Fatal incident at exxon refinery in singapore
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Fatal incident at Exxon refinery in Singapore. Key Learnings shared in the API symposium. Incident description. Inert entry job to changeover catalyst Set up two separate sources of air supply for the individual inside the vessel

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Fatal incident at Exxon refinery in Singapore

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Fatal incident at exxon refinery in singapore

Fatal incident at Exxon refinery in Singapore

Key Learnings shared in the API symposium


Incident description

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


Investigation

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


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