Health and Safety Executive

Health and Safety Executive Confined Spaces.

Presentation to IOSH Liverpool 2017Gerry McCulloch

HM Inspector of Health and Safety

A Regulator’s Case Studies,

My Role

• I am a Regulatory Inspector with 17 years experience in HSE• I joined the Chemical Industries Directorate six years ago.• I have learned about confined spaces entry (and permit to

work systems) on the job, with a couple of courses for good measure.

• This will be no different from many of you or the people you employ to work on and manage confined space entry.–My Knowledge is limited, so is yours and as is theirs.

• I teach HSE Inspectors about confined space entry; permit to work systems and the legislation which applies. I use case studies to teach one important lesson.—Don’t presume you know it all.

RELEVANT HSE LEGISLATION

• Provision and Use of Work Equipment Regulations 1998

• Control Of Major Accident Hazard Regulations 2015

• Dangerous Substances and Explosive Atmosphere Regulations 2002

• Health and Safety At Work etc. Act 1974 Sections 2 and 3

• The Management of Health and Safety at Work Regulations 1999

• Control of Substances Hazardous to Health 2002 (COSHH)

• Confined Spaces Regulations 1997

Why Go In

Safe To Enter

For high risk activities Permits to Work are expected

Instructions or procedures are adequate for most work activities, but some require extra care. A ‘permit to work’ is a more formal system stating exactly what work is to be done, where, and when.

HSE Energy Division -Inspection Guide Offshore

Inspection of Control of Work arrangements

A permit-to-work is not simply permission to carry out a dangerous job. It is an essential part of a system which determines how that job can be carried out safely, and helps communicate this to those doing the job

HSG250 Guidance on permit-to-work systemshttp://www.hse.gov.uk/pubns/priced/hsg250.pdf

Accepted Code of Practice to regulations (ACOP)

Dangerous Substances and Explosive Atmosphere Regulations (DSEAR) ACOP regulation 6(8) and Schedule 1:

• Para 321. Where the proposed work is identified as a high-risk activity, employers should ensure that strict controls are in place ….This should include implementing a permit-to-work system

Confined Spaces Regulations

ACOP regulation 4

• Para 138. A permit-to-work system is a formal written system and is usually required where there is a reasonably foreseeable risk of serious injury in entering or working in the confined space. The permit-to-work procedure is an extension of the safe system to work, not a replacement for it.

Tank scheduled for cleaning as

build up of waste was suspected.

Case StudyBiodiesel Plant--process flow reduced

Pre-esterification

buffer tank

Manway door

Original plan was

to clean out tank

and put it back into

service within 4

days.

Job given to site

logistics team as

maintenance team

were busy during

shutdown.

1st mistake !

logistics team don’t

understand plant

Planning—Is it a Confined Space with a specified risk?

YES ?NO ?

Behind manway

door…

Mound of “Burnt Oil”

was waist deep.

Attempts to vacuum it

out using a road tanker

failed.

Decision to go in and

shovel it out.---That’s

when it really fell

apart!

Confined Spaces Regulations 1997. Regulation 1 “specified risk” means a risk of—

(a) serious injury to any person at work arising from a fire or explosion;(b) without prejudice to paragraph (a)—

(i) the loss of consciousness of any person at work arising from an increase in body temperature;(ii) the loss of consciousness or asphyxiation of any person at work arising from gas, fume, vapour or the lack of oxygen;

(c) the drowning of any person at work arising from an increase in the level of a liquid; or(d) the asphyxiation of any person at work arising from a free flowing solid or the inability to reach a respirable environment due to entrapment by a free flowing solid;

Client Duty:Before considering entering a Tank.

Do they know and thoroughly understand the substances that are in their storage tanks?

Ask--Do you know for certain:

• The substances that might be present.

• The substances that can be formed when residues interact with air (O2) or cleaning agents.

• What happens when residues are disturbed through agitation, shoveling or heating

• Will the cleaning or preparation process introduce new hazards, e.g. solvents.

The Management of Health and Safety at WorkRegulations 1999, Regulation 3. [ACOP to Confined Spaces]

• Dutyholder must assess the risks connected with entering or working in a confined space.

• The risk assessment must be carried out by someone competent to do so. –This is not the logistics team who don’t understand the plant!

• Failure to include relevant information in the risk assessment could lead to inadequate precautions in the subsequent system of work.- This is what happened here.

The Permits To Work

Permit System was “borrowed” from another company.Permit issuer had been shown how to fill out form—this was ½ Hour Training.

The permits describe the tank as: • Isolated from all sources of ingress of dangerous fumes etc• Freed of all dangerous materials• The permit stated that contaminants have been tested and that

a gas monitor was used and that the results were “OK”. *• Permits were issued retrospectively after job started.

*Micro XT Detector used

Correction fluid

does not convert a

permit to work

system from one

company to

another!

Get the COSHH assessment right

When entering vessels/tanks, if the contents/atmosphere are below the Workplace Exposure Levels (WEL) listed in EH40* for COSHH then persons will also be safe from fire or explosion risk -- Providing that the COSHH controls are maintained and exposure is kept below WEL.

