gas oil pump of coker unit #1. The operator decided to seek assistance; the head unit operator and six or seven unit operators responded. The operators placed water and steam on the leak to suppress the vapor from the seal. The head unit operator decided to shut down the pump and transfer the product to the secondary pump. As the operator shut down the primary pump, the mechanical seal blew, causing a vapor cloud to generate from the seal. The operators continued to put steam and water on the seal and isolated the pump from the pipe line. The remaining product in the pipe line leading to the primary heavy gas oil pump vaporized, leading to the dispersion of the vapor cloud. The operators who responded were wearing bunker gear and several wore emergency respirators. Those with respirators isolated the pump from the pipe line by closing the suction and discharge valves. The operators who were not wearing emergency respirators stationed themselves upwind of the vapor cloud and put water on the cloud; however, the wind changed direction several times, exposing unprotected operators to vapors. Employees #1 and #2, two unprotected operators who responded to incident, were brought to Long Beach Memorial Hospital to be treated for inhalation of hydrocarbons. Employee #1 was hospitalized.
Source: OSHA.gov
On July 14, 2009, Employees #1 and #2 were performing a pneumatic test to verify leak tightness of a new meter station at the Midcontinent Express Pipeline. The test medium was nitrogen gas, and the system being tested included piping and two pressure vessels. Numerous leaks were found in the system during the test. The system reached the required test pressure of 2225 psig at approximately 3:25 p.m., and Employee #1 observed that the pressure on the system had dropped to 2205 by approximately 3:30p.m. Employee #1 was then replaced at the test table by Employee #2. As Employee #1 walked away from the test table, the door on the PECO separator (a pressure vessel) blew off, releasing pressurized nitrogen gas that sent projectiles flying. Employee #2 was killed, and Employee #1 suffered burns and was hospitalized.
Source: OSHA.gov
Water Samples Tested After Maine Firefighting Foam Spill, Below Guidelines for Dangerous Chemicals.
Read in this link
Worst Manufacturing Incidents in the U.S.
And the lessons we learned to prevent history from repeating itself.
"A December 1984 toxic gas leak in Bhopal, India killed and maimed thousands and led to chronic health problems. Survivors of the tragedy—which has been called the worst industrial accident ever—came to Harvard Chan School on Sept. 23 as part of a U.S. tour to share their stories and to build support for activities related to the 40th anniversary."
Read the article in this link
"The clock at Gate 1 stopped at 3:43 p.m. The explosion that shook
the BASF site in Ludwigshafen at this time on July 28, 1948 wrought
unthinkable destruction in a place that was still being rebuilt
following the Second World War and which was still under French
occupation three years after the end of the war. The disaster created a
widespread stir as a result of extensive international press coverage.
Similarly, aid also came from virtually all over the world after the
explosion, and soldiers from both the French and the adjacent American
occupation zones immediately made their way to the site to assist."
An employee was cleaning the chemical reactor with a flammable mixture of solvents when the reactor burst its rupture disc and the mixture was expelled into the plant. The solvent ignited and the vapor cloud explosion resulted in the plant's 43 employees being injured by flying debris and/or being thrown by the force of the explosion. The employee and two others died from the explosion. Many were injured.
It appeared that the reactor was not vented to a safe location and had primitive temperature controls, and the company did not enforce the mandatory attendance of operators at the reactors during operation. All of these factors, including minimal operating procedures (none specifically for cleaning), led to the explosion and the resulting extensive injuries and property damage.
Source: Osha.gov
Employee #1 was placing the #6 water condenser back on line, leaving the drain valve open while he opened a valve under the condenser. Hydrofluoric acid suddenly drained into the catch basin/drain system, and splashed the employee. He suffered first- and second-degree burns and later died of cardiac arrest.
Siurce: OSHA.gov
On November 17, 2005, Employee #1 and other employees noticed a plugged drain. The employee poured an undetermined amount of Red Devil Lye Drain Cleaner into the drain. A violent splash back deposited sodium hydroxide onto Employee #1 and the nearby surroundings. The employee was wearing his personal protective eyeglasses. Employee #1 suffered chemical burns on his head. The employee was hospitalized.
