Valero Refinery Asphyxiation Incident Case Study
Name
Institution
The accident investigation team composition
The investigation team shall contain people with expertise in the disciplines necessary to investigate the accident. The team will have a safety engineer, an environmental and occupational health specialist, a professional photographer, a closed space work environment specialist an accident specialist, Nitrogen and Inert gases specialists, a petroleum and petrochemical engineer, three accident investigator from the main parties involved Valero Delaware City Refinery, Valero Energy Corporation and Matrix Service Industrial, Contractors, Inc. the team will also include petrochemical refinery specialists from national bodies American Petroleum Institute, American Society of Safety Engineers and Compressed Gas Association
Type of evidence to collect in this scenario
In investigating this accident, I would major on to main types of evidence: photographic evidence and physical evidence. Photographic evidence is evidence that can be used to the appearance of the accident area or images seen by the witnesses. A camera is the basic too used to collected photographic evidence, although video cameras may also be used. Photographs can help record an keep perishable evidence, aerial views, overviews of the scene from multiple directions, site inventory, significant scene elements, and documents. Physical evidence includes human, material and environmental evidence. Mai human evidence for this investigation will include training records, witness statements, risk assessments, permitting procedures and records, safety policies and procedures, employee qualifications and certifications, and briefings. Material evidence will include tools and equipments. Environmental evidence on the other hand will include work environmental hazard in the reactors area, hazard analysis reports, and hazard awareness.
The people to interview, and why: A description of the sequence of events
In investigating the accident, I would interview people that were directly or indirectly involve in creating events or conditions leading to the accidents. The people are listed bellow in the manner in which thy interacted with the sequence of events occurred before the accident. Based on these the interviewees will include:
The CHSC foreman who was at the scene five hours before the incident
It was this foreman who oversaw the Catalyst Handling Services (CHSC) Workers that reloaded the reactor with new catalyst. This occurred several days before the accident. The workers working under him will also be interviewed to determine whether any of them new about the presence of the tape in the reactor and it wasn’t reported or removed before the concluded their activities and started venting nitrogen into the reactor (Chemical Safety Board, 2006).
The Valero operators
The Valero operators are responsible for opening the nitrogen vulvae. Their intention was to provide a nitrogen purge within the reactor which was part of the catalyst loading process. The after loading the catalyst the purge continued to provide protection to the catalyst, the many way which was the only point of discharge was covered by a piece of plywood (Chemical Safety Board, 2006). Unfortunately, despite leaving the nitrogen purge the worker never created a sing to indicate presence of nitrogen/inert gas purge danger around the manway. The question will serve to find out why no warning sign was place in the area or whether the person responsible for placing the sign at the place was complacent.
Valero Hydrocracker unit operator
On the night of the Valero Hydrocracker unit operator gave the Matrix nightshift boilermaker crew the safe work permit to proceed with the installation of the top elbow pipe on the reactor (Chemical Safety Board, 2006). This interview will be aimed at finding out whether the operator issued the permit from an informed point or had insufficient information while issuing the permit, whether he always works from an informed position or uninformed position.
The matrix pipe fitter at the scene
The matrix pipe fitter at the scene noted and informed the boilermaker crew about the about the tape in the reactor. He will be in a position to report what transpired in the discussions and initial plan by the boilermaker crew to retrieve the tape.
The boilermaker crew’s foreman
This foreman was present during the discussion on how the team would retrieve the tape. He was present as his team members tried to retrieve the temp and went in through the manway into the reactor. The boilermaker crew’s foreman may thus have basic information concerning the incident.
Crew adjacent reactor
These include the other workers that were working around the scene when the accident occurred. These workers reported seeing the first victim try to get the tape out of the reactor using a wire, but his efforts seemed unsuccessful. The crew did not see the first victim going into the reactor, but the saw the second victim slide a ladder into the reactor and descend inside the reactor. Then they saw the nightshift administrator who was at the scene behaving like he wanted to descend in, the withdrawing and pulling out his radio to report an emergency.