Testing is required, presumption is not an option.

*http://www.hse.gov.uk/pubns/books/eh40.htm “Burnt Fat—like in bottom of chip pan”.

Also contained Sulphuric Acid & Methanol.

Operators not told of this.

Methanol Lower Explosive Limit (LEL)

• Micro XT detector set to alarm at 20% of the LEL

• LEL for Methanol is 6% in air or 60,000ppm,

• Therefore micro XT alarms at 12,000ppm.

No alarm activation prior to or during tank cleaning.

• This led to the statement that, “contaminants have been tested and that a gas monitor was used and that the results were “OK”.”

MethanolWorkplace Exposure Limit (WEL)

• WEL is 200ppm over 8Hr Time Weighted Average

• Short term exposure limit (STEL) -250ppm over 15 minutes TWA.

• The health risks from exposure to methanol are present at significantly lower concentrations in air than those required to create a flammable atmosphere.

• This information was not provided to those exposed to methanol in this storage tank.

Flammability Vs Toxicity

http://www.hse.gov.uk/pubns/gasdetector.pdfFlammable Gas Detectors are NOT suitable to measure

concentrations for COSHH.

MethanolLower Explosive Limit (LEL) = 60,000ppmDetector alarms at 20% of LEL = 12,000ppm

Toxic by inhalation, oral or dermal exposure.Short Term Exposure Limit (STEL)= 250ppm

Get COSHH right & Flammability will not trouble you

Typical volatile constituents of crude oilPentane:- Lower Explosive Limit=14,000ppm,

COSHH TWA Exposure Limit=600ppm

Hexane; LEL=12,000ppm, COSHH Exposure Limit= 100ppm

n-Hexane; LEL=12,000ppm, COSHH Exposure Limit= 20ppm

Heptane; LEL=11,000ppm, COSHH Exposure Limit= 500ppm

Pre-cleaning, flushing and forced ventilation should be used to reduce concentrations to ALARP and below Workplace Exposure Limit.

Consequently…..

Operatives placed faith in unsuitable gas detectors. They were not trained in their use so after a quick check in the tank they left it outside on bund wall. (Sulphuric acid would likely poison sensor head anyway).

Plant Manager knew slurry had methanol and sulphuric acid in it but no one asked him and no one told employees in tank. (Draeger test kit for methanol available on site but not used).

Logistics team was given cleaning job instead of Plant Maintenance Team who were busy on shutdown. Didn’t use chemical suits or Air -fed respirators --these were maintenance teams PPE items.

Workers suffered acid burns and methanol toxicity.

Call To HSE from NHS Consultant in Public Health.

Two workers in NHS intensive care unit suffering methanol toxicity and acidosis of their blood from their exposure to methanol at the same workplace.

“Is this something HSE would look at”?

Yes it is!

Early site visit with HSL to obtain samples. ( 30+ tonnes to choose from )

Simple on-site test for acid. Laboratory later confirmed Methanol.Persuasive for a jury that it was reasonably practicable to check.

Company Pled Guilty

This Biodiesel incident is not a new thing!

What has happened before will happen again. What has been done before will be done again. There is nothing new in the whole world. Ecclesiastes 1: 9

Organisations have no memory; only people have memories and they move on. T Kletz, Lessons from Disaster 1993 p4

Safety Management Systems.Risk Assessment and Control Measures.

Carried out by Competent Persons

It is not possible to know all the hazards off the top of your head. If you enter confined spaces without sampling the atmosphere correctly or testing what is, or can be there, you will get it wrong at some point and the consequences can be fatal.

Testing for Hazardous Substances

https://www.youtube.com/watch?v=pmNWLYgMyz4

Dräger video for confined space entry gas testing

• Thorough understanding of what can be in the tank.

• Process Hazard Review/HAZOP/Risk Assessment.

• Test strategy may need to be bespoke for likely substances.

Case Studies—the important lesson they teach

Numerous Past Incidents from Diverse Hazards

Common failures--not checking for uncommon hazards. (uncommon but not unforeseeable)

So how do you check for uncommon hazards?

Case Study, Relining water separator fiberglass Tank. From safe to dangerous

Job involved grinding/wire brushing old inner surface to key in a new fiberglass coating.

Permanent site contractor issued with a vessel entry permit which covered 5 days.

Half way through job the contractor went to the stores and obtained a bucket of Acetone to wash down the tank walls prior to applying new coating.

Accident Cause—Plan, Do, Check, Act

• Unprotected lamp in a confined space

• Open painter’s bucket full of acetone

• Drips fell on lamp, broke glass, acetone ignited

• Flash fire

• IP wearing paper overalls

• No ventilation connected to tank

Root Cause—No safety conversation and permits being used as job lines

Expert Summary for Court Case

The company in control of the site—“…had the clear responsibility to initiate the permit to work procedure, which should have provided all those concerned, with clear unambiguous information and instructions. This was possible only by close collaboration and dialogue with the contractor in terms of the nature of the job to be done, where it was to be take place and what materials and methods would be used. Only through such an exchange can the permit to work be an effective means of providing a safe system of work.”

