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Inspection Detail
Inspection: 107489684 - Phillips Refining Company-Sweeney Complex
Inspection Information - Office: Houston South Area Office
Site Address:
Phillips Refining Company-Sweeney Complex
Texas Highway 35 At Fm Road 524
Old Ocean, TX 77463
Mailing Address:
, , 00000
Union Status: Union
SIC:2911
NAICS: 0
Inspection Type: Accident
Scope: Partial
Advanced Notice: N
Ownership: Private
Safety/Health: Safety
Close Conference: 11/10/1993
Emphasis:
Case Closed: 08/12/1994
| Type | Activity Nr | Safety | Health |
|---|---|---|---|
| Accident | 361145154 |
| Violations/Penalties | Serious | Willful | Repeat | Other | Unclass | Total |
|---|---|---|---|---|---|---|
| Initial Violations | 2 | 2 | ||||
| Current Violations | ||||||
| Initial Penalty | $10,000 | $0 | $0 | $0 | $0 | $10,000 |
| Current Penalty | $0 | $0 | $0 | $0 | $0 | $0 |
| FTA Penalty | $0 | $0 | $0 | $0 | $0 | $0 |
| # | Citation ID | Citaton Type | Standard Cited | Issuance Date | Abatement Due Date | Current Penalty | Initial Penalty | FTA Penalty | Contest | Latest Event | Note |
|---|---|---|---|---|---|---|---|---|---|---|---|
| 1. | 01001 | Serious | 19100119 F01 IA | 11/16/1993 | 12/19/1993 | $5,000 | $5,000 | $0 | 12/15/1993 | F - Formal Settlement | Citation has been deleted. |
| 2. | 01002 | Serious | 19100119 G01 I | 11/16/1993 | 12/19/1993 | $5,000 | $5,000 | $0 | 12/15/1993 | F - Formal Settlement | Citation has been deleted. |
Investigation Summary
Employees #1 through #3 were trip testing a small steam turbine. They brought the turbine up to trip speed with the governor disabled to allow three tests without the turbine spinning down between tests. The tests were done using a reed-type tachometer that measures speed using vibrating reeds held in contact with the turbine. During the trip test, the turbine failed catastrophically and all three employees were struck by flying debris. Employee #1 suffered a fractured hip and was killed. Employee #2 sustained face injuries and Employee #3 fractured his leg; both were hospitalized. The turbine was a remanufactured unit made from three separate turbines that were originally built in the 1940s. Complete documentation on the remanufactured unit and the three original units was not available. There were no specific testing procedures for this turbine.
Keywords: FRACTURE, WORK RULES, ENGINE, EQUIPMENT FAILURE, STRUCK BY, FLYING OBJECT, FACE, HIP, LEG
| # | Inspection | Age | Sex | Degree of Injury | Nature of Injury | Occupation |
|---|---|---|---|---|---|---|
| 1 | 107489684 | Hospitalized injury | Fracture | Occupation not reported | ||
| 2 | 107489684 | Hospitalized injury | Fracture | Occupation not reported | ||
| 3 | 107489684 | Fatality | Fracture | Occupation not reported |