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Failure To Recognise Hydrogen Sulphide Hazards: Lessons Not Learned - Part 6
Failure To Recognise Hydrogen Sulphide Hazards: Lessons Not Learned - Part 6
Description of the incident for some time before the incident. This was a crucial
factor in allowing events to proceed to the tragic scale
A drier was prepared for discharge of sieve in a way that had that they did.
been done many times before over the past twenty years. • The management of safety and risk assessment systems
The operators entering the drier to remove the top guard had a number of shortcomings. Disposal of the sieve was
and mesh used breathing apparatus and personal H2S moni- not included in the planning of the overall sieve
tors, demonstrating that the hazards of this gas were well replacement job. No risk assessment was carried out
understood for this operation. The sieve was then removed specifically for the disposal stage. Multiple jobs requiring
by raking it from the drier onto a chute carrying it to just different precautions were carried out under the one
above a high-sided tipper truck. The truck floor and the dis- Permit to Work, in contravention of company safety
charged sieve were water-wetted to restrict dust (it was procedures. There was no company supervision at the
windy) and to reduce the risk from any pyrophoric material. sieve unloading location.
After a while, a mound of sieve accumulated at the back of • No standby personnel were posted at the scene to pro-
the truck. A man entered the truck via a ladder to level the vide, for example, breathing apparatus or rescue services.
mound by shovelling it to the front of the truck. Ten minutes This is perhaps not surprising since the hazard that was
later, a second man joined him to help with the levelling. present was not recognized. Because of this, and other
This man collapsed very soon after entry. The first man tried factors, the immediate first aid response was inadequate.
to help him and was joined by a third man who actually • The fact that the high-sided truck, in effect, constituted a
jumped down into the truck from the platform on the drier. confined space in which concentrations of toxic gas could
All three became unconscious and died. A fourth man, who be confined and accumulate, was not taken into account.
also entered the truck via the ladder, to render assistance, A risk assessment would probably have identified this.
collapsed but was rescued. The emergency response was
delayed by unclear radio communications. Lessons from this incident
Investigation and cause of the incident The company did take this tragic accident most seriously and
put into place systems and improvements to address all of
It was established that the H2S concentration in the truck was
the above considerations. Thus:
sufficient to overcome workers in a few minutes and lead to
death unless they were rescued very quickly. The rear of the • Hazards identification, including potential incident scenar-
high-sided truck, in effect, constituted a confined space in ios and job safety analysis would be carried out with the
which ventilation by natural air circulation was insufficient to involvement of first line supervisors. Method statements,
reduce the concentration of any toxic vapours. containing clear roles, responsibilities and control features,
The workers in the truck, who were contractors, were would be prepared in advance of the starting of jobs.
not provided with breathing apparatus, escape masks or
• The understanding, communication and application of
personal monitors. The possibility of H2S release from the
manufacturer’s recommended safe practices would be
sieve at this stage was not fully understood or foreseen and
enhanced.
this resulted in inadequate management of the potential
• Safety induction would take account of different
risks. The initial emergency response was not effective.
languages and levels of literacy and its effectiveness
The mechanism for release of H2S in fatal quantities was
would be checked. Follow-up refresher training would
described as follows. The regeneration gas used prior to sieve
be provided as necessary.
discharge, contained approximately 830 ppm of H2S which
• The awareness of the specific hazards of H2S would be
begins to be adsorbed by the sieve during cooling. It is then
enhanced, tested and made the subject of routine
retained, not removed, during the nitrogen purge stage. Then,
refresher training.
since the molecular sieve’s affinity for water is much greater
• Enforcement of the use of personal protective equipment,
than its affinity for H2S, the latter is released on contact with
in particular breathing apparatus, would be ensured, and
water, in this case when it was wetted in the truck. More
emergency drills would cover a range of all identifiable
trapped H2S would have been physically released while the
scenarios and include all personnel who have a role to play.
sieve was being levelled by shovelling. There was little or no
prior knowledge amongst company staff or contractors about From LPB 194, April 2007
this mechanism for release of H2S though it is hard to imagine
that it had never happened before in 20 years. Perhaps it was References
just fortuitous that no tragic accident had occurred previously. 1. Man overcome by hydrogen sulphide fumes, LPB 184,
Other important findings of the investigation were: August 2005
• The mechanism for H2S release from the sieve in this 2. Hydrogen sulphide release from a process vessel, LPB
way was not known to either the company personnel or 168, December 2002
to the contractors. 3. Supply of wrong chemical leads to a release of
• The induction training given to contractors was not hydrogen sulphide gas, LPB 159, June 2001
effective. There was no testing of understanding, records, 4. A hydrogen sulphide release affects four workers, LPB
or recognition of any literacy or language difficulties. 155, October 2000
• There were no signs posted in or around the driers to 5. Hydrogen sulphide releases during oil tanker
warn of possible hazardous concentrations of H2S. operations, LPB 155, October 2000
• Personnel in the vicinity of the disposal operation did not 6. Hazardous substances in refineries, BP Process Safety
react to the very unpleasant smell which was apparent Series, IChemE, ISBN 978 0 85295 482 9