Type of Incident: Fatality
Location: Storm Water Drain (Process Area)
Brief Summary of the Incident:
A fire and explosion occurred at a Storm Water Drain (SWD) in Process Area. The First Intervention Team (FIT) immediately responded and managed to extinguish the fire within 32 minutes. The incident caused 1 fatality, 1 serious injury and 31 minor injuries. The immediate cause of the incident may have been due to the ignition of hydrocarbon vapour inside the SWD, which subsequently led to the deflagration to detonation transition. The source of the ignition remains inconclusive.
Key Findings:
1. Presence and accumulation of hydrocarbon inside SWD.
2. Incomprehensive operation and maintenance strategy for the Drainage System.
3. Inconsistency in implementing the activities covered under the control of ignition source procedure.
4. Gaps in management of incident investigation and lesson learnt.
Lessons Learnt:
1. All potential sources of hydrocarbon into SWD shall be identified and eliminated.
2. De-clogging of all funnels and drains of the Oily Sewer System shall be incorporated into the maintenance plan.
3. Operating Procedure for SWD shall be developed together with specific Equipment Reliability Strategy.
4. Control of Ignition Source procedure shall be developed and strictly implemented.
5. Effective communication of lesson learnt action items tracking and closure shall be strictly implemented.
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