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Fatal Incident Involving a Temporary Enclosure at a Chemical Facility

Fatal Incident Involving a Temporary Enclosure at a Chemical Facility. From an OSHA Technical Information Bulletin. Purpose. Provide information Hazard alert Requirements and regulations Recommendations and guidance Other information. Incident Description.

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Fatal Incident Involving a Temporary Enclosure at a Chemical Facility

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  1. Fatal Incident Involving a Temporary Enclosure at a Chemical Facility From an OSHA Technical Information Bulletin

  2. Purpose • Provide information • Hazard alert • Requirements and regulations • Recommendations and guidance • Other information

  3. Incident Description • Facility unit undergoing a turnaround. • 2 workers to inspect the flange surfaces of an open 48-inch piping system. • Piping system opened to remove a piece of process equipment for cleaning.

  4. 48” Pipe Black Tarp

  5. Incident Description • Plastic-wrapped pipe • New moisture-sensitive catalyst upstream

  6. North Open Valve N 2 Injection Open 48" Piping N Venting 2 Closed Valve South Reactor w/new catalyst Note: Actual process/piping significantly more complex. N2 injection point 150' and several stories in elevation from pipe opening. Incident Overview

  7. Incident Overview Reactor with Catalyst In-Line Mixer (removed) Black Tarp Open valves to north side open piping Nitrogen Purge

  8. Incident Description • Southside open pipe & enclosure • Midday black light inspection. • Black tarps draped to block light. • Workers entered enclosure. • No problems with inspection.

  9. Incident Description • North side open pipe & enclosure • Midday backlight inspection. • Black tarps draped to block light. • Workers entered enclosure. • Workers overcome upon entering.

  10. Incident Conclusions • One worker died, another hospitalized. • N2 throughout system. • Piping system was not straightforward. • OSHA cited the employer for 1910.146 Permit-Required Confined Space violations.

  11. Oxygen deficiency Flammable atmosphere Toxic atmosphere Oxygen enrichment Chemical exposure Thermal hazards Electrical shock Temperature extremes Engulfment Mechanical hazards Trapping/Pinch points Physical hazards Slips, Trips, Falls Unstable working surface Structural failure Other recognized hazards Permit RequiredConfined Space Hazards

  12. Nitrogen Hazard • Can’t be detected by human senses • N2 displaces oxygen in enclosures (confined spaces) resulting in oxygen-deficient atmospheres

  13. Human Response to Oxygen-Deficient Atmospheres

  14. Requirements, Recommendations & Guidance • If space meets the definition of a PRCS, must follow 1910.146. • Even if not technically a PRCS, 1910.146 recommended. • Other OSHA standards may apply: • 1910.134 – Respiratory Protection • IDLH Atmospheres • Recognition that temporary enclosures may be PRCSs.

  15. Requirements, Recommendations, & Guidance • Comprehensive confined space training. • Particular attention on hazardous atmospheres

  16. Related Information • OSHA Technical Information Bulletin on incident at: http://www.osha.gov • CSB Morten Report at: http://www.csb.gov/reports/1998/union_carbide/98005lafr.htm • OSHA PRCS Standard, Directive and Interpretation at: http://www.osha.gov

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