SAFETY ALERT
CCC CORPORATE HSE GROUP
Multiple Fatalities – Metallurgical Failure of Spherical Tank (Not CCC)
What Happened? (Incident Description)
On March 21st 2019 at approximately 08:00 AM an incident occurred
during the commissioning phase of a Non - CCC Project in Suez, Egypt.
The Incident occurred when a spherical tank ruptured while being purged
with nitrogen prior to putting the tank in service. The tank had successfully
passed leak testing at a pressure of 24 bar few days before the incident.
Due to the “non-availability” of a nearby nitrogen production facility, a
mobile liquid nitrogen tank connected to a liquid nitrogen vaporizer was
used to generate the needed nitrogen gas for the purging process.
Two Pressure Relieve Valves (PRVs) were installed on top of the spherical
tank and were tested earlier and it was confirmed the valves could
withstand a pressure of 10 bar.
The purging plan was to vaporize the liquid nitrogen and pressurize the
spherical tank using nitrogen in the gaseous form after vaporization with
the expectation the PRVs would operate at a pressure of 10 bar as
previously tested.
At a pressure of 4 bar, the spherical tank experienced a metallurgical
failure resulting in flying debris.
The scattered flying debris claimed the lives of 25 persons working below
& nearby the tank area.
What Went Wrong? (Causes of the incident)
“Root Cause Analysis (RCA) of the Metallurgical failure revealed that liquid
nitrogen flow rate was higher than the vaporizer capacity, resulting in
the nitrogen reaching the spherical tank in its liquid state (–196°C). The
liquid nitrogen accumulated in the spherical tank triggering steel ductile
to brittle transition causing the tank rupture at a pressure of 4 bar”.
1) Failure to identify the potential hazards
The flow rate of the liquid nitrogen was not controlled or restricted to
ensure it never exceeded the vaporizer capacity. The risk associated
with the use of liquid nitrogen was not adequately foreseen and
mitigated. If the flow rate was adequately controlled, the metallurgical
failure would not have occurred.
2) Failure to Plan correctly for the Task,
 The activity started without barricading the area creating a safe
buffer zone around the purging activity to prevent any unauthorized
access near the tank.
 No Detailed Risk Assessment or Effective HSE Communication
utilizing a JSTI was conducted.
Issue Date: April 7, 2019
 Calculations were not completed to select the proper vaporizer
incorporating a standard safety factor to prevent liquid nitrogen from
entering the tank.
3) Failure to effectively control Simultaneous Activities.
No permit to work System, No Supervision and No Safety Inspection
was implemented. Other ongoing activities in the tank area were not
stopped during the purging activity.
4) Poor site HSE Supervision and Monitoring,
The HSE and construction teams either failed to stop other activities
around the tanks during purging activities or were not present.
Lessons Learned
1) Ensure Effective Planning by Competent Construction and HSE
Engineers
A detailed Method Statement, Risk Assessment, Safe System of Work,
Supervision, HSE Checking and Inspection must be available and
properly implemented when performing such activities. The Engineers
who develop the method statement and risk Assessment must have
sound technical competency and experience to provide informative
and detailed plans.
2. Conduct Job Safety Task Instruction (JSTI)
Effectively communicate control measures using a JTSI to ensure all
involved workers are aware of the hazards and risks associated with
the task.
3) Effective Site Supervision must be enforced by the Senior Project
Management.
All activities must be monitored and supervised competently,
continuously and effectively in terms of safety primarily by construction
supervisors and aided by safety officers.
4) Communicate the Lessons Learned from this incident (the
content of this Alert) to the project workforce through the
following:
 A Stand-down to all site workers on site (one-time Stand-down to be
conducted with all site workers in the presence of Project
Management)
 The weekly TBT (Tool Box Talk). Designate one TBT to
communicate lessons learned from the incident to all site workers.
 The weekly SSMM (Safety Supervisory Management Meeting) for
managers, engineers and senior supervisors
 The weekly SO Meeting (Safety Officers Meeting) for all Safety
Officers
 The weekly CH Meeting (Charge Hand Meeting) for all Foremen
and Charge-Hand