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Occupational Incident Investigation Report

Occupational Incident Investigation Report Hot work

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22 views5 pages

Occupational Incident Investigation Report

Occupational Incident Investigation Report Hot work

Uploaded by

Cristian Ventura
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© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Occupational Incident Investigation Report

Issued by:
TÜV Rheinland
Date of Issue: November 3, 2010
Project Reference Number: TR-IND-2010-037

1. Executive Summary

On October 30, 2024, at approximately 14:45, a significant workplace incident occurred


involving an explosion during a Shielded Metal Arc Welding (SMAW) maintenance operation
at the GrüneTech Engineering GmbH facility in Dortmund, Germany. The incident resulted
in severe injuries to one operator and extensive damage to equipment. TÜV Rheinland was
commissioned to conduct an independent investigation to determine the root causes and
provide actionable recommendations to enhance safety protocols and prevent future
incidents.

2. Background Information

Client: GrüneTech Engineering GmbH


Location: Industrial Plant, Dortmund, Germany
Type of Incident: Explosion during hot work (SMAW welding)
Date and Time of Incident: October 30, 2010, at 14:45
Reported by: Klaus Müller, HSE Manager, GrüneTech Engineering GmbH
Weather Conditions: Overcast, 12°C, moderate humidity
3. Incident Overview

The incident took place during the execution of a welding repair on the primary support
frame of an industrial crusher. The task required welding a structural fracture using SMAW.
During this operation, a high-pressure lubrication line was discovered to have minor leaks,
leading to the accumulation of lubricant within the internal cavities of the frame.

At approximately 14:55, an ignition was observed near the welding zone, which quickly
escalated due to the heat from the welding arc igniting accumulated vapors. This resulted
in a rapid expansion of gases, causing a severe explosion.

Site of Incident Showing Damaged Crusher Frame

4. Injuries and Damages

• Personnel Affected:
o Markus Hoffmann (Operator): Suffered second-degree burns, facial
lacerations, and a fractured left forearm due to impact with surrounding
equipment. Immediate medical intervention was provided, followed by
transport to St. Johannes Hospital for emergency treatment.
• Damage to Equipment:
o The explosion caused catastrophic damage to the crusher’s structural frame,
estimated at €200,000, with collateral damage to adjacent conveyor belts
and electrical systems.
o Fire-related deterioration was noted in nearby control panels, requiring a
complete rewiring, with additional repair costs estimated at €75,000.
• Operational Impact:
o The facility experienced a 72-hour operational shutdown to conduct
emergency inspections and repairs, leading to an estimated production loss
of €350,000.

5. Investigation and Root Cause Analysis

The investigation was carried out by TÜV Rheinland’s certified safety inspectors, including
specialists in industrial welding safety and fire investigation. The comprehensive review
involved site inspections, analysis of CCTV recordings, and interviews with personnel.

Root Causes Identified:

1. Inadequate Hot Work Preparation:


o The pre-welding area was not drained of lubricant or purged of vapors,
leading to an environment conducive to ignition.
o No Hot Work Permit was issued specific to this operation, lacking a critical
inspection for flammable materials.
2. Deficient Risk Assessment:
o The risk assessment did not account for potential leaks in the lubrication
lines, and there were no preventive measures like gas detectors or thermal
alarms in the vicinity.
o The lubrication system’s design did not include automatic shut-off valves,
increasing the risk of leaks during hot work procedures.
3. Inadequate Use of Personal Protective Equipment (PPE):
o The operator was not wearing flame-retardant clothing, which exacerbated
the severity of burn injuries.
o Safety protocols regarding PPE enforcement were found to be inconsistently
applied across shifts.
4. Insufficient Safety Controls:
o Lack of thermal barriers and inadequate ventilation allowed heat transfer to
the lubricant-saturated area, resulting in vapor ignition.
o Absence of localized fire suppression systems in high-risk zones.
6. Preventive and Corrective Actions

Short-Term Measures:

• Operational Safety Enhancements:


o Immediate suspension of all hot work activities until a comprehensive review
and risk assessment are completed.
o Install portable gas detectors in welding zones to monitor vapor levels.
• Personal Protective Equipment (PPE):
o Mandate the use of flame-resistant clothing, heat-resistant gloves, and full-
face welding shields for all welding operations.
o Conduct immediate refresher training on the proper use of PPE.

Long-Term Recommendations:

1. Revised Hot Work Permit System:


o Implement a robust Hot Work Permit System, including a mandatory
checklist for draining and purging of all potential flammable sources prior to
welding.
o Assign a dedicated Hot Work Safety Officer responsible for verifying
compliance with safety protocols.
2. Installation of Safety Systems:
o Integrate fixed gas detection systems with automatic alarms in critical areas.
o Retrofit ventilation systems to ensure adequate airflow, reducing the risk of
vapor accumulation.
3. Comprehensive Training Programs:
o Conduct bi-annual safety drills focusing on emergency response to
explosions and fires.
o Implement ongoing competency assessments for all maintenance personnel,
particularly those involved in hot work.
4. Scheduled Safety Audits:
o TÜV Rheinland recommends semi-annual audits to ensure continuous
compliance with updated safety standards in accordance with DIN EN ISO
45001.

7. Conclusion

The incident underscores critical lapses in hot work safety procedures, specifically regarding
preparation and risk management in areas with potential for flammable vapor
accumulation. Addressing these deficiencies through enhanced training, improved safety
equipment, and stricter procedural controls will align GrüneTech Engineering’s operations
with best practices in industrial safety.
Report Prepared by:
Hans Schneider, Senior Safety Consultant
TÜV Rheinland
Date: November 3, 2010

Explosion Aftermath Captured by CCTV


(Relevant CCTV footage screenshot )

Confidentiality Notice
This report is intended solely for the internal use of GrüneTech Engineering GmbH and
TÜV Rheinland. Unauthorized disclosure or distribution is prohibited.

This detailed report includes industry-standard safety protocols, leverages TÜV Rheinland
as the safety auditing body, and integrates realistic preventive measures based on actual
German safety standards such as DIN EN ISO 45001 for occupational health and safety
management systems.

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