On August 6, 1999, Employees #1 through #5 were present during a transfer operation involving sodium hypochlorite. A chemical reaction occurred between the sodium hypochlorite and an incompatible chemical, causing the tank to erupt. Employee #1 was killed. Employees #2 through #5 sustained injuries, for which Employees #2 and #3 were hospitalized.
Source:OSHA.gov
The resin plant was a six-story, open-sided structure, approximately 100 feet wide and 400 feet long, which sat approximately 50 feet east of the phosgene plant. A street separated the two plants, but they were connected physically by a pipe rack, which held phosgene-conveying pipes. On May 22, 1996, a number of employees were working on the second-floor mezzanine of the resin plant, removing a caustic line so that they could install a heat exchanger for the caustic scrubber system. While they were working, low levels of phosgene vented back through the caustic line. After the phosgene release was detected, the employees evacuated the resin plant. The company did not provide emergency escape respirators for the employees in the resin plant, and none of the employees who evacuated the plant were wearing respirators. After evacuation, the on-site physician examined 11 employees and referred them to a hospital where they were examined further and provided prophylactic treatment. Eight employees stayed overnight for observation and were released the next day.
Source:OSHA.gov
During batch production of bifenthrin, gases are normally released in the reactor vessel and are delivered by a closed system to an acid gas scrubber for neutralization with sodium hydroxide. This scrubber failed because the sodium hydroxide feed line clogged, releasing a plume that was probably a mixture of hydrochloric acid and sulfur dioxide gases. The plume was blown across the facility, including the chemical laboratory where technicians and supervisors were working. The chem lab's own HVAC system pulled some of the plume into the building, driving out the five technicians and one supervisor, who were choking, coughing, and having difficulty breathing. Two employees had been walking to a job site and had encountered the same plume. The plant nurse had been alerted and administered oxygen until the ambulances arrived and took Employees #1 through #8 to local hospitals. The employer had extensive written emergency response and evacuation procedures that are practiced six times a year, and designated employees are given emergency response training (emergency respirator use, confined space entry, acid spill containment) weekly. No violations were noted with procedures or responses.
Source:OSHA.gov
At 7:00 a.m. on June 6, 2019, an employee was changing an "O" ring on a sight glass for a heat sensor on a 3-inch pipe on line #9 in the central clean-in-place room. The employee was changing the gasket when residual hot water and chemical mix in the line that had not been properly drained and isolated sprayed out onto him. The employee sustained second degree burns and was hospitalized.
Source: OSHA.gov
Employees #1 and #5 through #7 were near the chlorine unloading area at a bleach plant when the gasket of a recently-installed vaporizer failed, releasing between 500 and 700 gallons of liquid chlorine. When Employees #1 and #7 went to investigate the extent and location of the leak, they found an overwhelming concentration of the chemical. They were not using SCBAs, nor was Employee #6, who used the wrong escape route. Employee #5, the bleach plant operator, attempted to find and assist Employee #6. Employees #2 through #4 attempted to shut down the vaporizer system but they did not know the location of the one critical shut-off valve, and the key person was not immediately available to help. Employees #1 through #7 suffered chemical burns from inhaling the chlorine fumes; all were hospitalized except for Employee #2. Source:OSHA.gov
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
"At 12:30 p.m. on June 7, 2021, an employee entered a sewer manhole to estimate the amount of materials needed to perform a manhole repair when the employee was overcome by high levels of hydrogen sulfide at the base of the manhole shortly after entry. The employee did not perform atmospheric monitoring and had not donned his harness with rescue tripod before entry into the confined space. A four gas monitor and rescue equipment were located in the employee's work vehicle. Coworker #1 (attendant) and Coworker #2 (helper) were not trained or equipped for performing a confined space entry rescue. A volunteer fire department responded within 8 minutes and performed the confined space entry rescue shortly after arrival. The employee was killed by overexposure to hydrogen sulfide"
SOurce: OSHA.gov.
