Ows Explosion Case Study

Explosion at OWS sump near Sour Water Stripper Unit
-Shashi Vardhan, Additional Director
1.0 INTRODUCTION
An incident of explosion at OWS pit was reported resulting in fatality of a

contract worker and injury to one company employee and four contract
workers in a refinery.
2.0 INCIDENT
On the day of the incident, hot work permit was issued for installing a vertical
pump on the OWS pit. The LEL test was carried out by operations at 7.30 am
on the same day and zero reading was recorded on the work permit. The
maintenance crew lowered the pump inside the pit through pump opening
with the help of hydra. The pump was installed on the support plate and
stitch welding of the old and new plates was completed at three locations
(Two in the East side and one on the South Side). The explosion and fire
occurred when tack weld at the fourth location (west side) was attempted at
around 11:15 am. Six workers present at the site were hit by the rubbles of
pit cover and other structures present at the site. One worker was hit at back
of his head and succumbed to injury. Five additional workers had injuries
/fractures and were provided with medical support at Hospital.
3.0 SEQUENCE OF EVENTS
OWS pit was taken for maintenance for removal of sludge as the pumps were
frequently getting jammed during operation. The pumps were removed from
the base during the cleaning operation. Subsequently the pit was cleaned.
During installation of the second pump, it was observed that the pump
foundation bolts mounted on the support plate which is grouted to the pit top
roof was damaged and was required to be cut and replaced.
Two additional plates (spacer & support plate with base bolts welded) were
prefabricated which were required to be welded on the existing support plate
for proper installation of the pump.
The sequence of events connected to this pit and pump are as below:
a) OWS pit was emptied to ensure that liquid level is lowered to the
minimum extent possible using one pump.
b) Second day permit to carry out welding job for installation of second
pump was issued but job could not be taken up as the welding group
was engaged in some other activity.
c) On day-3, pump support repair and the damaged bolts on the support
plate were cut by grinding and an additional spacer plate was welded
on the existing support plate mounted on the pit roof.
d) On fourth day, hot work permit was issued at 9.00 hrs. and LEL test
was carried out at 7:30 am holding the instrument in hand and
extended downwards into the pit to the extent feasible.
e) The shift in charge who inspected the location at 8:30 am prior to
approving the permit reported minimum liquid level in the pit when
viewed through the man hole.
f) At around 9:45 am, maintenance crew arranged for a hydra to install
the pump. Prior to installation, area operator inspected the pit from the
pump opening and observed that the sump in the pit had very little
liquid. Clearance was given for lowering the pump through the pump
opening.
g) The pump was installed on the support plate and the stitch welding of
the old and new plates was completed at three locations (Two in the
East side and one on the South Side). The explosion happened when
tack weld at the fourth location (west side) was attempted at around
11:15 am.
Explosion in OWS manhole- the pump foundation totally

shattered
4.0 OBSERVATIONS/ FINDINGS
• Even though Operation emptied the sump, complete emptying of the

liquid from the sump could not be done. Some amount of liquid
remained in the sump.
• The liquid content remaining inside the sump is more likely to be either
sludge (H2S rich or oily) or oil. The ambient temperature was low at
the time the gas test was done as it was early morning (7.30 AM).
Subsequently, by 11:00 am, the when the ambient temperature rose,
vapors started emanating from the sludge. These vapors could either
be H2S gas or hydrocarbon vapors. H2S is flammable at 4 % to 43%.
• The explosive mixture inside the pit could be formed with hydrocarbon
vapors or H2S gas or the combination of these two. Since LEL level was
zero at 7.30 AM as mentioned in work permit, it indicates presence of
H2S gas inside the pit in range of flammable concentration.
• During initial tack welding spark from the welding torch could not have
reached inside the pit and when tack welding was attempted on the
other side the spark might have made contact with explosive mixture
present inside the pit.
• No mention was made in the work permit for measuring toxic gas (H2S)
concentration in the pit as additional safety precautions. It indicates
that job safety analysis (JSA) for carrying out this job was not done.
5.0 ABNORMALITIES/ ROOT CAUSE OF INCIDENT
• The concentration of Hydrocarbon vapors was less in the morning since

the ambient temperature at 7.30 am was low.
• At 11.00 am atmospheric temperature increased; the concentration of
HC / H2S vapors must have reached LEL level but at that time reading
was not taken.
• SRU/SWS unit OWS pit will normally have presence of oil & H2S vapors.
Since the material received in the pit had presence of H2S, the
explosive mixture could be formed by H2S vapors which was not
detected since the test was not carried out. The requirement of
carrying out testing for the presence of toxic H2S prior to carrying out
the hot job was not mentioned in the permit.
• Job safety analysis (JSA) for carrying out the job was not done
otherwise it would have clearly indicated the presence of H2S.
6.0 RECOMMENDATIONS/ LEARNINGS FROM THE INCIDENT
¾ The presence of explosive mixture must be measured just before the

start of hot job such as welding, cutting etc.
¾ The measurement of H2S must also be taken besides hydrocarbon
vapors wherever presence of H2S is expected.
¾ Work permit system needs to be strengthened and permit should be
issued for specific job and not for multiple jobs.
¾ The reference of electrical isolation should be given on hot work permit
to ensure electrical isolation of the equipment.
¾ Job safety analysis should be carried out before taking up any job.
Explosion in OWS: The manhole cover blown up

Ows Explosion Case Study

Uploaded by

Copyright:

Available Formats

Ows Explosion Case Study

Uploaded by

Document Information

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Ows Explosion Case Study

Uploaded by

Copyright:

Available Formats

Explosion at OWS sump near Sour Water Stripper Unit

-Shashi Vardhan, Additional Director

An incident of explosion at OWS pit was reported resulting in fatality of a

3.0 SEQUENCE OF EVENTS

Explosion in OWS manhole- the pump foundation totally

4.0 OBSERVATIONS/ FINDINGS

• Even though Operation emptied the sump, complete emptying of the

5.0 ABNORMALITIES/ ROOT CAUSE OF INCIDENT

• The concentration of Hydrocarbon vapors was less in the morning since

6.0 RECOMMENDATIONS/ LEARNINGS FROM THE INCIDENT

¾ The presence of explosive mixture must be measured just before the

You might also like