In September 2009, a fatal incident occurred in a cryogenic gas processing plant. The investigation of the incident indicated a number of potential issues that may have contributed to or caused the event. These issues include hot work procedures, electrostatic discharge, electrical conduit sealing, convective "breathing" due to multiple vents, equipment age, maintenance, and worker training. This paper provides an overview of the process and facility, a timeline of events, a summary of the investigative process, and a discussion of the lessons learned from this event.
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