Xcel Energy Confined Space Accident-Chemical Safety Board releases report
Denver, Colorado, August 25, 2010—The tragic accident that took the lives of five industrial painting contractors deep inside an Xcel Energy hydroelectric plant tunnel in Georgetown, Colorado, was the result of several vital safety failures, the U.S. Chemical Safety Board (CSB) determined in a final investigation report issued today in Denver.
Nationally, the investigation identified 53 serious flammable atmosphere confined space accidents that occurred from 1993 to April 2010, causing 45 fatalities and 54 injuries, the majority since 2001.
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The CSB also released a 15-minute safety video entitled “No Escape: Dangers of Confined Spaces,” which includes a detailed animation depicting the horrible tragedy that unfolded inside the mountain tunnel at Xcel’s Cabin Creek plant on October 2, 2007.
Here’s the video. Very graphic!
The accident occurred in the water tunnel, or penstock, of the hydroelectric plant, located 45 miles west of Denver. The penstock carries water from an upper reservoir to a lower one, driving power turbines. The painting contractors, from RPI Coating, Inc., were recoating a 1,530-foot steel portion of the 4,300-foot penstock when a flash fire suddenly erupted as the vapor from flammable solvent, used to clean the epoxy spraying wands, ignited, probably from a static spark in the vicinity of the spraying machine. The initial fire quickly grew, igniting additional buckets of the solvent, methyl ethyl ketone (MEK), and other combustible epoxy materials stored nearby.
The CSB concluded the causes of the accident included (1) a lack of planning and training for hazardous work by Xcel and its contractor, RPI Coating, Inc., (2) Xcel’s selection of RPI despite its h aving the lowest possible safety rating (zero) among competing contractors, and (3) allowing volatile flammable liquids to be introduced into a permit-required confined space without necessary special precautions.
The CSB report found that the permit-required confined space rule set by the U.S. Occupational Health and Safety Administration (OSHA) does not prohibit entry or work in confined spaces where the concentration of flammable vapor exceeds ten percent of the chemical’s lower explosive limit, or LEL. (The LEL is the concentration of vapor in air below which ignition will not occur.)
OSHA’s rule does state that an atmosphere exceeding ten percent of the LEL creates an atmosphere “immediately dangerous to life and health” and that steps should be taken to define safe entry conditions; however, the rule does not define what those safe entry conditions should be or specifically prohibit entry into such hazardous atmospheres, the report notes. The CSB recommended OSHA establish a fixed maximum percentage of the LEL for entry so that work in potentially flammable atmospheres would be prohibited.
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Additionally, the Board made recommendations to the company, the governor of Colorado, the Colorado Public Utilities Commission, trade groups, and other organizations.
CSB Board Member William B. Wark said, “This tragedy should never have happened. The companies did not effectively plan for the dangers of bringing significant amounts of flammable liquids into the tunnel, which was a hazardous confined space. Doing so was an unacceptable deviation from good safety practices.”
There were ten workers in the tunnel and one at the entrance at the time of the fire. Five were unable to get around the fire on the painting platform to get to the only available exit – the improvised tunnel entrance. Five workers on the other side of the platform made it to safety, although three of those workers sustained injuries.
The CSB found that Xcel and RPI failed to have technically-qualified confined space rescue crews immediately standing by at the penstock in case of emergency, as required by regulations. Workers called 911 for help but responders entering the penstock had to retreat in the thick smoke, as did workers who had approached the fire with extinguishers.
The closest confined space technical rescue unit – equipped and trained to enter the smoke-filled tunnel – was approximately one hour and 15 minutes away. The trapped workers died about one hour before this response unit arrived, their escape blocked by a steep vertical section of the tunnel deep inside the mountain.
CSB Investigations Supervisor Don Holmstrom, who led the investigation, said, “The five trapped workers communicated with co-workers and emergency responders using handheld radios for approximately 45 minutes, desperately calling for help, before succumbing to smoke inhalation. Their lives likely could have been saved had qualified, company-provided rescuers been in a position to respond immediately to a fire or other emergency.”
Board Member Mark Griffon, joining Mr. Wark and Mr. Holmstrom at the news conference, said, “Even before the operation began, the stage was set for disaster. Xcel not only did not adequately plan for the operation, but it selected the painting contractor with the lowest possible safety rating among the bidders, and it did so mostly on the basis of cost – it was the lowest bid.”
The investigation found that Xcel hoped to compensate for RPI’s safety record by closely supervising the contract work, but did not do so even when the company learned of safety issues during the initial penstock work.
