SINGAPORE - Small-bore pipelines used by a company to fill liquefied petroleum gas (LPG) cylinders had been modified some years ago so more cylinders could be filled at once, and were not protected from impact.

As a result, when the filling system malfunctioned and a cylinder toppled over, one of the pipes was dislodged, releasing LPG which ignited and caused a massive fire last year.

One Chinese worker was killed and two others were injured.

The workers, who were operating a filling station in Summit Gas System's Jalan Buroh site, were not wearing fire retardant clothing and their escape route was blocked by cylinders.

Another factor contributing to the accident was the emergency shutdown button for the filling line being located at the other end of the filling shed, with no other workers nearby to activate it when the fire first started.

LPG thus continued to flow into the supply line after the pipe was dislodged, fuelling the fire.

These were among the findings in a learning report released by the Ministry of Manpower (MOM) on Tuesday (March 10).

"Workers were not familiar with the actions to be taken in the event of an emergency," it noted.

The fire in the Jurong industrial area broke out on June 21 last year and took about 120 firefighters more than two hours to bring under control.

It involved hundreds of highly flammable LPG cylinders at the bottling and storage facility occupied by Summit Gas Systems.

Summit Gas Systems is a subsidiary of Union Energy Corporation, which supplies LPG cylinders to homes and businesses.

This is the first learning report published after the measure was introduced in 2018 to allow the MOM to share recommendations and learning points from accidents without waiting for criminal proceedings to conclude, which could take as long as three years from the date of the accident.

The reports are not admissible in court proceedings and do not state liability.

The ministry works with employers to identify proprietary information to exclude from the report.

Singapore aims to reduce its annual workplace fatality rate to less than one death per 100,000 workers before 2028, a target set by Prime Minister Lee Hsien Loong in 2017.

In 2018, the three-year average rate was 1.4 deaths per 100,000 workers.

The learning report, which was published by the Commissioner for Workplace Safety and Health, made several recommendations for workplaces that store and handle flammable substances like LPG:

- Protect small-bore pipelines from external impact with barricades or guards.

- Have a master shutdown button to stop the entire gas filling operation if needed.

- Ensure workers in areas where LPG or other flammable substances are present wear fire retardant clothing, to protect them against burns and make it easier for them to escape during a fire.

- Plan and implement an effective emergency response to any fire or explosion, and appoint and train people to activate emergency cut-offs of the main supply of flammable substances.

- Address possible new hazards from improvements to operations.

- Ensure electrical equipment and wiring do not pose a fire hazard.

- Maintain a safe distance between LPG cylinder storage areas and other parts of the workplace to minimise the spread of a fire.

The MOM said it hopes other companies with small-bore pipelines and other related set-ups - such as those in the chemicals industry - can be more aware of the risks and take action to mitigate these.

It has uploaded the report on its website and will disseminate it via the workplace safety and health bulletin, which has 72,000 subscribers, as well as through unions and business associations.

The ministry is continuing its investigation into the responsibilities of various parties involved in the Summit Gas accident.