Prevent over One-Third of Incidents Through Preparation for Maintenance Activities
"More than a third of the incidents investigated by the CSB occurred prior to, during, or immediately following maintenance activities, ultimately resulting in 86 fatalities and 410 injuries."
A recent CSB report summarizing and incident in November 2015, link below, discussed an incident where refinery employee suffered severe burns after opening a drain valve to a sewer during maintenance activities. Based on the immediate causes of the DCRC incident, this Safety Bulletin highlights issues that can arise when equipment is not securely isolated and emphasizes the need for general and equipment-specific procedures when taking equipment out of service.
Five key safety lessons can be applied to many high hazard facilities:
- Non-routine operational tasks surrounding maintenance should have standard operating procedures, covering tasks such as emptying, decontaminating, washing, steaming, purging, and draining equipment and vessels.
- For all equipment preparation activities, develop a process that requires preplanning and hazard identification prior to initiating the work.
- When isolating equipment for emptying or decontaminating activities prior to maintenance work, avoid reliance on single block valves. Always consider more protective measures for isolation such as including double blocks or blinds.
- When an equipment preparation task or isolation plan needs to be modified or expanded due to leaking valves or changing conditions, evaluate the hazard.
- Use closed systems such as tanks, drums, flares, etc.to control the draining, or relieving of hazardous energy in preparation to isolate equipment for maintenance.
Note: Burns were suffered on the face, neck and wrists indicating that flame resistant clothing and gloves were effective PPE.
- CSB Bulletin for the 2015 Chemical Release and Flash Fire at the Delaware City Refining Company: http://www.csb.gov/csb-releases-safety-bulletin-into-2015-chemical-release-and-flash-fire-at-the-delaware-city-refining-company/
- Also see the summary of incidents on pages 19-22: http://www.csb.gov/assets/1/19/Final_DCRC_Bulletin1.pdf