The CSB investigation found Xcel and RPI managers were aware of the plan to operate the epoxy sprayer in the tunnel and to use flammable solvent to clean the sprayer and other equipment.
Mr. Holmstrom said, “As a result of not performing a hazard evaluation of the work to be done, the companies failed to identify serious safety hazards involving use of flammable liquids within the confined space. Use of safer, nonflammable solvents was not evaluated, continuous air monitoring was not required, and key policies and permit forms did not establish a percentage limit for flammable vapor in the tunnel atmosphere.”
Board Member Wark noted the lack of planning for escape in an emergency. “The penstock had only one egress point – the tunnel entrance,” he said. “Xcel and RPI did actually identify this as a major concern in their planning. But despite this, no plans were made for prompt rescue in an emergency, and no rescuers qualified to enter this confined-space environment were standing by.”
The CSB investigation determined that while companies are required to perform a hazard analysis prior to issuing permits for work in confined spaces, regulatory standards pertaining to the use of flammables within confined spaces are inadequate.
Board Member Griffon stated, “Other OSHA regulations on confined and enclosed spaces – for example in the maritime industry and other sectors – prohibit work in such confined spaces above a specific percentage of the LEL, often ten percent. We are recommending that OSHA adopt such enforceable limits for all industry.”
The CSB recommended that OSHA amend its confined space rule to establish a maximum percentage substantially below the lower explosive limit for any given flammable for safe entry and occupancy while working.
The CSB made recommendations to nine other entities. These included that the governor implement an accredited firefighter certification program for technical rescue with specialty areas including confined space rescue; that the Colorado Public Utilities Commission (PUC) require regulated utilities to adopt provisions for selecting contractors based on safety performance measures and qualifications; and that the PUC require utilities to investigate all incidents resulting in death, serious injury or significant property damage and submit and make public written findings and recommendations within one year of the accident.
Numerous recommendations were made to RPI Coating, particularly aimed at revising its confined space entry program and guidance.
CSB investigators and board members cited difficulties encountered in the investigation resulting from efforts by Xcel Energy and RPI Coating to impede the investigation and prevent the release of the investigation report.
Citing a formal Letter of Admonishment sent to the Xcel chief executive officer earlier in the week, Board Member Wark said, “The lack of cooperation and efforts by Xcel to impede our investigation are unprecedented. Mr. Griffon and I join our chairman in criticizing these actions in the strongest terms.”
The letter, signed by CSB Chairperson Rafael Moure-Eraso, states Xcel Energy did not fully comply with CSB requests for documents or answers to questions in formal interrogatories. This required the CSB to seek assistance from the U.S. Attorney’s office in Denver, resulting in delays to the investigation and additional costs to taxpayers. In May, Xcel took the extraordinary and unprecedented step of going to federal court seeking to block release of the CSB report and the safety video. The court sided with the CSB in favor of release.
Xcel was given an advanced draft copy of the report last April for review for accuracy and for confidential business information in accordance with CSB review protocols. Xcel never responded, but in August 2010, contrary to the conditions of confidentiality attached to their receiving this preliminary copy, released it to a news organization.
The letter from Chairperson Moure to Xcel’s CEO concludes, “In light of this disappointing pattern of corporate conduct, I am writing you directly to ensure that you are personally aware of the actions taken by Xcel to delay the CSB investigation, block publication of the CSB final report, and distort the conclusions of the investigation by releasing an unauthorized draft copy of the CSB report. The CSB will issue a formal recommendation that Xcel shareholders be directly notified by management of the significant findings and recommendations of the CSB report, and of the actions Xcel management intends to take to implement needed safety improvements. In the wake of the corporate responsibility concerns raised by the Big Branch Mine accident in West Virginia and the disaster in the Gulf of Mexico, I strongly urge Xcel to renew its focus on safety and to swiftly implement the CSB’s recommendations.”
Yet Another Hot Work Accident in Colorado-CSB chief expresses regret
Washington, DC, July 9, 2010 — Dr. Rafael Moure-Eraso, chairperson and CEO of the U.S. Chemical Safety Board (CSB) said today he was saddened by news of the death of a Colorado welder yesterday while performing what is called “hot work” on a storage tank containing flammables at an environmental remediation company in Englewood, Colorado.
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Hot work is defined as welding, cutting, grinding, or other spark-producing activities that can ignite flammable substances. To date in 2010, the CSB has learned of 15 serious hot work-related fires and explosions that caused six reported fatalities and numerous injuries.
