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March
Summary
A high-pressure steam (3.7 MPa) discharge occurred during a maintenance process, resulting in three field workers burned to death. Proximate causes: • Lack of work rules/policies/ standards/procedures (wrong procedures for inspections);
Summary
A high-pressure steam (3.7 MPa) discharge occurred during a maintenance process, resulting in three field workers burned to death.
Proximate causes:
• Lack of work rules/policies/ standards/procedures (wrong procedures for inspections);
• Inadequate work rules plan (lack of the pre-start safety review before inspection).
Source: A web-based collection and analysis of process safety incidents (https://www.sciencedirect.com/science/article/abs/pii/S0950423016302285)
