Report to the Minister of Justice and Attorney General Public Fatality Inquiry

Transcription

1 CANADA Province of Alberta Report to the Minister of Justice and Attorney General Public Fatality Inquiry Fatality Inquiries Act WHEREAS a Public Inquiry was held at the Provincial Court of Alberta in the City of Calgary, in the Province of Alberta, (City, Town or Village) (Name of City, Town, Village) on the 5 th to 9 th inclusive day of June, 2006, (and by adjournment 12 th to 16 th inclusive year on the 19 th & 20 th day of June, 2006 ), year before Ian F. Kirkpatrick, a Provincial Court Judge, into the death of Ryan Eckhard and Ryan Silver 26 & 24 (Name in Full) (Age) of Calgary, Alberta and the following findings were made: (Residence) Date and Time of Death: August 9, 1999 at 12:00 Noon Place: Hub Oil Refining/Recycling Plant in South East Calgary, Alberta Medical Cause of Death: Statistical Classification of Diseases, Injuries and Causes of Death as last revised by the International Conference assembled for that purpose and published by the World Health Organization The Fatality Inquires Act, Section 1(d)). Explosion of a large container of waste oils and fuels Manner of Death: ( manner of death means the mode or method of death whether natural, homicidal, suicidal, accidental, unclassifiable or undeterminable The Fatality Inquiries Act, Section 1(h)). Accidental

2 Report Page 2 of 5 Circumstances under which Death occurred: Shortly before 12:00 Noon on August 9, 1999, an explosion occurred at the Hub Oil Refinery in Southeast Calgary resulting in the deaths of Ryan Eckhard and Ryan Silver, two of the Hub Oil employees working at the plant. On July 21, 2005, The Honourable Mr. Justice Brooker reviewed the circumstances giving rise to the charges against Hub Oil Company Ltd. following guilty pleas entered by the company to three charges under the Criminal Code of committing a common nuisance which endangered the lives, safety or health of the public and, in particular, which caused the injuries to Ryan Eckhard and Ryan Silver which resulted in their deaths. The facts in support of these charges were summarized by Mr. Justice Brooker at the sentencing of Hub Oil and I quote from the reasons as set out in the transcript found at Tab 6 of Exhibit 1 at this Inquiry: Hub Oil commenced operations at the South East Calgary plant in 1957 or 1958, as a refiner/recycler of used oil. Hub Oil accepted waste oil from sources ranging from major industries to small garages in the Calgary area, as well as small amounts from local residents. Recycling and fuel blending is a relatively simple process from a technical perspective. Heat is used to separate the usable components from water, waste fuels and solvents. These contaminants vaporize at different temperatures according to their volatility. The vapours are then directed through a system of overhead pipes to a reservoir where they are cooled and condensed. Noncondensables are redirected back to the heaters to be used as fuel. The usable components form a base oil that is further cleaned before re-sale. Hub Oil has modified the plant a number of times, the last time in Hub Oil originally employed a one-stage system for re-refining oil, passing the oil through one heater and vessel (or still ). By the late 1980 s, however, it was clear that modern oils contained additives that could not be removed with the temperatures achievable in the original still. In 1990, Hub Oil applied to build a two-stage system incorporating a second heater and still. This two-stage system was operational by the spring of Between 1991 and 1999, Hub Oil processed approximately 44,000,000 litres of used oil. In the two-stage system, oil was pumped from the waste storage tanks through a pre-heat system and into the first phase of processing now referred to as Unit #1. The oil would be heated to temperatures of 300 to 350 degrees Fahrenheit to drive off water and light hydrocarbons. As the heating evaporated water and light hydrocarbons, additional waste oil would be pumped into the system so that at the end of the processing cycle approximately 5,000 gallons remained within Unit #1. At the end of the processing cycle the burners were shut down. The oil was then held overnight in Still #1 before transferring to Unit #2 for high temperature processing. The heater in Unit #2 was also fueled by natural gas. The significant difference between Unit #1 and Unit #2 was that Unit #2 operated at peak temperatures of up to 690 degrees Fahrenheit. Vapours generated at these higher temperatures would be the heavier hydrocarbons, although there may still be some residual water. The vapours would then be piped through a series of heat exchangers

