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Xcel Energy Company Hydroelectric Tunnel Fire

Overview

On October 2, 2007, five people were killed and three others injured when a fire erupted 1,000 feet underground in a tunnel at Xcel Energy Company's hydroelectric power plant in Georgetown, Colorado. The fatally injured workers were trapped deep underground during an operation to coat the inside of the tunnel with epoxy using highly flammable solvents. The CSB final report identified a lack of planning for hazardous work, inadequate contractor selection and oversight, and insufficient regulatory standards pertaining to the use of flammables within confined spaces.

Incident Snapshot

Field Value
Facility / Company Xcel Energy Company
Location Georgetown, CO
Incident Date 10/02/2007
Investigation Status The CSB's final report was released at a news conference on 8.25.2010 in Denver, CO.
Accident Type Confined Space / Asphyxiation Investigation
Final Report Release Date 08/25/2010

What Happened

  • The incident occurred during recoating work inside the Cabin Creek penstock at Xcel Energy Company's hydroelectric facility.
  • Workers were applying epoxy coating inside a confined space using MEK and other flammable solvents.
  • A flash fire ignited at the sprayer during solvent flushing.
  • Thick black smoke spread through the penstock.
  • Workers located uphill of the sprayer were unable to exit through the only egress point.
  • Emergency response was delayed by the confined space conditions and the need to assemble appropriate rescue resources.
  • Five workers were fatally injured and three others were injured.

Facility and Process Context

  • The Cabin Creek hydroelectric plant is located off Guanella Pass, approximately 6 miles south of Georgetown, Colorado and 45 miles west of Denver.
  • Cabin Creek is a pumped storage plant, with upper and lower water reservoirs totaling 1,977 acre-feet, used to generate electricity primarily during peak demand periods.
  • The penstock is 4,163 feet long from the upper reservoir’s intake to the point at which the penstock splits into two pipes to feed the turbines in the powerhouse.
  • Of this space, 3,123 feet can be traveled by foot.
  • RPI was hired by Xcel to recoat roughly one-half of this relatively horizontal space (1,560 feet, or 475 meters, at a 2 degree incline).
  • This section of the penstock is 12 feet in diameter, welded and steel-lined.
  • The penstock had only one egress point.
  • In the lower portion of the penstock, a 4 by 6 foot opening was flame-cut into the steel penstock pipe to provide access for the recoating project workers and equipment.
  • The penstock is a permit-required confined space, as defined by OSHA.
  • The penstock’s unique size and lack of a secondary point of egress amplified the danger.
  • The work area being sandblasted and coated was sandwiched between two wooden bulkheads built to confine the sandblasting medium and epoxy coating materials, and to isolate the work area space of the penstock.
  • Ventilation and the control of nuisance dust was to be accomplished using two desiccant-style dehumidifiers and a 12,000 CFM dust extractor.
  • The sprayer was positioned in the penstock on wheeled scaffolding about 1,450 feet from the access door and approximately 90 feet from the west bulkhead.
  • Cabin Creek Pumped Storage Hydroelectric Project
  • Xcel Cabin Creek facility is a pumped hydroelectric power plant that supplies electricity to residential customers during peak demand periods.
  • The penstock was existing equipment (constructed in 1967) that was being refurbished by removing the old coating and applying new.
  • The penstock is described as a confined space and, in the report, as a large or continuous system that cannot be fully characterized from the entry point.
  • The penstock was at an elevation of 10,050 feet (3,063 meters) above sea level.
  • The upper reservoir was dewatered before the recoating work.
  • The work area was provided with forced, clean air ventilation conveyed through a 20-inch (51-centimeter) diameter plastic duct, magnetically attached to the metal wall of the penstock near the floor.

