Fall at Refinery (KV 168v2)


What Happened?

An employee was working with three coworkers inside a flue gas duct removing a refractory at a refinery. The work crew was moved to a new confined space area because the refractory needed to be immediately removed at the location. The employer required the workers removing the refractory to work within four feet of the leading edge associated with the 28 foot vertical fall hazard. Because of the heavy weight of the rivet buster, the work crew traded off using the tool until one got tired. One employee finished using the rivet buster, and handed the tool to a coworker. He then walked the wrong direction into the vertical flue duct section. The employee fell 28 feet onto a staging area. The employee and three coworkers were in a confined space adjacent to the fall hazard. All the employees, including the supervisor, required for all the permitted flue duct spaces to be "100 percent tie off". Nobody was tied-off because no anchor points were established in the duct. The employee sustained a broken femur and compound fracture of his left arm.

Contributing Factors

Lack of barrier restricting the movement by the fall hazard at the duct. 

Lack of fall protection for workers inside the duct as required by the confined space permit.

What Can We Learn?


Use of Procedures would have ensured that the crew tied off the hazardous area.

By using a Self-Check (Stop, Think, Act, Review), the workers would have considered the dangers of working in a confined area close to a vertical fall hazard.


Time Pressure led to the employees working in an unsafe environment as the refractory was in need of immediate removal.

Mental Stress/Fatigue caused the employee to lose focus and walk in the wrong direction leading to his fall.  

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?