3 Report Page 3 of 5 where they would condense. Non-condensable gases were piped to Heater #2 to be incinerated. At the end of the processing cycle in Unit #2, the burners would be shut down. The oil would be allowed to cool prior to the final processing which involved filtering and treatment with steam and acid to remove the remaining contaminates. The Dominion Bridge Company originally fabricated the vessel that became Unit #2 as a pressure vessel in 1963 for the Gulf refinery in Edmonton. It was 84 inches in diameter and 30 feet in length. The original design parameters were 720 degrees Fahrenheit and 90 PSI. It was originally used in a horizontal configuration. It had a capacity of approximately 7500 gallons. In 1971 the vessel was decommissioned and sold as scrap to Esso in Calgary. In 1985, Hub Oil purchased the vessel at a price of $ The vessel was stored at the site until 1990 when the plant changed from a one-stage to a twostage system, and it was pressed into service and re-configured as a vertical storage tank. Operators attempted to operate Unit #2 at less than 15 pounds per square inch ( PSI ), but the pressure could only be controlled indirectly and manually. There were no automatic controls. There was confusion as to how to interpret the pressure gauge. In the result, some operators unwittingly kept pressures during the critical one hour of high temperature over 15 PSI. The unit did not have a pressure relief valve, although it legally should have. The pressure relief valve was not installed for environmental reasons, that is, the escaping odors when the safety valve opened drew complaints from local residents and scrutiny by Alberta Environment. During the period July 15 to August 9, 1999, Hub Oil undertook its annual shutdown. During the shutdown much of the work focused on Heater #2. Heater #2 consisted of welded three-inch pipes around the perimeter of the heater. In order to replace the welded pipes it was necessary to clean all traces of hydrocarbon from inside the tubes to prevent ignition during cutting and welding. The tubes were cleaned by injecting steam into the heater inlet for about three days on each side. Some of the injected steam condensed to form water droplets on the inside surface of the tubes which ran down to low points at the bends in the heater tubes ( U-bends ). During the cleaning process water built up in each U- bend. To ensure that the water was either blown out of lower U-bends or that it evaporated, in preparation for start up, compressed air was sent through the tubes. The heater was pressure tested with air and when the air pressure was released to atmosphere, the Operations Manager observed a white cloud but no water and believed that the heater was completely clear of water. The Operations Manager was confident that they had done a good job of cleaning the system. He felt that because the steam was able to escape through the vapor line into the condenser box and there was no water left in the tank after the condensate was pumped out with a vacuum truck, the system must be clear. What the operators did not appreciate was that it is impossible to blow water out of about 60 vertical three-inch pipes approximately 30 feet long using plant compressed air. The air simply bubbles through the water. Unfortunately, the configuration of the pipes in the heater, combined with the dead

