I have written about this incident a couple of times, as it is full of learning opportunities. The biggest of which is the practice of REDUCING PPE after the initial opening was uneventful, and we have “verified” our positive means of isolation is holding. This is a common practice for long-duration jobs and plays a role in heat stress management. Basically, we are leveraging the positive means of isolation, allowing workers to reduce their PPE so they can work longer without breaks in the heat of the day. Keep in mind that Line and Equipment Opening is the “wild west” of process safety, as no agency or trade group has ventured into the waters to write a LEO RAGAGEP. So a PSM/RMP site has a lot of latitude in how this extremely high-risk task is performed. Here is CCPS’s version of the events.
In June 2024, a contractor employee was exposed to a small quantity of hydrogen fluoride (HF), a toxic and highly corrosive fluid. The contractor was hospitalized but recovered.
The site was in the process of replacing flange gaskets in HF service. The section shown in Figure 1 was where the incident occurred. A decontamination plan was developed with several drawings of the piping. In preparation, operations isolated upstream and downstream of this section, then connected it to a vacuum source. The vacuum system and nitrogen purge was used to decontaminate the piping inside the isolation boundary.