Two Oil Field Mechanics Die in a Pressure Vessel Rupture at an Oil Refinery in California

Details

• Corporate Authors:
  California Fatality Assessment and Control Evaluation Program (CA/FACE) ; California. Department of Health Services
• Description:
  A 48-year-old male craftsman (victim #1) and a 38-year-old male pipefitter (victim #2) died when a pressure vessel (sulfur recovery unit) ruptured at an oil refinery. The upper stage of the unit had been purged with nitrogen to remove residual hydrogen sulfide (H2S) and sulfur dioxide (SO2). This upper unit was designed to withstand a pressure of 3 pounds per square inch (psi) although the company typically ran the process at 5-7 psi. An operator noted a rise in the upper stage pressure during the purging procedure to over 20 psi. A few hours after beginning to purge the upper stage, members of the maintenance team were sent inside the lower stage to scrape catalyst and shovel the residue into a bucket. Victim #1 and a co-worker climbed through an upper manway to the lower stage. Victim #2 was stationed outside the unit. Victim #1 was crushed to death when the dome which divided the upper and lower stages of the unit collapsed on him. The co-worker working with victim #1 was able to crawl out from the manway and survived. Victim #2 was blown off the platform through a metal guardrail and fell approximately 12 feet to his death. The CA/FACE investigator concluded that in order to prevent similar future occurrences employers should: 1. not permit any confined space entry into a vessel while pressurization is taking place in any part of that vessel. 2. require that harnesses and retrieval lines be available for workers who are working in confined spaces. 3. install a pressure regulator in the purge (nitrogen) line set to no more than the design limits of the vessel (3 psi). 4. ensure that pressure relief mechanisms are installed and maintained in all pressure vessels. 5. implement a policy that states that any time a vessel is stressed beyond its design limits that an inspection must take place, and clearance given, before any work begins or resumes, or before the vessel is placed back into service.
• Subjects:
  Accident Prevention Accidents Accidents, Occupational Confined Spaces Occupational Health Oil And Gas Industry Personal Protective Equipment Safety Safety Management Workplace
• Keywords:
  Accident-analysis Accident-prevention Confined-spaces Equipment-design Injuries Injury-prevention Oil-industry Oil-refineries Oil-refinery-workers OSHA Region 9 Protective-equipment Protective-measures Safety-education Safety-equipment Safety-measures Safety-monitoring Traumatic-injuries Work-analysis Work-areas Work-operations Work-performance Work-practices

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• FACE - NIOSH and State:
  FACE ; Confined Space
• Series:
  Fatality Assessment and Control Evaluation Reports (FACE)
• Subseries:
  State
• DOI:
  https://doi.org/10.26616/NIOSHSFACE95CA014
• Publisher:
  National Institute for Occupational Safety and Health
• Document Type:
  Text
• Funding:
  Cooperative Agreement
• Genre:
  Field Study
• Place as Subject:
  California ; OSHA Region 9
• CIO:
  National Institute for Occupational Safety and Health (NIOSH)
• Topic:
  Workplace Safety & Health
• Location:
  North America
• Pages in Document:
  7 pdf pages
• NIOSHTIC Number:
  nn:20027070
• NTIS Accession Number:
  PB2007-112641
• Citation:
  Morgantown, WV: U.S. Department of Health and Human Services, Public Health Service, Centers for Disease Control and Prevention, National Institute for Occupational Safety and Health, FACE 95CA014, 1996 Sep ; :1-7
• Federal Fiscal Year:
  1996
• Performing Organization:
  California Department of Health Services
• Peer Reviewed:
  False
• NAICS and SIC Codes:
  31-33 - Manufacturing - (NAICS)
• Start Date:
  1991/09/30
• End Date:
  2006/08/31
• Collection(s):
  National Institute for Occupational Safety and Health
• Main Document Checksum:
  urn:sha-512:a621505173f72b9f5133f9971b70beeacca1eea5b4c49150146c90016e91eacb8fa63fe4d721651217239f8fc3806c316fd8cc272b32c7dabe85e3e5ed3b386a
• Download URL:
  https://stacks.cdc.gov/view/cdc/169020/cdc_169020_DS1.pdf
• File Type:
  [PDF - 35.16 KB ]