Employee Burned while Draining Oil (KV 201)

 

What Happened?

At 10:45 a.m. on July 31st, 2018, an employee was draining oil from a low-pressure receiver that was part of a mechanical refrigeration system. The employee was using a hose to drain the oil from a drain port and anhydrous ammonia was released in a vapor state before igniting. The employee received second and third degree burns over a significant portion of their body from the burning vapor. The initial report does not indicate when the employee died.

Contributing Factors

There are no contributing factors.

What Can We Learn?

Traps

Vague Guidance: The employee may have had vague guidance into how to properly drain the oil resulting in the anhydrous ammonia being released.

Overconfidence: Did the worker overestimate his knowledge, underestimate risks, and exaggerate their ability to control events?

Tools

The employee could have used a Questioning Attitude to question every aspect of what he was doing to ensure he was fully aware of the situation and consequences of anhydrous ammonia.

Were there Procedures in place that would have ensured the employee was draining the oil properly?

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?