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Accident: 170672372 - Employee Dies In Heater Explosion

Accident: 170672372 -- Report ID: 0452110 -- Event Date: 05/17/1993
InspectionOpen DateSICEstablishment Name
12380782805/18/19932911Ashland Inc #2 Refinery
Several operators were preparing to ignite a 2-B-3 crude heater after a two week turnaround. The lead operator had two very inexperienced workers helping him light the heater. Due to the lack of precise and clearly written procedures and proper training, a large concentration of fuel gas was allowed to enter the heater before the pilot light was ignited. The resulting explosion killed Employee #1, who received fatal injuries to the back of his head. The operators bypassed safety shutdown features and did not do a visual check of the emergency shutdown system to ensure that the features were closed. In addition, they did not check the firebox to ensure that it was gas-free before lighting the heater.
Keywords: pilot light, head, heater, work rules, gas, lockout, explosion, inexperience, untrained
Employee # Inspection Age Sex Degree Nature Occupation
1 123807828 Fatality Fracture Miscellaneous plant and system operators

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