Hexavalent Chromium Asphyxiation of Welder on LNG Construction Site 23 August, 2009

Statement
Who:Mr. Harendra, Welder What:Found unconscious inside a 24 stainless steel pipe. Attempts to revive were unsuccessful. Where:Train 7 53-XH0603 When:09:30 August 23, 2009

Sequence of Events
Welding crew conducted Toolbox Talk and Task Instruction Meetings. Two welders assigned to Joint #29 Two welders & one helper prepared equipment Argon dam installed during fit up on Aug. 20 Welders decided one work on Joint #29 24 and other work on Joint#98 16 Welder began Root & Hot pass welds on Joint #29 Completed welds and called down to helper on lower level You come up, I go In check and repair weld. Helper went up to work level, took approx. 2-3 minutes Welder was inside 24 pipe. Helper called to him with no response Helper called for help from welders in adjacent area. They attempted to call with no response Helper went to Foreman on ground level to make notification Emergency services notified and responded Victim retrieved from pipe unconscious/unresponsive CPR attempted but unsuccessful

Purge Dams for Argon Purging

Re-Creation

Victims last known position

Re-Creation

Position of Helper when last saw Victim

Findings
No evidence that the victim intended harm to himself No evidence that the victim fell into the pipe Evidence indicates the victim entered pipe on his own to inspect and repair his weld Tools in possession are TIG torch, filler wire and cell phone (light) Re-creation indicated person of similar size can move relatively easily inside 24 (ID 22) pipe Two welders assigned to the task but separated without direction from supervision

Re-Creation

Findings (cont.)
No Confined Space Entry was required to complete this job. (External welding only) 10.2% Oxygen measured approx. 20 minutes after entry by the victim Awareness on hexavalent chromium and around inert gases needs improvement Other welders interviewed indicated they might go into a pipe to check and repair weld Similar incidents have occurred at other locations within the industry The victim had excellent history as a welder and employee

Findings (cont.)
ISO indicated line 100% radiography Weld passed Radiography No Method Statement/JSA that would apply to this task. No record of confined space, hexavalent chromium or argon/inert gas training for the victim HSE Training Matrix inconsistencies between contractors 9 Welders & 5 helpers assigned to one Charge Hand Only Helper had Confined Space Training

Causal Factors & Root Causes

Entered 24 oxygen deficient atmosphere to inspect and repair weld No Training Decided not to train based on training matrix. Training based on task. Labels Needs Improvements No warning/labels on confined spaces

Enforcement Needs Improvement-Compliance with site procedures

Corrective Action Needs ImprovementPrevious external incidents

Causal Factors & Root Causes (Cont.)

No Evidence of Confined Space, Hexavalent Chromium or Inert Gas Training for Welder Communication Not Timely Training Matrix Update Decided Not to Train based on training matrix. Training based on task.

IP and Welder #2 decide to split up after assignment

Supervision during work needs improvement Administrative Control not used Not following Resource Control Guidance

Charge Hand had large Span of Control

Causal Factors & Root Causes (Cont.)

Task Instruction did not include any information about confined spaces, hexavalent chromium or inert/argon gases Pre-Job Briefing Needs Improvement

Corrective Actions
Provide awareness training on confined spaces for all field workers Provide confined space entrant, attendant, and supervisor training for all welders and pipefitters Revise current Safety Induction training to improve C.S. and hexavalent chromium and inert gases hazard awareness Provide training to all welders on hexavalent chromium, inert/argon gas hazards

Corrective Actions Cont.)

Post signage and barrier with confined space warning on all pipe opening 16 and greater. Add to the Golden Rules list Entry into a Confined Space without a permit Develop a process to implement hard actions based on external incidents. Specifically fatalities

Corrective Actions (Cont.)

Revise HSE training matrix to require CSE training for all welders Scrutinize training matrix for gaps Improve document control delivery process

Corrective Actions (Cont.)

Establish a clear rule for worker/supervision ratio and develop guidelines including considerations for geographical spread Include in the Sr. Mgmt Walk thru questions about supervisor interaction/visibility with workers

Corrective Actions (Cont.)

