Fatal incident involving a temporary enclosure at a chemical facility
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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

Fatal Incident Involving a Temporary Enclosure at a Chemical Facility

From an OSHA Technical Information Bulletin


Purpose
Purpose Facility

  • Provide information

  • Hazard alert

  • Requirements and regulations

  • Recommendations and guidance

  • Other information


Incident description
Incident Description Facility

  • 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.


48” Pipe Facility

Black Tarp


Incident description1
Incident Description Facility

  • Plastic-wrapped pipe

  • New moisture-sensitive catalyst upstream


Incident overview

North Facility

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


Incident overview1
Incident Overview Facility

Reactor with

Catalyst

In-Line Mixer (removed)

Black Tarp

Open valves to north side open piping

Nitrogen

Purge


Incident description2
Incident Description Facility

  • Southside open pipe & enclosure

    • Midday black light inspection.

    • Black tarps draped to block light.

    • Workers entered enclosure.

    • No problems with inspection.


Incident description3
Incident Description Facility

  • North side open pipe & enclosure

    • Midday backlight inspection.

    • Black tarps draped to block light.

    • Workers entered enclosure.

    • Workers overcome upon entering.


Incident conclusions
Incident Conclusions Facility

  • 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.


Permit required confined space hazards

Oxygen deficiency Facility

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


Nitrogen hazard
Nitrogen Hazard Facility

  • Can’t be detected by human senses

  • N2 displaces oxygen in enclosures (confined spaces) resulting in oxygen-deficient atmospheres



Requirements recommendations guidance
Requirements, Recommendations & Guidance Facility

  • 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.


Requirements recommendations guidance1
Requirements, Recommendations, & Guidance Facility

  • Comprehensive confined space training.

    • Particular attention on hazardous atmospheres


Related information
Related Information Facility

  • 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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