In its report on the Oct. 26, 2019, hydrogen sulfide gas release that killed a Texas oilfield worker and his wife, the U.S. Chemical Safety Board (CSB) says it found multiple safety issues at the site where the incident occurred.
Jacob Dean died after being overcome by poisonous hydrogen sulfide gas at the Aghorn Operating waterflood station in Odessa, Texas. His wife, Natalee, was killed by the fumes when she went to check on him.
The Aghorn Operating waterflood station is used as part of a process to extract oil from underground reservoirs in West Texas. According to the CSB, waterflood stations are common in Texas.
“At the Aghorn waterflood station, pumps, in a building called the ‘pump house,’ are used to pressurize and inject the water back into the oilfield. The injected water adds pressure to the reservoir allowing a larger quantity of oil to be extracted,” the CSB said in a statement.
According to the CSB, Jacob Dean went to check on a pump after the “waterflood station’s control system activated an oil level alarm.”
“The CSB found, however, that the pumper [Jacob Dean] failed to isolate the pump from energy sources before performing the work. At some point while the pumper was in the vicinity of the pump, the pump automatically turned on, and water containing hydrogen sulfide escaped into the pump house. The pumper was overcome and fatally injured by the toxic gas.”
His wife also was overcome when she went to check on him after several hours passed and he did not return home.
“After the incident, the CSB found that a plunger on the pump had shattered, which had allowed the release to occur. Due to the limitations of the available evidence, the CSB was unable to determine whether the pump failure and toxic release happened before the pumper arrived at the facility, or when the pump automatically turned on while the pumper was closing valves,” according to the statement released by the CSB.
In April 2020, OSHA proposed $105,253 in penalties and cited Aghorn with four serious and one willful workplace safety violations as a result of the incident. The company is contesting the citations.
The CSB’s report details the following safety issues found at Aghorn:
- Nonuse of Personal Hydrogen Sulfide Detector: The pumper was not wearing his personal hydrogen sulfide detection device inside the pump house on the night of the incident, and there is no evidence that Aghorn management required the use of these devices.
- Nonperformance of Lockout / Tagout: At the time of the incident, Aghorn did not have any written Lockout / Tagout policies or procedures. The pumper did not perform Lockout / Tagout to deenergize the pump before performing work on it.
- Confinement of Hydrogen Sulfide Inside Pump House: The pump house could be ventilated by two bay doors, exhaust fans, and natural vents. Due to the limitations of the available evidence, the CSB was unable to confirm whether the exhaust fans were operational at the time of the incident. The two bay doors were approximately 60% open. The building was not adequately ventilated during the incident.
- Lack of Safety Management Program: The CSB found the formal company safety or operational policies and procedures used by Aghorn Operating were incomplete and inadequate.
- Nonfunctioning Hydrogen Sulfide Detection and Alarm System: The waterflood station was equipped with a hydrogen sulfide detection and alarm system. However, the system’s control panel did not receive signals from the internal and external detection sensors on the night of the incident, and, therefore, did not trigger either of the two alarms.
- Deficient Site Security: As per Aghorn’s informal policy, when an Aghorn employee is working at the facility, the access gates are normally left unlocked. The unlocked gates allowed the pumper’s spouse to drive directly to the waterflood station and enter the pump house, where she was also fatally injured.
As a result of its investigation, the CSB made several recommendations to Aghorn Operating Inc. for safety improvements at all waterflood stations where the potential exposure to dangerous levels of toxic hydrogen sulfide gas exists. These include:
- Mandate the use of personal hydrogen sulfide detection devices;
- Develop a site-specific, formalized and comprehensive Lockout / Tagout program for each facility;
- Commission an independent and comprehensive analysis of each facility to examine ventilation and mitigation systems;
- Develop and demonstrate the use of a safety management program that includes a focus on protecting workers and non-employees from hydrogen sulfide;
- Ensure that hydrogen sulfide detection and alarm systems are properly maintained and configured, and develop site-specific detection and alarm programs and associated procedures;
- Ensure that the hydrogen sulfide detection and alarm system designs employ multiple layers of alerts unique to hydrogen sulfide; and
- Develop and implement a formal, written, site-specific security program to prevent unknown and unplanned entrance of those not employed by Aghorn.
In addition to recommendations to the company, the CSB made a recommendation to OSHA to issue a safety information product that addresses the requirements for protecting workers from hazardous air contaminants and from hazardous energy, and a recommendation to the Railroad Commission of Texas to develop and send a Notice to Operators to all oil and gas operators that fall under its jurisdiction that describes the safety issues described in the CSB’s report.
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