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What happened?
Workers were trying to set a blind flange in an active flare line.
Ambient oxygen was introduced and a flash fire occurred.
The resulting heat and pressure escaped through the partly opened flange.
A worker suffered injury when the pressure thrusted his arm upward and struck a nearby scaffold.
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Why did it happen?
Workers normalised the risk:
- Live flare system was opened for blinding purposes.
- Ambient air introduced to a closed system (increasing oxygen volume).
- Fuel gas with increased oxygen then only needed an ignition source to explode within the flare system.
Operating procedures were not followed during planning and execution.
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What did they learn?
Prior to blinding, understand block valve isolation and draining/pressure relieving verifications.
Know your fire triangle and avoid introducing all three elements.
Carefully review and understand work management permits/packages and carry out risk assessment/job hazard analysis.
Discuss when to ‘stop work’ before starting an activity.
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Ask yourself or your crew
How can something like this happen here?
What barriers do we have in place to prevent this? What needs to be improved?
What additional precautions need to be taken when opening flare systems?
Think of scenarios when we should stop work when doing a similar task. Discuss these.
Should an emergency arise, what is your role? Who do you contact? How?
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What happened?
Workers were trying to set a blind flange in an active flare line.
Ambient oxygen was introduced and a flash fire occurred.
The resulting heat and pressure escaped through the partly opened flange.
A worker suffered injury when the pressure thrusted his arm upward and struck a nearby scaffold.
Why did it happen?
Workers normalised the risk:
- Live flare system was opened for blinding purposes.
- Ambient air introduced to a closed system (increasing oxygen volume).
- Fuel gas with increased oxygen then only needed an ignition source to explode within the flare system.
Operating procedures were not followed during planning and execution.
What did they learn?
Prior to blinding, understand block valve isolation and draining/pressure relieving verifications.
Know your fire triangle and avoid introducing all three elements.
Carefully review and understand work management permits/packages and carry out risk assessment/job hazard analysis.
Discuss when to ‘stop work’ before starting an activity.
Ask yourself or your crew
How can something like this happen here?
What barriers do we have in place to prevent this? What needs to be improved?
What additional precautions need to be taken when opening flare systems?
Think of scenarios when we should stop work when doing a similar task. Discuss these.
Should an emergency arise, what is your role? Who do you contact? How?
Workers were setting a blind flange in an active flare line when a flash fire occurred. The incident was caused by ambient air being introduced to a closed system (increasing oxygen volume).