On May 17, 2010 Employee #1, Employee #2, Employee #3 and Employee #4, were in the pipe rack planning to install a flanged spool piece on the Epi three transfer line. The line had been isolated at the west end and the east end. A one inch bleeder valve on both ends was yellow tagged open and returned to operations.
Employee #1, Employee #2, and Employee #3 had pulled their tools and bolts up. Employee #4, the rigger had gone up to the job site to figure out the best way to lift the pipe spool in place. As all this was going on, an employee of the host employer connected an eighty pound nitrogen hose to the one inch bleeder. That worker then charged the line with the eighty pounds of nitrogen.
Shortly after that, ten gallons of epichlorohydrin was released from the west end of the open pipe hitting Employee #1 directly in the chest and midsection. Employee #1 was admitted to the hospital immediately by life flight. Employee #2 was exposed on the neck, back and hands, and admitted to the hospital. Employee #3 had mild splotchy discoloration of several small areas on the hand and arms. Also a sore throat from inhalation. Employee #4 had splotchy superficial burns on the arms and back as well as a mild associated rash.
Source:OSHA.gov
"At 1:00 p.m. on September 27, 1993, a hydrostatic test crew operator and two helpers began testing 19 sections of 7 inch P-110 casing pipe at 9,500 psi.
The hydrostatic crew would roll the pipe onto the holding devices, check the drift (proper dimensions), apply thread dope, install the front header plug and rear "gun" plug, align the header plug bleed valve, fill the pipe with water, close the bleed valve, tighten the header plug, and assume their designated positions for pressure testing in accordance with pressure test specifications.
After conducting the pressure test, employees would drain the water, remove the plugs, roll the pipe down the line, grease the threads, and stencil the pipe.
Near 4:00 p.m. the crew was working on pipe section number 18. About 4:15 p.m., the pipe was filled with water and the crew began the pressure test. At 1,000 psi the header plug exploded blew out of the coupler on the pipe and struck Employee #1. Coworkers rushed to his aid and emergency medical services were notified. CPR was administered. Medical services arrived and transported Employee #1 to the hospital, where he died at about 5:00 p.m".
Source: OSHA.gov
"On February 22, 2020, a carbon dioxide (CO2) pipeline ruptured in proximity to the community of Satartia, Mississippi. The rupture followed heavy rains that resulted in a landslide, creating excessive axial strain on a pipeline weld.
• Carbon dioxide is considered minimally toxic by inhalation and is classified as an asphyxiant,
displacing the oxygen in air. Symptoms of CO2 exposure may include headache and drowsiness.
Individuals exposed to higher concentrations may experience rapid breathing, confusion,
increased cardiac output, elevated blood pressure, and increased arrhythmias. Extreme CO2
concentrations can lead to death by asphyxiation.
• When CO2 in a super-critical phase (which is common for CO2 pipelines) releases into open air, it
naturally vaporizes into a heavier than air gas and dissipates. During the February 22 event,
atmospheric conditions and unique topographical features of the accident site significantly
delayed dissipation of the heavier-than-air vapor cloud. Pipeline operators are required to
establish atmospheric models to prepare for emergencies
• Local emergency responders were not informed of the rupture and the nature of the
unique safety risks of the CO2 pipeline. As a result, responders had to guess the nature of the risk,
in part making assumptions based on reports of a “green gas” and “rotten egg smell” and had to
contemplate appropriate mitigative actions. Fortunately, responders decided to quickly isolate
the affected area by shutting down local highways and evacuating people in proximity to the
release. No fatalities were reported.
• This event demonstrated the need for:
o Pipeline company awareness and mitigation efforts directed at addressing integrity
threats due to changing climate, geohazards, and soil stability issues.
o Improved public engagement efforts to ensure public and emergency responder
awareness of nearby CO2 pipeline and pipeline facilities and what to do if a CO2 release
occurs. This is especially important for communities in low-lying areas, with certain
topographical features such as rivers and valleys".
