Accident Report Detail

Accident Summary Nr: 200210391 - Ten employees injured when exposed to hydrogen sulfide gas

Accident Summary Nr: 200210391 -- Report ID: 0626000 -- Event Date: 12/14/1998
Inspection Nr	Date Opened	SIC	NAICS	Establishment Name
302099908	12/14/1998	1799	0	Repcon, Inc.
Inspection Nr	Date Opened	SIC	NAICS	Establishment Name
302099890	12/14/1998	2911	0	Coastal Refining & Marketing, Inc.
Inspection Nr	Date Opened	SIC	NAICS	Establishment Name
302099908	12/14/1998	1799	0	Repcon, Inc.
Inspection Nr	Date Opened	SIC	NAICS	Establishment Name
302099890	12/14/1998	2911	0	Coastal Refining & Marketing, Inc.

Abstract: Employees #1 through #10 worked at a crude oil refinery at which nearby process units (crude oil and gas oil treater) were undergoing a planned turnaround. The units had staggered shutdown and startup schedules, and they shared some product transfer piping leading to storage. When the product flow was rerouted by operations prematurely, sour naphtha liquid was released into the crude unit from an open connection installed on a new 6 in. piping section that served as an exchanger bypass line. The low-pressure release lasted for several minutes and allowed clouds of toxic hydrogen sulfide gas to accumulate in and around the nearby control room and through nearby process units. Emergency alarm and evacuation procedures were not executed according to plan. Operators responding in the field at first attempted rescue efforts without using emergency air packs, ultimately adding to the total of exposed employees. Numerous exposures to the evolved sour gas resulted in injury to both plant and contractor employees. Employees #1 through #10 were transported to the hospital, and Employees #2 through #4, #9, and #10 were admitted. None experienced permanent effects. Subsequent investigation revealed weaknesses and discrepancies in the plant lockout/tagout program, and poor implementation and upkeep of the process safety program. Unit isolation blinds and lockout/tagout blinds for the equipment were not clear to the operators due to poor tracking. Operating procedures were both outdated (e.g., the use of checklists) and/or unclear, such as to how to perform the final stages of unit startup.

Keywords: PPE, WORK RULES, INHALATION, AIR CONTAMINATION, EMERGENCY RESPONSE, HYDROGEN SULFIDE, LOCKOUT, CHEMICAL REACTION, CHEMICAL VAPOR, REFINERY

Accident Details
End Use		Project Type		Project Cost	Stories	Non-building Height	Fatality
Refinery		Maintenance or repair		$1,000,000 to $5,000,000	2	25

Employee Details
Employee #	Inspection Nr	Degree of Injury	Nature of Injury	Occupation	Construction
1	302099908	Hospitalized injury	Other	Welders and cutters	Distance of Fall: feet Worker Height Above Ground/Floor: feet Cause: Installing equipment (HVAC and other) Fatality Cause: Asphyxiation/inhalation of toxic vapor
2	302099890	Non Hospitalized injury	Other	Chemical technicians	Distance of Fall: feet Worker Height Above Ground/Floor: feet Cause: Fatality Cause:
3	302099890	Non Hospitalized injury	Other	Chemical technicians	Distance of Fall: feet Worker Height Above Ground/Floor: feet Cause: Fatality Cause:
4	302099890	Non Hospitalized injury	Other	Chemical technicians	Distance of Fall: feet Worker Height Above Ground/Floor: feet Cause: Fatality Cause:
5	302099890	Non Hospitalized injury	Other	Chemical technicians	Distance of Fall: feet Worker Height Above Ground/Floor: feet Cause: Fatality Cause:
6	302099890	Hospitalized injury	Other	Chemical technicians	Distance of Fall: feet Worker Height Above Ground/Floor: feet Cause: Fatality Cause:
7	302099890	Hospitalized injury	Other	Chemical technicians	Distance of Fall: feet Worker Height Above Ground/Floor: feet Cause: Fatality Cause:
8	302099890	Hospitalized injury	Other	Chemical technicians	Distance of Fall: feet Worker Height Above Ground/Floor: feet Cause: Fatality Cause:
9	302099908	Hospitalized injury	Other	Construction laborers	Distance of Fall: feet Worker Height Above Ground/Floor: feet Cause: Installing equipment (HVAC and other) Fatality Cause: Asphyxiation/inhalation of toxic vapor
10	302099890	Non Hospitalized injury	Other	Chemical technicians	Distance of Fall: feet Worker Height Above Ground/Floor: feet Cause: Fatality Cause:

Thank You for Visiting Our Website

You are exiting the Department of Labor's Web server.

The Department of Labor does not endorse, takes no responsibility for, and exercises no control over the linked organization or its views, or contents, nor does it vouch for the accuracy or accessibility of the information contained on the destination server. The Department of Labor also cannot authorize the use of copyrighted materials contained in linked Web sites. Users must request such authorization from the sponsor of the linked Web site. Thank you for visiting our site. Please click the button below to continue.