SHEQ Alert!

No.20081219

February2009

ExplosionatMansarovar:HotWorkonHeaterTreater

Summary

Tanksanddrumsthatseemtobeemptyusuallystillhave
residuesinthebottom,inseamsandothercrevices.Justa
teaspoonofpetrolinadrumcanbeenoughtocausean
explosion,whenheatedandturnedintovapor.Thisiswhat
occurredonDecember19th,2008atMansarovarEnergy
ColombiaLtd.(MECL)inPuertoBoyac.
TwodaysbeforeHeatertreaterEHT106(seefigureno.1and
no.2)wasdrainedandvented(bysamplevalvesand3/4
valveontop)inordertoreplacethestudboltsandgasketsof
thefiretubeflange.Onthedayoftheeventworkactivities
changedfromcoldtohotworkwhenthedecisionwas
madetoremoveseveralstudboltswithacuttingtorch.An
explosionoccurredwhichkilledaMecnicosAsociadosS.A.
(MASA)employeeandsix(6)otheremployees,four(4)from
MASAandtwo(2)fromtheclientMansarovar,hadtobe
transportedbytraumahelicoptertothehospital.Theyall
suffered2ndand3rddegreeburnsfromtheexplosion.

MecnicosAsociadosS.A.issuesthisSafetyBulletintofocus
attentiononhotworkhazardsthatcontributedtothe
explosionatMansarovarEnergyColombiaLtd.(MECL)in
PuertoBoyacandspecificactionscontractorcantaketo
preventsimilaraccidents,whichinclude:
Preparingtanksanddrumsforhotwork;
ProperexecutionofPermitToWorksystem;
Managethechangeofscope.

Figure1.HeatertreateratMansarovarEnergyColombiaLtd.

Figure2.RupturedpartitionofHeatertreaterEHT106

HeatertreaterEHT106

Justateaspoonofpetrolinadrum
canbeenoughtocauseanexplosion,
whenheatedandturnedintovapor.

TheelectrostaticHeatertreaterisahorizontalunit
andthefunctionofthistreateristo:
InletDegassing
FreeWaterremoval
Heating
Electrostaticcoalescingofwaterdroplets
ControlleddischargeofGas/Oil/andWater

Theheatingsectionofthetreatercomprisesofa
UTypefiretubewhichisavailablewithagasor
oilfiredburnersystemandassociatedlocalcontrol
panel.

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SafetyAlertNo.20081219|February2009

IncidentDescription

The15thofDecember,2008MASA
triedtostoptheflangefromleakingby
tighteningthestudboltsbyhandagain
andtheuseofsilicon.Despitethe
effortsmadebyMASApersonnel,the
leakingdidntstop.

th

The16 ofDecember,2008MASA
reportedverballytoMECLfield
managerthattheHeatertreaterwas
stillleakingandtherearenotableto
handtightenthestudbolts.
ThesamedayMECLcontracted
companyLAPSwhichisspecializedin
jointorqueconnections.

The17thofDecember,2008LAPS
diagnosedandadvisedtochangethe
studboltsandgasket.Thesameday
MECLpersonneldrainedtheHeater
treaterandopenedtheventilation
hatch(samplevalvesandthe3/4
valveontop).LAPSverifiedthestud
boltsfromthefiretubeflangewith
1.400poundoftorque.Noneofthe
boltscameloose.

Between11:30AMand01:00PMGMT
05:00aMASArepresentative
requestsworkpermitsbyfollowing
theproceduresofMECLandMECL
productionsupervisoraskedwelder
andhelpertoreturntotheworksite.
DuethechangeofworkMASA
workershadtopostponetheirlunch.

Between11:30AMand01:00PMGMT
05:00concernedwelderandhelper
arriveattheworksite.TheMECL
MajorMaintenanceEngineercalls
MECLProductionSupervisor.

Between11:30AMand01:00PMGMT
05:00MECLProductionSupervisor
andMECLProductionLeaderarrived
atthejobsiteforgastesting.
TheMECLProductionSupervisor
makesthemeasurementofthe
atmospheretodetectpresenceof
flammablegasses.
TheMECLProductionSupervisor
showsthereadingofthegastesterto
MECLProductionLeaderand
authorizedtheworkpermitfollowing
theproceduresofMECL.

MECLProductionSupervisorleftthe
jobsitetogiveinstructionstoanother
contractorandMECLProduction
Leaderwentbacktotheoffice
container.

