November, 2005

This is a repeating event

200505NovAll DayValero (Delaware) Refinery Asphyxiation 2005Valero Delaware City (US-DE) Origin: CSB Lessons:Competency,Control of WorkIndustry:RefiningCountry:United StatesLanguage:ENLoC:Maintenance error

Summary

The Valero Delaware City refinery asphyxiation death of two contractor employees who were preparing to reassemble a pipe on a pressure vessel while it was being purged with nitrogen. The first worker, in an attempt to retrieve a roll of tape from inside the vessel, was overcome by nitrogen, collapsed in the vessel, and died. His co-worker, the crew foreman, was asphyxiated while attempting to rescue him.

KEY ISSUES:
• OXYGEN-DEFICIENT ATMOSPHERE HAZARDS OUTSIDE CONFINED SPACE OPENINGS
• NITROGEN HAZARD AWARENESS
• UNPLANNED CONFINED SPACE RESCUE

ROOT CAUSES:
1. Workers suddenly involved in emergency activities allow emotions to override safe work procedures and training.


Image credit: CSB

Origin

CSBUS Chemical Safety Board

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