Consequences

  • Fatalities: 5
  • Injuries: 3
  • Environmental Release:
  • Facility Damage: The fire consumed several other open containers of MEK and numerous buckets of epoxy material positioned around the sprayer. Electrical problems resulted in the destruction of penstock equipment, and fire damage to the sprayer and associated equipment precluded the CSB from completely dismissing some ignition scenarios. A flash fire engulfed a number of buckets of solvent located on and around the scaffold of the epoxy sprayer; the fire caused thick black smoke conditions and burned material was observed coming out of the penstock.
  • Operational Impact: The penstock recoating project was delayed; the plant was shut down and water drained from the penstock for the work; the fire prevented the trapped contractors from exiting through the penstock’s only egress point. Entry into the penstock was delayed 2 hours due to high carbon monoxide (CO) levels; the incident scene was released back to Xcel on October 3, 2007 at 8:00 PM.

Key Findings

Immediate Causes

  • The circulation of MEK through non-conductive hose likely led to static discharge, igniting the MEK in the sprayer hopper and resulting in a flash fire.
  • The CSB concluded that the fire inside the penstock was most likely ignited by a static spark that originated from the electrically isolated (ungrounded) metal swivel connector attached to one end of the non-conductive hose being handheld inside the base hopper of the sprayer as MEK was being flushed through.
  • The rapid spread of fire and toxic smoke from burning epoxy prevented the workers uphill of the sprayer from exiting through the penstock’s only egress point, resulting in their deaths.
  • The CSB concluded that static electricity generated while flushing MEK in the base hopper was the most likely source of ignition.
  • The use of a non-flammable solvent would have prevented the Cabin Creek fire.

Contributing Factors

  • Xcel and RPI managers were aware of the plan to operate the epoxy sprayer inside the penstock and the need to use solvent to clean the sprayer and associated equipment in the open penstock atmosphere during the epoxy application portion of the project, however they did not perform a hazard evaluation of the epoxy recoating work.
  • Neither Xcel nor RPI treated the Cabin Creek penstock as a permit-required confined space, nor did they re-evaluate hazards in the space caused by changing work activities.
  • Neither Xcel’s nor RPI’s corporate confined space programs adequately addressed the special precautions necessary to safely manage the hazard of potential flammable atmospheres.
  • RPI monitored the atmosphere of the penstock for flammable atmospheres only at its entrance, 1,450 feet from the work activities, rather than where flammables were being used.
  • The majority of RPI employees working at Cabin Creek had not received comprehensive formal safety training; effective training on company policies; or site-specific instruction addressing confined space safety, the safe handling of flammable liquids, the hazard of static discharge, emergency response and rescue, and fire prevention.
  • The penstock had only one egress point.
  • No emergency responders with confined space technical rescue certification were at the hydroelectric plant and immediately available for rescue on the day of the incident.
  • Xcel’s prequalification process for determining which potential contractors were allowed to participate in the Cabin Creek bid process considered only the contractors’ financial capacity and did not disqualify bidders based on unacceptable past safety performance.
  • RPI received the lowest score, “zero,” in the safety category, which, according to Xcel’s evaluation form, meant that the proposal should have been automatically rejected; however, RPI was still allowed to compete for the contract.
  • Xcel added a safety addendum to the penstock recoating contract, but these problems did not result in Xcel increasing its scrutiny of RPI’s safety performance or taking corrective action.
  • Xcel corporate officials had not conducted safety audits examining company adherence to its corporate policies on contractor selection and oversight at each of its power-generating facilities.
  • Insufficient ventilation, improper equipment for fire prevention, and a tight schedule created an unsafe work environment even before the epoxy application activities began.
  • The work area ventilation setup was designed solely for the purpose of ensuring the penstock ambient conditions were optimal for the sandblasting and epoxy application activities.
  • The lack of heated hose, in combination with the extensive length of hose required to complete the application work, contributed to the crew’s inability to keep the epoxy at the appropriate temperature for proper epoxy application.
  • The crew was forced to repeatedly flush the hoses from the mixing block to the spray wands with MEK between each failed attempt, which contributed to the buildup of MEK in the atmosphere.
  • Unsafe lighting was also used within the penstock when flammables were present.
  • Fire extinguishers were not immediately available to the contractors after the initial flash fire because they were not situated by the sprayer and within the work area.
  • A tight 10-week project completion schedule, severe weather concerns, several unplanned work delays, and perceived production requirements placed RPI employees under intense pressure to complete the recoating work.
  • The use of solvent within the confined space of the penstock to clean the sprayer created a flammable atmosphere.
  • The large amount of solvent surrounding the sprayer, as well as numerous buckets of epoxy hardener and base, caused the flash fire to grow into a sustained, intense toxic fire.
  • Xcel and RPI managers did not establish effective daily communication concerning the hazards associated with the penstock recoating project.
  • Xcel did not effectively plan and coordinate with RPI to identify and control serious hazards in the recoating project, including the use of a flammable solvent within the penstock confined space.
  • The Xcel project manager or safety staff made documented safety observations only on two occasions at the penstock; these safety observations were ineffectively performed and failed to identify the serious confined space hazards.
  • Violations of Xcel safety standards and OSHA regulations were not promptly communicated and corrected.
  • RPI did not provide adequate training to its employees on its safety policies and procedures.
  • RPI relied primarily on the partnership committee‘s Training Center to provide training to its employees, but the Training Center is not responsible for providing company- or site-specific training to its members.
  • Only nine of the 14 RPI employees received onsite training at Cabin Creek prior to the start of the recoating project, and that training was both abbreviated and did not effectively address the hazards inherent to the penstock recoating work.
  • The onsite training for the RPI employees was brief and generic and included only a basic review of confined space awareness.
  • The hazardous communication training on September 10 did not include a site-specific discussion of safe use of flammable solvents in confined spaces.
  • Neither Xcel nor RPI discussed the lack of a secondary egress with the work crew during the onsite training.
  • RPI employees were not trained on the proper and safe use of the Graco epoxy sprayer system.
  • Xcel and RPI’s corporate safety policies and permits did not effectively establish safe limits for flammable atmospheres in permit-required confined spaces that would prohibit entry or occupancy when those limits were exceeded.
  • Xcel and RPI managers did not plan and coordinate the immediate availability of qualified confined space technical rescuers outside the penstock.
  • Xcel’s contractor selection practices typically provided only for disqualification from the bidding process based upon financial capacity, not safety criteria.
  • RPI did not disclose to Xcel regulatory violations resolved within the requested three-year period as part of the RFP evaluation process.

