Case Study on "Heat Exchanger Rupture Incident"

Case Study 4 pages (1252 words) Sources: 1

[EXCERPT] . . . .

" This infers that Goodyear was not completely prepared to react during a plant-wide evacuation, according to preexisting plans. It is possible that the one employee whom was injured trying to exit may not have been prepared by Goodyear to follow a safe exit route. Furthermore, regular practice of the drills may have helped team leaders familiarize themselves with the process, and better take headcounts of employees or realize an employee was missing. Depending on the number of employees each response supervisor was responsible for counting after evacuation, regular practice could have helped alert the response team that not all employees had properly exited the facility. In addition, CSHIB (2008) reported, "Operating procedures discussed plant-wide, alarm operations and emergency muster points for partial and plan-wide evacuations; however, some employees had not been fully trained on these procedures." With safety being a number one priority, management should have required a certain level of disaster readiness for all employees prior to actively working in the facility. This could have led to the obstruction of others in exiting the facility, and if any of the injured employees were untrained to act on emergency response procedures, then this could have been a factor that contributed to their injuries.

Another managerial or supervisory issue included that "although emergency response team members were familiar with the employee accountability procedures, not all supervisory and security employees, who were to conduct the accounting, had been trained on them." This lack of training produced confusion and uncertainty in relation to expected roles in the emergency response.

Material & Equipment Factors

The badge tracking system malfunctioned, during the incident. This prevented supervisors "from retrieving the list of personnel in their area (CSHIB, 2008)." Hence, the headcounts after evacuation were less precise. Management had declared the incident over, prior to accounting for all employees. One incident of inaccuracy helps substantiate the capacity for additional miscounts per use of the handwritten employee and contractor list. Thus, it is possible that additional employees could have been left within the facility, after management had officially declared that the incident was over.

B. Casual Factors

Material & Equipment Factors

If the closed isolation valve were reopened after replacing the ruptured disk, the overall incident would likely not have occurred. Since the isolation valve was not reopened, "the steam flowed through the heat exchanger tubes, heated the liquid ammonia in the exchanger shell, and increased the pressure in the shell." Eventually with the isolation valve closed the heat exchanger violently ruptured.

Personnel Factors

On June 11, an operator attempted to clean the piping of the heat exchanger. The cleaning process emitted steam, which increased the pressure within the shell. If the steam were not there, then the incident might not have immediately occurred. Or, if the operator did not clean the pipes, then it my have given the facility the opportunity find the isolated valve and reopen it. It did not seem mandatory that any operator receive verification that all the proper valves were open prior to doing any cleaning of the pipes. Such protocol could have prevented the rupture and prevented the fatality, injuries, and less important damage to the facility.

IV. Event & Causation Chart

References

Calfire. (2014, January 1). Casual and Contributing Factors. Retrieved November 26, 2014, from www.fire.ca.gov

CCOHS. (2014, February 1). Accident investigation. Retrieved November 26, 2014, from http://www.ccohs.ca/oshanswers/hsprograms/investig.html

Chemical Safety and Hazard Investigation Board. (2008). Heat exchanger rupture and ammonia release in Houston, Texas.

Closed isolation valve

Closed block valve

Connected

steam line

Heat exchanger erupted

Debris

struck and killed employee

Employee

injured trying to exit

Ammonia released

Five employees

Exposed

to ammonia

Evacuation called

Tracking system failed

Headcount

completed inaccurately… READ MORE

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