Dr. Moure said, “I am saddened by this accident and disturbed that such fatalities continue to occur. The CSB is vitally concerned about hot work accidents and this was expressed in our important safety bulletin and safety video, both issued within the past few months.”
According to information gathered by the CSB from the fire department and the company, a worker was standing on a ladder, welding on the side of a tank partially filled with a mixture of water and flammable hydrocarbons. Sparks ignited flammable vapor and the worker was thrown off the ladder, suffering fatal injuries.
The company stated that although it has a hot work permit system and had provided safety training to the victim, there was no monitoring for a flammable atmosphere before or during the welding. ( What a joke-how can anybody issue a permit when they haven’t measured the flammable gas concentration in the area-do they expect a piece of paper will actually prevent an accident?!). While current OSHA standards prohibit hot work in an explosive atmosphere, OSHA does not explicitly require the use of combustible gas detectors.
There have been more than 60 fatalities since 1990 due to explosions and fires from hot work activities on tanks. In seven of the 11 accidents discussed in the bulletin, no gas testing was performed prior to or during the hot work activities. In the remaining cases, monitoring was conducted improperly.
Dr. Moure said, “There is no secret to preventing these accidents. Companies should require effective monitoring of the atmosphere before and during all welding or other spark-producing activities near tanks that may contain flammable liquids or gases. Monitoring should be frequent or continuous and performed at multiple locations to assure that no flammable vapor is present which could be ignited. Monitoring the atmosphere and following the other six key lessons in our bulletin can help avoid these tragedies.”
Jaipur Oil Tank Farm Fire update-nine officials arrested for negligence
July 3, 2010 Jaipur, India- The Oil Tank farm here belonging to Indian Oil Corporation, a large Indian government owned oil company had a devastating fire about eight months ago. The reports were posted on this blog at that time.
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The fire had resulted in 11 fatalities and destruction of oil worth millions., plus a lot of collateral damage was caused to an adjacent factory. The fire had raged on for several days and had was very difficult to control and extinguish.
Well, now the investigation into the accident is over and nine officers have been found guilty of gross negligence. The investigation speed was surprisingly fast (look at how the Bhopal case went on for decades before resulting in convictions) and nine officers of the company, including a General Manager, have been arrested on charges of gross negligence. Such arrests, will hopefully, instill enough respect for Industrial Safety in organisations that pay only lip service to the philosophy of safety.
As in most other cases of accidents, the result of the mishap occuring was the end result of a lot of events, not just the result of one event. Look at what facts were dug out and presented by the investigation team:
- Non working Public Address System
- Non implementation of Emergency Response Procedures-so the police control room was informed of the accident after ONE HOUR after the accident
- Apparent non working of any automation system that was supposedly installed at the facility to prevent overfilling
This means that if a plant or facility is well designed by competent engineers and also well maintained, then it will automatically ensure safety. However the operations of the systems that have been installed years ago need to be checked at least every year by third parties (as is the practice in many countries). For sure this being done for mechanical items like pressure vessels and safety relief valves, but is it being done for Instrumentation and Control Systems, or other systems like Public Address Systems? The sooner this is done seriously, we will have lesser chances of such accidents-be it the BP Deepwater Horizon spill or the Jaipur tank farm fire.
CSB approves urgent recommendations to OSHA NFPA and others to prevent Kleen energy type natural gas explosions
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June 28, 2010 Middletown, CT On a 4-1 vote, the U.S. Chemical Safety Board tonight approved urgent safety recommendations to OSHA, NFPA and others. The draft recommendations, which were approved without amendments at a public meeting in Portland, CT, aim to prevent deadly explosions and fires during pipe cleaning and purging operations.
The recommendations – directed to the Occupational Safety and Health Administration (OSHA), the National Fire Protection Association (NFPA) and others, result from extensive CSB investigations into the February 7, 2010, explosion at the Kleen Energy power plant in Middletown that caused six deaths and multiple injuries, and the June 9, 2009, explosion at the ConAgra Foods Slim Jim plant in Garner, North Carolina, that killed four workers and injured 67.
The accident at Kleen Energy occurred during the planned cleaning of natural gas piping during the commissioning and startup phase of construction. Natural gas was forced through large piping that was to fuel the plant’s large electricity-generating gas turbines, in an operation called a “natural gas blow.” This gas was vented directly to the atmosphere from open pipe ends that were less than 20 feet off the ground and were located in congested areas adjacent to the power generation building.