Organizational and Systemic Factors

  • Xcel and RPI did not effectively coordinate and plan to control the hazards inherent in the recoating work.
  • Xcel and RPI lacked a competency evaluation of available confined spaces rescue services, as required by the OSHA Permit-Required Confined Spaces Rule.
  • Xcel and RPI failed to identify the life-threatening hazards of using flammable solvents in the penstock and arrange for immediately available emergency response services onsite prior to the start of the epoxy application.
  • Xcel and RPI did neither arrange for a competent outside rescue and emergency services provider nor ensure that their employees could perform rescue and emergency services competently when they were working within a permit-required confined space.
  • Xcel and RPI did not evaluate CCFA’s or other nearby responders technical capabilities.
  • Xcel and RPI did not establish effective daily communication concerning the hazards associated with the penstock recoating project.
  • Xcel did not effectively plan and coordinate with RPI to identify and control serious hazards in the recoating project, including the use of a flammable solvent within the penstock confined space.
  • Xcel’s and RPI’s corporate confined space policies in effect prior to the incident did not effectively establish safe limits for flammable atmospheres that would prohibit entry or occupancy when the limits were exceeded.
  • Xcel’s corporate policies allowed a contractor with “unacceptable” safety performance to further compete in the contractor selection process.
  • Xcel’s policies addressing contractor selection do not require that the records be verified and Xcel confirmed that it had not verified RPI’s submissions or researched its background.
  • Xcel ineffectively implemented its program for contractor safety oversight in a number of key areas identified by its contractor safety policy.
  • Xcel’s corporate policies and contracting documentation place primary responsibility for safety on the contractor for work under its control, but Xcel policies also contain specific contractor safety oversight requirements.
  • Xcel acknowledged to the CSB that it had not audited the performance of its corporate contractor selection and safety oversight program prior to the incident.
  • The SCPDI Training Center is responsible for providing in-depth safety training only to individuals who are either just entering the industrial/commercial painting field or those referred to the Training Center by their employer for a skills evaluation and are subsequently found to be lacking in painting skills and abilities.
  • These training gaps are compounded because the Training Center does not, and is not expected or required to, provide instruction on company-specific policies or site-specific hazards.
  • The PUC rules and the new mandated criteria do not require that past safety performance be considered as a factor in the competitive bidding process, nor do they include safety prequalification or disqualification procedures.

