On the evening of October 26, 2019, hydrogen sulfide (H2S) was released inside the pump house of an Aghorn Operating waterflood station in Odessa, Texas. An Aghorn pumper working at the station was fatally injured. His wife, who went to the facility to look for him when he did not return home, was also killed.
The pumper did not lock out Pump #1 before working on it. The pump activated automatically, and water containing H2S was released from it into the pump house. He was not wearing his personal H2S detector, and there was no evidence that Aghorn management required their use.
The CSB identified six safety issues: nonuse of the personal H2S detector, nonperformance of lockout/tagout, confinement of H2S inside the pump house, lack of a safety management program, a nonfunctioning H2S detection and alarm system, and deficient site security. The May 2021 report issued 9 recommendations: 7 to Aghorn, 1 to OSHA, and 1 to the Railroad Commission of Texas. All are closed.
Full recommendation text and current status: CSB investigation page.
See this incident worked through four investigation methods (5-Whys, fishbone, barrier analysis, fault tree): One Incident, Four Investigation Methods →
This incident involved breakdowns across 4 PSM-related areas (SOP · TRN · MI · EAP). Each represents a gap that process safety programs are designed to close.