Record Number: 2015 CIS Descriptors: MAINTENANCE AND REPAIR PETROLEUM AND NATURAL GAS INDUSTRY BURSTING FIRE, EXPLOSIONS FATALITY REPORT REPORT CHARACTERISTICS: DONOR: B.C. Coroner's Service JURISDICTION: British Columbia REPORT TITLE: Judgement of Inquiry INDIVIDUAL PRESIDING: Robert Trobak, Coroner PLACE OF INQUIRY: Fort St. John DATE OF INQUIRY : 1988-02-04 INFORMATION ABOUT DECEASED: NAME: Confidential OCCUPATION: Owner/Operator INDUSTRIAL SECTOR: Oil Refinery ACCIDENT INFORMATION: DATE OF ACCIDENT : 1987-07-24 PLACE OF ACCIDENT: Oilwell site; Progress, Alberta BRIEF CAUSE OF DEATH: Thermal cutaneous burns and inhalation injury. BRIEF MANNER OF DEATH: Explosion and fire. ACCIDENT DESCRIPTION: On the 25th of July, 1987, at 0925 hours the deceased died in Vancouver General Hospital from injuries he sustained in an industrial accident. The incident occurred approximately 36 KM east of the BC and Alberta border. There is a Shell Progress gas plant situated near Gordondale Alberta. The lease is approximately 8 KM north west of the plant. On the lease is a self-producing oil well, separator building and several large production tanks used to store the produced oil. The petroleum liquids being produced from the well cause a wax buildup that on a regular basis, decreases or stops the flow of oil coming to the surface. When the flow was being affected, Shell Canada Ltd. would contact a hot oil unit to de-wax the well. On the 22nd of July, 1987 the field operator for Shell Canada Ltd. notified his supervisor that the well needed to be de-waxed and he was requested to arrange for a hot oil unit to be contracted. The deceased, owner/operator of Handy Oilfield Service from Fort St. John, BC, was contracted as he had worked that well before on several occasions. On the 24th of July, 1987, the field operator met the deceased at the site at approximately 0800 hours. The hot oiler unit was mounted on the deck of a 1985 Mack 450 superliner truck. The deceased loaded approximately 50 bbl of oil from the production tanks on site, then backed into position on the south west side of the well, approximately 6 meters from the wellhead. The field operator assisted the deceased in rigging the hot oil unit to the well by means of a high pressure pipe. The process involves the injection of preheated oil into the well to melt any wax build up affecting well flow. Just prior to the accident the deceased was experiencing difficulty in keeping his hot oil injection pump running because "light ends" from the heated oil were flashing off inside the pump, resulting in a vapor lock. He cleared the vapor lock on two occasions prior to the accident by circulating the vapor out of the pump and into his holding tank. On his third attempt to circulate the vapor out of the pump, a large volume of vapor and a spray of hot oil escaped from the holding tank through the unsecured hatch. The vapor travelled across the truck deck and was ignited either by the magneto spark in the oil heater or the exhaust part on the unit. The resulting explosion and fire burned him. The fireld operator received burns in an attempt to extinguish the fire on the deceased. They were both driven to the gas plant first aid room where the extent of injuries were realized, treated and then they were driven in the crew cab to meet the ambulance about half way to Dawson Creek. The ambulance transported them to Dawson Creek Hospital and they were later transferred to the Vancouver General Hospital Burn Unit where the deceased died approximately 24 hours later. At autopsy, the death of this gentleman was attributed to thermal cutaneous burns and inhalation injury. The toxicology analysis indicated that alcohol, acidic drugs, basic drugs and opiates were not detected. The carboxyhemoglobin was 5 percent. An investigation was conducted by Alberta Occupational Health and Safety. During the investigation, meetings were held with three oil companies who require hot oil units on their leases and three hot oil unit operators. Contact was also made with two Alberta manufacturers of hot oil units. There was a conclusion reached that the hot oiling industry had been basically left on their own and with little pressure placed on them to follow existing OHS Regulations or to conduct operations in a safe manner. Shell Canada Ltd., was the principal contractor and owner of the lease where the accident occurred. The field operator was an oil and gas field operator with Shell Canada for four years. He had a total of eleven years experience in the oil field processes in general. On hot oiling operations specifically, he did not have much experience. The deceased, the owner/operator for Handy Oil Field Service Ltd. had 15 years experience with this employer and 30 years of relevant working experience. Because the Shell field operator was not familiar with the technical aspects of hot oiling, there was no inspection of the hot oil unit prior to the work commencing nor was there any discussion of safe working procedures. The hot oiler operator was considered the expert and the Shell operator was basically on site to operate the well and assist the hot oil operator. The field operator had never seen a written procedure developed by Shell for hot oiling nor had been given any formal training. CAUSES 1. The oil that was utilized in the hot oiling procedure, should never have been heated to the temperatures required to melt the wax in the well because of its volatile properties. It was felt a heavier oil from another location should have been used. 2. The hot oil unit was of poor design for use in flammable atmospheres. Apparently the holding tank vent line, which vented at truck deck level, vented approximately 1.5 m from the continously sparking magneto. The exhaust on the heater which reached temperatures of 280 degrees Celsius, exceeded the auto ignition temperature of some of the components of the condensate that was being heated. 3. It was felt there was an absence of adequate safe work procedures and competent supervision by Shell Canada Ltd. Also, apparent disregard for safety on the part of the deceased who left the hatch unsecured on his tank and heated the condensate to excessively high temperatures. PREVENTATIVE MEASURES 1. Since the accident the Occupational Health and Safety Division is assisting in: a) Initial contact with CPA to establish an Industry Committee to develop safe work procedures for hot oiler. b) Active involvement with industry to develop a standard for the design, construction and operation of hot oil units. c) Enforcement of the industry, develop safe work procedures and design standards for hot oilers. 2. The Hot Oil Company has implemented the following equipment changes and work procedures: a) The magneto spark in the hot oil heater has been converted from continuous to manually operated. b) The tank vent has been moved from the front of the tank to the rear, in addition, a flexible vent line has been added to increase the distance between escaping vapor and any ignition. c) Two man crews are now being used. d) In addition to the reverse flow check valve at the discharge pump, a second check valve is being installed at the wellhead. e) The company is contemplating issuing flame proof clothing to all employees. 3. Shell Canada Ltd. is developing a general "safe work procedure" for all hot oilers working on other leases. This procedure will include rigging up procedures, distances to be maintained from the well, types of oils to be used for heating and securing of equipment and a response to fires and other emergencies. This is an accidental death and as a result of the deceased's death it appears that every effort from all involved has been afforded to insure there is not a reocurrence of this type of accident. There are no recommendations.