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

Location: HES Kilgore

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

HESI300318
Incident 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