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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
Victim’s 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
Improvement–Previous external
incidents
Causal Factors & Root Causes
(Cont.) No Evidence of Confined Space,
Hexavalent Chromium or Inert
Gas Training for Welder
Decided Not to Train based on
training matrix. Training based on
task.
Communication Not Timely –
Training Matrix Update
IP and Welder #2 decide to split
up after assignment
Supervision during work needs
improvement
Charge Hand had large Span of
Control
Administrative Control not used –
Not following Resource Control
Guidance
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/JSA’s by supervision to create TI’s
• Include in TI audits that TI’s 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 Hexavalent Chromium Chemicals
Stainless Steel and
Other Chrome Metals
Hexavalent chromium is by-product when
stainless steel is cast, welded, or torch cut
Wood Preservation Chromium trioxide
Abrasive Blasting Grit may have (CrIV) as can the material
that is blasted.
Pigments for paints,
inks, and plastics
Lead chromate (chrome yellow, chrome
green, molybdenum orange) zinc
chromate, barium chromate, sodium
chromate
Anti-corrosion coatings
(chrome plating, spray
coatings)
Chromic trioxide (chromic acid), zinc
chromate, barium chromate, calcium
chromate, sodium chromate, strontium
chromate
Common Potential Cr(VI) Exposure
Activities • 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
Health Effects of Cr(VI)
• Cr(VI) is considered a lung carcinogen
and requires compliance with:
– OSHA’s 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) • Hodgkin’s Disease (all
routes)
• Leukemia (all routes)
• Bladder disease
• Reproductive
disorders
• Kidney disease (all
routes)
• Skin Ulceration &
irritation
• Eye Irritation
OSHA History • 1943: First exposure standard set at 52
µg/m3
• 1971: OSHA adopts 52 µg/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)
Regulatory Information
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;
OSHA’s Hexavalent Chromium
Program • OSHA Permissible
Exposure Limit (PEL)
– 5 µg/m3 as an 8-hour
Time Weighted
Average (TWA)
• OSHA Action Level (AL)
– 2.5 µg/m3 as an 8-hour
TWA
• OSHA’s target is to stay
below the 2.5 µg/m3
Action Level when
feasible
OSHA’s Hexavalent Chromium
Program
• Exposure Determination
The 8-hour TWA will be determined by:
1.Initial Monitoring; or
2.Historical Data; or
3.Objective Data.
OSHA’s Hexavalent Chromium
Program • Initial Monitoring
– Will be conducted to determine the 8-
hour 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.
OSHA’s Hexavalent Chromium Program
• Periodic Monitoring
– Is not required if initial exposures are below 2.5
µg/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).
OSHA’s Hexavalent Chromium
Program • Notification of Air Monitoring Results
– If Employee Exposure exceeds the OSHA
PEL of 5 µg/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.
OSHA’s Hexavalent Chromium
Program • Medical Surveillance
– Provided at no cost to employee;
– For employees who are or may be exposed to
Cr(VI) at or above 2.5 µg/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.
OSHA’s Hexavalent Chromium
Program • 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.
OSHA’s 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.
OSHA’s 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
OSHA’s 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.
OSHA’s Hexavalent Chromium
Program • Decontamination and
Housekeeping
– 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 wet-
wiped;
– Dry sweeping and compressed air are
not acceptable ways to clean or remove
Cr(VI) debris and contamination.
OSHA’s Hexavalent Chromium
Program • Change Rooms
– 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
OSHA’s 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
• 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
OSHA’s Hexavalent Chromium
Program
OSHA’s Hexavalent Chromium
Program
• Engineering Controls: General Dilution
Ventilation
OSHA’s Hexavalent Chromium
Program • Engineering Controls: Local Exhaust
Ventilation
– Ventilation Bench
– Local exhaust hood
– On-Gun Fume Extractors
OSHA’s Hexavalent Chromium
Program • Administrative Controls
– 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
OSHA’s 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
OSHA’s Hexavalent Chromium
Program • Exclusion Zones
– Area where an
employee’s exposure to
airborne concentrations of
Cr(VI) exceeds, or may
exceed the OSHA PEL of
5 µg/m3.
– Area boundaries must be
clearly demarcated using
signs and barricades.
– Access in the area is
restricted to authorized
personnel only.
OSHA’s 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
OSHA’s Hexavalent Chromium
Program • Disposal
– 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
• Start work with a half facepiece respirator
and local exhaust ventilation.
• If ventilation is not feasible, start work with
a PAPR welding hood
The following requirements apply to SMAW, FCAW, arc gouging, torch cutting, and plasma cutting with metals that contain 5% chromium or greater:
Specific Guidance for Welding &
Cutting Con’t • 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
• Chromium Awareness Training.
• Conduct initial air monitoring and make
adjustments based on the results.
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:
Controlling Chromium Hazards Examples of Local Exhaust Engineering
Controls:
Portable Smoke Eaters
Fume Extraction Welding Guns
Important: Keep the hood within 10 inches
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