During a shut down of a factory or manufacturing site for repairs or maintenance, safety should be considered a top priority. Any slip up in judgment or protocol can end in not just injury, but very likely long-term injury or death.
That was exactly, thankfully almost, the case for a manufacturing site Pearl Engineering Safety Consultant Scott Burkart was called upon to help manage during the summer of 2018.
The site had halted production for the purposes of demolishing and removing a stainless-steel tank used to treat effluent from the site and install a new one. Multiple contractors had been brought in to tackle multiple aspects of the job in order to get it done as quickly as possible and get production back up and running.
However, along the way critical steps were overlooked resulting in a near disastrous situation and the near death of a worker on the site. Scott was called in as a consultant to audit the situation, discovering key missteps in these critical points. He walked us through the situation outlining what happened and where they fell short in execution.
The Set-Up
In order to remove the tank, two workers were tasked with using a plasma cutter to disassemble it piece-by-piece from top to bottom. Prior to the beginning of cutting, a separate team was instructed to clear the tank and pressure wash the inside to remove any remnants.
This kind of cutting on stainless steel is known to produce chromium hexavalent, a potentially deadly vapor. In anticipation of this, the area was ventilated to the best of their ability and the cutters were provided with respirators, an air monitor and a small fan to vent.
When the workers began cutting, there was another separate team of contractors working below the tank dismantling piping on the tank, not equipped with ventilation protection. The on-site safety officer did not notify either team, the first of many mistakes.
During cutting, the cutter’s air monitor alarmed (a notice of the presence of something other than the chromium hexavalent) to which one of the steamfitters below climbed the tank to warn them, believing the cutters were not aware. As he climbed, he was exposed to the vapors and began to have trouble breathing and began to choke.
The steamfitter notified the safety officer but seemed to recover. Unbeknownst to the safety officer on-site, the cutters were also experiencing minor similar reactions but did not report them. All parties went back to work.
What Went Wrong
The biggest error in the beginning, Scott points out, was the allowance for a separate team to be working in close proximity to the cutters unprotected when a known potentially dangerous vapor would be present. Instead, they should have been instructed to work at a separate time or at the very least provided with protection and respirators.
Additionally, a supervisor on the site should have prevented the steamfitter from climbing up to alert the cutters. Not only did he put himself at risk of exposure to the vapor, but after it began hard for him to breath he risked losing consciousness and falling from the 15-foot tall tank.
The Fallout
Not long after continuing to cut, the monitor alarmed again and the minor reaction by the cutters continued. After continuing for multiple attempts to continue, cutting was finally halted to investigate.
The air monitor on site was not equipped with a data log, meaning they could not go back and review what had tripped the monitor and more easily find a solution.
While this occurred, the steamfitter, feeling lingering effects, left the site to drive to a nearby clinic to get himself checked out. He did so without notifying his supervisor. Fortunately, tests showed that there were not lingering health concerns and he would recover fine in time.
What Went Wrong
Someone exposed to a dangerous material should not be admitted to leave on their own unsupervised. Consider, Scott points out, the potentially dangerous outcomes that could have occurred. The worker was feeling fatigued when he left and got behind the wheel of a car. What if he had lost consciousness while driving? Not only would his life be jeopardized his life, but the life of other drivers. Thankfully, that was not the case.
The Solution
It was at this point Scott was called in. He brought with him a new monitor with a data log to identify what the team was up against. After cutting for just long enough for the monitor to alarm, it was determined that the workers were being exposed to a combination of 75 ppm Carbon Monoxide and 68 ppm Hydrogen Sulfide.
Cutting steel does not produce these vapors, neither does dust or debris as a result of cutting. So what was the source?
Upon further inspection, it was found that the inside of the tank was not properly pressure washed, and just the faint layer of residue that remained combined with the heat of the cutting produced the vapors.
While this situation was considered a “near miss” by Scott, the domino effect of missteps cannot be overlooked:
- Improper washing
- Improper ventilation
- No protection for steamfitters
- Not reporting the exposure immediately
- Letting the steamfitter leave and drive unattended
Nothing can be overlooked in a situation like this, and often times it can be in the race to get projects completed. Which is where it pays to have a third-party safety consultant on site to monitor your project. They will ensure safety precautions are taken and executed correctly.
If you need someone with the skills and expertise to provide safety consultation on your next project, contact Scott Burkart at sjb@pearlengineering.com.
