Fatal incident at Exxon refinery in Singapore

1. Fatal incident at Exxon refinery in Singapore Key Learnings shared in the API symposium

2. Incident description • Inert entry job to changeover catalyst • Set up • two separate sources of air supply for the individual inside the vessel • One source of air supply for the individual outside (confined space watch) • Supervisor standing down at the Grade • Low pressure alarm from one of the bottle banks. • The bottle bank happens to be the one which was common source for both individuals • Supervisor switches to a spare bottle bank • Supervisor tries to contact over radio after switching bottle bank - no response from both individuals . Activates the ER • The confined space watch survived but the individual inside the vessel died in the incident Spare bottle bank

3. Investigation • One of the breathing air bottle in the spare bottle bank had Argon • Individual inside the confined space got exposed to 18% Argon • Bottle with Argon was painted and identified as breathing air • Exxon has a policy to check CFA of the breathing air bottles that they receive. • Exxon uses random sampling – two out of 16 bottles in the bottle bank had CFA. • Conclusions: • Unintentional mistake by the BA supplier • Bottle must have been in previous service of Argon and was not fully depleted before it was recharged to be in the BA service • Exxon has gone to 100% sampling of BA cylinders that they receive following this incident