347422 Too Close For Comfort - Part 2
Learning from experience is one of the four pillars of Risk-Based Process Safety. Incidents that occur at one facility often provide opportunities to strengthen management systems at other facilities. Sharing the technical lessons learned from incidents is morally right and vital to improving process safety performance across the process and related industries. Most incidents also involve human factors, often as a key causal factor. Understanding these performance shaping factors can also be essential to minimizing future failures.
Most papers of case studies on process safety incidents are written and presented by a third party who was not directly involved in the incident. As such, the papers may lack the human element and other insights that can only be properly appreciated and articulated by someone directly involved in the incident.
In his early career the author was involved in two major incidents while managing the day-to-day operation of refinery process units. This paper describes the second incident involving several employees rendered unconscious from exposure to hydrogen sulfide. The first incident involving 2 major fires was presented at the 8th Global Congress. In both incidents the author found himself decidedly too close for comfort and could easily have become a casualty himself.
The incident occurred during commissioning of a major process unit, as a result of which eight men were exposed to sour gas. The blank isolating the reactor from the main fractionator column was being removed and the work had progressed to the point where the flanges had been jacked open and the blank removed, when the men on the job were overcome by gas. Breathing apparatus was not being worn. Members of the rescue party were also affected by gas.
The content of this paper will raise awareness of lessons learned relating to a number of elements of Risk-Based Process Safety and human factors.
See more of this Group/Topical: Global Congress on Process Safety