AIGA TP 31 - 22 - Recent - H2 - of - 2021 - Incidents - in - Gas - Industry - in - Asia

Training Package
TP 31/21
Recent (H2 of 2021) Accidents/Incidents

in the Gases Industry in Asia
Asia Industrial Gases Association

No 2 Venture Drive, #22-28 Vision Exchange, Singapore 608526
Tel: +65 67055642 Fax: +65 68633307 1
Internet : http://www.asiaiga.org | LinkedIn Profile: https://www.linkedin.com/company/asiaigaorg
Recent (H2 of 2021) Accidents/Incidents in the Gases
Industry in Asia
Disclaimer
All publications of AIGA or bearing AIGA’s name contain information, including Codes of Practice, safety
procedures and other technical information that were obtained from sources believed by AIGA to be
reliable and/ or based on technical information and experience currently available from members of
AIGA and others at the date of the publication. As such, we do not make any representation or
warranty nor accept any liability as to the accuracy, completeness or correctness of the information
contained in these publications.
While AIGA recommends that its members refer to or use its publications, such reference to or use
thereof by its members or third parties is purely voluntary and not binding.
AIGA or its members make no guarantee of the results and assume no liability or responsibility in
connection with the reference to or use of information or suggestions contained in AIGA’s publications.
AIGA has no control whatsoever as regards, performance or non performance, misinterpretation,
proper or improper use of any information or suggestions contained in AIGA’s publications by any
person or entity (including AIGA members) and AIGA expressly disclaims any liability in connection
thereto.
AIGA’s publications are subject to periodic review and users are cautioned to obtain the latest edition.
 AIGA 2022- Asia Industrial Gases Association. All rights reserved.

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Agenda
Incident cases
• Product Transportation including Loading/Unloading
• Handling of Cylinders
• Process Safety
• Occupational Safety/Maintenance Work/Construction
related
 Learning from the incidents
 AIGA references related to the incidents

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Incidents in Product Transportation Including
Loading & Unloading

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Event # 1
High Severity Product Vehicle Accident
Consequences: Roll Over with contractor driver LTI and 3rd party fatality
What Happened:
On 6th July 2021, approximately 12:52hr local time, a contractor operated ISO tank
vehicle carrying LCO2 was involved in a single vehicle rollover at a curved section of
the road. As a result, the contractor driver suffered left frontal subdural
hemorrhage, left leg and hand laceration. An unauthorized 3rd party non contractor
person travelling in the truck succumbed to his injuries. This person was not
wearing seat belt. There was no product release. During investigation it was found
that the vehicle was fitted with Roll Stability System(RSS) but the same did not
function as it was not verified for correct installation.
Lessons Learned:
 Need for strict review of driver selection process
 Ensure implementation of contractor safety requirement
 Driver monitoring for every trip and feedback to drivers be mandated
 Contractors to follow all functionality checks for all the installed technology on
periodic basis.
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Event # 1 Pictures

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Event # 2
Road tanker Rear-ending Incident
Consequences: Damage to 3rd party car
What happened:
The afternoon of Sep 29th at 12 25 pm, a LOX tanker driver by a contractor
driver rear-ended a car on the highway in a rainy day during delivery.
No injury and product release. The speed of the product vehicle was about 62
km/hr and apparently there was not enough safety space for the tanker that
was required for rainy condition and busy traffic.
Lessons learned:
 Lack of awareness of defensive driving was the key contributor to the
incident
 Importance of defensive driving in the adverse weather/road conditions
both in product delivery and personal driving.

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Event # 2 Pictures

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Event # 3
Cylinder Truck Rear-ending Incident
Consequences: Minor damage to truck cabin
What happened:
At 10 20 hrs on the 9th of Oct 2021, a cylinder truck scratched with two cars
ahead. The incident happened when the car ahead suddenly changed the
lane and braked. This caused the rear cylinder truck a side on collision
because of the slippery brake (there was oil on the road). The was no injury
to any person and product loss.
Lessons learned:
 A typical example of what happens if the driver has no awareness for defensive
driving.
 Importance of safety awareness for defensive driving is particularly important in
the adverse weather/road conditions both for product delivery and personal
driving.
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Event # 3 Pictures

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Event # 4
Vehicle Incident During Reversing
Consequences: Minor damage to truck wheel
What Happened:
On 6 Dec 2021, at about 11:15hrs, a mini bulk truck was reversing into the
customer’s unloading area. There were many customer products piled up around
both sides of the road. The road was very narrow, and the escort helped the driver
to reverse in. However, while turning right to reposition the truck, the front left
truck wheel scraped the product packaging.
Lessons Learned:
 Be aware of the surroundings - Be careful with risks and hazard around your path
when dealing with narrow access
 Follow procedures - Perform GOAL when dealing with slow speed maneuvering
 Liaise with customer to mark up and clear the access way

