OXYGEN

HAZARDS Safety Alert

Alert Number: GC /2018/016
Oxygen Flash Fire

Incident KEY MESSAGE

In AIGCO on 7th June 2018, while assembling 16
cylinder Ar-CO2 rack, third party fabricator opened
one of the oxygen cylinder valve when a flash fire  “Compatible for Oxygen service”
occurred at the pressure gauge end. There is no requirements should be added in
injury reported to the third party fabricator.
the special instruction section of
New Manifold: On 09th May 2018, distribution the purchase Order.
ordered 34 number of 16 cylinder Rack, SS Manifold
with BS3 pig tail connection with two master valve
 Established procedures should be
outlets and pressure gauge.
followed for changing cylinders
After receiving 14 new manifold and associated MS from one gas service to another.
frames, incident happened while assembling one of (CGA C-10 -2013)
the rack.
 Upon receiving purchased goods or
Root Cause:
even services from a supplier, it is
Oil traces: Traces of oil was observed in the pressure important that the shipment is
gauge. checked to make sure that the
Purchase Order: Requirement for oxygen cleaning correct quantity and quality was
not specified in the PO.
received. A receiving report should
Operations:
1. Less than adequate process checks for “cleaning immediately be completed.
of equipment for Oxygen service” during
assembly and at the time of receiving the new
manifold .
2. Gaps in following procedures related to “Change
in gas service of cylinders”

(After the incident, during inspection observed traces

of oil in all the 14 pressure gauges received from the
supplier)

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