LESSON LEARNED #14

Multiple Fatality due to Asphyxiation

Accident sequence of events

Facts

Event Site: Petrochemical Plant

Accident occurred during the inspection of a sewage

pit.
The activity, PTW covered, did not foresee the
entrance in Confined Space, as it was meant to be
performed by remotely operated video-camera from
the outside.
Due to unknown reasons one of the Victims entered
the pit, with NO fit-for-purpose PPEs.
Also nor rescue neither atmosphere monitoring
equipment were used.
The victim suddenly fainted in the pit.
Presumably with the intent of rescuing the first
Sewage Victim, the second one entered the pit, but fainted as
Pit well.
The rescue team was promptly summoned to rescue
the two Victims and try to resuscitate them.
Despite the above, the two Victims sadly passed away.

2
Some Pictures

Sewage
Pit

Accident scene
rescue reel

Sewage Pit
Detailed view

3
Direct Causes

First Victim entering the Confined Space wearing a mask

which was suitable for outdoor work (Filter Mask), but
Unauthorized entry in Confined Space wrong for the work in Confined Space.
Subsequent entry of second operator, presumably with
the aim of rescuing the mate, also with wrong mask.

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Root Causes
Violation of Confined Spaces safety
prescriptions
Complacency and lack of risk
perception by the Victims
Lack of preventative intervention
ability
Entrance with NO authorization, with NO fit-for-purpose
PPEs, with NO work plan, NO atmosphere monitoring
and NO external supervision.
Violation of procedures applicable to Confined Space
entry.
Issues like: the very narrow site and trap door, the
experience of the team about confined spaces, should
have allowed the components of the team to prevent
the first worker from accessing the pit, in the first
instance.
5
Lesson learned

What can we learn from this?

Do not start activities not captured in the PTW.

Do not start activities not agreed in advance, in order to shoot
troubles via shortcuts.
In case of changes to PTW or shared work plan, STOP and
consult your Superior or the Supervisor.

Stick to agreed and Use exclusively fit Team up with the

foreseen Task\ for purpose tools all colleagues to
Work Plan. and equipment. discuss about risks
and procedures
prior to work
commencement.
Toolbox Talk