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Event # 4 Pictures

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Event # 5
Rear-ending Incident by a Tractor Trailer
Consequences: Damages to tractor cabin and rear portion of 3rd party truck
What Happened:
On 10 October 2021 at 05:37hr, a tractor trailer carrying Liquid Nitrogen hit the
rear portion of a dump truck which was at stationary position along the public
road. Due to the collision tractor cabin received slight damage and also the rear
portion of the dump truck. Personnel in the tractor trailer were not injured.
Based on the dashboard video camera recording, it was noted that the driver was
feeling sleepy and fell into micro sleep at the time of the event.
Lessons Learned:
 Need for drivers’ awareness and training on fatigue management.
 Requirement of improved monitoring and management of driver working
hours of driver

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Event # 5 Pictures
3rd party vehicle
The Product Vehicle
(Sketch)
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Event # 6
Product Vehicle Accident
Consequences: Damage to 3rd party car
What happened:
When turning left at an intersection, a product vehicle entered the opposite lane
and collided with two cars. The road was relatively slippery due to light rain and
sleet. Driver entered the intersection at a speed of 54km/hr and slammed on the
brakes when turning left. The traffic light was already turning yellow before the
driver was turning to left. There were no injuries to the drivers the product vehicle
and also to passengers of the two cars. There was also no leakage of products.
There was a minor damage to the front bumper of the product.
Lessons Learned:
 All drivers need to slow down in advance according to Defensive Driving Training
requirements when turning.
 Reduce driving speed when driving under bad weather or road conditions.
 If Driver monitoring technology is available, use it to identify high-risk driving
behavior of drivers and correct it in time.

Tel: +65 67055642 Fax: +65 68633307 15
Event # 6 Pictures
Product Vehicle
1st car
2nd car
Slippery Road

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Event # 7
Driver Fall During Product Unloading
Consequences: Lost Time Injuries to driver
What happened:
On 7th November, around 16:00, a bulk product vehicle was unloading at
operating plant, when the helper stepped away from the valve box he
tripped over the trailing vehicle’s power cable for the pump. He suffered
bruised/swollen hand and 7th left rib hairline fracture.
Lessons learned:
 Emphasize housekeeping management to all drivers/helpers
 To create safety awareness / risk mitigation at customer sites

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Event # 7 Pictures
cable

No 2 Venture Drive, #22-28 Vision Exchange, Singapore 608526 18
Tel: +65 67055642 Fax: +65 68633307
Event # 8
Cylinder Truck Reversing Incident
Consequences: Injuries to helper
What happened:
On October 28th 2021, around 10:30am local time, a vehicle loaded with 120
cylinders of industrial oxygen was reversing at customer site met with an incident.
The helper was guiding the driver (left hand drive) when he noticed that the
remote control of the vehicle lifter was hanging outside the truck cage. He
stretched his hand out to secure the remote cable hanging outside the vehicle
cage while the truck was slowly reversing. His left arm was caught in between a
stationery rack frame in reversing area and side of the truck resulting in fracture
of his left arm.
Lessons learned:
 Conduct safety observation physically and through footages, active engagement
with drivers
 Implement engineering controls – reverse parking sensor to aid drivers

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Event # 8 Pictures

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Process Safety Incidents

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Event # 9
Process Safety Incident
Consequences: Hose whip causing Lost Time Injury to driver
What happened:
On 11th September, around 14:40, two drivers were unloading LCO2 at a customer’s site.
On noticing that there was a leakage at the hose adapter, driver ‘A’ stopped the pump,
isolated the hose and then tried to tighten the connection, when the hose suddenly
disconnected. The hose whipped hitting driver ‘B’ on his left lower leg, who was observing
beside. Before the unloading process, driver ‘A’ has chained gas hose and liquid hose
together because there was no eyelet connection point on customer’s tanker. The driver ‘B’
was sent to the hospital immediately and his left shin was fractured.
Lessons learned:
 Review and update adaptor management guidelines
 Upgrade all connections of customer tanks
 Perform yearly inspection of customer owned tanks
 Update procedure for driver coaching and in cab camera observations
 Encourage drivers to report unsafe conditions/risks and near misses
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Event # 9 Pictures
Tanker Hose Customer

