Three oil field workers died after breathing carbon monoxide (CO) gas in an oil well cellar. The incident occurred during perforation, a procedure to create holes in the pipe in the well to allow the well to be used for water disposal. During the procedure, water began flowing from a valve in the well cellar. No plan had been prepared for actions by the workers in the event that this occurred. The first worker (decedent #1), a 22 year-old male, entered the well cellar to turn off the valve. Upon entering the area, he collapsed and fell into the cellar. A second worker (decedent #2), a 24 year-old male entered the cellar to assist decedent #1 but was also overcome and collapsed. A third worker (decedent #3), a 26-year-old male, was overcome while kneeling near the opening to the cellar and also fell in. The decedents, all employed by a well maintenance contractor, were not wearing any personal protective equipment (PPE) at the time of the incident. No confined space atmospheric testing was performed prior to entry into the well space by any of the workers. Workers from another contractor, that was performing the well perforation, went into the cellar and pulled the decedents out when they saw what had happened. None of the rescuers wore any type of PPE nor was any available for their use at the incident site. Fire department paramedics arrived on the scene shortly after the incident occurred and pronounced decedent #2 dead at the scene. The other two victims were transported to the hospital where they both were later pronounced dead. Four additional workers were hospitalized, but survived the incident. The CA/FACE investigator concluded that in order to prevent similar future occurrences, employers and contractors should: 1. ensure that their Injury and Illness Prevention Programs (IIPP) effectively address all the present and potential hazards of their employees' worksites. 2. test the atmosphere of confined spaces before any employees are allowed entry. 3. if feasible, ventilate confined spaces so that employees are not exposed to hazardous air contaminants. 4. insure employees are provided and wear approved respiratory equipment when entering confined spaces where there is the presence or suspicion of harmful mists, fumes, or gases, or oxygen deficiency. 5. insure employees are provided and wear approved safety harnesses and life lines when entering confined spaces not kept safe through forced air ventilation. train employees in rescue operations so that in the event of an emergency, workers understand the risks and how to safely avoid them, and should provide and keep available equipment for rescue operations.
Region-9; Accident-analysis; Accident-prevention; Accidents; Injuries; Injury-prevention; Traumatic-injuries; Work-operations; Work-analysis; Work-areas; Work-performance; Work-practices; Safety-education; Safety-equipment; Safety-measures; Safety-monitoring; Training; Confined-spaces; Personal-protection; Personal-protective-equipment; Protective-equipment; Protective-measures; Maintenance-workers; Safety-programs; Occupational-health-programs; Occupational-safety-programs; Oil-industry; Oil-recovery; Oil-refineries; Oil-refinery-workers