SAFETY NEWSLETTER

DATE: August 2002



ISSUE No.02.01

MULTIPLE FATALITIES - H2S RELEASED FROM MOLECULAR

SIEVES AFTER CONTACT WITH WATER

Three contractor employees died at a natural gas processing plant as a result of

inhalation of H2S released during the unloading of molecular sieves from a
NGL drier. Two of the victims were trying to rescue the first worker. The
incident description and the learning points derived from the analysis of this
tragedy are presented below.
Identified main areas for remedial actions are:
0 Lack of detailed knowledge of the properties of molecular sieves.
ㄱ Inadequate awareness of hazards and management of risks.
ㄴ Insufficient and inadequate controls (system of work)
ㄷ Ineffective emergency response.
Description of the process
The Processing Plant concerned produces lean gas and natural gas liquids from
associated gas from oil wells. This associated gas contains water vapour and
H2S. The process involves compression of gas, refrigeration followed by
separation of condensed liquids, dehydration of vapours and liquids and final
separation into lean gas and NGL by a cryogenic process.

New0201#.doc Page 1
 The natural gas liquids are passed through a bed of molecular sieves to remove
water prior to the cryogenic process step. When the bed of sieves becomes
saturated with water, it is regenerated by passing a stream of hot gas (250 deg.
C) through the bed, followed by cooling of the bed with cold gas.
After some 3-4 years the beds have to be replaced. Normal procedure at this
location was to dump the sieves, after regeneration, cooling and purging with
Nitrogen into a truck for subsequent disposal.
Description of the incident
The drier was prepared for dumping the sieves in a similar way that had been
done many times over the previous 20 years. Appropriate safety precautions
and equipment were provided for the entry of personnel into the drier in order
to remove the top guard and mesh. Removal of the sieves was done by raking
them from the drier onto a chute ending above a high-sided tipper truck. The
truck had been wet with water and the dumped sieves had been wetted using a
fire hose in order to reduce the risk from any pyrophoric material and to restrict
dust in the windy conditions. After a while a mound of molecular sieves had
formed at the back of the truck. A contract labourer decided to enter the truck
to level the mound by shovelling the sieves to the front of the truck. Entry to
the body of the truck was by a ladder behind the cab. After some 10 minutes a
second contractor also entered the body of the truck to help. Shortly afterwards
he collapsed. The first contractor went to his assistance and was joined by a
third contractor who jumped into the truck from the elevated platform on the
drier. All three became unconscious and died. A fourth man who climbed the
vehicle ladder to see what was happening also became unconscious but was
pulled from the area by rescuers. Emergency response was delayed by unclear
radio communications.
Incident analysis
Three main events were identified:
ㄹ H2S was present in the truck (semi-enclosed space) at sufficient
concentration to overcome workers within minutes and ultimately cause death.
ㅁ Workers in the truck were unprotected (no SCBA/escape masks/personal
monitors)
ㅂ Initial emergency response was not effective.
A major contributing condition was also identified:
ㅅ There was a lack of awareness of the H2S hazard associated with the
dumping of the molecular sieves and thus inadequate management of the risks.

Page 2 480519939.doc
 The H2S was evolved (de-sorbed) from the molecular sieves in the truck. The
gas used for regeneration of the sieves prior to dumping is a residue gas
containing approximately 830 ppm of H2S. The molecular sieves will start to
adsorb H2S from the regeneration gas during the cooling of the bed. This H2S
will not be removed from the molecular sieves during the Nitrogen purging
stage. However, since the affinity of the molecular sieves for water far exceeds
the affinity for H2S, the H2S will be released when the sieves are contacted
with water (dumping in a layer of water in the truck and spraying with water).
Further, during the levelling of the molecular sieves any trapped H2S will be
released.
Failings identified were:
ㅇ Staff and contractors did not know that H2S could be released from the
molecular sieves.
ㅈ The information provided by the sieve manufacturer did not give explicit
adequate warning of the risk of desorption of H2S after contact with water.
ㅊ Contractors could not recall the content of the site safety induction that they
had received some years before.
ㅋ The effectiveness of this induction was limited (no test, no records,
language/literacy problems).
ㅌ Over several years the H2S content of the gas had increased but adequate
action had not been taken to enhance awareness of staff and contractors of the
hazard. The need to carry escape masks was not recognised, there was no
requirement to carry personal H2S monitors.
ㅍ Staff did not react to the unpleasant smell which was apparent for some time
before the event.
ㅎ There were no warning signs in or around the driers indicating the presence
of H2S in hazardous concentrations.
ㄱ Dumping the molecular sieves, which was supervised by the Civil group,
was not included in the planning of the overall molecular sieve replacement by
the Mechanical group.
ㄴ Multiple jobs requiring different precautions were on a single Work Permit.
The requirements of the Company Permit to Work System were not met.
ㄷ No job safety analysis (task risk assessment) was conducted for the task of
dumping the molecular sieves, and no tool box talk was given.
ㄹ There was no Company supervision present at the job location, during
unloading of the molecular sieves.

New0201#.doc Page 3
ㅁ There was no immediate availability of rescue staff with breathing apparatus
and resuscitation equipment
ㅂ The immediate first aid response was inadequate.
Lessons to be learned from this incident
ㅅ Understanding of the Hazards and Effects Management Process (HEMP)
needs to be improved, in particular the relationship between HEMP and the
planning of activities through identification of incident scenarios and job
safety analysis (task risk assessment).
ㅇ Incident scenarios and appropriate job safety analysis (task risk assessment)
should be performed with the involvement of first line supervision. Method
statements should be prepared which clearly define roles, responsibilities and
the controls to be applied. Communication through tool box talks should be
carried out.
ㅈ Manufacturer’s recommended practices for safe handling of molecular
sieves should be understood, communicated and applied.
ㅊ Safety induction should be tailor made for the target audience, be
multilingual if necessary and preferably visual. Effectiveness needs to be
checked and recorded and refresher training requirements defined.
ㅋ The awareness of the hazard of H2S should be enhanced for all staff and
contractors. The effectiveness of such awareness training should be checked
and refresher training requirements defined.
ㅌ The use of adequate PPE should be enforced, including the provision of
warning notices.
ㅍ Emergency drills should address a range of scenarios and involve all staff
who may have a role to play.
_______________________________________________________________
_______________________
The contents of this newsletter represent Shell Global Solutions International and Shell International
Chemicals best professional judgment of the matters dealt with. However, it is offered for
information only and should not be relied upon as authoritative guidance in any particular situation.
Recipients of this newsletter should seek advice from their own technical advisers and the vendors of
their specific equipment. Shell Global Solutions International and Shell International Chemicals
accept no liability whatsoever for any loss or damage arising out of or in connection with the
contents of this newsletter, no matter how it arises and even if it is wholly or partly caused by any
negligence of Shell Global Solutions International and Shell International Chemicals.

Page 4 480519939.doc
New0201#.doc Page 5