Carsington Reservoir site in Derbyshire 1983

An underground chamber, 3 metres deep, used for the determination of ground water flow, requires inspection. Access is via a manhole 0.6 metres in diameter. The chamber is situated adjacent to a pumping station near the base of the reservoir.

A high concentration of carbon dioxide from the surrounding limestone had depleted the oxygen concentration.

The contractor had not been made fully aware of the dangers presented. A work permit system would have demanded safety equipment and continuous oxygen level monitoring.

four men died

Most deaths in confined

spaces are of would be

rescuers.

Checking for Unforeseen Hazards?Hot work – MV Spyros ship repair

The Greek tanker, Spyros, exploded at Singapore on October 12, 1978. It killed 76 people.

Sparks from the cutting torch used during repairs, caused a fire which ignited an explosive vapour mixture within the aft starboard bunker tank of the vessel.The fuel tank had been contaminated by crude oil.

The crude oil had been syphoned off by the ship from the cargo tanks to the ship’s bunker tank by using an adapter or spool pipe. When the ship was under way, this adapter was fitted at the deck manifold from the bunker inlet to the cargo discharge and so the ship got a “free” top up. However, this spiked the ship’s bunkers with a low flash element and so any hot work in an area considered more safe was in fact not so.

Test the space do not presume you know what is inside.

MV Diamond---Hot work during ship repair in Liverpool

• She was discharging in September at Liverpool a cargo of about 63,00 te of coal • During discharge, crane grab anti-spin devices kept snagging on the hatch cleats, steel

bars to stop snagging were welded to the hatch sides. No gas tests were made.• “Bad gas” or “paint type” smells were reported by contractors but dismissed as “fluro-

carbons” by the crew who said a 3 day old burning permit was in force.• As the coal was removed ballast water was added, this pushed out remnants of a

previous flammable liquid cargo from within hold of ship. • When the cargo of coal was emptied two men were dispatched to burn off the steel

bars previously fitted to stop snagging .• There were 2 consecutive explosions. One man was found below the inverted

starboard hatch cover the other was found in the bottom of hold 5

Continue to monitor the space for changes to conditions.

Confined Space, Initial Enforcement Expectations.

1. On a site where confined space (CS) entry may take place and there are specified risks with no risk assessment then HSE may consider serving an Improvement Notice (IN)

2. If duty holder undertakes CS tasks that do not actually require a CS entry then Prohibition Notice (PN).

3. Who is the competent person – are they suitably experienced to undertake a confined space risk assessment? ----NO: IN

4. Does the risk assessment or safe system of work deal with medical emergencies NO: IN (as assessment is not suitable and sufficient)

5. Have the personal capabilities of individuals entering the CS been assessed:? NO: IN6. Is there an adequate emergency plan for the work?----NO: IN and if CS work on site

happening and no adequate emergency plan then PN7. Has the risk assessment / safe system of work been discussed with the work team and

provided to those entering? If not and work going on then PN

Confined Space (CS) Enforcement Expectations Continued.

7. Is a person (inc supervisor) nominated to be in control. Does that person understand the responsibilities for the team?----NO: IN, and if work happening then PN

8. Is the role and need for a standby / topman specified in the risk assessment?---NO: IN.9. If CS work going on without standby man then PN10. Client or contactor cannot demonstrate training: IN11. Is there a dedicated communication method for raising an alarm in case of emergency

inside / outside the confined space? NO: IN, and if work taking place then PN13. Does the emergency plan rely solely on the emergency services? Yes: IN, if work happening

then PN14. Are appropriate detectors used where there is a risk of oxygen depletion and/or toxic gas

generation? if no and work happening then PN15. Are detectors and PPE (where appropriate) calibrated and tested? NO: IN, and if work

taking place then PN

Auditing Permits to Work-- HSG 250

Permits are expected for confined space entry, you should audit the permit alongside the CS job.

Using Appendix 3 Checklist for the assessment of permit-to-work systems on your site inspection can pick apart any permit to work system that is not working as it should.

Checking your records of Appendix 4 Permit-to-work monitoring checklist will tell a visiting HSE Inspector if you are bothered!

http://www.hse.gov.uk/pubns/priced/hsg250.pdf

HSG 250.

Wise words

“...A concern for safety which is sincerely held and repeatedly expressed but, nevertheless is not carried through into action, is as much protection from danger as no concern at all.”

Anthony Hidden QC Clapham Junction Inquiry

Confined Space Videos on Youtube & CSB Case studies of recent and current incidents

• https://youtu.be/BoRcThZp4fc welding leading to crude oil boil-over

• https://youtu.be/DECyAxDk88U Domino following lightning strike.

• https://youtu.be/HA6yh0TB5ag Worksafe BC Videos-Good Collection

• https://youtu.be/J6rvv3oJ3qg CSB analysis of incident with cheapest contractor

• https://www.youtube.com/watch?v=pmNWLYgMyz4 Dräger Confined Space Entry

• http://www.csb.gov/investigations/completed-investigations/?Type=2

• https://youtu.be/zWkcuR0adeI?t=158 CSB Dangers of Hot Work

Any Questions