Revise Pipe Erection Method Statement/JSA to address welding and hexavalent chromium, inert/argon gases Create a process to Update Method Statements/JSA with information from external fatality incidents that have application to this work site Include in Task Instruction (TI) audits & training material the use of Method Statements/JSAs by supervision to create TIs Include in TI audits that TIs are completed at the Task Location

Hexavalent Chromium in Welding Environment, Safety & Health

Background Information What is Chromium?

Chromium is a naturally occurring element Contributes to hardness and corrosion resistance Commonly used in manufacturing activities such as: Steel hardening; and Electroplating Paints Commonly used as a pigment in coatings such as paint

Background Information What is Cr(VI)?

Hexavalent Chromium is produced when chromium containing materials are heated to an extreme temperature Cr(VI) is a toxic material

Background Information Who is Affected by Cr(VI)?

The primary industries affected by Cr(VI) include:
Metal alloy fabrication and installation; Heavy duty coatings and paint production and application; and Chrome electroplating Wood treating

Hexavalent Chromium in Construction

Uses
Stainless Steel and Other Chrome Metals Wood Preservation

Hexavalent Chromium Chemicals

Hexavalent chromium is by-product when stainless steel is cast, welded, or torch cut Chromium trioxide

Abrasive Blasting
Pigments for paints, inks, and plastics

Grit may have (CrIV) as can the material that is blasted.

Lead chromate (chrome yellow, chrome green, molybdenum orange) zinc chromate, barium chromate, sodium chromate Chromic trioxide (chromic acid), zinc chromate, barium chromate, calcium chromate, sodium chromate, strontium chromate

Anti-corrosion coatings (chrome plating, spray coatings)

Common Potential Cr(VI) Exposure

The most common potential exposures found at construction projects are: Welding & cutting operations involving chromium metals Welding & cutting operations on chromium paints Spray painting chromate or chromic oxide coatings such as paints Abrasive blasting with contaminated grit or on Cr(VI) contamination Burning or cutting chemically treated wood

Activities

Health Effects of Cr(VI)

Cr(VI) is considered a lung carcinogen and requires compliance with:
OSHAs Occupational Exposure to Carcinogens/Teratogens/Mutagens Core Process Number 317.

Health Effects of Cr(VI)

Cr(VI) enters the body by:
inhalation Ingestion absorption through the skin.

Health Effects of Cr(VI)

Inhalation Cancer (lung) Nasal septum ulcers & perforation Asthma Irritation (nose, throat, lungs) Nosebleeds Teeth Discoloration Death

Health Effects of Cr(VI)

Hodgkins Disease (all routes) Leukemia (all routes) Bladder disease Reproductive disorders Kidney disease (all routes) Skin Ulceration & irritation Eye Irritation

Regulatory Information

OSHA History
1943: First exposure standard set at 52 g/m3 1971: OSHA adopts 52 g/m3 standard 1993: OSHA petitioned to reduce PEL 2003: OSHA ordered to lower PEL standard Feb. 28, 2006: Final revised standard issued May 30, 2006: Implementation begins November 26, 2006: Required to be in full compliance with OSHA Standard (except engineering controls)

OSHA Chromium Standards Promulgated in 2006

1910.1026 General Industry 1915.1026 Shipyards, Marine Terminals, and Longshoring 1926.1126 Construction

OSHA Regulation 1926.1126 Components

Lower personal exposure limits; Exposure Assessment Schedules; Engineering & Work Practice Controls; Personal Protective Equipment Controls; Hygiene Areas & Practices; Medical Surveillance; and Communication of Hazards to Employees;

OSHAs Hexavalent Chromium Program OSHA Permissible

Exposure Limit (PEL) 5 g/m3 as an 8-hour Time Weighted Average (TWA) OSHA Action Level (AL) 2.5 g/m3 as an 8-hour TWA OSHAs target is to stay below the 2.5 g/m3 Action Level when feasible

OSHAs Hexavalent Chromium Program

Exposure Determination
The 8-hour TWA will be determined by:
1.Initial Monitoring; or 2.Historical Data; or 3.Objective Data.