Connection
Adapter

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Event # 10
Consequences: LOX piston pump blast - no injury
What happened:
At a filling station, a LOX piston pump suddenly blasted during normal operation. Nobody
was injured but the pump was heavily damaged.
From the video taken by the on-site personnel immediately after the accident, it was found
that there was no icing on the liquid inlet pipe of the # 1 oxygen pump, but thin icing on the
return valve and thick icing on the outlet pipeline. According to this observation, LOX was
not suck into the pump. It suspected that LOX in the pipeline of # 2 pump back flown to the
outlet check valve of the #1 pump body , and formed an oxygen enriched atmosphere in
the pump chamber. The high temperature formed by the long dry running of the pump
might have caused ignition of the low ignition point material in the pump.
Lessons learned:
 Gap in pump layout design: Two pumps installed in parallel and work at the same time
but without any check valve on outlet lines.
 The requirements regarding the confirmation after cooling down of the pump in the
operating procedures should be clear.

Tel: +65 67055642 Fax: +65 68633307 24
Event # 10 Pictures
flow chart, P1 is the pump involved in the incident)

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Event # 11
Consequences: Gas Leak during maintenance work
What happened:
On Nov 3, 2021, at 22:32hrs, Contractor A and B were repairing the chain conveyor
at a HYCO plant site. During the maintenance work, contractor ‘A’ found alarm
flashing from his personal gas detector and evacuated immediately. Contractor ‘B’,
who stood at the top of the ramp assisted ‘A’ and then evacuated the platform
after ‘A’. The attendant of the confined space entry also had alarm on his gas
detector at same time. He yelled and helped both ‘A’ and ‘B’ out. Both contractors
walked to Safety Work Permit Centre without any assistance and rested there. At
about 23:00hrs, the supervisor arrived and decided to send ‘A’ and ‘B’ to the
hospital for medical evaluation. Both contractors were treated with 2 hours of
medical oxygen in high-pressure oxygen chamber by the doctor.
Lessons learned:
 The back flow hazards must be assessed when issuing Safety Work Permit
 Physical isolation must be in place to prevent back flow of syngas
 Personnel ‘4-in-1’ type gas detectors were in good operational condition

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Event # 11 Pictures

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Event # 12
Near Miss Process Safety Event
Consequences: Potential serious injury
What happened:
When a LOX pump was started, the overcurrent protection trip occurred. The pump
was then disassembled for inspection. Friction marks between the first-stage
impeller and the pump casing were found, with metal debris around, suggesting
that there was contact between the impeller and the casing. If this fault was not
detected and removed in time, might have caused combustion and explosion of the
LOX pump, resulting in potential serious injury.
Lessons Learned:
 In the project phase, the products provided by the supplier should be inspected
to ensure that the quality meets the technical specifications.
 In the project phase, a process for confirming construction quality and steps
shall be established.

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Event # 12 Pictures
Friction
Marks
Metal
Debris

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Accidents/Incidents in Handling
of Cylinders and Portable Liquid
Containers

Tel: +65 67055642 Fax: +65 68633307
Event # 13
Incident in Manual Handling of Cylinder
Consequences: Recordable Injury
What happened:
On 22 Dec 2021, at about 11:20hrs, our driver was moving cylinder into the
customer's trolley. As the cylinder was wet, it slipped off, pinched and cut our
driver’s left index finger.
Driver immediately call his supervisor, inform customer personnel and went to the
hospital for medical treatment. His supervisor also went to the hospital separately.
Lessons learned:
 Proper PPE must be worn for the task
 Review cylinder cage design with the customer
 Site survey and risk assessment to be conducted before start of work

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Event # 13 Pictures

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Event # 14
Cylinder Unloading Incident
Consequences: Fracture injury to cylinder truck helper
What happened
A driver and escort were unloading cylinders at the customer’s site. The driver was
moving the cylinders from the basket to the tailboard alone as the escort was busy
securing other cylinders on the truck. When the driver was moving the second
cylinder, the first cylinder on the tailboard dumped and hit the escort’s left foot.
The diagnosis results showed that the 1st - 4th metatarsal base of the escort’s left
foot was fractured. The escort went back to work on the next working day with
modified assignment.
Lesson learned:
 The driver violated the SOP requirement that cylinders need to be secured.
 The BSV and safety checks did not cover the driver’s safety behavior at customer site.

