UK HSE: fatal injury following catastrophic failure of pressure test equipment

What happened?

A 64-year-old worker was fatally wounded by shrapnel ejected from testing equipment.  He was leak testing eight 1500 litre cylinders, by applying compressed air inside to create pressure.  Whilst in the process of venting the air through the test manifold, it catastrophically failed and fatally injured the worker.  See the full press release here.

What was the cause?

UK HSE investigation by found that prior to installing the fittings, 1.5 litres of a mineral oil-based corrosion inhibitor had been placed into each of the cylinders.  The incident occurred because the inhibitor contaminated the leak test manifold during venting of cylinders and was subjected to enough pressure inside the manifold to ignite and cause the test equipment to fail.

The company was fined £700,000 with full costs of £169,498.82.  The HSE inspector noted: “This was a tragic and wholly avoidable incident, caused by the failure of the company to identify any additional risks that arise when work processes are adapted.[IMCA bold for emphasis]