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FATAL INCIDENT AT EXXON REFINERY IN SINGAPORE

Key Learnings shared in the API symposium

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INCIDENT DESCRIPTION

Inert entry job to changeover catalyst

Set up

two separate sources of air supply for the individual inside the vessel

One source of air supply for the individual outside (confined space watch)

Supervisor standing down at the Grade

Low pressure alarm from one of the bottle banks.

The bottle bank happens to be the one which was common source for both individuals

Supervisor switches to a spare bottle bank

Supervisor tries to contact over radio after switching bottle bank - no response from both individuals . Activates the ER

The confined space watch survived but the individual inside the vessel died in the incident

Spare bottle bank

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INVESTIGATION

One of the breathing air bottle in the spare bottle bank had Argon

Individual inside the confined space got exposed to 18% Argon

Bottle with Argon was painted and identified as breathing air

Exxon has a policy to check CFA of the breathing air bottles that they receive.

Exxon uses random sampling – two out of 16 bottles in the bottle bank had CFA.

Conclusions:

Unintentional mistake by the BA supplier

Bottle must have been in previous service of Argon and was not fully depleted before it was recharged to be in the BA service

Exxon has gone to 100% sampling of BA cylinders that they receive following this incident