Upload
betty-harmon
View
213
Download
1
Embed Size (px)
Citation preview
Copyright of INSERT COMPANY NAME HERE 1
FATAL INCIDENT AT EXXON REFINERY IN SINGAPORE
Key Learnings shared in the API symposium
Copyright of INSERT COMPANY NAME HERE
INCIDENT DESCRIPTION
Inert entry job to changeover catalyst
Set up
two separate sources of air supply for the individual inside the vessel
One source of air supply for the individual outside (confined space watch)
Supervisor standing down at the Grade
Low pressure alarm from one of the bottle banks.
The bottle bank happens to be the one which was common source for both individuals
Supervisor switches to a spare bottle bank
Supervisor tries to contact over radio after switching bottle bank - no response from both individuals . Activates the ER
The confined space watch survived but the individual inside the vessel died in the incident
Spare bottle bank
Copyright of INSERT COMPANY NAME HERE
INVESTIGATION
One of the breathing air bottle in the spare bottle bank had Argon
Individual inside the confined space got exposed to 18% Argon
Bottle with Argon was painted and identified as breathing air
Exxon has a policy to check CFA of the breathing air bottles that they receive.
Exxon uses random sampling – two out of 16 bottles in the bottle bank had CFA.
Conclusions:
Unintentional mistake by the BA supplier
Bottle must have been in previous service of Argon and was not fully depleted before it was recharged to be in the BA service
Exxon has gone to 100% sampling of BA cylinders that they receive following this incident