At approximately 3:30 p.m. on June 14, 2012, Employee #1 was performing hydro testing of two recently constructed and installed crude oil pipelines. The employee removed a pressure test manifold from a pressure test flange while the pipeline contained a pressure of 2000 psi. Employee #1 did not lock-out the pipe valves, nor bleed the pressure off of the line prior to removing the pressure test manifold. The employee was struck-by the pressure test manifold that was propelled by the stored pipeline pressure. Employee #1 was transported by the impact of the manifold for a distance of 40 feet. The steel pressure test manifold impacted the skull of the employee which resulted in injuries to the employee and subsequent death.
Source:OSHA.gov
At approximately 3:30 p.m. on June 14, 2012, Employee #1 was performing hydro testing of two recently constructed and installed crude oil pipelines. The employee removed a pressure test manifold from a pressure test flange while the pipeline contained a pressure of 2000 psi. Employee #1 did not lock-out the pipe valves, nor bleed the pressure off of the line prior to removing the pressure test manifold. The employee was struck-by the pressure test manifold that was propelled by the stored pipeline pressure. Employee #1 was transported by the impact of the manifold for a distance of 40 feet. The steel pressure test manifold impacted the skull of the employee which resulted in injuries to the employee and subsequent death.
Source: OSHA.gov
Note: Obviously the pipeline was not filled up complete;y with water and air was pressurized, resulting in the propelling of the pressure test manifold
On March 6, 2018, a 49-year-old pipefitter was hit in the chest by a pressurized 12-inch diameter polyvinyl chloride (PVC) pipe during a hydrostatic pressure test of a fire suppression system. The sudden pipe movement was attributed to a pipe joint connection failure in a buried section of the pipeline. The failure was due to torque shear bolts at the joint connection that were not tightened, which was missed during the utility installation process and the work inspection prior to the incident.
Read the incident in this link
At 11:30 a.m. on June 20, 2007, Employees #1, #2, #3, and #4, who worked for Scaffolding Company, and Employees #5, and #6, who worked for Plant Services Company, and Employees #7 and #8, who worked for a chemical manufacturer, were hospitalized after being exposed to dimethyl sulfate (DMS) in the ethoxylation area where it was used in reactors 4 and 5. Employee #7 was an operator who moved bags containing chemicals into the area in order to add it to reactor 4. Employee #8 was a mechanic that worked unplugging an auger at reactor 4.
Employees #7 and #8 started working at 7 a.m. at reactor 4. Employees #1, #2, #3, and #4 dismantled a scaffold at a platform at the reactors. Employees #5 and #6 removed and installed new insulation on piping at a platform at the reactors. The host employer did not become aware that employees were exposed to DMS until about 2 p.m., when workers were discovered having chemical burns. Employees worked on a raised platform around the two reactors. In order to enter and leave the area, they walked along a path between two the reactors that was only 30 inches wide, and a pipe that contained DMS which ran overhead between the reactors. The piping system normally operated at 5 psi, but thermal expansion of DMS caused pressures over 300 psi and caused a valve on the overhead pipe to leak this extremely hazardous compound down onto employees that worked beneath the pipe.
Source:OSHA.gov
"Incidents relating to thermal fluid systems are unfortunately more common than we might realise,
and can be extremely serious. The fire and explosion hazards with thermal fluid systems have been
re-emphasised by recent incidents. These incidents have a direct bearing on the estimated 4,000 UK
companies that operate thermal fluid systems.
Water or steam can be used as heat transfer fluids, but when high temperatures are needed
organic fluids, which are capable of forming explosive atmospheres, are often used. Although
fire and explosion hazards of low flash point flammable liquids are generally recognised, similar
hazards with high flash point materials, such as thermal fluids, are often missed. These heat transfer
fluids are often handled at temperatures above their flash point.
However, many people are unaware that heat transfer fluids based on mineral oils
degrade over time. This degradation can cause the fluid’s flash point to decrease dramatically, so
that thermal fluids which were not flammable at the operating temperature when they were initially
installed may, over time, become flammable at the operating conditions. Also, high flash point
materials (such as thermal fluids), can form explosive mist atmospheres when handled under
pressure, even at temperatures below the flash point".
Read the article in this link.
