‘Completely Preventable Mistake’ Caused Fatal Refinery Accident in Texas скачать в хорошем качестве

‘Completely Preventable Mistake’ Caused Fatal Refinery Accident in Texas

On October 10, 2024, at around 4:23 p.m., some 27,000 pounds of toxic hydrogen sulfide gas were released during a maintenance activity at the PEMEX Deer Park Refinery in Deer Park, Texas. The refinery makes more than a quarter of a million barrels per day of motor fuels, like gasoline, diesel, and jet fuel, that are exported to the U.S., Mexico, and Latin America. The toxic release fatally injured a pair of contract workers and injured several others. So, what happened? Instead of opening a pipe flange on empty piping, contract workers from industrial service company Repcon, Inc. -- which specializes in welding, pipe fabrication, and maintenance -- mistakenly opened identical piping about five feet away that contained hydrogen sulfide gas. The pipe released pressurized hydrogen sulfide gas and fatally injured one of the Repcon workers. The hydrogen sulfide traveled downwind, where a worker from ISC Constructors, an industrial engineering and construction company, inhaled the toxic hydrogen sulfide and was also fatally injured. The release continued for nearly an hour until PEMEX's emergency responders reassembled the leaking flange, stopping the release. Thirteen other contract workers were transferred to medical facilities and evaluated for hydrogen sulfide exposure. Officials in Deer Park and Pasadena, Texas, issued shelter-in-place orders that were in effect for several hours. While the facility was not physically damaged, PEMEX reported property damage of $12.3 million due to the loss of use of the Amine Unit and downstream processes. This week, the U.S. Chemical Safety and Hazard Investigation Board (CSB) released its final report following a comprehensive investigation. In a statement, CSB Chairperson Steve Owens said, “Two people died, and the surrounding community was put at risk because of a completely preventable mistake.” The CSB found that the refinery lacked an effective method to clearly identify the correct piping flange before work began. Drawings and flange lists were insufficient to distinguish nearly identical segments, and the identification tag for the correct flange was placed out of view. According to the CSB, accidental releases from opening the wrong equipment are common in the chemical and refining industries. The agency also said no industry-wide standard currently addresses this issue. The refinery had issued a broad work permit covering multiple jobs with varying hazards and without clear hold points. Workers overlooked a written instruction to stop work and obtain an operator’s presence before opening the hydrogen sulfide piping. The permit also failed to address the hazard of opening piping in an operational unit upwind of other contractors. On the day of the incident, workers were reassigned from a shutdown unit to a partially operational unit containing hydrogen sulfide. This abrupt change led workers to believe they were still working in the shutdown environment, and they were not specifically informed of the risks in the operational unit. Finally, the CSB found gaps between the facility's written procedures and its actual practices. While the refinery’s policies aligned with industry standards, management and operations personnel often misunderstood or deviated from them. The CSB’s report issued several safety recommendations to the refinery and the American Society of Mechanical Engineers (ASME). The CSB recommended that PEMEX label all piping in the relevant unit at the refinery in accordance with ANSI/ASME labeling standards, implement procedures to ensure that workers are clearly informed of hazards and safeguards before beginning work, and establish a comprehensive conduct of operations system consistent with the Center for Chemical Process Safety’s guidance on operational discipline, including enforceable performance metrics and routine audits. Separately, the CSB recommended that ASME develop written guidelines establishing a standard practice for marking equipment prior to opening, including clear identifiers and requirements for removing markings after work is complete. PEMEX Deer Park has been operating for nearly 100 years and is the only Petróleos Mexicanos refinery in the United States that processes heavy and light crude oil from all over the world, primarily Mexico, the U.S. and Canada. #PEMEX, #DeerParkRefinery, #HydrogenSulfide, #RefinerySafety, #ChemicalSafety, #CSB, #ASME, #IndustrialAccident, #ProcessSafety, #WorkplaceSafety, #OilAndGas, #H2S, #IndustrialMaintenance, #PlantSafety, #SafetyInvestigation