4 Report Page 4 of 5 oil space in the bottom of Still #2 that insulated the water from boiling, prevented the measures that were taken from removing all of the water. The accepted, and certain, method of removing the water from the heater tubes would have been to remove the plugs at the bottom of the U-bends in the heater. These plugs are very difficult to remove. The presence of a small amount of condensation in Still #2 would not have been of any great concern to the Operators. However, without knowing the quantity of water in the bottom of the still, there was nothing that Operators could have done to avoid the explosion. Notwithstanding the Operators best efforts, the tubes still contained more water than required to cause the vessel to rupture. During the morning s operations, the water in the bottom of Still #2 had been heated to its boiling point (approximately 250 to 275 degrees Fahrenheit depending on the pressure in the still), while the oil in the vessel was in the order of 650 to 690 degrees Fahrenheit at the top and a lower temperature at the bottom. However, the water could not boil because there was an insulating layer of oil between the water pool at the bottom of the still and the outlet to the pump circulating oil to the heater. This delayed the rise of water temperature until the oil temperature out of the heater was near its peak temperature at about 11:40 a.m. At the point when the water pool in the bottom of the still started to boil, it began to mix with the hot oil causing more rapid boiling and more mixing such that all of the water flashed to steam in a very short time. With the rupture of Still #2, 5000 gallons (30,000 litres) of waste lubricating oils, fuels and solvents ignited immediately in a massive explosion. This in turn led to further explosions as tanks containing fuel ignited. Ryan Eckhard and Ryan Silver were killed instantly in the explosion. Keith Brown suffered from Tinnitus in his ear. Maryann Junkar sustained a severe cut to her left foot. Ed Parsley was burned and had debris in his eyes. Dean Siemens had second-degree burns to both hands as well as minor burns to ears and forehead cuts. Barney Krocker suffered first and second-degree burns to 30 percent of his body, including the back of his head, his back and both arms. Carol Smailes and Rick Wickman, who were driving by Hub Oil when it exploded, both suffered from injuries to their left arms. Ms. Smailes had radiating heat burns and Mr. Wickman second-degree burns with blistering resulting in some scarring. The initial explosion sent metal debris over residential areas north of Hub Oil. At some unspecified time prior to the August 1999 shutdown, Hub Oil s former Maintenance Superintendent had experienced over pressurization by reason of water left in the heater tubes after cleaning Heater #1. Although he had the Hub Oil lab analyze samples to ensure that there was no water left in the system, there was a violent explosion which resulted in the end of the heat exchanger being blown off. The former Maintenance Superintendent clearly understood that to remove water from the system each of the plugs at the bottom of each exchanger tube had to be removed.

5 Report Page 5 of 5 Approximately two years before the explosion, an independent contractor had carried out the process of cleaning the heater. However, the plugs had already been removed to permit the entry of a high-pressure cleaning wand. The Operators did not know of the former Maintenance Superintendent s previous experience with over pressurization. The significance of the removal of the plugs was not understood. The success of the earlier cleaning led Operators to believe that it was not a complex process. Hub Oil failed to give its employees the critical information that they needed to remove the water from the system. Without that knowledge they did not understand the significance of removing the plugs; they could not appreciate the risk in failing to do so. Recommendations for the prevention of similar deaths: The cause of the explosion at the Hub Oil Refinery was the overheating of water trapped in heater tubes connected to a pressure vessel. The water rapidly boiled to temperatures well in excess of the boiling point and flashed to steam in a very short time, causing the pressure vessel to rupture. The water had accumulated in the heater tubes during the annual shut down of the facility for a 3½ week period during the summer of Despite the operators best efforts, this water had not been removed from the system by the cleaning process employed during the shut down. A pressure relief valve, which might have averted the tragedy, was not installed at the facility as it would have allowed objectionable odors to be released into the surrounding community. This pressure vessel had originally been designed to be operated horizontally but had been modified and reconfigured as a vertical storage tank. However, the attempts to ensure that vessel could be operated in a safe and efficient manner in this new capacity were unsuccessful. In light of these considerations, it is recommended that oil refineries be prohibited from utilizing pre-used oil refinery equipment in any configuration other than that in which the equipment was originally designed to be operated by the manufacturer. Any other use requiring a substantial change to the equipment or the way in which it is intended to be deployed should be approved by the appropriate municipal or provincial bodies prior to the activation of the equipment on site. The appropriate authorities would have to determine what types of equipment would require such approvals. It is also recommended that when operating licences for facilities such as Hub Oil are coming up for renewal, the residents and occupants of the surrounding communities be given notice and be allowed to address the licencing bodies in order to voice any concerns or recommendations they may have. DATED October 27, 2006, at Calgary, Alberta. original signed by I. F. KIRKPATRICK, A Judge of the Provincial Court of Alberta