Investigation Report
PEMEX Deer Park Chemical Release
PEMEX Deer Park Chemical Release
- CSB
- Investigation Report
- Hazardous SubstancesProcess Safety
- Human factorsHydrogen sulphideLoss of containmentProcess safety
- Inspection and maintenance
- Gas detectorProcess pipework and pipelinesRespiratorValve
- Contractor managementOperating and work proceduresPermit to workSimultaneous operations coordination
- Downstream and process industries
- Onshore facility
Summary
CSB investigation of a fatal hydrogen sulphide release during refinery maintenance in Deer Park, Texas. Workers opened the wrong flange on active piping. The report examines equipment identification, permit scope and hold points, interacting maintenance operations, contractor reassignment and operational discipline, recommending clearer marking and work authorisation arrangements.
Classifications: Human factors; human performance; ergonomics.
Classifications: Hydrogen sulphide; H2S; H₂S; hydrogen sulfide.
Classifications: Loss of containment; containment loss.
Classifications: Process safety; major accident hazards.
Classifications: Inspection and maintenance; asset inspection; equipment maintenance.
Classifications: Gas detector; gas monitor; gas detection instrument.
Classifications: Process pipework and pipelines; process piping.
Classifications: Respirator; respiratory protective equipment; RPE.
Classifications: Valve; valves.
Classifications: Contractor management; contractor assurance.
Classifications: Operating and work procedures.
Classifications: Permit to work; PTW; work permit.
Classifications: Simultaneous operations coordination; SIMOPS; simultaneous operations.
Classifications: Downstream and process industries; refining; petrochemicals.
Classifications: Onshore facility; onshore plant.
Themes: hazardous substances, process safety.