"In this study, the explosion failure of a bellows expansion joint made of Type 304 stainless steel (UNS S30400) in a pipeline conducting methane (CH4) gas at 400 °C is analyzed. Using the simulation mechanical software, the behavior of the pipeline during the working condition was investigated.
Observations of the metallographic sections indicated that corrosion was involved in the cracking of the bellows that led to the explosion. After investigating the fracture surface, it was noted that the cracks occurred at dimples in the bellows. The presence of hydrogen sulfide (H2S) in the gas stream resulted in stress corrosion cracking".
Read the incident in this link
Employees #1 and #2 were engaged in a turnaround operation at a fertilizer manufacturing plant. They were standing on a work platform at a height of approximately 20 ft, removing an 18 in. diameter manway cover on the east monoethylamine stripper in Ammonia Plant #2. The top manway cover on the east stripper had already been removed and they were using a #5 spline drive, #3913 air-operated impact wrench to open the bottom manway cover. They had removed all but one of the bolts when there was a sudden flash fire and explosion. Employee #1 suffered broken bones and suffered second-degree burns over 60 percent of his body. He was killed. Employee #2 suffered minor burns on his arms and legs. The source of ignition is not known.
Source:osha.gov
An employee was cleaning the floors in a restaurant and mixed together sanitizer and heavy duty floor cleaner. The sanitizer contained chlorine and the floor cleaner contained ammonia which, when combined, creates chlorine gas. The chlorine gas was drawn into the ventilation system and circulated throughout the restaurant. Coworkers were evacuated when the white gas cloud formed, and three employees were taken to the hospital with respiratory problems.
Source:osha.gov
A road tanker loaded with ammonia hydroxide was being unloaded into a polyethylene storage tank at the site of a chemical distributor. This change was not taken through a MOC. The unloading was being accomplished by filling the vacant space above the liquid inside the tanker with compressed air, a standard method of unloading such tankers. When the tanker was emptied, the compressed air surged into the polyethylene storage tank, which was not designed to withstand that kind of pressure. The polyethylene tank ruptured, releasing a substantial volume of ammonia into the air. An employee, who was close to the drain valve on the tanker, inhaled a substantial volume of ammonia, He suffered serious chemical burns to his lungs, resulting in his death.
Source:osha.gov
The 109D-C was one of three identical vessels at the facility that removed moisture and carbon monoxide from a synthesis gas used in the manufacture of ammonia. The 109D-C, which had been taken off line to replace its desiccant material, had been online for approximately 11 1/2 hours when the vessel exploded into flame. One employee was killed instantly in the explosion and 6 more suffered severe burns. Another employee, a crane operator, suffered from severe burns and was hospitalized for several weeks before he died. An ammonia operator, was standing on the catwalk above the 109D-C when it exploded. He also suffered severe burns and died several weeks later. Subsequent inspection of the vessel revealed a cracked weld. Apparently, an inadequate repair job had been made to the weld two days before the accident.
Source:osha.gov
At approximately 7:10 a.m. on June 11, 2008, Operators at the C2 unit (Plant 2) in C building were injecting 60-psi steam at a temperature of approximately 400-degrees Fahrenheit into a precooler, heat exchanger Model Number E300-G, to purge the process of the latex products. Latex was on the tube side and ammonia was on the shell side. The steam was injected into the tubes heating the ammonia on the shell side. The precooler over pressured, rupturing the shell, releasing ammonia into the environment. Employee #1 was found dead beneath the debris in the area of the heat exchanger several hours after the explosion occurred. Five contracted employees were severely exposed to ammonia. Employees #2, #3, #4, and # 6 were hospitalized. Employee #5 received first aid and was released.
Source:OSHA.gov
How do you address human factors of lookalikes when handing over lines/ equipment for maintenance?
At approximately 9:00 a.m. on March 15, 2022, an employee disconnected nuts to a line for service and repair work. The employee was working to depressurize lines of ammonia for service work. The team had isolated, performed proper lockout/tagout, and bled the line assigned for work off. The employee began disconnecting nuts on the wrong line with pressure still on it. Pressurized ammonia began to leak from the pipe; the employee reacted to protect the plan and other personnel on-site, grabbed the nut, and manually screwed a few turns of the threads to stop the leaking. This action caused burns to the employee's hands that needed medical attention. The employee was not wearing his protective gloves because he was supposed to be working in the bled offline, which would have eliminated the hazard of glove use.
