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What happened?
18 inch blind was being installed on a flare knockout drum and flare header.
Positive purge was applied to the system (as the flare was live).
Purge operator choked back on the purge.
This caused negative pressure, pulling air in and leading to a back flash.
Crew suffered 1st and 2nd degree burns around face masks, to heads and faces.
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Why did it happen?
Purge operator did not maintain minimum positive flow – he deviated from the plan.
He wanted to minimise flow into the faces of the crew installing the blind – he was trying to be helpful.
Air was pulled in and caused a back flash when the worker choked back on the purge.
The worker did not identify the hazard, or understand what would happen.
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What did they learn?
Ensure the risk assessment has considered all the relevant hazards including explosion, flash fire, asphyxiation, poisoning, chemical burns, thermal burns and physical injuries.
If the plan needs changing, stop the work, make a new plan and obtain approval to proceed.
For opening processes under pressure: use specific procedures, ensure communication, minimise peripheral activities, and include contingency actions for unexpected or emergency situations.
Follow established PPE requirements. Implement what hazards and mitigations were identified in the risk assessment.
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Ask yourself or your crew
Why did these people do what they did? What were their intentions?
What other actions could have been taken?
How can something like this happen here?
Have you ever deviated from a plan to be helpful?
What hazards might we not fully appreciate when we work on flare systems?
What safeguards do we have in place to prevent something like this happening on our flares?
What changes do we need to make to how we work today?
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Published on 27/03/19
4035 Views
18 inch blind was being installed on a flare knockout drum and flare header. Crew suffered 1st and 2nd degree burns around face masks, to heads and faces.