Failed Safeguards or Barrier Breakdowns

  • A hazard evaluation of the epoxy recoating work was not performed.
  • Effective controls were not evaluated or implemented during pre-job safety planning, such as substituting MEK with a non-flammable solvent.
  • The Cabin Creek penstock was not treated as a permit-required confined space during the recoating project.
  • A confined space monitoring plan was not established.
  • Continuous monitoring in the work area where flammables were being used was not provided.
  • A maximum permissible percentage of the lower explosive limit (LEL) for safe entry and occupancy inside a permit space was not required or established.
  • The atmosphere of the penstock was monitored only at the entrance, rather than where flammables were being used.
  • No reevaluation of the safety hazards was held when work changed from sandblasting to epoxy coating application.
  • Conductive hose was not used with the sprayer.
  • Explosion proof portable lamps were not used to illuminate the spray areas.
  • Fire extinguishers were not in close proximity to all painting operations.
  • No emergency responders with confined space technical rescue certification were immediately available.
  • No plan for an alternate escape route out of the penstock was in place.
  • A safety/rescue chamber was not provided in the penstock.
  • Xcel’s prequalification process did not consider safety performance.
  • RPI’s safety record was rated “zero” in the safety category, but the proposal was not automatically rejected.
  • Xcel did not increase its oversight of RPI nor implement corrective actions after serious safety problems were identified.
  • Xcel and RPI did not establish effective daily communication concerning hazards.
  • Xcel and RPI did not arrange for timely rescue.
  • The site was not pre-equiped with appropriate firefighting equipment specific to the unique hazards of the penstock.
  • Xcel and RPI managers did not establish effective daily communication concerning the hazards associated with the penstock recoating project.
  • Xcel did not effectively plan and coordinate with RPI to identify and control serious hazards in the recoating project, including the use of a flammable solvent within the penstock confined space.
  • The Xcel project manager or safety staff made documented safety observations only on two occasions at the penstock; these safety observations were ineffectively performed and failed to identify the serious confined space hazards.
  • Violations of Xcel safety standards and OSHA regulations were not promptly communicated and corrected.
  • RPI did not provide adequate training to its employees on its safety policies and procedures.
  • Only nine of the 14 RPI employees received onsite training at Cabin Creek prior to the start of the recoating project, and that training was both abbreviated and did not effectively address the hazards inherent to the penstock recoating work.
  • The onsite training did not include a site-specific discussion of safe use of flammable solvents in confined spaces.
  • Neither Xcel nor RPI discussed the lack of a secondary egress with the work crew during the onsite training.
  • The orientation did not cover emergency response and evacuation plans or safeguards for minimizing fire hazards within the confined space.
  • RPI employees were not trained on the proper and safe use of the Graco epoxy sprayer system.
  • Xcel’s and RPI’s corporate safety policies and permits did not effectively establish safe limits for flammable atmospheres in permit-required confined spaces that would prohibit entry or occupancy when those limits were exceeded.
  • Neither company ensured that emergency response organizations or personnel with confined space technical rescue qualifications were immediately available with the necessary fire-fighting equipment outside the penstock.
  • Xcel’s contractor selection practices typically provided only for disqualification from the bidding process based upon financial capacity, not safety criteria.
  • RPI did not disclose to Xcel regulatory violations resolved within the requested three-year period as part of the RFP evaluation process.

