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Valero Refinery Asphyxiation Incident
FINAL REPORT: Case Study
Location: Delaware City, DE
Accident Occurred On: 11/05/2005
Final Report Released On: 11/02/2006
Accident Type: Confined Space / Asphyxiation
Company Name: Valero

statistics

Total # of Recommendations
8
Total # of Open Recommendations
2
Total # of Closed Recommendations
6
Total % of Open 25 vs. Closed 75

investigation information

Image
Accident Description
Two contract employees were overcome and fatally injured by nitrogen as they performed maintenance work near a 24-inch opening on the top of a reactor. One of the workers died attempting rescue.
Investigation Status
The CSB issue a case study report and a safety video based on this incident at a news conference in Newark, Delaware, on November 2, 2006.


 

Recommendations

American Petroleum Institute (API)
2006-2-I-DE-6

Revise Guidelines for Safe Work in Inert Confined Spaces in the Petroleum and Petrochemical Industries (API, 2005) to clearly address the following: - An oxygen-deficient atmosphere rapidly overcomes the victim. - There is no warning before being overcome. - An oxygen-deficient atmosphere might exist outside a confined space opening. - Rescuers must strictly follow safe rescue procedures.

Status: Open - Awaiting Response or Evaluation/Approval of Response
Open - Awaiting Response or Evaluation/Approval of Response (O - ARE/AR) - The recipient has not submitted a substantive response, or the evaluation by CSB staff of a response is pending, or the Board has not yet acted on staff recommendation of status.
 

American Society of Safety Engineers (ASSE)
2006-2-I-DE-7

Revise Safety Requirements for Confined Spaces, ANSI/ASSE Z117.1 to emphasize that: - An oxygen-deficient atmosphere rapidly overcomes the victim. - There is no warning before being overcome. - An oxygen-deficient atmosphere might exist outside a confined space opening. - Rescuers must strictly follow safe rescue procedures.

Status: Open - Awaiting Response or Evaluation/Approval of Response
Open - Awaiting Response or Evaluation/Approval of Response (O - ARE/AR) - The recipient has not submitted a substantive response, or the evaluation by CSB staff of a response is pending, or the Board has not yet acted on staff recommendation of status.
 

Compressed Gas Association (CGA)
2006-2-I-DE-8

Issue a safety alert to address nitrogen/inert gas hazards in confined spaces. Emphasize that: - An oxygen-deficient atmosphere rapidly overcomes the victim. - There is no warning before being overcome. - An oxygen-deficient atmosphere might exist outside a confined space opening. - Rescuers must strictly follow safe rescue procedures.

Status: Closed - Acceptable Action
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

Matrix Service Industrial Contractors, Inc.
2006-2-I-DE-5

Conduct confined space control and inert gas purge procedure refresher training for all affected personnel. Emphasize: - The requirements to maintain posted warnings at all access points to confined space temporary openings. - The need to maintain posted warnings, barricades, and access controls as required by the client. - An oxygen-deficient atmosphere rapidly overcomes the victim. - There is no warning before being overcome. - An oxygen-deficient atmosphere might exist outside a confined space opening. - Rescuers must strictly follow safe rescue procedures.

Status: Closed - Acceptable Action
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

Valero Delaware City Refinery
2006-2-I-DE-1

Conduct safe work permit refresher training for all permit-preparers and approvers and affected refinery personnel and contractors. Emphasize: - All proposed work requires a jobsite visit by the requestor and a unit operator to identify special precautions, equipment status, and personal safety equipment requirements. - The conditions for marking the "nitrogen purge or inerted" (Yes/No/NA) status box. - The permit must clearly identify all hazards and special personal protective equipment requirements. - "Fresh Air" work restrictions apply to "Set up only" permits whenever an IDLH atmosphere is suspected or known to be present in the work area.

Status: Closed - Acceptable Action
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

2006-2-I-DE-2

Conduct confined space control and inert gas purge procedure refresher training for all affected refinery personnel and contractors. Emphasize: - The requirements to maintain posted warnings at all access points to confined space temporary openings. - The requirements to maintain posted warnings, barricades, and access control log at equipment during purging. - An oxygen-deficient atmosphere rapidly overcomes the victim. - There is no warning before being overcome. - An oxygen-deficient atmosphere might exist outside a confined space opening. - Rescuers must strictly follow safe rescue procedures.

Status: Closed - Acceptable Action
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

Valero Energy Corporation
2006-2-I-DE-3

Audit work permit procedures and nitrogen purge safety procedures at each Valero U.S. refinery. Determine if issues identified in this Case Study are occurring elsewhere. Implement corrective action, including training, where necessary.

Status: Closed - Acceptable Action
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

2006-2-I-DE-4

Require Valero U.S. refineries to revise and conduct nitrogen hazards awareness training. Emphasize: - An oxygen-deficient atmosphere rapidly overcomes the victim. - There is no warning before being overcome. - An oxygen-deficient atmosphere might exist outside a confined space opening. - Rescuers must strictly follow safe rescue procedures.

Status: Closed - Acceptable Action
Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.
 

 
 

Related Video

Hazards of Nitrogen Asphyxiation
11/2/2006 5:00:00 AM
Two contract workers suffocate while servicing a refinery process vessel. read more

Download QuickTime Video

Related News

Copy_of_Opening
CSB Releases Safety Video with Computer Animation; Valero Refinery Delaware City, Delaware, Nitrogen Asphyxiation Incident on November 5, 2005
11/2/2006
Washington, DC, November 2, 2006 - The U. S. Chemical Safety Board (CSB) today issued a Safety Video on the November 5, 2005 nitrogen asphyxiation incident at the Valero Refinery in Delaware City, Delaware. The video includes a computer animation depicting events leading to the accident, and features commentary by Lead Investigator John Vorderbrueggen, Board Member John Bresland, and a field expert.
read more
Danger_tape1
CSB Issues Case Study in 2005 Valero Refinery Delaware City, DE, Accident; Report Notes Inadequate Nitrogen Asphyxiation Hazard Awareness Training and Improper Confined Space Rescue Actions
11/2/2006
Wilmington-Newark, Delaware, November 2, 2006 - A tragic accident in which two workers were asphyxiated inside a nitrogen filled confined space could have been avoided through better hazard awareness training and proper confined space rescue actions, the U.S. Chemical Safety Board reports in a Case Study released today.
read more
Danger_tape
CSB to Conduct Full Investigation of Nitrogen Incident at Valero Delaware City Refinery
12/1/2005
Washington, DC, December 1, 2005 - The U.S. Chemical Safety and Hazard Investigation Board, (CSB) announced today that it is conducting a full investigation of a fatal incident at the Valero Refinery in Delaware City, Delaware, on November 5. Two men died from nitrogen asphyxiation the night of November 5, 2005. The two were contract workers employed by Matrix Services, Inc. They were working in the refinery's hydrocracker unit, which produces light distillates from heavy gas oils.
read more
 
 
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