Fatal Incident Involving a

Temporary Enclosure at a
Chemical Facility

From an OSHA Technical Information

Bulletin
Purpose
 Provide information
 Hazard alert
 Requirements and regulations
 Recommendations and guidance
 Other information
Incident Description
 Facilityunit undergoing a turnaround.
 2 workers to inspect the flange surfaces
of an open 48-inch piping system.
 Piping system opened to remove a
piece of process equipment for
cleaning.
 48” Pipe

Black Tarp
Incident Description

 Plastic-wrappedpipe
 New moisture-sensitive catalyst
upstream
Incident Overview

Open Valve North

N2
Injection
Open 48"
Piping N 2 Venting

Closed Valve South

Reactor w/new
catalyst

Note: Actual process/piping significantly more complex. N 2 injection

point 150' and several stories in elevation from pipe opening.
 Incident Overview
Reactor with
In-Line Mixer (removed)
Catalyst

Black Tarp

Open valves
to north side
open piping

Nitrogen
Purge
Incident Description
 Southside open pipe & enclosure
 Midday black light inspection.
 Black tarps draped to block light.

 Workers entered enclosure.

 No problems with inspection.

Incident Description
 North side open pipe & enclosure
 Midday backlight inspection.
 Black tarps draped to block light.

 Workers entered enclosure.

 Workers overcome upon entering.

Incident Conclusions
 One worker died, another hospitalized.
 N2 throughout system.
 Piping system was not straightforward.
 OSHA cited the employer for 1910.146
Permit-Required Confined Space
violations.
 Permit Required
Confined Space Hazards
 Oxygen deficiency  Engulfment
 Flammable atmosphere  Mechanical hazards
 Toxic atmosphere  Trapping/Pinch points
 Oxygen enrichment  Physical hazards
 Chemical exposure  Slips, Trips, Falls
 Thermal hazards  Unstable working surface
 Electrical shock  Structural failure
 Temperature extremes  Other recognized hazards
Nitrogen Hazard
 Can’t be detected by human senses
 N2 displaces oxygen in enclosures
(confined spaces) resulting in oxygen-
deficient atmospheres
Human Response to Oxygen-
Deficient Atmospheres
Atmospheric Oxygen
Possible Consequences
Concentration [%O2]

Meets OSHA minimum requirements for

19.5
worker protection
Unconsciousness without warning; so
8-10 quickly that individuals cannot help or
protect themselves

6-8 Fatal injury < 6 minutes

4-6 Coma < 40 seconds with subsequent death

Requirements, Recommendations
& Guidance
 If space meets the definition of a PRCS,
must follow 1910.146.
 Even if not technically a PRCS, 1910.146
recommended.
 Other OSHA standards may apply:
 1910.134 – Respiratory Protection
 IDLH Atmospheres
 Recognition that temporary enclosures may
be PRCSs.
Requirements, Recommendations,
& Guidance
 Comprehensive confined space
training.
 Particular
attention on hazardous
atmospheres
Related Information
 OSHA Technical Information Bulletin on
incident at: http://www.osha.gov

 CSB Morten Report at:

http://www.csb.gov/reports/1998/union_carbid
e/98005lafr.htm

 OSHA PRCS Standard, Directive and

Interpretation at: http://www.osha.gov