Case description:

On March 13, 2001, the United States in Augusta, Georgia BP amoco - polymer factory (hereinafter referred to as the Augusta three workers of the factory in the open end cover with hot melt the plastic process reservoir were killed in the process, the reason is that they didn't know there is a pressure in the reservoir, part of the bolt coming down the end cover of sudden and spewed hot melt plastic killed workers and ejected energy nearby pipeline rupture, escaping from the pipe of the hot liquid burned, caused the fire.

Case analysis:

When someone is doing maintenance or other work around the equipment or on the equipment, the power source of the equipment will be started accidentally, which will cause injuries to people. Therefore, it is necessary to establish a lock and break/hang procedure (LOTO) to cut off the power source to protect personal safety.

This accident is also the result of the absence of several process safety management elements. For example, process safety information (PSI) is not perfect, change management (MOC) is not complete, process hazard analysis (PHA) is insufficient, accident and attempted investigation (NM) system failure, and employees lack the necessary Training.

The workers failed to comply with the existing company policy of lockout/tag-out and equipment disassembly (LOTO) because the blocked discharge pipe on the polymer recovery tank prevented them from confirming the presence of pressure in the tank. The devicebreaker does not specify what to do when safety measures are not met. On the day of the incident and during routine production, the company's procedures and the occupational safety and health agency's (OSHA) lockout/tagout regulations determined that the polymer recovery tank was impossible without pressure. The cured polymer plugs the drain, which is used to make sure there is no pressure in the tank. In this case, there was no requirement for administrative review and authorization, and despite the lack of absolute confirmation that there was no pressure in the tank, the workers continued to open the tank cover.

Case experience:

Whenever the following situations occur, the employee has correct execution of the duties and rights lock off/on program (LOTO) and shall be responsible for its correct application: need to put any part of your body or a location close to the equipment, the equipment can produce unexpected move, release of stored energy, charged electric system, or will release gases, liquids or other substances may cause harm to the staff. A simple description of these rules is that when you place any part of your body in or near a dangerous device, you must first isolate and lock the source of the ability.