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Event # 14 Pictures
Escort Driver

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Occupational Safety, Maintenance
& Construction Work Related
Incidents

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Event # 15
Truck Maintenance Incident
Consequences: Lost Time Injury to technician
What happened:
On 9 June 2021, at approximately 1600hr, two technicians were performing the
dismantling of the inner base bearing of the right rear end of a tire of a Truck. The
technicians had difficulty in removing the base bearing from the axle and hence, they
decided to use hammer and cold chisel to free up the inner bearing base. While trying
to forcefully remove the base bearing using the said tools, tiny metal shrapnel from
the inner bearing base flew and hit both technicians on the middle of their chest. Both
technician required medical treatment at hospital. The incident resulted in a 7 days of
lost time.
Lessons learned:
 PPE requirement must be made specific and communicated to affected technicians.
 There must be a clear safety guideline and risk assessment conducted for the work to
be carried out.
 Always have a programmed schedule for maintenance works to prevent any emergency
servicing.

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Event # 15 Pictures
The above photos show through re-enactment of how the employee was performing his task and resulted in a
sprained ankle after contacting with the flexible hose
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Event # 15 Pictures
Chest injury was sustained after the shrapnel flew onto the chest portion.

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Event # 16
Manual Handling Activity
What happened:
On 6th September at around 4:45 pm one employee injured his left-hand little finger
while moving an UPS from MCC room to store. The UPS was being moved to store for
packing. There were 3 stairs(steps) from MCC room door to ground.
Six people lifted the UPS and while moving from 3rd stair to 2nd stair, this incident
happened. The UPS slipped when they tried to take first move from 3rd stair to 2nd
stair of the MCC room.
Lessons learned:
 Manual lifting policy/guideline to be prepare and circulate the same
 Competency development and certification of Mechanical Employees.
 Slope/alternate arrangement for enclosure where steps are there for such movement
 Taking through training and assessment to understand the intensity of complacency.
 Involving the relevant person/Experts for individual jobs

Tel: +65 67055642 Fax: +65 68633307 39
Event # 16 Pictures

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Event # 17
Slip, Trip and Fall
Consequences: Lost Time Injury to Customer Service Engineer
What happened:
On Aug 2nd 2021, at 10:30am, a customer service engineer was replacing the
filling nozzle gasket, he fell down to ground from height of 40 cm. He felt
uncomfortable, then drove to nearby hospital by himself. After inspection and
check in hospital, one of his thoracic vertebrae was found fractured. The injured
engineer stayed in hospital for further treatment
Lessons learned:
 Communicated with the customer to install a metal grate between the two
foundation slabs to overcome the gap
 Immediate meeting across Customer Engineering Services(CES) teams, to
communicate the event and quick learning, done in the afternoon.
 Survey, if there are similar conditions at other customer sites
 Equip engineers with solid wrenches in CES teams.
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Event # 17 Pictures

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Event # 18
Maintenance Incident
What happened:
An employee was cleaning the waste inside a new water tank. When he was about
to climb out of the water tank, because the wet gloves, he took off the gloves and
crawled out. In the process of turning around, his fingers touched the sharp edge
of a steel structure, resulting in finger cuts. He got a medical treatment at hospital
immediately with no working day loss.
Lessons Learned:
 JSA (Job safety analysis) is important before issue the PTW (permit to work),
even working with a new water tank.
 Consistently use the personal protective equipment during the job with
potential risk.

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Event # 18 Pictures

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Event # 19
Slip, Trip and Fall
Consequences: Lost Time Injury
What happened:
An ASU operator slide off the third step on the straight climb when was climbing
down the stair, unfortunately his right foot stepped on the pull-tab of a cover plate
(for filling pearl sand), which result in the fracture of his ankle.
Lessons Learned:
 Pre-startup safety review (PSSR) is important to confirm the design and the
installation are safely to reduce the potential risk in the working environment.
 Risk assessment and analysis should be a basic skill for the front-line operator.

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Event # 19 Pictures

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Event # 20
Maintenance Incident
Consequences: Lost Time Injury
What happened:
On Oct 9, 2021, at about 16:35hrs, contractors were working on destructive test of
heat exchanger. MI engineer was checking on the position of damaged coil-tube.
His right foot mis-stepped on single steel-made scaffold board, which was set on an
open 900mm depth. His right low back landed on the ground tube of the
suspended scaffold. Site activities were stopped, and the incident venue was
secured.
The engineer walked down from the purification unit to office area. Then he was
sent to the hospital for medical examination. CT scanning showed that his 10th to
12th rib were fractured.
Lessons Learned:
 Erect proper scaffold to cover all openings, with handrails and toe boards
 Sub-standard scaffold should not be tolerated
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Event # 20 Pictures

