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HAZOP Case Study

CSB Investigation of H2S Poisoning in a Pump House in Texas: Aghorn Operating Waterflood Station Hydrogen Sulfide Release

https://www.csb.gov/aghorn-operating-waterflood-station-hydrogen-sulfide-release-/

1:50 - 6:50 Event Summary

  • Oil and water mixture sits and separates in an initial holding tank

  • Water (Produced Water) is pumped out of the bottom to reintroduce into the well then pumped to the suction tank

  • Waterflood station or pump house used to pressurize water

  • High pressure piston pumps inject water back into the well to allow greater amounts of oil to be recovered

  • Pump house occasionally occupied 2x per day

  • H2S alarm and critical warning light not functional

  • Alarm notification to service personal of an oil level alarm with pump malfunction of some kind

  • Personal H2S monitor not brought into pump house by the operator

  • Pump plunger had shattered and H2S was released with the water

  • Operator was fatally injured by H2S

  • Wife also fatally injured by H2S

References
  1. Guymon, C. (2025). Foundations of Spiritual and Physical Safety: with Chemical Processes.
Foundations of Spiritual and Physical Safety with Chemical Processes
HAZOP Intro
Foundations of Spiritual and Physical Safety with Chemical Processes
Logic and Safety