The19thofDecember,2008;01:00PM
GMT05:00concernedwelderentered
thescaffoldandstartedtocutthestud
bolts.Finishedcuttingthefirststud
boltanexplosionfollowedand
expelledthe13TONfiretube.
Thewelderwaskilledduringtheact
whencrushedbetweenthefiretube
andthecrane30feetaway(seefigure
no.3).
Hishelper,standingunderneaththe
scaffoldsufferedburnsinhisfaceand
onhishands.
Three(3)otheremployeesfromMASA
andtwo(2)employeesfromMECL
suffered2ndand3rddegreeburns.All
ofthemweretransportedtotheburn
centerinBogotabytraumahelicopter.
AnemployeefromMASApassedaway
fivedayslaterinthehospitaldueto
hisinjuries.

The18thofDecember,2008LAPS
verifiedthestudboltsagainwitha
maximumof3.200poundoftorque.
Theyremovedseveralstudbolts
wherebyeight(8)studboltsdidnt
camelooseoffiretubeno.1andten
(10)didntcamelooseoffiretubeno.
2.

The19thofDecember,2008;10:30AM
GMT05:00MASAusedhandtools
(impactwrench,extensionbarand20
hammer)toremovethestudbolts
withthefollowingresult:
Firetubeno.1:Three(3)studbolts
couldntbeloosedbyhand.
Firetubeno.2:Six(6)studbolts
couldntbeloosedbyhand.MASA
welderandhelperlefttheworksite
forlunch.

Between11:30AMand01:00PMGMT
05:00MECLsupervisordecidesthat
thestudboltswillbecutwithatorch
andcallstheconcernedwelderand
helper.

Figure3.HeatertreaterEHT106withexpelledfiretubeafterexplosion.

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SafetyAlertNo.20081219|February2009

IncidentAnalysis

MecnicosAsociadosS.A.(MASA)
usedphysicalevidence,interviewsand
informationfromMansarovarEnergy
ColombiaLtd.(MECL)toestablishthe
likelyfailuresequence:

Noformalhandoverbetween
production(MECL)and
maintenance(MASA);

ScopechangemadebyMECLnot
communicatedtoconcerned
responsible(s)inMASA;

Noworkpermitsforhotwork(only
coldwork).Lastminutedecisionin
thefield;

Noworkpermittrainingexecuted;

Gastestinginsufficient.Only
externaltestandMECLemployee
nottrained;

Hotworkisanyprocessthatgenerates
flames,sparksorheat.Itincludes
welding,cutting,grindingandsawing.

Thepreparationofthetankordrum
shouldbeconsideredaspartofthe
riskassessmentandcontrolmeasures
shouldbeidentified.

Isolation

Tanksshouldbeisolatedfromother
equipment,preferablybyremoving
pipesections.Ifpossible,disconnect
smalltanksandremovethemtoasafe
place.Donotrelyonisolationvalves;
evensmallleakscanhaveserious
consequences.

Emptying

Heatertreaterwasonlydrained;

Procedures(e.g.PermitToWork
system)availableandutilized,but
notexecuted.

Thetankordrumshouldbeemptied
bypumpingordrainingtheliquidinto
asuitablecontainer.Theresidues
shouldbedisposedofinlinewith
environmentalrequirementsandnot
tippedintodrains,sewersorwater
courses.

TimepressuretogetHeatertreater
inoperationagain;

Noproperhazardassessment,
includingintheassessment,people
trainedinthehazardassessment
processandtechnicalcompetentin
theworktobedoneandits
associatedrisks.

Inthisdocumentthree(3)important
activitieswillbehighlightedwhich
contributedtotheaccidentat
Mansarovar:
Preparingtanksanddrumsforhot
work;
PermitToWorksystem;
ManageofChange.

Hotworkisanyprocess
thatgeneratesflames,
sparksorheat.Itincludes
welding,cutting,grinding
andsawing.

PreparingTanksand
DrumsforHotWork

Cleaning

Inmostcases,cleaningwillbe
necessaryandincludethemethods:
Washingorjettingusingwateror
detergentsolutions;
Steamcleaning;and
Solventwashing/jetting.

Controlmeasureswillbeneededto
ensurethatthecleaningoperations
arecarriedoutsafely.

