Chemical Exposure (KV92)

 

What Happened?

On August 22, 2012, four employees were reinstalling a valve at a natural gas processing plant. It was thought that the valve had been isolated per the associated lockout/tagout. However, harmful chemical fumes were released from the open pipe and engulfed the workers. Upon investigation it was discovered that valve was not properly isolated by the lockout/tagout which allowed chemical fumes to flow upstream and impact the workers. All four crew members were hospitalized.arges with ropes. The employee stated there was poor lighting and everyone was in a hurry to finish work since it was Friday. The employee misjudged the distance of and fell between the two barges head first. He received serious injuries to his left leg and right shoulder. The crew was able to extract the employee from between the two barges.

Contributing Factors

The work was being performed during a maintenance turnaround; a time of high activity and longer work schedules. 

What Can We Learn?

Tools

Procedures were not followed. The valves should have been locked out to keep the crew from being exposed to the hazardous vapors and fumes.

A Questioning Attitude would have encouraged the crew to ensure the lockout/tagout was correct.

Traps

The Mental Stress and Fatigue associated with the hours and workload of a maintenance turnaround may have contributed to not verifying job safety.

Time Pressure was also likely at play as the crew may have experienced an urgency to complete their work due to the turnaround completion date.   

Ask the Right Questions

How does this relate to our work?

Where do we have similar traps?

What Tools can we use to avoid a similar incident?

Was a stop work point missed?