(181c) The Day an HF Release Caused a Serious Operator Injury - Lessons Learned from Incident Investigation

Results of an Incident Investigation following an onsite anhydrous hydrofluoric acid (HF) release with extreme impact to an operator ranks as one of the major events in my career. It confirmed how vital application of PSM is to prevention of and preparedness for response to high hazard loss of containment scenarios. The thorough work completed by plant personnel leading up to the day the HF release and operator injury occurred included a thorough Management of Change (MOC) process for installing a new sight glass in an HF line. The Author was personally engaged in the MOC process, the Pre-Startup Safety Review and all system and field checks prior to charging the line with HF. He was present when the release occurred and observed the emergency response as well as the medical procedures used to save the operator’s life (with multiple calcium gluconate injections, decontamination and stabilization of the patient) prior to transfer to the hospital.

Even when PSM is fully implemented properly, there are still factors that can lead to loss of containment and operator injury. This event happened early in my career, cemented the need for thorough PHA, MOC and PSSR as well as Incident Investigation to learn from the incident. Dealing with an extremely hazardous substance such as HF during a loss of containment event and having trained responders, procedures, supplies and trained medical staff ready to respond to HF contamination and its toxic effects. This incident and the HF Plant Team’s response to it; that resulted in saving the operator’s life, left an indelible lesson in my mind. The incident investigation evaluated all contributory factors and determined the root cause of failure. This drove home why PSM matters so much to me while implementing PSM across the industry.