CSB investigators obtained gas company records showing some two million standard cubic feet of natural gas were released to the atmosphere during gas blows on February 7—enough, the CSB calculated, to provide heating and cooking fuel to a typical American home every day for more than 25 years!! The gas found an ignition source and exploded.
In the CSB proposed recommendations, OSHA is urged to pass regulations that would prohibit the use of natural gas for pipe cleaning, the cause of the explosion at Kleen Energy, and would prohibit the venting or purging of fuel gas indoors, the cause of the explosion at the ConAgra Slim Jim plant. Both explosions resulted from releases of natural gas during the installation and commissioning of new piping that led to gas-fired appliances.
OSHA is also urged to require that companies involve their workers and contractors in developing safe procedures and training for handling fuel gas.
In testimony this morning at a field hearing before a subcommittee of the U.S House of Representatives Committee on Education and Labor, held in Middletown, CSB Board Member John Bresland said there is a “significant gap” in the current gas safety standards for general industry and construction, “a gap that threatens the continued safety of workers at facilities that handle flammable natural gas.”
An urgent recommendation directed at the NFPA urges the code-development organization to enact a tentative interim amendment as well as permanent changes to the National Fuel Gas Code that addresses the safe conduct of fuel gas piping cleaning operations. Under the draft recommendation, NFPA would be asked to remove key exemptions in the code for natural gas power plants and for high-pressure gas piping and to require the use of inherently safer alternatives to natural gas blows. CSB investigators determined that compressed air is a feasible and economical alternative to using natural gas for pipe cleaning and is already used by many companies.
Mr. Bresland told the House Committee, “At our CSB public meeting later this evening, I intend to vote for and support new urgent safety recommendations that we have developed, calling for OSHA to enact new regulations to control this hazard, and I will encourage the other Board members to do the same.”
Other draft recommendations would seek related safety improvements from the State of Connecticut and other states, the leading gas turbine manufacturers, the American Society of Mechanical Engineers, and the Electric Power Research Institute.
At the public meeting, newly appointed CSB Chairman Dr. Rafael Moure-Eraso will preside; Dr. Moure and Mr. Mark Griffon were confirmed by the Senate on Wednesday June 23 and were commissioned by President Obama the following day.
The CSB public meeting begins at 6:30 p.m. at the Saint Clements Castle conference facility, 1931 Portland-Cobalt Road, Portland, Connecticut, (860) 342-0593. The public is invited; no prior arrangements are needed. Attendance is free and there will be ample seating and free parking.
The CSB investigation team, headed by Investigations Supervisor Don Holmstrom, will present a report on the Kleen Energy accident as well as a review of existing regulations applying to the practice of gas blows at power plants and general industry.
The Board will hear from two witness panels, including –
· Professor Paul Amyotte – Dalhousie University (Canada)
· Ervin Patterson – Commissioning Management Services, Inc.
· Larry Danner – GE Energy
· Representative Matthew Lesser – Connecticut House of Representatives
· Professor Glenn Corbett – John Jay College of Criminal Justice (New York)
· Michael Rosario – Local 777, United Association of Plumbers and Pipefitters
· Steven Schrag – Connecticut Council for Occupational Safety and Health
Following a public comment period in which any interested person may speak, the Board will vote on the recommendations. The CSB staff is expected to propose (subject to Board approval) that upon passage of the urgent recommendations, the Kleen Energy and ConAgra investigations would be concluded. Although no additional written report is planned beyond the statement of more than 60 factual findings, the CSB plans to develop a computer-animated safety video describing the two accidents and the recommendations for safety change.
Mr. Bresland told the House committee, “We believe that the 18 urgent recommendations proposed today – together with the two urgent recommendations we issued on February 4 – address all of the principal root causes of these two tragic accidents. If adopted by the recipients, I have no doubt that future accidents will be avoided and lives will be saved as a result.”
Oklahama Oil Site Explosion-CSB releases report
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Oklahoma City, Oklahoma, April 23, 2010 — A fiery explosion that took the life of a 21-year-old member of the public in Weeletka, Oklahoma, on April 14 occurred at an unattended oil and gas production site that was unsecured and likely lacked fire or explosion warning signs, CSB investigators have determined following a four-day field assessment. Investigators arrived in Weleetka on Sunday evening and have been examining the site, conducting witness interviews, and gathering other View of tanks involved in the April 14, 2010, explosion and fireinformation throughout the week.
The accident occurred at approximately 9:00 p.m., while six individuals aged 18 to 32 were socializing at the rural site, which was normally unmanned. The site, which had four petroleum storage tanks and two brine storage tanks, was operated on private land by two production firms, Three MG Family Inc. and Enterprise Energy, who leased the mineral rights. A third company, ScissorTail Energy, operated a gas metering and collection system connected to the production equipment.
