LFI : Abu Dhabi Liquefaction Company (ADGAS) owns and operates an LNG

Plant at Das Island located approximately 160 km North West of Abu Dhabi City. The
plant consists of two identical Trains (Trains 1 and 2) and a third Train (Train 3) and
associated facilities.

H2S Gas release leading to fatality from height

Overview of Incident

At the start of the night shift of 21st November 2008, day 30 of the major overhaul of
LNG Train 2, the Maintenance and Operations Teams were preparing for the last shift of
mechanical work and including some hot work, after which activities related to re-
streaming the train for gas-in, was to commence.

De-spading activities on Platform 10 metres above ground Access ladder

The key activity was to de-spade the Sour and Liquid Flare and Blow-down systems,
which during streaming was isolated from Train 1. After despading, the system isolation
valves were to be opened hus making the system operational, and thereby linking the
flare systems of Trains 1 and 2. The de- spading was being carried out on a platform 10
metres long and accessed via an 8 metres high caged
vertical ladder.
At approximately 05:25 the next day(Day 31 of the overhaul), a Supervisor and Fitter
from the assigned contractor began to de-bolt the spade on the verge of breaking
containment, they donned their breathing apparatus while a Safety Assistant and
another Fitter were present without BA. A BA Technician was also located at ground
level and operated the BA line.
At the same time, and in contravention of the Operations Procedure, the flare valves
were opened whilst the despading activities were taking place. This resulted in sour gas
from Train 1 being admitted to the Train 2 system, up to the crossover at the de-spading
location.
The BA Technician (at ground level) smelled gas and observed that one of the Fitters
and the Safety Assistant had started to descend the caged ladder and at a point of about
halfway down the Fitter suddenly fell to the ground at the base of the ladder,
immediately followed by the Safety Assistant, striking his head fatally against the ladder
cage during the fall and landing atop the Fitter.
The BA Technician at ground level was initially overcome by H2S before recovering
enough to make his escape. Another Fitter located close-by was also overcome by H2S
and collapsed unconscious.
At 0531, gas alarms were activated by the escaping gas and then the emergency alarm
was raised, Yellow A alert was instituted, Fire and Rescue crews mobilised, the deceased
Safety Assistant, injured Fitter (broken leg) and the two individuals overcome with H2S
where taken to Das Clinic. The accident site was cordoned off and the Incident
Command Centre (Das) and Crisis Management Centre (Abu Dhabi HQ) were manned
until the ‘all clear’ was declared at 10:08.

This particular incident was thoroughly investigated and the Board of Enquiry
identified that the accident was a result of multi causes and categorised as follows:
• Immediate cause
• Root causes
• Indirect contributory causesear’ was declared at 10:08.

Immediate Causes

Release of high concentration of toxic H2S gas: Acid gas at low pressure from Train 1
Sulphur Plant containing a high concentration of H2S was released during de-spading
activities. The release was a result of the decision by ADGAS Night Shift Operations
Coordinator to open the isolation valves before the completion of de-spading activities.

Inadequate wearing of PPE:

Only two of the four contractors present at the elevated platform were wearing BA,
while the other two were exposed to high concentrations of H2S.

Falling from height:

The two contractors exposed to high concentrations of H2S lost consciousness whilst
descending the caged ladder. This resulted in them falling, which caused one fatality and
one serious injury.
Root Causes

Non adherence to Operating Procedure: The re-commissioning of the Flare system

was not carried out by the ADGAS Night Shift Operations Coordinator as per the
prescribed procedure.
Non adherence to Safety Procedures: The Contractor Supervisor did not ensure that
the area was prepared as per the requirements of the PTW.
Lack of hazard awareness: The ADGAS Night Shift Operations Coordinator was not
aware that Train 1 Sulphur Plant was not operational and as a result 15 tons of gas,
containing high concentrations of H2S was being continuously flared.
Non adherence to PTW: The ADGAS Senior Operator (as instructed by the ADGAS
Night Shift Operations Coordinator) signed the PTW allowing work to commence
without checking the worksite to ensure site readiness as per PTW requirements.

Indirect Contributory Causes

Lack of H2S awareness: It was evident from the behaviour of all Contractor Labour
personnel including the Safety Assistant that the potential consequence of H2S
inhalation was not well known to them.
Pressure to meet Turnaround completion target: There was a perceived sense of
urgency to complete the job quickly as ‘gas-in’ had been planned for the next shift and
there appeared to be pressure on the Operations nightshift crew to complete all
necessary activities.
Inadequate work practice: During the investigation, it became evident that this
particular contractor had been the subject of a number of Near Miss Reports (700), PTW
violations (over 100).

Lessons Learned

1. Review and amend Operational Procedures to address associated hazards when

de-spading activities are taking place.
2. Review and amend the PTW process / procedure so that it is the Performing
Authority that raises the PTW and collates the associated attachments such as
the Task Risk Assessment and not Operations as is the case. The PTW close-out
process must also be improved to ensure that all PTW’s are closed out prior to
conducting ‘gas-in’.
3. Revise roles and responsibilities during Turnaround activities.
4. Review and improve H2S Hazard Awareness training.
5. Conduct competency assessment for safety technicians with BA standby role,
including his responsibilities.
6. Key critical operations such as de and re-streaming the process train to be
conducted by ADGAS Maintenance personnel.
7. Conduct a comprehensive review of the Emergency Response Procedure to
clearly define roles and responsibilities.
8. Develop adequate safety training and site hazard awareness programmes to
ensure safety compliance of Contractor safety personnel prior to site work.
Training objectives should be set to ensure that the training delivers sufficient
knowledge transfer to fulfil the training needs of the organisation and the
individual.