Lost Time Incident Region: Global Shell Retail Program

Country/Date: Johor, Malaysia / 28-May-2015

Description: Jahor, Malaysia; Shell Retail Program.

Technician working for Jacobs controlled contractor was doing ‘flushing’ as part of the commissioning of a replacement dispenser (‘gas pump’/USA) at a retail station prior to calibration. Open fuel container was not grounded and static discharge triggered a flash fire in the container. The technician pulled a trolley with the burning container away from the dispenser, splashing burning fuel onto his lower (rear) extremities. This caused 2nd and 3rd degree burns to the lower 20% of his body. The burning fuel spread across the concrete and engulfed a small flatbed truck belonging to the contractor. The truck was destroyed.

Key Findings

• CCTV video of the incident was taken from two views and showed ignition was caused by static electricity.

• Previously (1 Aug 14) Contractor had been provided with a JHA for the work activity. Worker was not in compliance with that JHA nor with internal Contractor work guidelines.

• Worker was very experienced with more than 10-years experience doing the specific work activity. He was working alone per Contractor (not Jacobs) work protocol.

• The worker placed containers on a plastic trolley, not in contact with the concrete surface as mandated. No grounding was done

• The worker had been issued fire retardant coveralls but was not wearing them

• The contractor has classified the dispensing works as low risk and hence did not require a job hazard analysis or PTW prior to work commencement. Last Minute Risk Assessment was not done either.

Lessons Learned

• The Construction Readiness Reviews for work done by GSA contractors must be as robust as for principal contractors/PCCs

• All work on fueled systems, including during Commissioning (flushing/calibration) must be managed as High Risk.

• JHA mitigation measures (including PPE) and SOPs prevent incidents and injuries but only if workers comply with them

• Assurance required verification of worker training prior to release for them to commence work in the field. Further investigation is ongoing.

Actual Severity: 4 Worst Potential Severity: 5