Breakdowns in communication led to the death of a pipefitter at Total Lindsey Oil Refinery, an inquest found.
Returning a narrative verdict at the inquest of Robert Greenacre, a jury concluded there had been "a series of miscommunications". North Lincolnshire and Grimsby coroner Paul Kelly read the unanimous narrative verdict of the jury to the court, which has been sitting for two days at Cleethorpes Town Hall.
The verdict stated Mr Greenacre died from inhalation of combustible products which gushed out of a pipe and the subsequent explosion at the refinery, at 11.45am, on June 29, 2010.
He said: "It was due to a series of miscommunications during maintenance work to column 23-1 at Lindsey Oil Refinery, North Killingholme, which resulted in the incorrect flange being opened and the subsequent release of hot crude oil which led to an explosion and fire which resulted in the deceased's tragic death."
The coroner passed on his sympathies to the family of the 24-year-old, of Hampstead Park, Scartho Top, who attended the hearing.
Mystery still surrounds why the two pipefitters were working on the wrong part of pipework. The inquest heard conflicting evidence from the process operator, Malcolm Dunwell, and pipefitter Richard Quickfall.
Mr Dunwell said he had directed Mr Greenacre and Mr Quickfall to the correct length of pipe.
Mr Dunwell, who has worked at the refinery for 22 years, said he had gestured to the two men and they had "nodded and smiled" in recognition.
He said the flange was not marked with any green tags, which could have identified the exact position of the replacement part to be installed.
The noise from the refinery had prevented him speaking directly to the two men.
But Mr Quickfall told the inquest that he and Mr Greenacre had unbolted the flange which had been identified to them.
Health and Safety Executive inspector John Moran said there was a discrepancy in the evidence. "I have no means of corroborating this account. It will not come to light," he said.
About 10 tonnes of crude oil gushed from the pipe and caused a large plume of vapour to escape, as reported.
The ignition of the gas which caused the explosion had "possibly come from one of the nearby furnaces at the refinery", said Mr Moran.
The safety tag system should have been used to identify the correct part of the pipe, he said.
He said the lack of a valve mechanism to close down the flow of oil between the foot of the column and the area where the two men worked was "not good practice."
Mr Moran declined to comment after the hearing on whether there would be further action taken by the Health and Safety Executive.
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