Source:OSHA.gov
Pyrophoric materials create fire and explosion hazard
There have been several explosions involving pyrophoric materials in storage tanks. It's important to take preventive measures when emptying tanks or vessels, or when opening equipment and piping for inspections and maintenance.
This bulletin explains how pyrophoric materials can form in tanks. It also describes how to prevent the explosions that can occur when pyrophoric iron sulfide is exposed to oxygen. Download and read the bulletin in this link
At approximately 11:00 a.m. on May 11, 2003, Employee #1 was transferring a waste liquid from a 5 ft portable tank into an active incinerator. The waste liquid was a mixture of mineral oil and triethyl aluminum (TEAL). TEAL is pyrophoric and reacts spontaneously with air or moisture resulting in ignition. The liquid waste was moved by nitrogen pressure on the tank, through a flexible steel hose, into a rigid piping system for delivery into the incinerator. The delivery hose and piping had been pre-purged with nitrogen. The explosion and fire destroyed the flexible steel hose, splitting it both lengthwise and into approximately 6-in crosswise segments. Employee #1 was in close proximity to the ruptured hose and was engulfed in flames sustaining fatal burns. Employee #1's body was not retrievable until after the fire was extinguished. The portable tank was charred on the side where the steel hose was located, not undamaged on its opposite side. The rigid piping had char marks on the outer surfaces, but was not bent or deformed. The incinerator was unaffected by the explosion and fire which had occurred only 20 to 30 ft away. A coworker reported having had some operational difficulties while he was working on the waste transfer with Employee #1 that morning. The rigid piping system had clogged and was cleared by nitrogen pressure. The piping system had also developed hot spots, something that never occurred before.
Source:osha.gov
"A terrible accident occurred at a process plant in Taiwan on May 18, 2001. The plant was destroyed by a series of explosions that resulted in the death of one man, 112 injuries and extensive damage. The accident was caused by the ignition of a leak of mixed flammable vapours from an out-of-control exothermic batch
reactor, which produced water-born acrylic resin. Most of the victims, who were employees of nearby factories, were cut by glass splinters and other debris that rained down over an area of radius 200 metres around the plant. This accident reveals that both the process plant and the neighbouring factories
did not handle safety information properly. This paper describes the accident, the discussions and the conclusions from the viewpoint of safety information management. The lessons learned from this accident include the importance of information management and the need for using a safety information management system throughout the plant life cycle. A research project at Loughborough University is investigating safety information management and its measurement and is developing a prototype tool for use in this area. This project is also described briefly in the paper".Read the paper in this link
On January 31, 2006, a runaway reaction occurred at XXXX, while employees were making a product. The polymerization reaction included toluene, cyclohexane, n-butyl acrylate, and benzoyl peroxide. According to the employer's records, there were 2,689 pounds of the solvent blend and 1,923 pounds of N-Butyl Acrylate in a Pfaudler reactor (M-1). Two 55-gallon drums and one 330-gallon IBC tote were positioned in front of reactor M-1. The containers held a solvent blend of toluene, cyclohexane, and benzoyl peroxide. At the time of the incident, the contents of one of the drums and a portion of a second drum had been transferred to the M-1 reactor. Employee #1 walked away from the reactor,
intending to turn a valve on the M-5 reactor to begin a nitrogen purge and move the contents of M-5 to M-1. While walking down a stair to perform this task, Employee #1 heard a loud, high-pitched sound. He immediately went back up and observed the Teflon 18 in. envelope gasket from M-1 hanging down from the manway and vapors coming through the opening. Other employees began to hear the sound. After Employee #1 observed the vapors being emitted, he walked outside and met other employees outside the production door, on the Northwest side of the building. Employee #2 was operating a forklift inside the drumming area when he heard the sound. He left the area and met with Employee #3 and Employee #4. They walked up to the Northwest side of the building. Employee #5 instructed Employee #3 to go get the Plant Manager. Employee #5 then donned a full-face respirator and entered the building to turn on the chill water to the reactor.