The nightshift administrator
The night shift administrator was at the scene when the victim went into the reactor and almost followed the second victim, before hesitating, reporting the accident and calling for help.
Valero Emergency Response Specialists and Matrix safety personnel
These were the first responders to the call for help assessed the conditions and helped to pull out victims from reactor without endangering their own lives. These will be able to provide additional information concerning the accident scene.
Most obvious contributing causes and flaws in the contractor’s or Valero’s safety management systems
In this accident there are various contributing issues that brought about the accident. The first issue is failure to install a warning sing indicating nitrogen/inert gas purge. If this sign has been place on the barricade around the area, the victim would have been warned and would have approached the area with caution (Chemical Safety Board, 2006.a).. Failure to barricade the area and provide warning was failure in the Valero’s safety procedures.
The second contributing factor is the failure of the safe work permit to warn the victims of the accident victims that the reactor was filled with nitrogen. The permit was indicated nitrogen gas or inert atmosphere not applicable. This is again another failure in the Valero’s safety systems.
The third contributing factor is the company training programs and industry good practice guidelines do not adequately warn workers of the oxygen deficient atmosphere inside confined space or open point to confined spaces. The Valero procedures, Industry guidelines, and OSHA standards do not provide proper warning to workers regarding low oxygen hazards near openings outside confined spaces (Chemical Safety Board, 2006.a). Poor safety training program are weakness in both the contractor’s and Valero’s safety management systems.
The human urge to rescue fellow worker is yet another factor that contributed to the fatality of the second victim. In most cases when a worker is in distress other worker fell the urge to help and may end up doing so without observing safety precautions (Chemical Safety Board, 2006.a). The second victim went into the reactor to help his colleague without any breathing apparatus and succumbed (Chemical Safety Board, 2006.a). This indicates limitations in the contractor’s safety management system. The contractor organization should have equipped its employees with the knowledge that they are not supposed to rush into a situation to rescue their collegues.
The Chemical Safety Board’s recommendations
The recommendation given to the responsible organization by the Chemical Safety Board (CBS) are appropriate give the circumstance surrounding the accident. The recommendation addressed all the events or condition that contributed to the accident (Chemical Safety Board, 2006.b). To Valero Delaware City refinery, the recommendations include refresher training to all preparers and approvers of safe work permits as well as other employee affected by the incident; and conduct refresher training of the refinery personnel and contractors on how to work in confined spaces and procedures for inert gas purge. The recommendations to Valero Energy Corporation included auditing of all nitrogen purge procedures and all work permit procedures in all its refineries in the U.S. This had to be targeted at identifying if any of the issues noted in case study recurred in the other refineries. Corrective measures had to be undertaken in areas where the issues were recorded. Second, Valero Energy cooperation had to perform nitrogen hazard awareness in all its refineries. CSB recommendations to Matrix Service Industrial Contractors, Inc. were: conducting refresher training of all employees affected on how handle inert gas purge and confined spaces, while the American Petroleum Institute was advised to revise all its safety guidelines for workers working in confined spaces, or spaces with inert gases in Petrochemical and Petroleum industry (Chemical Safety Board, 2006.b). The board recommended the American Society of Safety Engineers to also review its Confined Spaces Safety Requirements ANSI/ASSE Z117.1 and the Compressed Gas Association to issue an alert on safety concerning nitrogen/inert gas risks in confined spaces. CSB gave clear explanation of what was supposed to be done as part of the recommendations to ensure that they are perfectly enacted to prevent a repeat of the accident in future (Chemical Safety Board, 2006.b).
References
Chemical Safety Board (CSB). (2006.a). Case Study: Confined Space Entry – Worker and Would-be Rescuer Asphyxiated. Washington, DC: U.S. Chemical Safety and Hazard Investigation Board.
Chemical Safety Board (2006, November 2.b). Hazards of Nitrogen Asphyxiation (Video). Retrieved from http://www.csb.gov/investigations/detail.aspx?SID=25&Type=2&pg=1&F_All=y.
