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What happened?
A double-walled liquefied petroleum gas (LPG) tank was being demolished.
The suspended deck and dome-roof had been partially dismantled.
The contractor welders' task was to take down a vertical section of the plate by ‘banana peel’ method.
The first section didn’t fall as expected and got caught in a bent position. The right edge sheared in a metal curl and got lodged behind the adjacent inner wall.
Welders began cutting the snagged portion, which suddenly broke. The welders fell through the gap, resulting in 1 fatality and 1 serious injury.
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Why did it happen?
The investigation concluded that a sudden release of stored energy was the immediate cause.
When the situation/plan changed – caused by the need to cut snagged felled plates – they did not trigger management of change (MoC) procedure.
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What did they learn?
Ensure the risk assessment includes both known and obvious risks, as well as unusual risks and hazards like stored energy.
Ensure the permit includes all hazards and associated risks.
Assess and trigger management of change procedures when required.
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Ask yourself or your crew
How can something like this happen here?
What decommissioning or demolition activities do you have in your operations? How ‘visible’ are they, and do you fully recognise the associated risks?
What dilemmas do you face in determining the work method in your activities?
How do you ensure workers are capable of managing risks when the situation/scope of work changes?
How is stored energy identified as part of your risk assessment and permit to work process?
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What happened?
A double-walled liquefied petroleum gas (LPG) tank was being demolished.
The suspended deck and dome-roof had been partially dismantled.
The contractor welders' task was to take down a vertical section of the plate by ‘banana peel’ method.
The first section didn’t fall as expected and got caught in a bent position. The right edge sheared in a metal curl and got lodged behind the adjacent inner wall.
Welders began cutting the snagged portion, which suddenly broke. The welders fell through the gap, resulting in 1 fatality and 1 serious injury.
Why did it happen?
The investigation concluded that a sudden release of stored energy was the immediate cause.
When the situation/plan changed – caused by the need to cut snagged felled plates – they did not trigger management of change (MoC) procedure.
What did they learn?
Ensure the risk assessment includes both known and obvious risks, as well as unusual risks and hazards like stored energy.
Ensure the permit includes all hazards and associated risks.
Assess and trigger management of change procedures when required.
Ask yourself or your crew
How can something like this happen here?
What decommissioning or demolition activities do you have in your operations? How ‘visible’ are they, and do you fully recognise the associated risks?
What dilemmas do you face in determining the work method in your activities?
How do you ensure workers are capable of managing risks when the situation/scope of work changes?
How is stored energy identified as part of your risk assessment and permit to work process?
Two contractor welders were executing a demolishing activity on a redundant tank. After the scope of work changed, one of the welders lost his life and the other was seriously injured.
