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Incident Report: Gas Cutting Safety Alert

On 7th July 2014 at 05:10 PM, HDS, a sub-contractor of XYZ Gas Cutter, Mr. Chandra Pal, was engaged in channel cutting with a gas cutting set in the ABC Fabrication yard at ground level. Flashback arresters (FBA) were fixed on both sides (cylinder and torch). During the gas cutting job, unfortunately, the oxygen hose pipe blasted with fire due to backfire from the torch. The distance was approximately 1.5 meters from the torch. Immediately, the gas cutter controlled the situation by releasing all pressure gauges and releasing the pressure of the hose pipe from the torch. Fortunately, nobody was injured. (Photo Attached)

Investigation Report

After opening the FBA-Flashback Arrester, we found that the backfire control system of the FBA was not proper. The spring and nozzle, which control the backfire, were not provided by the manufacturer in the FBA.

Action Required/Taken

- Use only ISO-marked FBA and all gas cutting set materials.
- All Flashback Arrester-FBA working systems should be checked before issuance from the store.
- Awareness training should be conducted for all gas cutters by the HSE Department and, if possible, by the manufacturer.
- Check all FBA backfire control systems at the site/plant that are in use.

If you have more ideas for backfire protection, please input your suggestions.

Regards,

From India, JaipurJaipur
Attached Files (Download Requires Membership)
File Type: docx PHOTOS-Near Miss.docx (159.7 KB, 349 views)

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Dear C.R. Siani,

Your investigation report clearly addressed that it happened 100% due to a manufacturer defect. Did you notify the manufacturer of this issue? Did you read the manufacturer's O&M manual for FBA? Do you have proof of the training documents you provided to your employees on this equipment? Are you sure it will not happen in ISO-marked FBAs? How do you check the FBA working system – who is responsible for the check?

For your information, FBAs are generally reliable in performing the intended function as long as the device is used according to the manufacturer’s instructions. If an end-user neglects or ignores the manufacturer’s stated or published safety and maintenance recommendations, that person is an accident waiting to happen, and no accessory safety device will prevent all possible accidents. As someone who has handled accident litigation cases for the past several years, I can state unequivocally that most oxy-fuel accidents are caused not by equipment malfunction, but by user neglect, impatience, or lack of experience in using equipment safely.

Please do me a favor and provide me with details of the FBA that you used at your plant/work site. I will talk to the manufacturer to get some information that will help educate ourselves.

Action Required According to Your Report

Manufacture manuals should be available on-site or practically accessible; whoever is operating the equipment should go through the O&M manual prior to operating the equipment – this should be the responsibility of the supervisor and EHS personnel.

Appropriate training should be provided to all personnel involved with this task as per manufacturer requirements – this should be the responsibility of management and safety personnel.

Choose the right materials for the task. Manufacturer instructions should be followed whenever operating the equipment.

I don’t think it’s a small issue if it’s really a manufacturer defect. I’m sure I’ll bring that issue to the next level without involving you. Please provide me with the details I need from you.

I’m eagerly looking forward to your reply. If you’re not comfortable sharing the info on social networks, I’m available at [Email Removed For Privacy Reasons].

Thanks in advance.

From United States, Fpo
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Compliance with IS 11006-1984 for Flashback Arresters (FBA)

FBA should comply with IS 11006-1984, but I have never seen any IS-certified FBA in India. Most of us are using FBA, which normally acts just as an NRV. Some of the branded items comply with EN 730. At the same time, they are manufacturing the product with different serial numbers that do not comply with IS or EN codes. Therefore, we should be aware and careful when selecting a product.

Thanks

From India, Bangalore
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I would also like to add one more point here which I doubt might have also been there. It is also to be investigated whether it was repaired in-house or by anyone who is not authorized to do so. Its maintenance history should also be checked along with the points that you mentioned above.

Also, if you have an FBA of the same make used by other contractors, it should also be checked for the same.

Regards,
Hansa Vyas

From India, Udaipur
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Dear Hansa, Welcome back! You're right. I spoke to some technical experts back in the States. I wrote an email to Mr. Saini, and he provided manufacturer details. However, I am not able to find them online, so I will need to get more details from him again as quickly as possible. Once I have the necessary information, I will contact the manufacturer to find out the real cause of the accident. If it's a manufacturer defect, I am certain I will take it to the next level and have that product banned from the market. We will see...

Thank you.

From United States, Fpo
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boss2966
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Importance of Using Standard Flashback Arresters

That's the reason we are insisting on using the standard product of Flashback Arrester while performing cutting and welding activities. If the flashback arrester is not working properly, it may endanger the lives of many people working around the area.

Regards,

From India, Kumbakonam
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To the extent I know about FBAs, I think Hansa Vyas's hunch is right — more of an O&M issue than related to the manufacturer. We Indians are known worldwide for what we call 'Jugaad' — improvising. However, I know that many times, we go overboard even when the necessary tools, systems, and SOPs are in place. Anyway, let's wait for Raghu's inputs.

Best regards,
TS

From India, Hyderabad
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Dear Members, FYI, we have changed all FBAs at the site. Thanks to all, and special thanks to Mr. Raghu, who conducted a thorough investigation. I have discussed with our Project Head about sending the MOM copy to our team for further investigation. However, he is not permitting the sharing of the MOM or allowing another agency to visit the site. We have limitations. I apologize for not being able to send the company's document. (I have referred to the company as ABC in the report.) Thanks to all again. Regards.
From India, JaipurJaipur
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Dear Raghu, The FBA shown on the website is not an FBA. It is just an NRV, and I am sure it is not ISI certified. The FBA should have:
1. Flame arrestor
2. NRV
3. Temperature-sensitive cut-off valve
4. Pressure-sensitive cut-off valve

Please let me know if I am wrong. I am looking forward to comments from our senior members.

From India, Bangalore
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You're right. I am not sure about what's available on their website. Additionally, I went through the product description on their website, which is not clear. I wrote an email to clarify the product description, as usual, like some manufacturers—they simply ignored my email.

Request for Manufacturer Details

Do any of our members have the details of the manufacturer providing the IS standard FBA in India? If so, please share it with us; it will benefit a lot of our people.

Thanks, Mr. Vijay, for driving this question to our board.

From United States, Fpo
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Dear Vijay,

Apologies for the delayed response. You know very well that most people in this world are more advanced than us, especially in safety. They have better equipment and stronger regulations. We do have strong regulations compared to others, but the enforcing authorities have failed in India.

When I worked in India in my earlier days, I didn't have many opportunities to move forward and learn. When I came across this topic, the only thing that came to mind was why we need to go beyond FBA and check valves. Why not just buy a torch handle with built-in flashback arrestors and check valves, which is safe and easy for everyone?

I expected some of our members to comment, which is why I waited. However, despite over 300+ views, there have been very few comments and participation in this thread.

Share your knowledge, guys. That's the only thing you can give to the next generation.

Thank you to those who participated in this thread.

See the attached document. This is what I am using on my site :) It meets all the required international standards.

Regards.

From United States, Fpo
Attached Files (Download Requires Membership)
File Type: png Good Practice - FBA and Check Value.PNG (842.8 KB, 44 views)

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