Recommendations

  1. 2008-01-I-CO-R1 — Recipient: Occupational Safety and Health Administration (OSHA) — Status: Closed – Reconsidered/Superseded — Summary: Amend the OSHA Permit-Required Confined Spaces Rule for general industry (29 CFR 1910.146) to establish a maximum permissible percentage substantially below the lower explosive limit (LEL) for safe entry and occupancy in permit-required confined spaces.
  2. 2008-01-I-CO-R2 — Recipient: Occupational Safety and Health Administration (OSHA) — Status: Closed – Acceptable Alternative Action — Summary: Publish a “Safety and Health Information Bulletin” addressing the hazards and controls when using flammable materials in confined spaces that includes actionable guidance regarding: a. The importance of implementing a hierarchy of controls to address hazards in a confined space that first seeks to eliminate hazards or substitute with a less hazardous material(s) or method(s). Examples include performing work outside of a confined space where reasonably practicable or substituting a flammable material with a non-flammable one. b. The necessity of establishing a maximum permissible percentage substantially below the lower explosive limit (LEL) for safe entry and occupancy of permit required confined spaces. c. The need to comprehensively control all potential ignition sources and continuously monitor the confined space at appropriate locations and elevations when work activities involve the use of flammable materials or where flammable atmospheres may be created. d. The importance of treating confined spaces with the potential for flammable atmospheres above 10 percent of the LEL as a hazard immediately dangerous to life or health (IDLH) that requires rescuers to be stationed directly outside the permit space and available for immediate rescue with appropriate fire-extinguishing and rescue equipment. e. The requirement that confined spaces such as penstocks be managed as permit-required that are so large or part of a continuous system that they cannot be fully characterized from the entry point. Such spaces need to be monitored for hazardous atmospheres both prior to entry and continuously in areas where entrants are working.
  3. 2008-01-I-CO-R3 — Recipient: The Governor of the State of Colorado — Status: — Summary: Implement, through the Division of Fire Safety, an accredited firefighter certification program for technical rescue that encompasses appropriate specialty areas including confined space rescue.
  4. 2008-01-I-CO-R4 — Recipient: The Colorado Public Utilities Commission — Status: Closed - Unacceptable Action/No Response Received — Summary: a. Require regulated utilities to investigate the facts, conditions, and circumstances of all incidents resulting in death, serious injury or significant property damage as defined in Section 3204 b. Require utilities to submit a written investigation report to the Commission within one year of the incident that contains the investigation findings, root causes and recommendations for preventing future incidents that focus on needed changes to utility safety systems. All reports shall be made public. c. Authorize the commission to issue orders addressing needed corrective actions to be taken as a result of the incident. d. Require utilities to submit periodic reports to the Commission detailing action taken on the incident report recommendations and Commission orders. All reports shall be made the public.
  5. 2008-01-I-CO-R5 — Recipient: The Colorado Public Utilities Commission — Status: Closed - Unacceptable Action/No Response Received — Summary: Require all regulated utilities to fully cooperate with all government safety investigations including facilitating access to witnesses, facilities, and equipment; providing copies of requested records; and responding to interrogatories and other investigative requests for information as expeditiously as possible.
  6. 2008-01-I-CO-R6 — Recipient: The Colorado Public Utilities Commission — Status: Closed - Unacceptable Action/No Response Received — Summary: Require that competitive bidding and contractor selection rules for construction, maintenance or repair of regulated utilities include procedures for prequalifying or disqualifying contractors based on specific safety performance measures and qualifications.
  7. 2008-01-I-CO-R7 — Recipient: Director of the Division of Fire Safety and the Director the Division of Emergency Management for the State of Colorado — Status: — Summary: Publish a safety communication that will inform fire service and emergency planning organizations in the state about the confined space safety lessons learned from the Cabin Creek incident including a. The need to train and certify emergency response personnel who perform technical, including confined space, rescue. b. The importance of a written confined space rescue plan for each designated permit space. c. The importance of treating confined spaces with the potential for flammable atmospheres above 10 percent of the LEL as a hazard immediately dangerous to life or health that requires rescuers to be stationed directly outside the permit space and available for immediate rescue with appropriate fire-extinguishing and rescue equipment. d. The need for confined space rescue procedures to instruct emergency responders to not enter or occupy a confined space containing a flammable atmosphere 10 percent of the LEL or greater.
