Nov 19, 2020 in Case Studies

Case Study Report

Case Study Report

As a result of an incident at the workplace, one employee died after entering a toluene storage tank and one firefighter was killed during the rescue mission when the tank exploded. This report presents the analysis of the problem, including factors that contributed to this incident; the conclusions of the case; and the suggestions to prevent this from occurring in other similar incidents, comprising standards and regulations that apply to these types of operations.


The incident presented in the case study resulted in explosion and death of two people, the worker and the firefighter. Prior to the event, the toluene storage tank was contaminated and the decision to drain and clean the reservoir was made by the director of a bulk petroleum storage plant. Because the only entrance point to the tank was located on top of the vertical tubular tank, the cleanout entrance point had been decided to be installed at the bottom of the tank when emptied. The maintenance supervisor along with the unskilled laborer aimed to do all the necessary work, after the contractor provided a cost estimate for installing the portal. The site survey revealed that the tank had to be drained, cleaned from all sludge, and ventilated before installing the portal. Right before the incident occurred, the tank was drained to its lowest level; however, some amount of toluene and sludge was left in the bottom of it. The reservoir was also ready for a dry run through the access point at the top of it. In order to do that, a self-breathing apparatus (SCBA) was rented for the laborer to use in performing the planned procedure. The ladder did not fit into the 16-inch diameter opening, so the supervisor decided to secure a knotted rope to the vent pipe on the top of the tank. The rope was lowered into the hole, even though the diameter opening was too small for the laborer to wear the SCBA. When the worker was already in the tank, having no opportunity to wear the mask and not responding to the supervisors commands to come out of the tank, the facility manager called the fire department. After several attempts of the fire officials to rescue the victim from the tank, the explosion occurred. As a result, one firefighter was killed from the detonation, several firefighters were injured, and the laborer inside the tank supposedly died at the time of explosion.

There are several aspects that contributed to the incident described above. One of the factors was that even after the contractor presented the information that the tank had to be drained, cleaned from all sludge, and ventilated, before the portal was installed, it had been decided to perform the procedure having some amount of toluene and sludge in the bottom of the tank. Another major factor was associated with the fact that an unskilled laborer had been involved in the operation process and he was supposed to perform most of the necessary work. The process of draining and cleaning of hazardous materials must be performed by a skilled worker who is aware of the potential harm associated with it. In the case presented, the laborer was an immigrant on his first day back on the job after only 2 months of work in another workplace. Since the case does not provide information about the level of the laborers competence, it has been assumed that he was not properly instructed on the details of the procedure or was not instructed at all. Moreover, there was lack of communication between the supervisor and the laborer, possibly, due to the background difference of the two. Another factor that contributed to the incident was the improper preparation of the tools for performing the intended procedure, such as the decision of the supervisor to use a knotted 1/4 inch rope instead of the ladder, which did not fit into the 16-inch diameter access hole, and to loosely strap the SCBA to the worker so that it was held over his head until he cleared the opening instead of wearing the SCBA from the beginning. Finally, failure of the supervisor to clearly analyze the situation before (study the situation, consider all the harmful consequences, and prepare all the necessary safety and health tools in case of emergency) and after (call the fire department earlier, provide all the information on the hazardous material in the tank, and on the possible state of the worker inside of it to the fire officials) the laborer entered the tank, also contributed to the tragic consequences of the operation.

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In order to prevent a similar incident from occurring in the future, it is necessary to involve only high-skilled employees who are trained specifically to work in the potentially harmful environment that contains hazardous materials. It is highly recommended to provide all the information on the nature of the operation as well as its possible consequences, because the safety and health of the workers are the primary responsibility of the supervisor. In general, it is crucial to have an Accident Prevention Plan, provide it to the worker, and follow all its guidelines as closely as possible.

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There are certain instructions, standards, and regulations that apply to these types of operations. Guidelines on occupational safety and health management systems are presented and controlled by the International Labor Organization (ILO) that is the specialized agency of the United Nations (UN), an intergovernmental organization. The ILO has created guidelines as a tool for helping entities and competent institutions to maintain continual improvement in occupational safety and health. These guidelines have been designed according to the internationally agreed regulations and standards. They intend to protect employees from occupational hazards while enhancing their productivity (International Labour Organisation, 2009). ILO also presented International Labor Standards on Occupational Safety and Health. They include the Constitution of ILO that states that employees must be protected against sickness, injury, or disease associated with his/her employment. It also contains the fundamental principles of occupational safety and health underlined in numerous protocols from various occupational and health conventions, health and safety in specific branches of economy, protection against the risks, and codes of practice (International Labour Organisation, n.d.)

This report focused on analyzing the incident that led to the death of the employee as a result of performing the operation in the hazardous environment and the firefighter as a result of the explosion. According to the safety and health program, some recommendations were made in order to prevent similar incidents in the future. Besides, ILO international guidelines and standards that apply to these types of operation have been presented as well.


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