FATAL INCIDENT AT EXXON REFINERY IN SINGAPORE

Key Learnings shared in the API symposium

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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

Spare bottle bank

individualofinside the vessel died in the incident Copyright INSERT COMPANY NAME HERE

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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