  8. 2008-01-I-CO-R8 — Recipient: Xcel Energy, Inc. — Status: Closed – Acceptable Action — Summary: Revise your policies for solicitation and procurement of construction services to a. Ensure that requests for proposals (RFPs) and selection processes include criteria and procedures for prequalifying or disqualifying contractors based on specific safety performance measures and qualifications. b. Implement written verification procedures for the safety information and documentation submitted by contractors during the bidding and selection process.
  9. 2008-01-I-CO-R9 — Recipient: Xcel Energy, Inc. — Status: Closed – Acceptable Action — Summary: Revise your contractor safety policies to require a comprehensive review and evaluation of contractor safety policies and procedures such as the permit-required confined space program and safety performance of contractors working in confined spaces to ensure that any bidding contractor meets or exceeds Xcel Energy safety requirements.
  10. 2008-01-I-CO-R10 — Recipient: Xcel Energy, Inc. — Status: Closed – Acceptable Action — Summary: Conduct periodic safety audits of contractor selection and oversight at your power-generating facilities to ensure adherence to corporate contractor procurement and safety policies.
  11. 2008-01-I-CO-R11 — Recipient: Xcel Energy, Inc. — Status: Closed – Acceptable Action — Summary: Report key findings, causes and recommendations of the CSB report to Xcel shareholders so that the owners of Xcel are fully informed of the report contents and how Xcel intends to prevent a similar accident in the future.
  12. 2008-01-I-CO-R12 — Recipient: Xcel Energy, Inc. (Xcel) — Status: Closed –Unacceptable Action/No Response Received — Summary: Revise your confined space entry program and practices. At a minimum: a. Require continuous monitoring for flammable atmospheres at appropriate locations and elevations within a confined space where work activities involve the use of flammables or where flammable atmospheres may be created. b. Prohibit entry or require evacuation of a confined space if the atmospheric concentration of flammable vapors is 10 percent of the LEL or higher. c. Ensure that confined spaces such as penstocks be managed as permit-required that are so large or part of a continuous system that they cannot be fully characterized from the entry point. Ensure that such spaces are monitored for hazardous atmospheres both prior to entry and continuously in areas where entrants are working. d. Ensure that evacuation plans for penstocks that have only one egress point provide for alternative escape routes and/or refuge chambers. e. Ensure the implementation of a written confined space rescue preplan for each designated permit space. Address staging and methods of rescue for each designated permit space including whether a rescue team is required to standby outside the space. Require that confined space rescue teams be standing by at the permit spaces where the hazards pose an immediate threat to life or health including the hazard of a potential flammable atmosphere.
  13. 2008-01-I-CO-R13 — Recipient: RPI Coating, Inc. (RPI) — Status: Closed -Acceptable Action — Summary: Revise your confined space entry program and practices. At a minimum a. Require continuous monitoring for flammable atmospheres at appropriate locations and elevations within a confined space where work activities involve the use of flammables or where flammable atmospheres may be created. b. Prohibit entry or require evacuation of a confined space if the atmospheric concentration of flammable vapors is 10 percent of the LEL or higher. c. Ensure that confined spaces such as penstocks be managed as permit-required that are so large or part of a continuous system that they cannot be fully characterized from the entry point. Ensure that such spaces are monitored for hazardous atmospheres both prior to entry and continuously in areas where entrants are working. d. Ensure that evacuation plans for penstocks that have only one egress point provide for alternative escape routes and/or refuge chambers. e. Ensure the implementation of a written confined space rescue preplan for each designated permit space. Address staging and methods of rescue for each designated permit space including whether a rescue team is required to standby outside the space. Require that confined space rescue teams be standing by at the permit spaces where the hazards pose an immediate threat to life or health including the hazard of a potential flammable atmosphere.
