Accident: Aghorn Operating Waterflood Station Hydrogen Sulfide Release
Location: Location: Odessa, TX
Accident Occurred On: 10/26/2019 | Final Report Released On: 05/21/2021
Accident Type: Release
Investigation Status: The report was released on May 21, 2021.
A release of hydrogen sulfide led to the death of one worker as well as a member of the public.
For all waterflood stations where the potential exists to expose workers or non-employees to H2S concentrations at or above 10 ppm, mandate the use of personal H2S detection devices as an integral part of every employee or visitor personal protective equipment (PPE) kit prior to entering the vicinity of the facility. Ensure detector use is in accordance with manufacturer specifications.
For all Aghorn facilities, develop a site-specific, formalized and comprehensive Lockout / Tagout program, to include policies, procedures, and training, to protect workers from energized equipment hazards, such as exposure to H2S. Ensure the program meets the requirements outlined in 29 CFR 1910.147 and includes energy control procedures, training, and periodic inspections.
For all waterflood stations where the potential exists to expose workers to H2S concentrations at or above 10 ppm, commission an independent and comprehensive analysis of each facility design vis-à-vis ventilation and mitigation systems to ensure that, in the event of an accidental release, workers are protected from exposure to toxic gas levels.
For all waterflood stations where the potential exists to expose workers or non-employees to H2S concentrations at or above 10 ppm, develop and demonstrate the use of a safety management program that includes a focus on protecting workers and non-employees from H2S. This program should include risk identification, assessment, mitigation, and monitoring of design, procedures, maintenance and training related to H2S. This program must be in compliance with 29 CFR 1910.1000 – Air Contaminants and 29 CFR 1910.147 – The Control of Hazardous Energy (Lockout / Tagout).
For all waterflood stations where the potential exists to expose workers to H2S concentrations at or above 10 ppm, ensure the H2S detection and alarm systems are properly maintained and configured, and develop site-specific detection and alarm programs and associated procedures based on manufacturer specifications, current codes, standards, and industry good practice guidance. The program must address installation, calibration, inspection, maintenance, training and routine operations.
For all waterflood stations where the potential exists to expose workers or non-employees within the perimeter of the facility to H2S concentrations at or above 10 ppm, ensure that the H2S detection and alarm system designs employ multiple layers of alerts unique to H2S, such as with the use of both audible and visual mediums, so that workers and non-employees within the perimeter of the facility would be alerted to a significant release. The system design must meet manufacturer specifications, current codes, standards, and industry good practice guidance.
For all waterflood stations where the potential exists to expose non-employees to H2S concentrations at or above 10 ppm, develop and implement a formal, written, site-specific security program to prevent unknown and unplanned entrance of those not employed by Aghorn, starting with a requirement for employees to lock access gates upon entering and departing the facility.
Issue a safety information product (such as a safety bulletin or safety alert) that addresses the requirements for protecting workers from hazardous air contaminants and from hazardous energy.
Develop and send a Notice to Operators to all oil and gas operators that fall under the jurisdiction of the Railroad Commission of Texas that describes the safety issues described in this report, including: 1. Nonuse of Personal H2S Detector 2. Nonperformance of Lockout / Tagout 3. Confinement of H2S Inside Pump House 4. Lack of Safety Management Program 5. Nonfunctioning H2S Detection and Alarm System 6. Deficient Site Security