Source: OSHA.gov
On August 1, 2007, Employee #1 was working as a Sampler in East Palo Alto. He was opening sealed 55-gallon metal drums containing flammable liquid which had been received in a batch of 12 metal drums on July 26, 2007. The drums had to be sampled to verify whether the waste received was consistent with information on the manifest and the waste profile the facility kept on its records.
The Drum Sampling Area was located adjacent to the North Drum Storage Area, which was designated for storage of waste solvents and organic wastes. An air hose was available to be used with an impact wrench .The pneumatic impact wrench (air gun) was equipped with an attachment to open the bung on the drum and weighed approximately 7 pounds.
At approximately 8:30 a.m., Employee #1 had lined up all the 12 drums and put sampling jars on top of each drum, while the Production Manager and several other workers were standing nearby, chatting. Employee #1 was wearing his full-facepiece respirator, gloves, rubber apron and Tyvek over his long sleeve uniform and long sleeve T-shirt. After opening four or five drums using the air gun, he attempted to open the next drum, which did not show any indication of bulging or deformity. As soon as the air gun hit the bung, the drum burst open in flames. The accident was most likely caused by the mechanical sparks created from the impact of the air gun with the drum bung, which ignited the flammable vapors released from the drum. The exploding drum hit Employee #1 in the stomach area and engulfed him in flames. His clothes caught on fire. Employee #1 started running up the aisle, where he was spotted by the Production Manager, who rolled him down on the ground to put out the flames on his clothes. Another employee sprayed him with a Class D fire extinguisher. Employee #1 was taken to Stanford Medical Center Emergency Room by paramedics, where he was treated for first- and second-degree burns on his right ear.
Source: OSHA.gov
"After a series of highly publicized operator errors at its Cleveland plant, a chemical manufacturer, installs a software based control system to prevent accidental releases of toxic substances. The system relies on a machine learning model trained on millions of hours of operating data from their facilities. Using sensor data from the plant, the model can identify when it is safe to open the plant’s exhaust vents. Thanks to its extensive “experience,” the model adapts seamlessly to process changes and physical modifications within the complex plant, which were blamed for confusing human operators in the past. The new
software system proves highly reliable and becomes a trusted tool within the company. Months later, a windstorm disrupts several of the plant’s sensors. Based on the flawed sensor input, the
control system continues to read “safe,” and the plant operators act accordingly, leaving the vents open, even as managers elsewhere in the plant begin an unscheduled production run in response to an urgent customer request. The run produces a cloud of lethal chlorine gas, which escapes through the open exhaust vents and drifts toward downtown."
Source: https://cset.georgetown.edu/publication/ai-accidents-an-emerging-threat/
Interesting article Ai in PSM- adouble edged sword for PSM
https://www.leancompliance.ca/post/ai-in-psm-a-double-edged-sword-for-process-safety-management
At 6:45 p.m. on October 28, 2021, an employee was circulating a tank of hydrogen sulfide when a burner box, which was 15 feet away, was turned on and the hydrogen sulfide that was in the atmosphere ignited. The employee was hospitalized to treat second and third-degree burns to his hands and face.
Source: OSHA.gov
"On or about January 28, 1993, Employee #1, a contract welder, was repairing and replacing flanges on storage tanks in order to install a closed ventilation system. The storage tanks contained sodium sulfide, which reacts with acid to generate hydrogen sulfide gas. This highly flammable gas accumulated in a vapor space. Prior to the accident, a tank flashed while being cut or welded into by the employee. When a lighted torch was brought in proximity, the tank ruptured. Employee #1 died. Employee #2 had gone up on a tank to tell Employee #1 not to cut into the tank when the tank exploded. Employee #2 was hospitalized."
Source: OSHA.gov
"At 10:30 a.m. on September 30, 2019, an employee was performing maintenance on a storage tank battery for oil and gas operations support. The employee was on a crew which was working on a line which was not pressurizing properly. As the employee was working on the line, the pop off valve relieved causing the employee to be struck by released hydrogen sulfide. The employee fell off the tank, rupturing his kidney and fracturing his left fibula and right hip. The employee was hospitalized".
Source: OSHA.gov