  14. 2008-01-I-CO-R14 — Recipient: RPI Coating, Inc. — Status: — Summary: Based on the findings and conclusions of this report, hire a certified safety professional to conduct periodic safety audits at your worksites. At a minimum, assess safety training, confined space safety, safe handling of flammables, emergency response, rescue, and fire prevention.
  15. 2008-01-I-CO-R15 — Recipient: RPI Coating, Inc. — Status: — Summary: Ensure that all journeyman painters have received safety training equivalent in content to that covered in the Joint Apprenticeship program. At a minimum, address confined space safety, safe handling of flammables, emergency response and rescue, and fire prevention.
  16. 2008-01-I-CO-R16 — Recipient: The Society for Protective Coatings (SSPC) — Status: — Summary: See below for recommendations text.
  17. 2008-01-I-CO-R17 — Recipient: American Public Power Association (APPA) — Status: Closed – Acceptable Alternative Action — Summary: Publish safety guidance addressing the hazards and controls for using hazardous materials including flammables in confined spaces and the unique hazards of penstocks. At a minimum a. In controlling hazards in confined spaces, implement a hierarchy of controls by first attempting to eliminate hazards or substitute with a less hazardous material(s) or method(s). Examples include performing work outside of a confined space where reasonably practicable or substituting a flammable material with a non-flammable one. b. Establish a maximum permissible percentage substantially below the LEL for safe entry and occupancy of permit-required confined spaces. c. Recommend that confined spaces that are large, or part of a continuous system such as a penstock, always be managed as permit-required as defined in the OSHA Confined Space Standard, and that such spaces always be monitored for hazardous atmospheres both prior to entry and continuously in areas where work is being performed. d. Ensure that evacuation plans for penstocks that have only one egress point provide for alternative escape routes or refuge chambers. e. Provide guidance for implementing a written confined space rescue plan. Address staging and methods of rescue for each designated permit space including whether a rescue team is required to stand by outside the space. Require that confined space rescue teams be standing by at the permit
  18. 2008-01-I-CO-R18 — Recipient: Southern California Painting and Drywall Industries Joint Apprenticeship and Training Committee (SCPDI-JAT Committee) — Status: Closed – Acceptable Action — Summary: Require that all journeyman painters who are employees and/or members have received safety training equivalent in content to that covered in the Joint Apprenticeship program. At a minimum, address confined space safety, safe handling of flammables, emergency response and rescue, and fire prevention.
  19. 2008-01-I-CO-R19 — Recipient: Southern California Painting and Drywall Industries Joint Apprenticeship and Training (SCPDI-JAT) Committee — Status: Closed—Acceptable Acton — Summary: Include a safety knowledge and skills component to your journeyman and apprentice evaluation criteria.

Key Engineering Lessons

  • Use a non-flammable solvent where practicable; the CSB determined that the use of a non-flammable solvent would have prevented the Cabin Creek fire.
  • Do not rely on non-conductive hose and isolated metal components when flushing flammable solvents; the CSB concluded the ignition was most likely from static spark associated with the hose/swivel connector arrangement.
  • Treat large or continuous systems such as penstocks as permit-required confined spaces and monitor hazardous atmospheres both prior to entry and continuously in the work area where flammables are being used.
  • When a penstock has only one egress point, evacuation planning must include alternative escape routes and/or refuge chambers.
  • Fire extinguishers and rescue equipment must be immediately available at the work area when flammables are present in a confined space.
  • Hazard evaluation must be re-done when work changes from sandblasting to epoxy coating application and solvent flushing.

Source Notes

  • Priority 1 final report used to resolve conflicts and establish authoritative findings.
  • Priority 3 recommendation status summaries were used to update recommendation statuses and later corrective actions.
  • Priority 4 supporting documents were used only where they did not conflict with higher-priority sources.
  • All facts are limited to the provided source extracts; no external information was added.

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