11 May Work for the contractor crews is assigned/schedul
Work for the contractor crews is assigned/scheduled each morning. On the day of the incident, the day-shift (6 am to 6 pm) crew had been tasked with isolating the acid gas feed stream for the Claus unit. Due to other work priorities, the crew did not isolate the line as planned. A shift turnover for the night contractor crew did not happen due to mandatory safety training that delayed their arrival at the worksite. Upon their arrival at the work site, the night crew held a job safety analysis (JSA) review of the scheduled task (line breaking of the acid gas feed line to replace a segment) to be performed and the hazards present. No pressure gauges or monitoring was present to indicate that the acid gas feed line was operational. The crew initiated the line breaking activity (open the line to the atmosphere) at approximately 7:45 pm under self-contained breathing apparatus (SCBA), which almost immediately resulted in the uncontrolled release of acid gas. A nearby ignition source from a welding operation ignited the flammable gas. The following actions were initially taken:
The evacuation alarm was sounded and the refinery emergency response team (ERT) was activated.
The plant manager and the local fire department were notified of the incident.
The incident command was established at the refinery office near the main refinery access gate to the south (this is the furthest distance within the refinery boundary from the incident location).
The refinery ERT incident commander implemented actions required under the approved refinery emergency response plan.
The ERT was not able to immediately isolate the acid gas feed pipeline.
The fire department arrived on location and assumed the incident command of the
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