OSHAs Hexavalent Chromium Program Initial Monitoring

Will be conducted to determine the 8hour Time Weighted Average (TWA); Samples will be collected from workers breathing zone; Will be collected to accurately characterize full shift exposure on each shift, for each job classification, in each work area; Representative sampling will be conducted so that samples will be collected from employee(s) expected to have the highest Cr(VI) exposure.

OSHAs Hexavalent Chromium Program

Periodic Monitoring
Is not required if initial exposures are below 2.5 g/m3; Is not required if initial exposures are below the AL and another monitoring event, taken at least seven days later, confirms the result; Is required every 6 months if exposures are above the AL but below the PEL; Is required every 3 months if exposures are above the PEL; and Is required if there are changes in the production process, raw materials, equipment, employees, work practices, or control methods that may result in exposure to Cr(VI).

OSHAs Hexavalent Chromium Program

Notification of Air Monitoring Results
If Employee Exposure exceeds the OSHA PEL of 5 g/m3, air monitoring results will be posted at the job site or will be given to the employee in writing, as soon as possible, but no more than 5 working days later after results have been received. Employees will also receive written notification of the corrective actions being taken to reduce exposures to or below the OSHA PEL.

 Medical Surveillance

OSHAs Hexavalent Chromium Program

Provided at no cost to employee; For employees who are or may be exposed to Cr(VI) at or above 2.5 g/m3 for 30 or more days in a 12-month time period; Annually For employees experiencing signs or symptoms of health effects associated with Cr(VI) exposure; Within 30 days after initial assignment or if exposed during an uncontrolled release; and At the termination of employment.

 Medical Surveillance Contents of Exam Medical & work history with emphasis on past, present, and future exposure to Cr(VI); History of respiratory dysfunction, asthma, dermatitis, skin ulceration, nasal septum perforation, and smoking status; and Physical exam of the skin and respiratory tract.

OSHAs Hexavalent Chromium Program

 Medical Surveillance Physician or other licensed health care professional (PLHCP) Statement
Will provide a written medical opinion within 30 days of the exam and will state:
Any detected medical conditions that would place the employee at risk if further exposed to Cr(VI); Limitations to employees exposure to Cr(VI) or use of PPE; and A statement that the results of the medical exam have been explained to the employee.

OSHAs Hexavalent Chromium Program

OSHAs Hexavalent Chromium Program

Respiratory Protection is

needed:
When engineering and work practice controls do not reduce worker exposures below the PEL of 5.0; During installation of engineering and work practice controls; During maintenance and repair activities; During emergencies

OSHAs Hexavalent Chromium Program

Personal Protective Equipment - Selection & Use Skin and eye contact must be assessed to determine if protective clothing is necessary. Certain activities will require protective clothing (e.g., painting, abrasive blasting);

If protective clothing is determined to be needed, the protective clothing must be removed at the end of shift or at the completion of the task involving Cr(VI); Do not allow items contaminated with hexavalent chromium to be removed from the workplace until properly cleaned or processed.

 Decontamination and Housekeeping

OSHAs Hexavalent Chromium Program

Decontamination of outer garments and equipment is necessary whenever reusable protective clothing is required; Decontamination of outer garments and equipment is necessary whenever an Exclusion Zone has been established; Outer garments and protective clothing shall be either HEPA vacuumed or wetwiped; Dry sweeping and compressed air are not acceptable ways to clean or remove Cr(VI) debris and contamination.

 Change Rooms

OSHAs Hexavalent Chromium Program

When PPE is required due to a Cr(VI) skin hazard, change rooms will be provided with separate storage facilities for PPE and street clothes to prevent cross-contamination.

Washing Facilities
When skin contact with Cr(VI) occurs, employees must wash their hands and faces at the end of the shift and prior to eating, drinking, smoking, chewing tobacco or gum, applying cosmetics, and using the toilet.