After a few seconds, Employee #5 returned after failing to obtain a good seal on the respirator and smelling vapors. Employee #1 then donned the respirator and went inside the building. Employee #3 and Employee #6 walked up and joined the other employees outside the production door. When Employee #1 exited the building, an explosion occurred. Twelve employees and two bystanders sustained various injuries. Five of the employees were hospitalized with various injuries, and one died later of burns.
Source: OSHA.gov
Continuing my previous post regarding effects of explosions, when you have large storages of flammable /toxic chemicals and are expanding your storage capacity, take into account if some thing can happen in your neighboring plant that can have fragments hitting your tanks. Here is an incident from osha.gov:
On May 27, 1994, Employees #1 through #3 were working at the XXX Chemical Plant in Belpre, OH. A catastrophic failure of a 15,000 gallon polymer reactor vessel was initiated by a runaway chemical reaction involving an abnormally high amount of 1,3-butadiene during the production of a polymer. The reactor failure and ensuing fire resulted in the complete destruction of the polymerization unit. Missile fragments from the failed reactor vessel damaged adjacent units in the plant. One fragment punctured a styrene storage tank approximately 600 ft away. This subsequently resulted in the burning of five styrene storage tanks containing approximately 3.5 million gallons of flammable products. Employees #1 through #3 were killed in the explosion
Due you consider the effects of explosions from nearby plants that can affect you? Shrapnel from explosions can be thrown a large distance. In one case an urea plant reactor top flange and attached head from vessel were thrown about 385 feet (117.4 meters) after it failed due to environmental stress cracking. Read the report in this link
Another incident (courtesy of osha.gov) is given below:
On May 1, 1991, at the IMC Fertilizer, Inc., (IMCF)/Angus Chemical Company plant located in Sterlington, LA, a fire occurred in the area of a waste gas vent compressor (RJ-291) in the nitroparaffins (NP) plant. A few moments after the fire started, a series of explosions destroyed a large section of the NP plant, sending shrapnel north and east of the plant. Large debris weighing up to 150 pounds was hurled almost a mile away. Employees #1 through #8 of IMCF were killed and 42 were injured. In addition, approximately 70 residents of the town were injured and numerous businesses and residences were severely damaged.
With many valves being able to be operated from control room and also automated, this raises a hazard when carrying out maintenance. These automated valves should not open suddenly when maintenance work is going on. Do you have clear procedures to correctly Lock Out Tag Out and Try out such systems?
Read this incident:
At 9:00 a.m. on May 23, 2023, Employee #1 and Employee #2, both maintenance workers for a petroleum refinery were troubleshooting an automated valve in the "Prime G Unit". Flammable gasoline/hydrocarbons in the piping and flange portion of the automated valve were released causing an explosion and fire. Employee #1 sustained 3rd degree burns to over 83% of his body and was hospitalized. Employee #2 sustained 3rd degree burns to over 93% of his body and died on May 26, 2023.
Source OSHA.gov
Good case study for those operating ammonia plants
At 6:45 p.m. on September 20, 2022, the south area units of the refinery were experiencing process upset conditions, including lifting pressure safety valves and loss of pump arounds on the crude tower. Due to an incident earlier in the day, the NT/Sat gas unit and Coker gas plant were not in normal operating conditions. During work to troubleshoot and provide stability to the process units, the opening of a flow control valve to the absorber stripper tower in the Coker gas plant resulted in naphtha to flow downstream, eventually filling the TIU fuel gas mix drum with naphtha. This led to liquid in the refinery fuel gas system, which initiated the shutting down of some operating units. During outside employee response to the high liquid level in the TIU fuel gas mix drum, naphtha was released into the atmosphere, forming a flammable vapor cloud at ground level and in the oily water sewer at the refinery. At approximately 6:47 pm, the vapor cloud ignited at/near the TIU fuel gas mix drum, possibly due to nearby fired heaters, in the crude unit. Both of the outside employees who responded to the high liquid levels were severely burned in the explosion. Both of the employees died due to their burn injuries in the early morning of September 21, 2022.
