Company Alert

IR-2018-24299 – Kuwait - EF/1852 (ISS2) –

Explosion at Substation Battery Room, Cat 4, LTI
Element 2 : Risk Management
INCIDENT DESCRIPTION:
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On 24 June 2018, @ 14:30 hrs., Contractor’s pre-commissioning
team consisting of five persons was engaged in the charging of a
string of 578 nickel cadmium cells in the battery room of the ISS2
substation when an explosion occurred. All five members of the
pre-commissioning team were transferred to the local hospital for
treatment. Four of the persons within the battery room sustained
minor electrolyte burns and were released on the same day. The
fifth person, the vendor’s representative, suffered more serious
injuries including extensive electrolyte burns, damaged liver, and
a fractured left leg leading to a lost-time injury (LTI). The IP was
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discharged from the hospital on 5 September and at time of
writing confirmed he has made a full recovery.
CONTRIBUTING/CAUSAL FACTOR(S):
Inadequate ventilation – The cause of the explosion was Hydrogen (H2) accumulation due to inadequate
ventilation. H2 is released during battery charging and becomes an explosion hazard when it saturates the
atmosphere by at least 4%.
Inadequate Warning System – The fixed H2 detection system within the battery room was not yet functional and
a portable H2 detector was not used.
Misperception of Risk / Lack of Training – The personnel involved in the activity were unaware of the risk of H2
emission during charging operations and the possible sources of ignition, e.g., temporary (not-Ex certified) AC
chillers, mobile phones, laptop, and static build-up on clothing/tools.
Inadequate Development of Procedures – A thorough Risk Assessment/Method Statement was not developed.
The pre-commissioning team relied on the Vendor’s procedure which covered only the supplied vendor’s
equipment.
Poor Planning – Battery charging was carried out despite that fact that the permanent H2 detection system was
not commissioned.

KEY LEARNING(S):
 Thorough Risk Assessment/Method Statement (RAMS) to be developed to address potential hazards
involving battery charging operations.
 Pre-commissioning team involved in battery charging operations shall include a competent and experienced
supervisor and the team shall be coached on the specific safety requirements identified within the RAMS.
 Contractor shall assess whether the permanent HVAC system in the battery room is capable of diluting the H2
released during battery charging operations. Supplemental external AC chillers may be necessary based on
Contractor’s assessment.
 Undue pressure must not override safety measures just to meet turnover schedules. A functional H2 detection
system must be utilized during battery charging operations.

Issued by: John Curtis

Signature:
Authorized by: Robert Harrington

Remove from notice

Date of issue: 05 November 2018 05 November 2019
boards by:

Distribution: Global HSE

10. 24.06.18 - 24299 - Kuwait-EF1852 (ISS2) Explosion at Substation 722.._ Rev:7 Improvement Suggestion 1