Case study fire

English

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A team of 6 workers were roller painting in a confined space when a flash fire occurred.

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One worker was killed and three others injured before work started.

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An entry permit for painting and cleaning work in a confined space was applied.

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The safety assessor conducted a gas test.

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The results of the gas test showed that the confined space was safe for entry and he endorsed the
permit.

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Two days before the incident, the worker started roller painting.

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On the morning of the incident, a gas test was conducted.

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No abnormalities were observed and the entry permit was endorsed.

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The workers carried out vacuuming and clearing work using thinner, which was a flammable substance.

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At noon, a second gas test was conducted.

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Following the gas test, the quality of the painting in the confined space was inspected to assess the
quality of the work done.

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The workers were then instructed to perform some touch ups to the paint job.
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After the safety assessor conducted another gas test, the workers brought in drums of paint and
hardener into the confined space.

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One of the workers makes the paint and hardener in the confined space for 5 minutes.

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He then distributed the mixture into the empty drums.

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The roller painting commenced.

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30 minutes later a flash fire occurred.

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Painting in a confined space had resulted in the death of 1 worker and injured three others.

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What went wrong?

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Accumulation of flammable vapors The activities in the confined space had accelerated the accumulation
of flammable solvent vapors in the confined space.

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These activities include the mixing of paint and hardener in the confined space, distributing the mixture
into empty drums, drying of paint.

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Adequate measures were not in place to eliminate the accumulation of flammable vapors.

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No gas monitoring.

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Portable gas detectors were not provided to monitor the concentration of flammable gases in the
confined space.
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Lighting with exposed filament, electrical wires, not properly maintained light bulbs with exposed
filaments, and exposed electrical wires are sources of ignition.

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No effective maintenance regime was in place to ensure that the lights and wires were in good condition.

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Lessons Learned Risk Assessment Before starting any work in a confined space, always conduct a risk
assessment to identify safety and health hazards.

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Measures to minimize risks should be implemented.

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Avoid accumulation of flammable vapors.

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Mix the paint and hardener outside and not in the confined space to avoid accumulation of flammable
vapors in a confined space.

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Provide portable gas detectors.

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Provide workers with suitable portable gas detectors to monitor the concentrations of flammable gases
or vapors while working in confined spaces.

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The concentrations should not exceed 10% of their lower explosive limits.

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Use flameproof lighting.

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Flameproof lighting should be used in confined spaces.

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Establish a regular maintenance regime to ensure that lighting and live wires remain in good condition.
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Ventilation dilution or forced ventilation should be used to dilute solvent vapors to prevent accumulation
of flammable vapors within the confined space.

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Use a stronger force to control airflow during increased painting activities.

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Ideally, both exhaust and forced ventilation methods should be used together.