The US Chemical Safety and Hazard Investigation Board (CSB) recently released its final report on a hydrogen sulfide release in Odessa, Texas
that killed two people. In the report, CSB provides five safety recommendations that could have helped prevent a tragic loss of life.
On October 26, 2019, an employee of a waterflood station responded to a pump oil level alarm. The waterflood station receives produced water, a by-product of oil extraction from approximately 68 crude oil wells in the area. The water is injected back into the oil-bearing formation to improve the extraction of oil from underground reservoirs.
The employee isolated the pump from the process but did not perform lockout/tagout to cut the pump off from energy sources. On the night of the incident, the pump automatically turned on, and water containing hydrogen sulfide (H2
S) –a flammable, colorless gas with a characteristic odor of rotten egg–was released from the pump.
The employee died from exposure to the gas. Hydrogen sulfide is both an irritant and a chemical asphyxiant with effects on both oxygen utilization and the central nervous system.
The employee’s wife later entered the waterflood station through a routinely unlocked gate to search for her husband. During her search, she was exposed to the released H2
S and was also fatally injured.
Safety Violations and CSB's Recommendations
The CSB’s investigation identified five safety violations that contributed to these fatal injuries. Their report released this week also made recommendations to address these deficiencies.
1. Nonuse of PPE
The employee was not wearing his personal H2
S detection device upon entering the waterflood station. No evidence exists to show that the facility required the use of these devices.
If the potential exists to expose workers or non-employees to >
10 ppm of H2
S, mandate the use of personal H2
S detection devices as an integral part of every employee or visitor personal protective equipment (PPE) kit prior to entering the vicinity of the facility.
2. Nonperformance of lockout/tagout
At the time of the incident, the facility did not have any written Lockout/Tagout policies or procedures.
Develop a formal, site-specific, and comprehensive Lockout/Tagout program. The program should meet OSHA’s requirements outlined in 29 CFR 1910.147 and include energy control procedures, employee training on lockout/tagout
, and periodic inspections.
3. Inadequate ventilation of the pump house
The available ventilation methods did not sufficiently ventilate the H2
S gas from the building during the incident. This directly contributed to the high H2
S levels that killed the employee and his spouse.
Develop and demonstrate the use of a safety management program that includes a focus on protecting workers and non-employees from H2
S. This program should include risk identification, assessment, mitigation, and monitoring of design, procedures, maintenance, and training related to H2S.
The program must be compliant with 29 CFR 1910.1000 – Air Contaminants, and 29 CFR 1910.147 – The Control of Hazardous Energy (Lockout/Tagout).
The Hydrogen Sulfide Safety online course provides required employee training and develop's employee awareness of H2S hazards, detection and monitoring methods, and emergency response requirements.
4. Lack of Safety Management Program
Other than a pamphlet on the dangers of H2
S, the company had no chemical safety protocols in place.
Develop detection and alarm programs that address installation, calibration, inspection, maintenance, training, and routine operations.
5. Deficient Site Security
Unlocked gates allowed the employee’s wife to drive directly to the waterflood station and enter the pump house. She was exposed to lethal levels of H2
Develop and implement a formal, written, site-specific security program to prevent unknown and unplanned entrance of those not employed by the company.
The US CSB is a Federal agency charged with investigating industrial chemical accidents. The independent agency's board members are appointed by the President and confirmed by the Senate. The CSB's mission is to "drive chemical safety change through independent investigation to protect people and the environment."
Prepare Now to Protect Your Facility
Don’t wait for a disaster to happen at your facility. Lion's regulatory consultants, trainers, and subject matter experts can offer specialized EH&S expertise to empower your company
to assess overall compliance responsibilities and complete specific regulatory projects. We can assist you with the following safety concerns:
- OSHA safety site assessment
- Lockout/Tagout (LOTO) planning
- General industry safety site assessment
- OSHA workplace Hazard Communication (HazCom) plans
- Safety Data Sheet (SDS) authoring
- Chemical facility emergency planning
- OSHA recordkeeping
- Emergency Action Plans (EAP)
- HAZWOPER planning
- Personal Protective Equipment (PPE) assessment and selection
- Confined space entry plan and/or procedures
- OSHA violation consulting
- Employee safety training and training plans
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