The blast occurred about 10 minutes after the group arrived at the site. Witnesses stated that they were drawn to the site when they saw the open gate while driving along a public roadway. Witnesses further stated that oil sites were a common gathering place for local residents and that they were largely unfamiliar with the hazards.
Based on witness interviews, CSB investigators determined that a lit cigarette or lighter was the likely ignition source for the explosion, which happened as the 21-year-old male who later died was peering into the hatch on top of one of the tanks. That tank contained what was later described as approximately 160 barrels of light crude oil. The resulting explosion and fire engulfed the victim and caused a second explosion in an interconnected tank. The victim suffered third-degree burns over 85% of his body. He was able to describe the accident to emergency response and ambulance personnel, but died the following morning at a Tulsa burn unit. Another individual suffered second-degree burns. A fire burned for more than three hours at the site until it could be extinguished by several responding fire departments using foam.
“The catwalk leading to the top of the tank was unsecured and readily accessible,” said CSB Investigator Vidisha Parasram. “The tank hatches had no mechanism which would permit them to be secured or locked. No fire or explosion warning signs or other warning signage was visible anywhere on the site following the accident.” Ms. Parasram said the CSB would continue to study whether any signage could have been destroyed in the fire, but that even the undamaged portions of the facility and the entrance gates had no posted warnings. Eyewitnesses said they saw no signs on the night of the accident or during previous visits to the site.
The site entrance was protected only by an unmarked gate which multiple witnesses described as being wide open on the night of April 14, and generally open and unlocked at other times. Apart from the gate the site had no fencing or other protective measures that would keep members of the public safe from hazards on the site.
“Following this accident, our investigative team was able to observe a number of other oil and gas production sites in the area. The vast majority were unsecured and had no warning signs,” said CSB Investigations Supervisor Don Holmstrom, who leads the CSB regional office in Denver. “Oil and gas sites that lack security measures and warning signs are an accident waiting to happen.” State officials told the CSB that Oklahoma has approximately 257,000 active and unplugged oil and gas production sites; Oklahoma requires fencing and warning signs only at sites that have toxic hydrogen sulfide gas hazards, according to state officials.
The deadly blast occurred one day after the release of a new CSB safety video at a public meeting in Hattiesburg, Mississippi. The safety video, “No Place to Hang Out,” is aimed at educating young people on the hazards of socializing at oil sites, a common practice in rural areas, the CSB found. The video tells the story of the tragic deaths of 18-year-old Wade White and 16-year-old Devon Byrd, killed October 31, 2009, when an oil tank, located in a clearing in the woods near the home of one of the boys in the rural town of Carnes, suddenly exploded while the two were hanging out at the site.
A CSB preliminary analysis released on April 13 showed that 24 similar explosions and fires occurred at oil and gas production sites between 1983 and 2009. Those accidents resulted in 42 fatalities and a number of injuries; all the fatalities occurred among teenagers and young adults under the age of 25. In most cases, the explosions were ignited by a cigarette, match, or lighter. The CSB found no specific federal standards or industry guidance for security or public protection measures at oil and gas production sites. Certain states including Ohio and Colorado require fencing and other public safety measures at sites in urban areas. Ohio requires tank hatches to be sealed and locked at unattended oil sites.
Counting the accident on April 14, the CSB has thus far identified a total of seven oil site explosions and fires in Oklahoma since 1990 that killed or injured members of the public, the highest total for any state. Four of these accidents caused multiple fatalities.
CSB Board Member William Wark said, “The CSB is concerned about these ongoing accidents across the country that are needlessly taking the lives of young people. To me, it is self-evident that hazardous oil and gas sites should be secured against unauthorized entry and posted with extensive and specific warning signs. And we need to educate teenagers and young adults to stay away from these sites – they are dangerous.” Mr. Wark said the CSB team received outstanding cooperation from local law enforcement and fire officials during the investigation.
The day prior to the explosion in Weleetka, the CSB Board issued a statement “urging oil and gas production companies to ensure that they provide adequate security and warning signage around sites that have tank fire or explosion hazards; and further urging state legislatures, local governments, and regulators to review rules governing oil and gas tank sites to ensure they require adequate barriers, security measures, and warning signs.” Mr. Wark said a CSB task group will be working over the next several months to develop additional specific safety recommendations, incorporating the findings from the recent accidents in Mississippi and Oklahoma.
