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- REPORT
CHARACTERISTICS:
DONOR: Alberta Community and Occupational
Health
Occupational Health and Safety Division
JURISDICTION:
ALBERTA
REPORT TITLE: Fatality Investigation Data
Base
INFORMATION ABOUT DECEASED:
NAME: Confidential
SEX: Male AGE: 33
OCCUPATION: chemicals, petroleum, rubber, and
plastic processing
INDUSTRY:
cement and chemical treatment
of wells
Industrial sector: mines, quarries and
oil
ACCIDENT INFORMATION:
DATE OF ACCIDENT:
Confidential
PLACE: LEGAL DESCRIPT AREA: Grande Prairie
region
NATURE OF INJURY:
burn or scald (electric burns not
electric shock)
TYPE OF ACCIDENT:
explosions
SOURCE OF
INJURY:
chemicals (not coal/petroleum products, hydrogen
sulphide)
ACCIDENT DESCRIPTION:
A well servicing
crew were preparing to service an oilwell which produced gas
at
2300 p.s.i. Opening up the wing valve of the well head, they found
they had
a good seal between the tubing and the pack off nipple
which was attached to a
Christmas tree saver. Just prior to
starting the operation they discovered
they had used the wrong
size of pack off nipple for the size of tubing in the
oilwell.
When they backed off the pack off nipple from the tubing, no
one
closed the wing valve. Gas escaping from the tubing through
the wing valve,
towards the direction of the worker and
nitrogen trucks caught fire instantly,
fatally injuring two
workers.
INVESTIGATION:
DATE: 1979-07-27
UNSAFE
ACT(S):
operating without authority, failure to secure or
warn
UNSAFE CONDITION(S):
hazardous spatial layout or work
area arrangement
improperly guarded,
unguarded
other
INDIRECT CAUSE(S):
unsafe job
procedure
worker's deliberate disregard of known safe
procedures
EMPLOYER ACTION(S):
eliminate unsafe
conditions
eliminate unsafe procedure
OHSO
ACTION(S):
approval of new procedures, equipment,
etc
OTHER'S ACTION(S):
other
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©2004 Canadian Centre for Occupational
Health & Safety 