DSM-AW-201603 Downstream Manufacturing April 2016

Refinery Fire Injuries due to Open Draining of Light Hydrocarbon

Target audience for this alert
 Production
 Maintenance & Turnaround
 Process Safety & HSSE
 Site Leadership

What happened
On 21 August, 2015, a fire broke out during a Turnaround in a Crude Distilling Figure 1 – Hose on open sewer pit

Unit at a Shell refinery. Six contract workers were injured.

Turnaround status had been formally declared ten days earlier, on 11 August. When the fire ignited, four Project
contractor workers were on scaffolding in two different fireboxes, executing permitted hotwork activities associated
with a Project. Two other Project contractor workers were on the scaffold, outside of the fireboxes. (Figure 2 shows
where people were working when the incident occurred.)

Why it happened
Light hydrocarbons were being drained from a hose into an open sewer pit as part of a valve removal activity. The
light hydrocarbon vapours were ignited by nearby permitted hotwork. There were three permitted hot work
activities in the area, with a fire watch on the ground. The fire watch had covered the open sewer pit with a fire
blanket to prevent sparks from the hotwork from entering the sewer pit. When the draining started, the hose
whipped out from under the blanket and sprayed light hydrocarbons through the air, near the hotwork. The
investigation team identified the probable ignition source to be an oxyacetylene torch being used to cut a pipe in a
firebox almost directly above the open sewer.

1
Separate Operations Coordinators were assigned to the Project work and Turnaround scope. The Coordinators
were all unit Operators trained and authorized to perform activities such as gas testing, issuing of permit
clearances, etc. Nine Turnaround Coordinators were each assigned a part of the unit and coordinated all of the

1
Note that at the site, these people were referred to as AGSTs, a term not commonly used at most other sites, and the Turnaround Coordinator
was a supervisor of the TA AGSTs.
Turnaround work in their area, which often involved permitting 30-40 work activities in their area each day. Three
Project Coordinators were each assigned to Project work that crossed multiple areas of the unit. The hotwork, which
had been approved via a hotwork permit, was part of the Project scope. The valve removal activity was part of the
Turnaround scope. On the day of the incident, work activities in the morning were delayed by a safety stand down
and rain, leaving many scheduled activities to be completed in the afternoon.

One Turnaround Coordinator was working with

Figure 2 – Location of individuals when the incident occurred.
two contract pipefitters and their supervisor to
prepare for a valve replacement job. The valve
(labelled A in Figure 3) was in a light gasoline
line that tied into the plant’s Hydrocarbon
Solvents (HCS) header. The header was still in
operation at a pressure of 8 barg (115 psig).
The spade at Valve A was being used as the
battery limit isolation point for the Turnaround
because the valve at the battery limits (valve B)
was defective, and the design battery limit spade
could not be turned. (Figure 3a shows the unit
isolation.)

The Turnaround Coordinator had been told that the battery limit valve (valve B) was passing. He wanted to
determine the size of the leak through valve B to make plans to change valve A. He planned to determine the leak
rate by running a ¾” hose from valve A to the nearby open sewer pit. The piping between the NRV and valve C
had already been removed for replacement by the same contractor team as part of the Turnaround scope. The
contractor team laid one end of the hose on top of the pit, beneath the fire blanket covering the pit. In order to
connect the other end of the hose to valve A, they removed the relocated battery limit spade and non-return valve
whilst the Turnaround Coordinator attended to other jobs elsewhere in the unit. (See Figure 3b.) On return, the
Turnaround Coordinator then instructed the contractor pipefitter to open valve A. He then saw a forklift about to
enter the pump alley, near the pit, and went to intervene on the forklift.

After the contractor pipefitter opened the valve several quarter turns, the hose whipped away from the open sewer
pit and sprayed light gasoline through the air, near the hotwork. Although he closed the valve quickly, a vapour
cloud of sufficient size formed and ignited.

Figure 3a – Column tops to HCS header Figure 3b – Hose Installation

The two contractor workers who were in the firebox where the ignition likely occurred were the most severely
injured. After the incident, it was found that the acetylene hose they were using had burned through, resulting in a
secondary fire. The contractor workers were delayed in leaving the work area, because they had to fully remove
their fall protection harnesses due to difficulties in unhooking their lanyards. The site required full tie off for workers
inside of the scaffolding.

