Page 24 - Serious Incident Prevention How to Achieve and Sustain Accident-Free Operations in Your Plant or Company
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Effective pipe isolation procedures
Effective management systems for
Increased management over-
Improved safety auditing proce-
Evaluation of hazards
maintenance work:
sight
dures
Inadequate isolation and depres-
surization of pipe containing
naphtha
TABLE 1-1 10 Analysis of Serious Incident Causes and Preventative Actions Potential Preventative Probable Cause Known Consequences Actions Serious Incident Prevention Effective process to ensure instal- Piping elbow was made of car- Property damage: $65 M lation of piping consistent with de- bon steel instead of the chrome Operat
OSHA fine: $400,000
Fatalities: 1
Injuries: 46
Incident Description A fire occurred after naphtha was released from a pipe that was being replaced. At the time of the naphtha release and fire, workers were positioned on scaf- folding with limited means of es- cape. An intense fire occurred after a 6˝ diameter elbow ruptured and released hydrocarbons. The sus- tained heat
Location and Year (References) Refineries California USA 1999 (21) Louisiana USA 1993 (22) Sodegaura, Japan 1992 (23)
