Chemical Process Safety (PSM/RMP)

Line Break gone bad (hydronic piping in a boiler room)

Another pressurized piping fatality… On March 27, 2024 @ 9:30 a.m. Employee #1, 21, had been installing hydronic piping in a boiler room. Employee #1 began loosening a clamp holding a pressure testing cap that was under 100 PSI of pressure. The testing cap became a projectile, striking Employee #1 in the face. Employee #1…...

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Pressure Test Gone Bad (China Sewage Septic Tank)

According to reports, the sewage explosion occurred during a pressure test of the septic tank pipeline conducted by qualified engineers as part of the pipeline installation process. This incident should be all we need to demonstrate why we test before the pressure retaining equipment is put into service and NEVER use hazardous materials to perform…...

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Decommissioning is the final stage of a Process Life Cycle

An ammonia leak occurred inside the machinery room of a public athletic club with indoor ice facilities. The leak happened during the decommissioning work of an ammonia refrigeration condenser by a licensed refrigeration contractor, which resulted in the facility enacting its Ammonia Release Emergency Protocol. The incident was likely caused by the contractor not properly…...

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Pressure Safety Valve/Relief Valve Installation Failure

One of the top questions newcomers to process safety ask is, “Why do I have to have a written procedure to remove and install new relief valves?”From the EPSC Learning Sheet October 2024What Happened:The bonnet vent in a Balanced Bellows Pressure Safety Valve (BB-PSV) was found in service, but still fitted with a shipping plug…....

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Mechanical Exhaust Ventilation – EMERGENCY SHUTDOWN Switch

A lot of folks recognize the need for mechanical exhaust ventilation in areas where there is a flammable and toxic exposure hazard.  The general rule of thumb for this mechanical exhaust ventilation is 1 CFM per square foot of floor space with at least six air changes per hour.  But there are two (2) other…...

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Pressure Test Gone Bad (HVAC unit)

On November 1, 2022, at 12:45 p.m., an employee, 30, was installing heating, ventilation, and air conditioning (HVAC) equipment at a residential building. When the employee was pressure testing a pipe fitting, an object flew off the HVAC unit and struck the employee in the face and head. The employee was killed by blunt force…...

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New Hazard – Static Discharge from Isolation Tag (CCPS)

I was raised in process safety, with a focus on flammables, and I was taught that one thing you just don’t allow into your flammable process is plastics! But even I was unaware of how much plastic I had always overlooked, which was right under my nose, such as my LOTO tags. New Hazard –…...

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Improper “cleaning” of the process leads to 16 workers being treated and released (bromo acetone and hydrogen bromide)

The process in progress at the time of the event was the manufacture of methatrexate, an anti-cancer drug. Shortly after employee #1 began to draw bromine liquid into the supposedly clean and empty charging pot, he heard a hissing sound. He then saw a purple haze spewing out from under the lid of the pot…....

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Lack of Training and Poor labeling of Emergency Shutdown Button, and an altered excess flow valve leads to serious event

When we use the phrase “cascading failures,” this event is nearly a perfect example.  1) A gas station employee attempted to fill a propane tank without the required training. This led to the uncontrolled release of approximately 1500 liters (396 gallons or 1,600 pounds) of liquid propane and evacuated nearby homes. 2) When the staff…...

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Failure to PROPERLY pressure test, leak test, and purge gas lines after testing leads to NG explosion @ fruit orchard

An explosion occurred inside a mobile trailer containing five (5) gas-fueled clothing dryers at a fruit orchard and processing facility. The blast caused damage to the building, and the facilities manager, who was inside when it took place, received burns and contusions. In 2019, the gas-fueled clothing dryers were installed and converted from natural gas to…...

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Hazards of filling PIT LPG cylinders (Hydrostatic RV w/ INCORRECT Set Point)

In recent years, we have seen many facilities begin to fill their own PIT LPG cylinders on-site rather than contract this service out. Typically, we find this “change” was poorly managed: no PPE Hazard Assessment, no (or very poor) training on the task, LPG improperly located, improper electrical classification around the LPG tank and the…...

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