Current Status : Ongoing
Industry : Oil & Gas
Claim Amount : RM 2xx,xxx.xx
Description of the Incident
What Happened
Explosion at NGV Compressor BayConsequences
Fatality to Technician, Damage to NGV Compressor Bay and other facilites, Stoppage of businessoperation on NGV, DOSH issued 'Notice of Prohibition' (NOP) to 67 nos. NGV Filling Station,
Incident was reported in National News and social media and , with the potential for Multiple fatality
to other workers around the area.
Detailed Description of the Incident
A day before the incident, on 24th October 2016 at about 8.00pm, the Technician (deceased)been called by the NGV Filling Station dealer to rectify gas leak at the compressor enclosure. The Technician responded to the request and arrived at about 10.00pm that night and managed to shut-off (closed) the valve and promised to return the following day as he needs to get spares. The NGV Filling Station was then barricaded using cones to prevent vehicle entry.
On 25th October, the technician return to the NGV Filling Station with his colleague. During breakfast at about 9.00am, the Technician (deceased) received another maintenance work request from Pasir Gudang Station and instructed his colleague to attend to problem at Pasir Gudang station while he attempted to rectify the leak problem by himself. The Technician (deceased) was working alone throughout the day and can be seen going in and out the vicinity through the CCTV recording.
Prior to the incident, at about 2.30pm, the Technician (deceased) called his colleague in Pasir Gudang to return immediately to NGV Filling Station to assist him. He also called his immediate through his handphone supervisor for assistance but the conversation stops there. The supervisor admitted that during the telephone conversation, he could hear a loud hissing sound and hang-up immediately suspecting that something could have happened.
The explosion occurred at about 2.45pm as a result of uncontrolled internal pressure build-up at the recovery Vessel of 3-Stage compressor causing it to rupture releasing blast wave and vapour cloud. The impact of metal contact and presence of explosive gas (methane) had caused the nearby facilities to caught fire and badly burned the working technician.
The Fire and Rescue team arrived soon after and managed to extinguish (put-off) the gas fire and retrieved the Technician (deceased) body to a safer place and brought to the nearby hospital for post-mortem.
This incident led to damage to business performance, damage to property or equipment, damage to reputation, environmental damage and fatality or serious injury. This incident is reportable under relevant legislation.
Discussion of Findings
Site visit and interview with witnesses revealed the following :1) PTW / JSA were not applied/issued and Tool box meeting were not implemented at site because
plant owner representatives has the understanding that the PTW, JSA were only applicable for
planned / preventive maintenance but not corrective maintenance.
2) The plant / contract owner puts heavy reliance on the expertise of the Specialist contractor to
managed the Full Service Maintenance (FSM) contract on all maintenance work at site.
3) Apparently, safe work practice at site were not priority. From training record, emphasis was given for all site workers to attend the PTW training organised by plant owner but did not emphasis / enforce implementation of Permit To Work (PTW), Job Safety Analysis (JSA), Risk Assessment (RA), implementation of Stop Work and enforcement of prohibited item and wearing of PPE, etc.
4) The working technician received instruction from his immediate superior to remove the PRV and
install plug at PRV nozzle. Obviously, he is not aware of the impact as his competency / skill is in
Electrical not mechanical. The technician (deceased) is not a competent mechanical technician as
he has never attended trainign to undertake mechanical works on critical equipment.
5) The uncontrolled pressure build-up at the Recovery Vessel due to the pressure relief valve (PRV)
which had been removed and plugged had caused the Recovery Vessel to rupture thus releasing
blast wave and vapour cloud. The impact of metal contact caused gas fire to nearby facility (storage
cascade).
6) Upon inspection, the Certificate of Fitness (CF) of the Recovery Vessel had expired and not
reviewed due to the high demand / sales of NGV gas to public.
7) There seems to be many internal arrangement in assigning workers between main-contractor and
sub-contractor in executing the work. This practise has been going-on for some time and therefore
felt there is no requirement to seek approval from plant owner.
8) Supervisor confirmed communicating with the technician (deceased) to receive instruction through
his mobile phone and admitted hearing loud hissing sound at the end of the conversation suspecting
something had happened at site. Please note that the use of mobile at site has been a practised
since the site workers are not given a walkie-talkie and that the communication has taken place
Conclusion
Based from the analysis, site visits and feedback from interview with witnesses, it can be concluded that the rupture of Recovery Vessel is due to uncontrolled pressure build-up inside the Recovery Vessel caused by negligence of Plant Owner who failed to take reasonable care to avoid causing foreseeable harm to another and which failure caused the harm. Full particulars whereof are as follows:-a) Plant Owner has failed to revalidate / renew the Certificate of Fitness (CF) for the 3-Stage Air
Compressor Recovery Vessel which is non-compliance to the Factory Machinery Act 1967 (Act 139), Part II, Section 19;
b) Plant Owner has failed to comply to the Occupational Safety and Health Act and Regulation Act 514 – Part V, Section 20 – to ensure, so far as practicable, that the plant is so designed and constructed as to be safe and without risks to health when properly used;
c) Plant Owner has failed to appoint / assign Site Safety Supervisor who shall be responsible to promote safe conduct of work within the worksite, inspecting and rectifying any unsafe place of work, correcting any unsafe practise, etc. as stated in the Factory Machinery (Building Operations and Works of Engineering Construction Regulation 1986 Part II - Act 1967 (Act 139), Part II, Section 25;
d) Plant Owner has failed to enforce mandatory usage of Protective Apparel (PPE) which is noncompliance to the Factory Machinery (Building Operations and Works of Engineering Construction Regulation 1986 Part II - Act 1967 (Act 139), Part II, Section 19;
e) Plant Owner has failed to enforce mandatory usage of Safety Helmet which is non-compliance to
the Factory Machinery (Building Operations and Works of Engineering Construction Regulation
1986 Part II - Act 1967 (Act 139), Part II, Section 24;
f) Plant Owner has failed to ensure their representative were available at site to issue Permit to Work (PTW), review Job Safety Analysis (JSA), enforce mandatory usage of PPE and that the deceased has been fully trained and adequately supervised and control usage of prohibited item;
g) Plant Owner and the contractor has failed to ensure that the deceased has been fully trained and
adequately supervised which is non-compliance to the Factory Machinery Act 1967 (Act 139), Part III, Section 26.
h) Plant Owner and the contractor has failed to ensure the functionability of Gas Detection and
Alarm System and Emergency Shutdown Device (ESD) so as to prevent the explosion from happenings.
