Record Number: 2375 CIS Descriptors: CHEMICAL BURNS PETROLEUM AND NATURAL GAS INDUSTRY EXPLOSIONS ETHYLENE GLYCOL UNSAFE PRACTICES FATALITY REPORT REPORT CHARACTERISTICS: DONOR: Office of the Chief Coroner JURISDICTION: British Columbia REPORT TITLE: Judgement of Inquiry INDIVIDUAL PRESIDING: Dr. Robert Trobak, Coroner PLACE OF INQUIRY: Prince George DATE OF INQUIRY : 1990-09-18 INFORMATION ABOUT DECEASED: NAME: Confidential OCCUPATION: Unavailable INDUSTRIAL SECTOR: Petroleum and natural gas industry ACCIDENT INFORMATION: DATE OF ACCIDENT : 1989-12-05 PLACE OF ACCIDENT: Buick Creek well site, north of Fort St. John BRIEF CAUSE OF DEATH: Cardiac renal failure. BRIEF MANNER OF DEATH: Forty percent of body sprayed with hot ethylene glycol. ACCIDENT DESCRIPTION: The deceased died on December 5, 1989 after receiving burns from a glycol burner on November 14, 1989. His death was investigated and determined to have been accidental. The deceased and Evan Wangness arrived at the Buick Creek well site, north of Fort St. John just before 0800 hours on November 14, 1989. The deceased and Evan were employees of Petro Canada Resources Production Department and were performing routine operating duties that morning. As they were doing a routine check, it became apparent the glycol pump had stopped on the dehydration or reboiler unit. This unit uses glycol heated to 325 degrees Fahrenheit to separate water from the natural gas by vaporizing the water. The dehydrator is not a pressurized unit; it is maintained at normal atmospheric pressure. Any pressure that accumulates in the unit is to go out through an accumulator vent line or a still column vent that is vented to the atmosphere. While considering what the problem was, one end of the reboiler unit blew off spraying both men with the hot glycol. Evan was standing close to the reboiler unit and was struck by the end plate. Both men were wearing fire retardant clothing. Although badly scalded, they were able to return to their vehicle and drive to the main road where they flagged down a Westcoast Petroleum truck. The driver of this truck initiated the call for the air ambulance. Both men arrived at the Fort St. John General Hospital, by separate helicopters. Evan was considered more severely injured and was prepared for immediate transport to the Burn Unit in Vancouver. The deceased was considered less severely burned; he was kept in the Fort St. John Hospital overnight before being transferred to the Burn Unit in Edmonton the next day. The deceased had suffered scald burns to approximately 40% of his body from the hot glycol. Glycol has the molecular structure of antifreeze. This means if the chemical contacts with the skin it is an irritant but is not harmful. If the chemical is ingested, it could be fatal. When the hot glycol sprayed the deceased, he received burns that were considered partial thickness in severity - the skin integrity had been broken allowing the glycol to become absorbed by the body. While at the University of Alberta Hospital in Edmonton, the deceased received skin grafts to the burned areas on November 20 and 27. By November 30, he had developed tracheo bronchitis and soon after he developed acute gastric bleeding along with renal failure. On December 5, the deceased went into cardiac arrest and could not be resuscitated. The cause of his death was determined to have been cardio-renal failure due to burns caused by hot ethylene glycol. COMMENTS ON RECOMMENDATIONS BY CORONER: Mr. P. Papenfus, Safety Officer for Petro Canada and Mr. W.B. Holland, Safety Officer for Workers' Compensation Board were able to check the reboiler unit soon after the incident. They noticed both the accumulator vent line and the still column vent line were froze shut while the bypass valve around the filter and pressure regulators was open. This caused the pressure in the reboiler unit to increase. As the unit is not designed for high pressure it blew out at a weak point. The outside temperature for the week prior to the accident was very cold, approximately -22 degrees Celsius. During this time, the column tracing lines were not open to prevent the freezing of the two vents. When Mr. William A. Jensen, an employee of Petro Canada Resources, arrived at the scene shortly after the incident, he went into the building to shut down the well. He noticed the bypass valve was open. In his experience, opening the bypass valve would have been a normal action to take prior to changing the filters of the vent. An indication of plugged filters would have been a cold and empty accumulator. By opening the bypass, the tower returns are allowed to get into the reboiler. The pressure in the tower is about 130-140 pounds. Having this pressure enter the reboiler would possibly have accounted for the explosion due to over pressuring of the reboiler. I find the deceased died as a consequence of the burns he received from a toxic substance being sprayed on him when the reboiler unit he was standing next to exploded. I classify this death as accidental. Petro Canada Resources Department held a Major Accident Review and Follow-up Analysis Meeting on December 1, 1989. This meeting made nine recommendations to prevent further accidents of this nature along with seven standard operating procedures to be followed when working with reboilers. Workers' Compensation Board has also made recommendations to prevent a reoccurrence of this type of accident. I can make no further recommendations.