Final reportFirePersonnel Injury
External heater treater fire with three burn injuries, Grand Isle Block 115
A fire external to a heater treater on an LLOG-operated production facility injured three workers with burns. BSEE convened a panel investigation (2018-002).
Source information
- Source
- Bureau of Safety and Environmental Enforcement
- Investigating authority
- Bureau of Safety and Environmental Enforcement
- Report / reference no.
- BSEE Panel 2018-002
- Publication date
- Aug 30, 2018
- Last verified
- Oct 4, 2026
Event description
BSEE’s panel found that flammable gas released while oil tank thief hatches were open reached a fired heater treater. A JSA for the circulating task listed isolating the vessel and turning off burners as a critical step.
Source / investigation findings: BSEE
Probable / root cause
Personnel failed to sufficiently mitigate hazards, and there was a lack of sufficient engineering controls (BSEE panel causes).
Contributing factors
- LLOG’s JSA for “Circulating Emulsion Pad from Treater and Oil Tanks” listed “isolate the inlet and outlet of vessel and turn off burners” as a critical step; BSEE found that following it would likely have eliminated the heat source.
- Neither the dry nor wet oil tank had an enclosed flow path from the heater treater or chemical totes, so thief hatches were opened, releasing flammable gas to atmosphere.
Recommendations
- Consider the location(s) of fired elements relative to potential gas releases when performing facility-level hazard analyses.
- Consider the use of permanent containment systems for vessel draining and chemical treatment.
- Consider conducting visual inspections of natural draft burners, ensuring airtight integrity between flame arrestors and fire tubes.
- Consider the use of a portable gas detector when operating in the vicinity of fired vessels.
- Consider increasing operator supervisory presence when using contractor-employed supervisory personnel during non-routine operations.
- Consider ensuring production SOPs are used for site specific equipment and/or conditions.
Lessons learned
Gulf of America educational summary
Open hatches released gas next to a burner that the job plan said should have been shut off. The fix was already written in the JSA — it just was not done on the day.
- Treat “turn off burners / isolate the vessel” steps as hold points, not suggestions.
- Carry a portable gas detector when working near fired equipment.
- Non-routine production tasks deserve closer supervision than routine ones.
Plain-language interpretation by Gulf of America. Not a finding of BSEE or any investigating authority.