August 5, 2021

CSB Releases Safety Video on 2019 Toxic Gas Release

A new safety video published by the U.S. Chemical Safety and Hazard Investigation Board (CSB) focuses on a release of toxic hydrogen sulfide gas that occurred on Oct. 26, 2019, at a waterflood station operated by Aghorn Operating Inc. near Odessa, Texas. The release fatally injured an Aghorn pump worker, while he responded to an alarm at the station, and his spouse, who entered the station through unlocked gates to search for the worker after he did not return home that evening. CSB’s video covers the facts of the incident and features an animation that explains the facility’s operation and the events leading to the gas release. The video also includes segments from interviews with Katherine Lemos, CSB chairperson, and Lauren Grim, the agency’s lead investigator.

The video, titled “Silent Killer: Hydrogen Sulfide Release in Odessa, Texas,” highlights six safety issues identified by CSB’s investigation as causing or contributing to the two people’s deaths. First, although the pump worker possessed a personal hydrogen sulfide detection device, he did not wear it on the night of the incident and Aghorn management did not require the use of the device. Second, at the time of the incident, Aghorn did not have a written lockout/tagout policy, so the pump worker did not disconnect the pump from its power source before performing work on it to address the cause of the alarm. This allowed the pump to automatically activate and release water containing hydrogen sulfide gas while the worker was in the pump house.

The third safety issue identified by CSB was the lack of ventilation in the pump house, which prevented the toxic gas from being exhausted out of the building. Fourth, CSB found that Aghorn lacked an effective safety management program, having created its lockout/tagout procedure only after the fatal incident occurred. Fifth, the waterflood station’s hydrogen sulfide detection and alarm system was nonfunctional on the night of the incident. Finally, CSB determined that Aghorn’s informal policy was for pump workers to leave access gates unlocked while working at waterflood stations, a deficiency in site security that allowed the pump worker’s spouse to enter the facility, where she was exposed to the toxic gas.

In an executive summary accompanying the video, CSB lists seven recommended actions for Aghorn to take in the wake of the incident, addressing the safety issues previously mentioned. Additionally, CSB recommends that federal OSHA issue a safety information document addressing requirements for protecting workers from hazardous air contaminants and for the Railroad Commission of Texas, the state regulator, to send a notice to all oil and gas operators under its jurisdiction describing the safety issues outlined in the report.

To watch the safety video, download a PDF of the executive summary, and learn more about the incident and investigation, visit CSB’s website.