On November 30, 2010, a contractor supervisor received a permit to clean out a catalyst knockout drum. While inspecting the drum, the contractor and supervisor entered the drum without following confined space entry procedures. The contractor became unconscious from nitrogen and chemical exposure and later died from suffocation. The major root cause was violating the confined space entry permit. Key learnings include understanding the scope of work, conducting a job safety analysis for non-permitted work, understanding the risks of bypassing safety procedures, and assessing risks before starting hazardous jobs.

1. EHSS ALERT
Date of the incident: Severity Class: Classification:
Nov. 30, 2010 A Fatality
Description:
On 30th November 2010, a Contractor supervisor, received a work permit for de-
chocking & cleaning of the drain line of a Catalyst Knockout drum. After completing
the drain line de-chocking, contractor supervisor & contractor (victim) moved up to
the man way of the drum which was opened by the Maintenance team, for
inspection. Contractor employees started flushing by water from outside, because
they observed lumps and deposits at the bottom of the vessel. Contractor (victim)
entered inside the man way while his supervisor was holding him using rope tied to
his waist. Victim started scrubbing the deposits from internal walls and suddenly
became unconscious inside the vessel due to Nitrogen & Naphthalene traces.
Supervisor tried to pull the victim out but without success, then he decided to call
Operation for help. Emergency response team responded immediately to the
emergency scene and removed the victim from the vessel. Cardio-pulmonary
resuscitation (CPR) was done without success. Victim was transferred to the hospital
who declared the victim dead due to suffocation resulting from nitrogen suffocation.
Major Root Cause:
•The violation of confined space entry permit is
the major root cause leading to the incident. Contractor Supervisor
•Clear instruction from Operation team not to
enter inside the drum, was not followed
Key Learnings:
•Detailed understanding level of the scope of
work is crucial for all involved parties.
•Job Safety Analysis should be conducted for
any Job that is not covered under a Work
Permit default procedure.
•The consequences of short cut in the Work Contractor Employee
Permit procedure is increasing risks of Victim
accidents and injuries.
•Impact of operator absence during critical job
execution could lead to serious accidents and
injuries
•Job executers shall assess and raise any work
risk prior starting the activity