Gasfreeing

Vaporsandothervolatilematerialcan
sometimesberemovedbyblowingair
orsteamthroughthetank.Thisis
termedgasfreeing.Thevapor
concentrationshouldbemonitored
usingagasdetector.Gasfreeing,on
itsown,israrelyadequate,asmost
tanksanddrumswillstillcontainliquid
orsolidresiduestrappedinseamsand
Page3of5

Figure4.HeatertreaterEHT106

crevices.Agasdetectormaynot
detecttheseresiduesbuttheymay
stillbecapableofproducing
flammablevaporswhenheatedby
hotworkoperations.

Inspection

Inspectingtheinsideofatankordrum
thathaslimitedopeningsisdifficult.
Mirrorsandtorchescanbeused,but
anylightusedinsidethetankmustbe
flameproof,e.g.designedforusein
flammableatmospheres.Never
assumethatatankisfreeof
flammablevaporsorliquid;always
inspectitcarefully.

Agasdetectororexplosionmetercan
beusedtocheckforvapor,butit
needscareandtrainingtobeused
safely.Itwillnotdetectsolidmaterial
ornonvolatileliquids.

Inerting

Anotherwaytoreducetheriskofan
explosionistoreplacetheairinthe
tankordrumbyfillingitwithwateror
aninertgas,suchasnitrogen.Thiscan
beusefulwherecleaningisdifficult,
althoughthetankshouldalwaysbe
cleanedasmuchaspossible
beforehand.

Ifwaterisused,aventforthesteam
willbenecessary.Contaminatedwater
mayrequirespecialistwastedisposal.

Ifaninertgasisused,itcanbedifficult
topreventthegasescapingandair
gettingbackin.Therefore,anoxygen
meterwillbeneededtomonitorthe
oxygenlevels.Thismethodshouldbe
lefttospecialists.
SafetyAlertNo.20081219|February2009

Apermittoworksystem:

PermitToWork
System

a. Ensuresappropriatepeopleare
authorisedtocarryout
designatedwork.Thisdesignated
workmaybeaspecifictypeof
work,oranytypeofworkina
specificarea;

APermitToWorksystemisaformal
writtensystemusedtocontrolcertain
typesofworkwhichareidentifiedas
potentiallyhazardous.Itisalsoa
meansofcommunicationbetween
site/installationmanagement,plant
supervisorsandoperatorsandthose
whocarryoutthework.

Apermittoworkisadocumentwhich
specifiestheworktobedoneandthe
precautionstobetaken.Permitsto
workformanessentialpartofsafe
systemsofworkformany
maintenanceactivities.Theyallow
worktostartonlyaftersafe
procedureshavebeendefinedand
theyprovideaclearrecordthatall
foreseeablehazardshavebeen
considered.

Apermitisneededwhenmaintenance
workcanonlybecarriedoutifnormal
safeguardsaredroppedorwhennew
hazardsareintroducedbythework.
Examplesareentryintovessels,hot
workandpipelinebreaking.

Thepermittoworkformmusthelp
communicationbetweeneveryone
involved.Itshouldbedesignedbythe
companyissuingthepermit,taking
intoaccountindividualsiteconditions
andrequirements.
Separatepermitformsmaybe
requiredfordifferenttasks,suchas
hotworkandentryintoconfined
spaces,sothatsufficientemphasiscan
begiventotheparticularhazards
presentandprecautionsrequired.

b. Makesitcleartopeoplecarrying
outtheworktheexactidentity,
natureandextentofthejoband
thehazardsinvolved.Italso
outlinesanylimitationsonthe
extentoftheworkandthetime
duringwhichthejobmaybe
carriedout;

c. Specifiestheprecautionswhich
needtobetaken,includingsafe
isolationfrompotentialriskssuch
aselectricityandhazardous
substances;

d. Ensuresthepersonindirect
chargeoftheplantorinchargeof
theareawheretheplantis
located,isawareofallthework
beingdoneunderthepermitto
worksystem;

e. Providesasystemofcontinuous
control;

f. Providesarecordshowingthe
natureoftheworkandthe
precautionsneededwhichis
checkedbyacompetentperson
orpeople;

g. Providesforthesuitabledisplay
ofpermits;

h. Providesaprocedurefortimes
whenworkhastobesuspended;

i. Providesforcrossreferencingof
permitsforworkactivitiesthat
mayinteractoraffectone
another;

j. Providesaformalhandover
procedureforusewhenthe
permitisissuedforaperiod
longerthanoneshift;and

Figure5.StudboltsflangeofHeatertreater

k. Providesaformalhandback
proceduretoensurethatpartof
theplantaffectedbytheworkis
inasafeconditionandreadyfor
reinstatement.
Page4of5

Thepermittoworkform
musthelpcommunication
betweeneveryone
involved.

