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Case Studies Explosions

In recent years, more lives of workers were lost due to chemical explosions. This WSH Bulletin aims to highlight the lessons learnt from 4 fatal incidents. The Fault Tree Analysis comprising the 5M (i.e. Man, Machine, Medium, Management and Mission) was used to identify the causal factors. The 5M-Model provides in-depth analysis of the cases and identifies the contributing factors which might have led to the incidents. Please see Annex A for a more detailed explanation of the 5M-Model. Case Study 1

Description: A worker was filling up a pressure receiver with nitrogen gas for pressure testing. A co-worker came along and asked if he needed any help. The worker said he could handle the pressure test. Moments after the co-worker went to the back of the workshop to resume his work, there was a strong gush of wind from the front of the workshop. When he rushed to the front, he saw the pressured receiver had ruptured. The worker was found dead. Contributing Factors: Mission: Non-destructive testing was not conducted on the pressure receiver prior to the pneumatic pressure testing Machine: The pressure receivers were not fabricated in accordance with accepted industry practice. There was no construction drawings or design calculation. Weldment in pressure receiver had insufficient penetration and fusion to the parent metal. They were fabricated by workers who were not trained in welding work. The pressure receivers were also not surveyed by a competent person. Man: The worker was not trained to carry out pressure testing work.

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Management: Absence of specifications for welding. Absence of safety measures for pressure testing. Did not conduct any examination on the quality and integrity of the weldment before pressure tests. Root Cause: Pressure receiver unable to withstand the pressure built up during pressure testing. Recommendations: 1. Comply with fabrication codes and standards: Pressure vessels must be fabricated from proper technical drawings with details of welding and testing. A competent person or third party inspector should be engaged to verify the fabrication. 2. Ensure proper training in welding work: All welding work must be carried out by welders who are properly trained and qualified to apply the Welding Procedure Specification (WPS). WPS specifies how a welded joint is to be carried out to ensure that the designed strength can be achieved. The welder must be tested on his competency in WPS and be issued with a Welder Qualification Record (WQR). Appropriate non-destructive testing should be carried out to ascertain the integrity of weldments before proceeding with pneumatic tests. 3. Use non pneumatic testing: The American Society of Mechanical Engineers (ASME) code warns that it is hazardous to use compressed air or gas as a testing medium. It specifies hydrostatic tests for pressure vessels. Hydrostatic test uses water as the testing medium, and it should be done after all fabrication has been completed and all the other non-destructive examinations have been performed. The British Standards BS 5500: Specification for Unfired Fusion Welded Pressure Vessels, further elaborated that pneumatic testing is potentially a much more dangerous operation than hydraulic tests (testing with liquids), as any failure during a pneumatic test is likely to be of a higher explosive nature. 4. Safe work procedures: Safe work procedures must be properly documented and implemented to ensure adequacy of safety precautions for the test. Some areas to be considered include: adequacy of blast protection extent of area cleared for test safety purposes procedure to prevent local chilling during filling and emptying of the vessel Case Study 2

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Description: Two workers were carrying out modification works to the pipe lines on top of 2 chemical tanks. One of them cut and fit the pipes while the other was responsible for welding the pipes. An explosion occurred when welding work to a pipe joint was being done. The worker was thrown to the ground and died on the spot. Contributory Factors: Medium: The tank was previously cleaned with a highly flammable chemical. The cleaning chemical was then pumped out and manholes of the tanks were left open for a few days before they were closed. The tanks were not ventilated by mechanical means, such as using blowers. They were not used since the cleaning. Some residual cleaning chemical were found in the tank. Management: Absence of safe work procedure for hot work. No gas testing was conducted prior to the welding work. Root Cause: Sparks from the welding work ignited the flammable vapour in the pipe connected to the tank. Recommendations: 1. Test for flammable and hazardous gases: Gas testing should be conducted to detect the presence of any flammable or hazardous gases in the tanks before allowing the workers to work. 2. Safe Work Procedures: Safe work procedures for hot work should be implemented to ensure no incompatible operations are carried out concurrently.