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Lessons learned from the safety events(1)
★ Transportation safety
○ Continue reinforcing Driver Fatigue Awareness programs
○ Periodic monitoring of In cab camera output is important in preparation to Driver
coaching / feedback sessions
○ Constantly remind Drivers about Defensive Driving Skill areas– Speed management,
adapting to road conditions, pre planning, rolling the eyes, etc.
○ Revisit your Vehicle inspection programs – tyres, periodic maintenance verification,
any mobile equipment like lift gates / cranes on vehicles, etc.
★ Handling of Cylinders
○ Discuss about the importance of Human Factors in manual handling
○ Communicate clear roles and responsibilities to the teams with training
○ Following Safe Practices is critical
○ Never stand in the ‘line of fire’

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Lessons learned from the safety events(2)
★ Process Safety
○ Operating Procedures: Follow procedures; Stop and ask questions
○ Ensure Risk Assessments and Hazard Reviews are done consistently for all
changes or new processes or systems
○ Permit to Work/LOTO: Discuss whether these are implemented per standards
○ Ensure proper inspection of vendor supplied equipment before installation at
project site
★ Occupational Safety, Maintenance Work and Construction

○ Designs: Ensure detailed design safety reviews by competent personnel
○ Employee Training and Safety Orientation: Critical for carrying out any
hazardous work
○ Unsafe act : Not following correct procedure and use of PPEs
○ Good Housekeeping keeps everyone safe
○ Being mindful and attentive on task is important
○ Always use 3 point contact

Tel: +65 67055642 Fax: +65 68633307 50
List of Useful AIGA documents for incident prevention
❑ AIGA SP 01 & 02: Safety Poster on ‘Driver Fatigue’

❑ AIGA SP 03 & 04: Safety Poster on ‘Driving Distraction’
❑ AIGA SP 11: Safety Poster on ‘Safe Transport of Cylinders and PLCs’
❑ AIGA SB 11: Human Behaviour in Transport Safety Operations
❑ AIGA SB 12: Transportation Safety, Challenges and Improvement Strategy
❑ AIGA SB 27: Vehicle Specification and Maintenance
❑ AIGA 008: Safety Training for Employees
❑AIGA 011: Work Permit System
❑ AIGA 015: Safety Management of Contractors
❑AIGA 041: Defensive Driving
❑AIGA 066: Selection of Personnel Protective Equipment
❑ AIGA 099: Process Safety Management Framework
❑AIGA 119: Overview of Fleet Safety Technology and Vehicle Specification

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Thank you
website: http://www.asiaiga.org

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AIGA TP 31 - 22 - Recent - H2 - of - 2021 - Incidents - in - Gas - Industry - in - Asia

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Training Package

Recent (H2 of 2021) Accidents/Incidents

Asia Industrial Gases Association

 AIGA 2022- Asia Industrial Gases Association. All rights reserved.

Asia Industrial Gases Association

Asia Industrial Gases Association

Asia Industrial Gases Association

Asia Industrial Gases Association

Asia Industrial Gases Association

Asia Industrial Gases Association

Asia Industrial Gases Association

Asia Industrial Gases Association

Asia Industrial Gases Association

Asia Industrial Gases Association

3rd party vehicle

The Product Vehicle

Asia Industrial Gases Association

Asia Industrial Gases Association

Asia Industrial Gases Association

Asia Industrial Gases Association

Asia Industrial Gases Association

Asia Industrial Gases Association

Asia Industrial Gases Association

Tanker Hose Customer

Asia Industrial Gases Association

Asia Industrial Gases Association

flow chart, P1 is the pump involved in the incident)

Asia Industrial Gases Association

Asia Industrial Gases Association

Asia Industrial Gases Association

Asia Industrial Gases Association

Asia Industrial Gases Association

Asia Industrial Gases Association

Asia Industrial Gases Association

Asia Industrial Gases Association

Asia Industrial Gases Association

Asia Industrial Gases Association

Asia Industrial Gases Association

Asia Industrial Gases Association

Asia Industrial Gases Association

Asia Industrial Gases Association

Asia Industrial Gases Association

Asia Industrial Gases Association

Asia Industrial Gases Association

Asia Industrial Gases Association

Asia Industrial Gases Association

Asia Industrial Gases Association

Asia Industrial Gases Association

Asia Industrial Gases Association

★ Occupational Safety, Maintenance Work and Construction

Asia Industrial Gases Association

❑ AIGA SP 01 & 02: Safety Poster on ‘Driver Fatigue’

Asia Industrial Gases Association

Asia Industrial Gases Association

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