Investigation Report
Valero Delaware City Refinery Asphyxiation Incident — Case Study
Valero Delaware City Refinery Asphyxiation Incident — Case Study
- CSB
- Investigation Report
- Unknown
- Confined space hazardsOxygen deficiencyRegulation and legislation
- Confined space entryInspection and maintenance
- Breathing apparatus
- Competence and trainingEvacuation, escape and rescueExclusion zonesPermit to work
- Downstream and process industries
Summary
This case study examines two contractor deaths in a nitrogen-purged reactor, including an attempted rescue. It analyses permit deficiencies, missing warnings and barriers, and possible oxygen deficiency outside access openings. Lessons and recommendations address pre-job reviews, inert-gas hazard training, breathing equipment and qualified rescue personnel.
Classifications: Confined space hazards; confined-space hazards.
Classifications: Oxygen deficiency; oxygen deficient; oxygen displacement; oxygen depletion.
Classifications: Regulation and legislation; safety legislation; regulatory requirements.
Classifications: Confined space entry; tank entry; enclosed space entry.
Classifications: Inspection and maintenance; asset inspection; equipment maintenance.
Classifications: Breathing apparatus; SCBA; self-contained breathing apparatus.
Classifications: Competence and training; competency assurance; safety training.
Classifications: Evacuation, escape and rescue; EER; escape and rescue.
Classifications: Exclusion zones; red zones; restricted access zones.
Classifications: Permit to work; PTW; work permit.
Classifications: Downstream and process industries; refining; petrochemicals.