Should we apply our Line Break and Equipment Opening safe work practice to utilities such as steam? (Double Fatality w/ Steam release)

Line Breaking and Equipment Opening (LEO) hazards are oftentimes not well recognized or respected, even in PSM/RMP-covered processes.  Once we are removed from a “covered process,” the lack of recognition and lack of respect only increases.  But in my career, some of the more serious accidents involving LEO on lines/equipment did NOT involve processes covered by PSM/RMP; instead, they were on “utilities”, most notably steam.  In 2020, we saw a horrific accident in a recycling plant that collects and recycles cooking oil and meat byproducts, which is commonly used in the manufacture of dog food when two (2) maintenance technicians were attempting to remove a clog from a piece of equipment that utilized high-pressure steam.  They knew the equipment was normally pressurized with steam and they knew the machine was “clogged” and decided to relieve the steam by cracking open a flange on the bottom of the equipment’s pressure vessel.  But they forgot one important safety procedure before doing so and their attempt resulted in their deaths.  The two workers were 51 and 56 years old.

NOTE: the citations are being contested by the employer

At 6:52 p.m. on August 10, 2020, two employees attempted to remove a clog from a hydrolyzer. Neither employee locked out or isolated the stored energy and was unable to get the steam to release from the pressure vessel. Employee #1, a senior maintenance worker, made the decision to open a flange positioned at the bottom of the pressure vessel to release the steam. As Employee #1 slowly loosened the bolts, steam would unexpectedly release, causing the employees to jump away from the escaping steam to prevent burning. This continued for approximately ten (10) minutes when Employee # 1 decided to take a break to cool down and let the area clear out of steam.

Employee #1 instructed Employee #2 to take a break as well. While Employee #1 was taking his break, Employee #2, another maintenance technician, decided he would assist in the removal of the flange and began to repeat the process that Employee #1 was used to release the steam. When Employee #1 returned, he noticed Employee #2 performing the same method of steam removal as he was doing and scolded Employee #2 for not following his directions.

During the course of the argument, both Employee #1 and Employee #2 was untightening the bolts and suddenly the flange cover broke free, releasing high-pressured steam and engulfing the employees.

The coworkers on-site attempted to render first aid and 911 was called for emergency services. Employee #1 and employee #2 were transported to the hospital and admitted to the burn center. Employee #1 and Employee #2 sustained steam burns to over 70 percent of their body and died on August 14, 2020, as a result of their injuries.