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Valero Refinery Asphyxiation Incident
Delaware City, DE, Issued on November 2, 2006

Click here for Investigation Information Page
Summary
On November 5, 2005 two contractor employees were asphyxiated while preparing to reassemble a pipe on a pressure vessel while it was being purged with nitrogen. The first worker, in an attempt to retrieve a roll of tape from inside the vessel, was overcome by nitrogen, collapsed in the vessel, and died. His co-worker, the crew foreman, was asphyxiated while attempting to rescue him.

Recommendations Listed by Recipient
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Collapse Valero Delaware City Refinery 2006-2-I-DE-R1
Conduct safe work permit refresher training for all permit-preparers and approvers and affected refinery personnel and contractors.

Emphasize:

- All proposed work requires a jobsite visit by the requestor and a unit operator to identify special precautions, equipment status, and personal safety equipment requirements.

- The conditions for marking the "nitrogen purge or inerted" (Yes/No/NA) status box.

- The permit must clearly identify all hazards and special personal protective equipment requirements.

- "Fresh Air" work restrictions apply to "Set up only" permits whenever an IDLH atmosphere is suspected or known to be present in the work area.

Status: Closed - Acceptable Action The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board. 2006-2-I-DE-R2
Conduct confined space control and inert gas purge procedure refresher training for all affected refinery personnel and contractors. Emphasize:

- The requirements to maintain posted warnings at all access points to confined space temporary openings.

- The requirements to maintain posted warnings, barricades, and access control log at equipment during purging.

- An oxygen-deficient atmosphere rapidly overcomes the victim.

- There is no warning before being overcome.

- An oxygen-deficient atmosphere might exist outside a confined space opening.

- Rescuers must strictly follow safe rescue procedures.

Status: Closed - Acceptable Action The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.