As is evident by several Permit-Required Confined Space incidents over the years, workers MUST FULLY understand the limitations of the respirators they are using. This latest incident involved a worker who was vacuuming, and the nozzle became stuck inside the tank. To free the nozzle, the worker—wearing a respirator with organic filters used explicitly for working outside the tank—fully entered the tank, where he went unconscious. Coworkers found the worker inside the tank lying under the fluid. Cardiopulmonary Resuscitation (CPR) was administered to revive the worker.
A comprehensive investigation revealed:
- Stop Work Authority (SWA)1 was not invoked, which is a deviation from standard safety protocols.
- There was non-compliance with the company’s confined space entry policies.
In addition to procedural lapses, a significant contributing factor to the incident was human behavior. Expressly, it was noted that an employee felt compelled to rush,
leading to hasty and ill-informed decisions. This haste ultimately led to unauthorized and unplanned entry into the tank, further exacerbating the situation.
Corrective actions to be implemented include:
- Providing additional refresher training for confined space rescue.
- Invoking safety stand-downs.
- Installing X-Brace on manways for personnel barrier.
- Ensuring management meets with supervisors to go over policies and procedures before every job.
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