Routine Line/Equipment Opening MUST be done via SOP or SWP

This is a classic case of a “routine opening” within a PSM/RMP-covered process that turned fatal for an operator. ALL openings of a process containing a hazardous energy source, PSM/RMP or NOT, can be some of the most hazardous tasks we can ask personnel to perform.

At approximately 1:00 a.m. on August 14, 2011, Employee #1, a process operator, was working at a PSM-covered chemical processing plant that produced oil field chemicals. He had transferred materials from a batch process through production piping. Isopropylamine was charged to the reactor from drums using a 2 in. transfer hose. Suction would move material from the drums into process lines feeding the reactor. After the transfer was completed, the hose would be capped to keep it clean and prevent residual material from being released. This was a normal procedure to facilitate adjustments to the batch mixture as needed.

Bleed valves were in place to relieve pressure on the hoses as connections were made and removed. Pressure remained in the hose when Employee #1 removed a cap during the cleanup of the area. Isopropylamine sprayed his face, eyes, nose, and mouth, and knocked off his face shield and goggles. Employee #1 immediately made his way to a shower and eye wash and called for help. He was transported to St. John’s Hospital, where he went into cardiac arrest and died.

Source: https://www.osha.gov/ords/imis/establishment.inspection_detail?id=314934407