### TapRooT® Investigation Report

Incident: 523293

Strapping Losurf-300M vapor flash fire Date and Time of Incident: 5/5/2009 Date and Time Investigation Started: 5/7/2009 Incident Classification(s):  ̄ Injury-Illness  ̄ Restricted Duty HES Kilgore Location: Summary 2:00:00 PM 9:30:00 AM

Employee was strapping final level of Losurf-300M when a reaction occurred causing the employee to need medical attention Incident Description Employee had been strapping chemicals during the day. Incident occurred during second stage of the day. Employee had completed strapping BE-9 and when to obtain the final strapping for a tote of Losurf-300M that was about empty (hose still connected to tote). The employee was standing in an up right position and was wearing hard hat, safety glasses, face shield, long sleeve frc coveralls, radio and head set, and chemical apron. Employee was utilizing a plastic framed tape measure with a metal tape. A robber hose is placed over top of the tape in a fashion that the tape goes though the rubber hose. The employee placed the robber hose on the lip of the poly tote and lowered the tape down toward the remaining Losurf-300M. Just before or as the end of the tape came in contact with the surface of the Losurf-300M a flash fire occurred. Employee received burus to his face and was placed on restricted duty. It is believed that static charged was created on the metal tape as the hose ran through the rubber hose. When the static discharged the vapors in the tank (Ethanol) ignited. Causal Factor: rubber hose with metal tape inserted through hose
Root Cause:Human Performance Difficulty

Management System Standards, Policies, or Admin. Controls NI Technical error Corrective Action: l Implementation: Due Date: 5/18/2009 Date Complete: Responsible Dept.: PE Responsible Person:Mgmt, PSL Remove conductive strapping devices (tape measures) and replace with non conductive measuring stick (wood or fiberglass that specifically indicates that it is non conductive) Corrective Action: 2 Implementation: Due Date: Date Complete: Responsible Dept.: PE Responsible Person:Mgmt, PSL Long term corrective action to incorporate load cell technology for measuring chemicals Investigator/Team Travis Johnson Robert English Lem Tennison Jeff Keith Craig Robertson Casey Jones

Printed by the TapRooT® System Software on 5/13/2009 Page 1



### HESI300318Incident Type Injury/Illness - Lost Time
Incident Date Incident Facility
Incident PSL Customer- Location May 5, 2009 Kilgore
PE - Frac Petrohawk Sample #5-1
INCIDENT DESCRIPTION: Employee was strapping final level of Losurf-3OOM when a reaction occurred causing the employee to need medical attention
ROOT CAUSES:Human Performance DifficultyStandards, Policies, Admin Controls NI- Technical error Behaviors:

 ̄ Line of Fire

 ̄ Selection of Tool INVESTIGATION DETAILS: Employee had been strapping chemicals during the day, Incident occurred during second stage of the day, Employee had completed strapping BE-9 and when to obtain the final strapping for a tote of Losurf-300M that was about empty (hose still connected to tote), The employee was standing in an up right position and was wearing hard hat, safety glasses, face shield, long sleeve frc coveralls, radio and head set, and chemical apron. Employee was utilizing a plastic framed tape measure with a metal tape. A rubber hose is placed over top of the tape in a fashion that the tape goes though the rubber hose. The employee placed the rubber hose on the lip of the poly tote and lowered the tape down toward the remaining Losurf-300M. Just before or as the end of the tape came in contact with the surface of the Losurf-300M a flash fire occurred. Employee received burns to his face and was placed on restricted duty. It is believed that static charged was created on the metal tape as the hose ran through the rubber hose, When the static discharged the vapors in the tank (Ethanol) ignited,
NAMES OF INVESTIGATION TEAM:
Travis Johnson Lem Tennison Robert English Jeff Keith Craig Robertson Johnny Sanders
CORRECTIVE ACTIONS:

 ̄ Remove conductive strapping devices (tape measures) and replace with non conductive measure stick (wood or fiberglass)

 ̄ Long term corrective action to incorporate load cell technology for measuring chemicals



### HESI300319