Managementof
Change

TheU.S.ChemicalSafetyandHazard
InvestigationBoard(CSB)issueda
SafetyBulletinitofocusattentionon
theneedforsystematicallymanaging
thesafetyeffectsofprocesschanges
inthechemicalindustry.
Thebulletindiscussestwoincidents
thatoccurredintheUnitedStatesin
1998.Eachcasehistoryoffersvaluable
insightsintotheimportanceofhaving
asystematicmethodforthe
managementofchange(MOC).An
MOCmethodologyshouldbeapplied
tooperationaldeviationsand
variances,aswellastopreplanned
changessuchasthoseinvolving
technology,processes,and
equipment.

LessonsLearned

Safetyissues/warningsrecognized
bySISamanagementteam,butno
promptaction.

Collaborationbetweenexecution
andHSEtobeenforcedby
managementteam.

Neverchangefromcoldtohot
workwithoutproperriskanalysis
andpermit.

Dontrelyonexperience.Respect
safetyawarenessandbarriers.

Valueculturalimpactondecision
making.

ClientHazardAnalysispriorto
bid/nobiddecision.

Managesafetyinthefieldinstead
ofkeyperformanceindicators
(KPIs).
SafetyAlertNo.20081219|February2009

Recommendations

MansarovarEnergyColombiaLtd.

Assuresafeworkprogramsandbarriersare
inplaceandemployeesaretrained.For
example:PermitToWorktraining,Job
SafetyAnalysis,LockOutTagOut,etc.

OVLinaconsortiumwithSINOPEC(TheNationalOilCompanyofChina)
hasacquiredOmimexdeColombiaon20thSeptember,2006.The
acquiredcompanyhasbeensubsequentlymergedintoMansarovar
EnergyColombiaLimited(MECL),a50:50JointVenturebetweenOVL
andSINOPEC.Earlier,OmimexdeColombiawasasubsidiaryofOmimex
Resources,Inc.whichisaprivatelyheldcompanybasedinFortWorth,
Texas,U.S.A.

Establishgatekeeper(forthiscontract)
onsitetoassureallsafetybarriersarein
place.Makeroledescriptionclearby
positionandauthorizationstowardsclient
andmaintenanceorganization.

Establishformalhandoverofequipment
betweenoperations(MECL)and
maintenance(MASA).Reviewhandover
proceduresandactivitieslike:Preparing
TanksandDrumsforHotWorkprocedure.

Assureemploymentconditionsdontaffect
safeworkpractice.Discusscontractand
laboragreementsandfollowupwith
representativesofCOPASOorotherworkers
committees.

MansarovarEnergyColombiaLimitedholds100%interestinthe
VelsquezfeemineralpropertylocatedintheMiddleMagdalenaBasin
andalsoholds100%interestintheVelsquezGalnPipeline,whichruns
189kmfromtheVelsquezpropertytoEcopetrolsBarrancabermeja
refinery.Inaddition,Mansarovaralsoholdsa50%interestinthenearby
NareandCocornAssociationContracts,surfacerights,drillingand
otheroilfieldequipmentforaselfsustainedoperation.Theother50%
interestinNareandCocornAssociationContractsareheldby
Ecopetrol,theNationalOilCompanyofColombiaMansarovaristhe
operatorofthefieldsandthepipelinewithinitscontract.Mansarovar
currentlyproducesapproximately21,500bblperday.

Conductaudittoallcontractsexecutedby
MASA.ReviewSHEQatrisksituations
identifiedandrelatedtotheMansarovar
accidentandidentifiedinthissafetyalert.

IncludeSHEQinTenderprocedureas
decisionmakingitemtoassurerisksare
identified,reviewedanddiscussedbefore
BID/NOBIDdecision.

Assureswiftreportandresponseofsafety
issuestoMTandviceversa.Theproposalis
todiscussrecordableincidentswith
concernedManagementTeamofthe
OperatingCompanyandSISaMT
representativeswithin24hours.

ExecuteManagementsafetywalkstoassure
executivepersonalcanfeedbacksafety
issuesand/orconcernsdirectlytotop
management.Makesuremanagement
supportsrefusetoworkdecisionsmadeby
executivepersonalinthefield.

Reference
i

U.S.ChemicalSafetyandHazardInvestigationBoardManagementofChange;No.200104SB|August2001
http://www.csb.gov/safety_publications/docs/moc082801.pdf

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SafetyAlertNo.20081219|February2009