04年训练讲义 灌气安全.ppt

Fatality at Industrial Oxygen Filling Plant (2/2) Neck of the ruptured cylinder Sheared valve thread * Fu?zeile * Incident Date: 7 July 2007 Description: On 7th July 2007, at an unknown time, a Security guard found a ruptured Butane cylinder at a customer site (Young Sang) foam-blowing factory. There were no injuries or damage to property. Immediate causes: -??????????? Butane cylinders pressurised with Nitrogen -??????????? Butane cylinder hydraulically full Basic causes: - No TRV’s or pressure gauges fitted on the system - Incorrect customer process. Butane Cylinder Rupture (1/3) * Butane Cylinder Rupture-Customer installation (2/3) * HAZARD TRIANGLE-Butane Cylinder Rupture(3/3) Cylinder ruptures and gas ignites from nearby work. Employee sustains severe burns and dies. Cylinder is over-pressurised and ruptures while in cylinder area. No injuries or damage to property. Customer using nitrogen to pressurise cylinders. Installation not to standard. Cylinder ruptures and gas ignites from nearby work. Employee sustains burns and is off work for two days. Cylinder ruptures and employee sustains cold burns on legs. Near- Misses or First Aid Hazards- Unsafe Acts- People Created  Unsafe Conditions Recordable Injuries (MTCs) Major(LWCs) Fatal Inputs (control) Inputs (control) Outcomes (No Control) Outcomes (No Control) * Fu?zeile * Cylinder rupture whilst filling (1/4) * Fu?zeile * Unable to identify the defective cylinder Incident IMMEDIATE CAUSES BASIC CAUSES LACK OF CONTROL Cylinder Rupture Cylinder internal condition badly corroded Insufficient training Cylinder contaminated Lack of appreciation of risks by the customer Inadequate pre-fill inspection process Causal tree-Cylinder rupture whilst filling(2/4) Customer negligence Improper storage Cylinder valve not close after used RPV not in place RPV is not mandatory for Industrial O2 cylinder Replacement program not in place Defective cylinder sent for filling * Fu?ze