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Two workers were preparing to ‘box up’ a hydrocracker reactor by reinstating the piping inlet elbow at the top manway. The reactor was being purged by nitrogen from a temporary supply and vented to atmosphere through the open manway. A roll of duct tape had inadvertently been dropped into the reactor, landing on a vapour/liquid distribution tray about 1.5m below the manway opening. One of the workers tried recovering the duct tape from outside the reactors with a long wire hook but earlier fell in or climbed into the reactor and passed out. A second worker hurriedly inserted a ladder and climbed into the reactor to attempt a rescue. A third worker approached the manway, observed the 2 workers lying motionless on the distribution tray, and radioed for emergency assistance. The stricken workers were recovered from the reactor, but both were unresponsive and could not be revived.
Ask yourself and your crew:
- How can something like this happen here (e.g. on our site)?
- What safety measures (i.e. procedures, controls/barriers) do we have in place to mitigate the risk?
- How do we know the risk controls/barriers are working?
- What improvements or changes should we make to the procedures, controls/barriers or the way we work?
Original content courtesy of IChemE Safety Centre
