11 Key Lessons Taken from Heat Exchanger Rupture and Ammonia Release at Goodyear Texas

heat-exchanger-ruptureCSB’s case study is a very good source of safety lessons. It provides free and real safety lessons for all of us. I like to read it and would like to share it with you now.

A few days ago, CSB released a case study about the Goodyear Texas heat exchanger rupture and ammonia release on June 11, 2008. In that accident at work, a heat exchanger which is used to cool down chemicals used to make synthetic rubber, ruptured and ammonia was released. It caused one employee died and injured six others.

I have read the case study and I thought that it was very good safety lessons. Here are the key safety lessons that I have summarized for you.

1. Rupture disk, relief valve and pressure control valve were kept isolated after maintenance work finished. They could not function when over pressure occurred.

2. The use of lock out/tag out procedure on equipment that was undergoing maintenance was not performed completely.

3. Work progress of rupture disk maintenance was not adequately communicated between maintenance worker and production operator.

4. The work order system that requires verification signature from production operator was not followed.

5. Heating ammonia inside a closed space was very dangerous operation and should be avoided without any over pressure protection.

6. The operator, who carried out heat exchanger tube cleaning with steam, did not fully understand the properties of chemical, in this case ammonia.

7. Some employees have not fully received on site emergency response training.

8. Plant-wide evacuation and shelter-in-place drill were not conducted according to schedule as required by the company’s procedure.

9. The plant alarm system was not reachable in case of emergency. It prevented workers from activating it.

10. The employee accounting procedure in emergency did not include members of emergency response team. It should cover all the workers and other people who entered the plant site.

11. Worker headcounts drills in emergency did not conducted by the company in regular basis according to the company procedure.

If you think that the above safety deficiencies are yours, so take action now. Improve them before they harm your workers and damage plant facility.

Note: to read the full case study, please click here.

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