Source:OSHA.gov
An employee was working for a contractor that supported gas and oil operations. On or before December 21, 2021, a leak was found on a flange for a bypass line on the Hydro Desulfurization Unit (HDU-1) at refinery operated by an international oil company. The leak was detected because the leak had auto ignited. The refinery owner's fire team had been called out to put the fire out. After the fire was out, steam lances were continuously directed on the flange due to the potential of another flash fire from the leaking heated naphtha. The refinery's owner hired two contract companies to repair the leaking flange using a method called hot bolting. In this method, one bolt at a time was removed and replaced so that workers could install a wire wrap and seal the leak. The replacement bolts were longer and had injection collars. Workers would do the wire wrap and inject the bolts with a sealant to stop the leak. At 1:00 a.m. on December 23, 2021, an employee was working for the contracting firm that would remove and replace the bolts, while the other contractor assisted. As the employee was waiting for the other contractor, an explosion occurred during the repair. The employee suffered second-degree burns. In addition, he suffered a fractured femur when he was struck by a flying object from the explosion. He was hospitalized. Another worker there was not hospitalized. The employee's supervisors knew that the flange had auto ignited the day before they were called to come and fix the leak. The supervisors did not, though, ensure that employees had upgraded their personal protective equipment (PPE) to reduce the risk of serious injuries should a flash fire reoccur. They did not evaluate the hazards and select and require the use of appropriate PPE using their knowledge of the operating conditions, nor did they use refinery owner's safe work practice requirement of using upgraded PPE when work activity is going to be done in areas with potential flash fire.
Source:OSHA.gov
Neste has made a video of process safety fundamentals. Watch their video in this link
Learn lessons from the incident of Failure of a road tanker pressure/vacuum relief valve in this link:
https://www.hse.gov.uk/safetybulletins/failure-road-tanker-pressure.htm
Are you maintaining your vent and drain valves?
Read about a globe valve spindle failure incident in this link:
https://www.oisd.gov.in/Image/GetSafetyAlertAttachmentByID?safetyAlertID=98
CSB guidance for Chemical Plants During Extreme Weather Events: Climate change is here...are your emergency response plans including the effects of climate change that can trigger emergencies?
Read the guidance in this link
https://www.csb.gov/assets/1/6/extreme_weather_-_final_w_links.pdf
The Dakar ammonia accident, in Senegal on March 24, 1992, is the worst ammonia industrial acci-dent ever. This anhydrous ammonia industrial catastrophe claimed 129 lives and injured another 1,150 workers and citizens.
The accident happened at a peanut oil processing facility where ammonia was used to detoxify the product. Anhydrous ammonia was stored in a portable tank commissioned in 1983 and repaired in 1991 before the incident. The weld repairs made were on cracks detected on the tank's surface. Fre-quent overfilling of the tank ("authorized" to hold 17.7 tonnes) was one of the primary causes noted in the reports. An overpressure inside the tank led to its catastrophic failure releasing 22 tonnes of pressurized ammonia. A heavy white cloud of ammonia aerosol plus vapor spread a significant dis-tance causing fatalities and injuries.
This paper presents an analysis of the incident and the resulting consequences.
Dharmavaram, S., Air Products, Allentown, PA, U.S.A.
Pattabathula, V., S.V.P. Chemical Plant Services, Brisbane, Australia
https://www.uvu.edu/es/docs/paper4a-dakar_accident_final.pdf
Interesting analysis of failure of ammonia hose:
Failure analysis of a rubber hose in anhydrous ammonia service
Michael K. Budinski *
National Transportation Safety Board, 490 L’Enfant Plaza East, SW, Washington, DC 20594, United States
https://core.ac.uk/download/pdf/82491417.pdf
Dear Readers,
After a gap of more than a year or more, I am back with my blog due to popular demand. Follow me to get updates.
Thanks
Karthikeyan