Eating and Drinking Areas

Must be maintained free of Cr(VI) Employees must not enter with PPE or other contaminated equipment

OSHAs Hexavalent Chromium Program

OSHA requires use the standard industrial hygiene controls to help eliminate or reduce exposure to Cr(VI):
Engineering Controls first level of protection Administrative Controls second level of protection Personal Protective Equipment last level of protection

OSHAs Hexavalent Chromium Program

Engineering Controls
Substitution: substitute chromium-containing materials with non-chromium materials or substitute with a material containing less chromium Ventilation: used to remove harmful fumes and gases. Two types of ventilation strategies include:
General Dilution Local Exhaust

OSHAs Hexavalent Chromium Program

Engineering Controls: General Dilution Ventilation

OSHAs Hexavalent Chromium Program

Engineering Controls: Local Exhaust Ventilation
Ventilation Bench Local exhaust hood On-Gun Fume Extractors

 Administrative Controls

OSHAs Hexavalent Chromium Program

The following are examples of Administrative Controls that will be implemented on Construction Sites: Surface Coating Removal Prior to Welding or Torch Cutting Remove all surface coating to no less than 4 inches on either side of the proposed weld. Prohibit use of power grinders as a tool to remove surface coatings. Use a containment system to collect paint chips. Employee Training and Written Safety Plans Demarcated and Posted Exclusion Zones

OSHAs Hexavalent Chromium Program

Administrative Controls continued
Equipment and Surface Cleanup No dry shoveling, sweeping, or brushing Distance maintained between cross-contamination activities (grinding and welding) Personnel Decontamination When protective clothing is required a dirty change room and a contamination-free street clothing change room shall be established Wash hands and face before eating, drinking, smoking, or applying cosmetics Air Monitoring and Medical Surveillance Work Practices such as Wet Methods

 Exclusion Zones

OSHAs Hexavalent Chromium Program

Area where an employees exposure to airborne concentrations of Cr(VI) exceeds, or may exceed the OSHA PEL of 5 g/m3. Area boundaries must be clearly demarcated using signs and barricades. Access in the area is restricted to authorized personnel only.

OSHAs Hexavalent Chromium Program

Exclusion Zone warning signs must include the following wording:

DANGER HEXAVALENT CHROMIUM CANCER HAZARD AUTHORIZED PERSONNEL ONLY RESPIRATORS REQUIRED IN THIS AREA

 Disposal

OSHAs Hexavalent Chromium Program

Cr(VI) contaminated materials must be collected and disposed of in sealed, impermeable bags or other closed, impermeable containers Bags or containers of Cr(VI) waste will display a label with the following wording:
DANGER CONTAINS HEXAVALENT CHROMIUM AVOID CREATING DUST CANCER HAZARD

Hexavalent Chromium Craft Supervisor and Employee Training Welding Processes

Cr(VI) Fume Generation in Materials that Contain Chromium

The welding and cutting processes that typically generate Cr(VI) fume levels above the PEL are:
SMAW or stick welding Flux cored arc welding (FCAW) Arc Gouging Plasma Arc Cutting Torch cutting Oxy lance

This applies to base and filler metals that have 5% or greater chromium content.

Cr(VI) Fume Generation

The welding processes that typically generate Cr(VI) fume levels below the PEL are:
STT welding GMAW (MIG welding) GTAW (TIG welding) Grinding

Specific Guidance for Welding & Cutting

The following requirements apply to SMAW, FCAW, arc gouging, torch cutting, and plasma cutting with metals that contain 5% chromium or greater:

Start work with a half facepiece respirator and local exhaust ventilation. If ventilation is not feasible, start work with a PAPR welding hood

Specific Guidance for Welding & Cutting Cont

Start work within an established Exclusion Zone Conduct initial air sampling Adjust controls based on air sampling results Medical surveillance may be required when this work is conducted for 30 or more days per year Worker & Supervisor Training

Specific Guidance for Welding & Cutting

The following requirements apply to GTAW, GMAW, & STT involving chromium-containing materials, and it applies to all other welding & cutting process with less than 1% chromium:

Chromium Awareness Training. Conduct initial air monitoring and make adjustments based on the results.

Controlling Chromium Hazards

Examples of Local Exhaust Engineering Controls:
Important: Keep the hood within 10 inches
Portable Smoke Eaters

Fume Extraction Welding Guns

Local Exhaust for Confined Space Welding

Fans or Venturi eductors

Ducts

Hoods

Mechanical Dilution Ventilation

Consist of fans/blowers and flex duct

Controlling Chromium Hazards

Examples of Respirators for Welders:
Half facepiece
Powered Air Purifying Respirator