Line Break Gone Bad (Worker misidentified flange that needed unbolting)

A worker on a contracted maintenance crew at an oil refinery partially unbolted a flange on a live crude oil heat exchanger. An undetermined volume of oil was released. Another worker, a refinery employee who participated in the incident response, was exposed to the resulting crude oil vapors, which are believed to have contained hydrogen sulfide (H2S). The second worker sustained injuries from the exposure. No other injuries were reported.

Investigation conclusions

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