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Cylinder Explosion—The Case of the Greasy Oxygen Cylinder
P O W E R P O I N T ® T R A I N I N G
Target Audience: This case is most appropriate for workers who work with or around compressed gas cylinders.This session is probably not appropriate for workers who do not have compressed gas cylinders in their work area.
Learning Objectives: This case and its training message primarily have to do with how to store and handle compressed gascylinders – specifically oxygen cylinders. It can be used in conjunction with a complete Compressed Gas Safety TrainingSession, or it can be used as refresher training.
Background for the Trainer:
This training session presents a case study of an actual accident inspected and documented by the Occupational Safetyand Health Administration (OSHA). The case presented in this training session is:
– Accident: 014506299
– Report ID: 0830500
– Inspection: 101591337
You may choose to present this training information in a lecture format, or make the training presentation interactive byengaging your class in discussions that will help them identify facts of the case, potential causes of the accident, and futureaccident prevention measures. In either case, students will benefit by learning from a real-life scenario.
Before beginning your training session, print and make copies of the one-page Case Study Student Handout, which isprovided on the disc. The Case Study Student Handout can be used as a worksheet during the training session, or as atake-away reminder once the training session is complete.
Also, print and make copies of the Case Study Quiz, which is provided on the disc as a fully customizable Worddocument. The students can take the quiz at the end of the training session in order to help reinforce the informationpresented. Note that the same quiz is included at the end of this PowerPoint presentation as actual slides to review in class.
Consider taking pictures of compressed gas cylinders stored and used in your workplace. You can add these pictures to thepresentation by inserting them into existing slides or creating new slides.
Make sure the trainees understand the message as you go along. Periodically ask questions to test their understanding.
Speaker’s Notes:
Welcome everyone. Today we will conduct a case study of an actual accident investigated by the Occupational Safety andHealth Administration (OSHA). This is an actual tragic workplace accident that had real-life implications for the worker,the worker’s family, co-workers, and the employer. The Case Study may be disturbing and may even involve a fatality.
The purpose of this training session is to teach and reinforce the importance of properly handling and storing compressed gascylinders in our workplace in order to prevent tragic accidents. In particular, it deals with how to work with oxygen cylinders.The intention is to learn from the accident and take steps to prevent a similar accident from changing our lives.
Use the questions on this slide to elicit discussion.
Training options: After reviewing this slide and the accident description, give the class 5-10 minutes to discuss
the accident description in small groups; or ask the students to try to determine some of the facts, potential
causes, and possible prevention measures. In either case, use the Case Study Student Handout as a way to
encourage discussion as you go through this presentation.
Speaker’s Notes:
Let’s take a few minutes and, using the Case Study Student Handout, work in groups to try to determinethe facts of the accident, potential causes of the accident, and possible prevention measures. Then we will
review the Case Study together in class.
Consider some of the questions on this slide when discussing the Case Study in your groups.
Try to get the trainees to put themselves in the place of the person in the case study. What would they have done
in this case? Point out how a near miss can turn into a catastrophe in the presence of emergencies. In this case, the
workers may have become complacent about proper cylinder storage practices because nothing had ever happened
to them.
Speaker’s Notes:
Since the accident report does not specifically say what caused the explosion, we will discuss some of the possible
causes.
It is likely that the brass tube pigtail leaked oxygen during the transfer from the large cylinder to the small cylinder.
This could have occurred because the pigtail was not rated for the high pressure that was contained in the largecylinder, and it leaked. Or, the pigtail may not have been adequately tightened, and it leaked through a seal. Oxygen
will not burn or explode by itself. Oxygen is not a fuel, it merely supports the combustion process. Something would
have to ignite a nearby fuel source for the leaking oxygen to help create an explosion.
Another possibility is that the pigtail was intended to transfer acetylene only and it was not supposed to be used to
transfer oxygen. If this was the case, the pigtail could have contained remnants of acetylene gas – oxygen can beexplosive when combined with acetylene gas. Or, the thread sealant may not have been compatible with oxygen and
actually reacted with the oxygen. It is very important not to exchange a gauge or pigtail from one gas to another. The
results could be disastrous.
With the exposed grease and oil nearby, it is also likely that the pigtail, cylinder valves, or even the cylinders
themselves were contaminated with grease or oil from the worker’s hands. This grease or oil could have provided the
necessary fuel that the leaking oxygen needed.
Acetylene is a very flammable gas that is often used for welding or torch cutting operations. Most acetylene cylinders
are equipped with pressure relief valves to prevent the cylinder from exploding when exposed to high temperatures.
Instead, the pressure relief valve will release acetylene when heated up, which adds fuel to the fire.
The scene is set for a fire – we have leaking oxygen and plenty of fuel sources. Now all that is needed is an ignitionsource. Since we do not know what the other two workers in the immediate area were doing, we can speculate that their
activities may have contributed to igniting the explosion. They could have been welding, or smoking, or using a
hammer to bend a piece of metal – thus causing a spark. Even static electricity could have ignited this fire.
Can you think of any other causes that may have contributed to this accident?