Case Studies

for
for the
the

Oil and Petrochemical

Sector
Prepared on 8 November 2006

Please note that all cases are shared for learning purposes
only and in no way implies any liabilities on any parties.

WSHAC Workplace Safety & Health Advisory Committee

© 2006 WSHAC
 2

Case Study 4

EXPLOSION AND FIRE AT

CHEMICAL
MANUFACTURING PLANT

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© 2006 WSHAC
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Brief Description

Date March 2005

Work Discharging of
Process chemicals
from tote bin
into a hopper
Casualty One death
and One
injured

WSHAC Workplace Safety & Health Advisory Committee

© 2006 WSHAC
 4

Synopsis

2 workers were carrying out the discharging
of P2S5 from a tote bin into a hopper.

5 minutes into the process, an explosion
followed by a fire occurred at the discharging
area.

1 worker managed to escape and suffered
20% burns at the back of his body.

WSHAC Workplace Safety & Health Advisory Committee

© 2006 WSHAC
 5

Synopsis

The explosive force caused the tote bin

involved to topple and land on the deceased.

WSHAC Workplace Safety & Health Advisory Committee

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Observations and Findings

Inert atmosphere required in the hopper
not maintained.

Workers had not checked if the valve
supplying nitrogen gas to the hopper was
open.

It was not work procedure to conduct the
check.

WSHAC Workplace Safety & Health Advisory Committee

© 2006 WSHAC
 7

Root Cause Analysis

Evaluation of loss Fatal
Type of contact Pinned under tote bin

Immediate cause Fire and explosion hazard

Basic cause 1. Improper design

2. Inadequate work procedures
3. Lack of proper training
Failure of SMS 1. Inadequate hazard analysis
2. Inadequate safe work
practices
3. Insufficient safety training

WSHAC Workplace Safety & Health Advisory Committee

© 2006 WSHAC
 8

Corrective Measures

Review plant processes

Review hazard analyses

Conduct safety training

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© 2006 WSHAC
 9

THE END

WSHAC Workplace Safety & Health Advisory Committee

© 2006 WSHAC