Underlying causes
 The conflicting work activities (draining to an open drain and nearby hot work) went undetected.
 Different individuals organized and permitted the unit turnaround work and the project work. When the
Turnaround Coordinator developed the plan to use the open sewer pit, he saw and knew of no conflicting
work. The Turnaround Coordination meetings were short and focused on the progress of the Turnaround
work. Both the Turnaround Coordinators and the Project Coordinators were focused on their own work
scope and meeting the Project and Turnaround timelines.
 The Project Coordinator had posted his work scope in the meeting room, and the permitted hot work
activities had been going on for a few days, with a fire watch positioned below the fire boxes. The
Turnaround Coordinator may have assumed that the fire watch was just one of a number of people passing
near the open sewer pit.
 Draining of light hydrocarbons to the open sewer pit was believed to be acceptable by Operators in the unit.
 The Turnaround Coordinator wanted to determine the leak rate of the Battery Limit Isolation valve (B), and
draining via the hose to the open sewer pit allowed that. On the day of the incident, there were seven
other hoses in the open sewer pit. (A closed draining header had been installed for the Turnaround, but it
was not used.). Many units in the plant only had open Continuously Oil Contaminated pits (sewer pits).
The site’s De-Oiling procedure specified that “open loop” draining to these pits up to a maximum of 50
litres (13 gallons) may be undertaken “as first resort”. The Operator was the person left to make the
decision about the volume.
 The Turnaround Coordinator knew that there had been a lot of open draining for the Turnaround, due to
the amount of hydrocarbon remaining in the unit when Turnaround work began. Decontamination of the
unit had been repeatedly disrupted by other unit trips, a furnace fire in the unit, and problems with a MOV
that required developing a new decontamination plan. Operators had also lost track of what equipment
and lines had been flushed and what had not, because operators on different shifts had inconsistently
marked the status on the P&IDs. By the time the inconsistency was detected it was too late to understand
what had been flushed and what had not.
 The Turnaround started with job packs for some of the work scope incomplete, meaning that planning was done
as needed for some jobs. Prior to the Turnaround, Coordinators charged with preparing the job packs were
repeatedly pulled back into shift work due to limited personnel resources and unit operating issues. In addition,
the Turnaround Steering Committee approved significant addenda items including Project scope changes up
until the start of the Turnaround.
 To develop the plan for changing valve A, the Turnaround Coordinator had the pipefitters remove a unit
isolation spade. He believed that he was authorized to remove it in order to replace the valve. Since there was
an air gap between the unit and valve A, due to earlier removal of a piping section, he believed that the
temporary removal of the spade would not impact the unit isolation. He also knew that at the site, spades were
removed when circumstances required it. The spade at valve A did not have a Battery Limit tag or Lock Out
Tag Out (LOTO) on it and the unit isolation list still showed a blind at valve B as the isolation point. Had the
LOTO been in place, additional review of the work would have been required to remove it.
Lessons learned
 Open draining of light hydrocarbons should be widely recognized as a significant HSSE threat. DSM-2500008-
ST Draining of Volatile Hydrocarbon Liquids contains requirements for managing this risk.

 Concurrent work activities require planning and good communication.

 When concurrent work activities are managed by separate work groups, activities for each work group
should be discussed and planned to ensure that there are no conflicting activities. Co-signing of permits
by Permit Issuers from adjacent work areas or on the same systems is one way of achieving this.
 During Turnarounds, the Project and Turnaround work should to be integrated into one execution
schedule and permitted by one operations group. (See Section 2.8 of the DSM-The Turnaround
Management standard, DSM-1520001-ST and DSM-1520001-RP-22, Turnaround and Project
Integration for more information.)

 Turnaround Status is achieved when “(1) The unit or equipment is shutdown and depressurized and battery limit
blinds / spades are installed to de-energize the equipment to the satisfaction of operations and (2) Unit de-
inventory has been confirmed by operations,” according to DSM-2500006-ST Process Isolation and Control of
Process Energy.
 Decontamination activities should be tracked and documented, with deviations escalated for approval.
Decontamination targets should to be achieved and any shortfall escalated and approved before
declaring Turnaround Status.
 A sampling plan should be in place to confirm that the unit is deinventoried.

 Turnaround planning, including development of detailed work plans and packages, can be impacted by late
scope additions and resource constraints. The completion status needs to be closely tracked and resources
channelled to ensure that the preparation work is complete before the start of Turnaround. Addenda scope needs
to be reviewed for resource impact before approval.

 Battery limit valves should be isolated with locks, tags, and status recorded in isolation records. Battery limit
spades should be tagged. Any changes to the battery limit isolation should be reviewed and approved before the
change is made.

 Workload for the Operation Coordinators should be managed up front and monitored during the execution
phase. Situations when the workload is too high need to be escalated so that additional resources are channelled
to assist the Operation Coordinators or to review the plan of the Turnaround to allow for the number of activities
to be spread out over a longer duration.

 During hotwork, a firewatch should be looking for potential fires and potentially flammable materials in the area
and should be empowered to stop work as appropriate. Firewatches should also be easily identifiable in the
work area.

 An open ended hose can move in unexpected ways when flow starts and pressure changes. The open end of a
hose should be secured in a safe and stable manner to avoid ‘whipping’.

 Consideration should be given to the balance between the potential need for egress and fall protection risks on
properly constructed and approved scaffolds.
Further information
 Learning Materials – to open in pdf, right click on the paper clip near the icon and select ‘open file’

Safety Meeting LFI Summary Safety Meeting

Learning Session DSM DSM-AW-201603.doc 1-pager DSM-AW-201

 DSM-2500008-ST Draining of Volatile Hydrocarbon Liquids

 DSM-2500006-ST Process Isolation and Control of Process Energy
 DSM-1520001-ST Turnaround Management
 DSM-1520001-RP-07 – Turnaround Decontamination
 DSM-1520001-RP-22 – Turnaround and Project Integration
 DSM-1520001-RP-21 – Turnaround Operations Planning
 HSSE & SP Control Framework Hotwork Guide

 DSM Maintenance and Turnaround Excellence Manager

 M HSSE
 Manufacturing LFI Coordinator