Case Study 3

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Description: Three workers tried to restart a steam utility boiler that had been shut down due to technical problem. When they tried to fire up the boiler using the temporary bypass method, an explosion occurred in the furnace. It ripped open the boiler and released its content of high pressure steams. The workers were badly injured with more than 50% second degree burn on their bodies. Two of them subsequently succumbed to their injuries. Contributing Factors: Machine: There were difficulties in lighting up the boiler due to low LPG pressure in the burner firing system. Man: The workers tried to restart the boiler using a temporary bypass method. However they opened the bypass valves without closing the block valve. This allowed a large amount of LPG to enter into the furnace, causing the explosion. Management: Safety Management System (operational integrity management system) was not implemented effectively. This resulted in several violations, including the unauthorized temporary bypass and the removal of security seals on yellow-painted bypass valve. The decision to use temporary bypass method was only made known to the team of professionals and was not communicated to other workers. It was neither not documented nor approved by the Management. Root Cause: Sudden build up of pressure in the boiler by explosive gas-air mixture (LPG) Recommendations: 1. Safety Management System: Effective operational integrity management system should be put in place to prevent violations such as unauthorized use of work method (temporary bypass). Proper approval must be obtained prior to effecting any change in the process, operational procedures or methodology. 2. Review and Inspect: Thorough inspection and examination of the utility steam boiler should be carried out to ensure that the boiler is functioning in a safe operating condition. It is also necessary to review and audit the boilers burner management system to identify weaknesses and implement necessary rectification works to close the gaps and improve the system. 3. Control Measures: Control measures and safe work procedures must be established, communicated and implemented to ensure the safety and health of all workers involved. All workers should undergo adequate training on the safe work procedures to operate the boiler which includes the use of emergency equipment, activation of alarms and the communication system.

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Case Study 4

Description: Four workers were washing a storage tank. They were provided with a new set of high pressure water jet gun. This gun was shorter, lighter and working at twice the pressure than the one they had normally handled. Three of them were on top of the tank, washing the interior of the tank with high pressure water jet. The fourth worker was controlling the water jet machine at the ground level. There was a loud explosion and the entire tank roof was ripped off. Two of the three workers on top of the tank were killed instantly. The other two were injured. Contributory Factors: Machine: Storage tank not properly grounded to prevent accumulation of static electricity that may lead to an electric discharge. Management: Inadequate safety considerations in the tank cleaning procedure. No checking of flammable gas in the tank. No proper ventilation of the tank prior to the cleaning process. Man: The worker was not familiar with the handling of the new water jet gun. The higher frequency of the metal water jet gun striking with the edge of the metallic manhole was probably the source of ignition for the air mixture in the tank. Medium: The tank was not ventilated prior to the commencement of the tank washing operation. There were flammable substances in the tank. Root Cause: Flammable substances in the tank ignited by spark generated from frequent striking of stainless steel water jet gun against the edge of the tank.

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Recommendations: 1. Risk assessment: Through the risk assessment, employers and workers would need to identify potential hazards and take appropriate actions so as to eliminate the hazards or reduce the risks involved. For this case, risks associated with the use of stainless steel high pressure water jet guns should be identified and appropriately managed. 2. Safe Work Procedures: Safe work procedures should be instituted for such cleaning works which involved the potential generation of flammable substances. Hazards ad necessary control measures necessary for such work should be communicated to the workers. 3. Mechanical Ventilation: Perform gas checks and mechanical ventilation to supply fresh air to dilute the concentration of flammable substances prior to the start of the chemical blending and tank washing process.

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Annex A 5M - Model Man refers to the specific individual(s) directly involved in the operations execution, taking into account his/their reliability (attitude, discipline, psychological factors and physical health) and proficiency (knowledge, judgement and hands-on skills). Mission relates to the task that has to be achieved, including the objectives and the aspects of planning, preparation, operating area and contingencies. Management refers to all those who can influence the control of the operations. It involves the supervision, control and scheduling of the operations. It also concerns with the provision of training and management of the risks associated with the operation. Machine refers to the tools for the operation and its reliability (failure rate, accuracy and dependability) and capabilities (its suitability to the tasks, degree of automation, and ability to provide for the needs of the human). Medium refers to the physical environment of an operation. It includes visibility, weather conditions, density of events, the degree of real-time supervision or control and support and the nature of terrain.