Weak Sulphuric acid FRP tank collapse

In a factory, where 10 MT weak sulphuric acid was stored, suddenly the suction line valve tank nozzle assembly got broken and through this opening sulphuric acid drained out from the tank. This resulted in vacuum formation in the tank. This FRP tank hit against the supporting channel legs due to the formation of vacuum.
Causes :
1. The FRP tank was not maintained with a adequate strength and stability

2. The FRP tank was not tested and certified by the Competent person every year

 Source: DGFASLI

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Urea prill tower incident

In a Fertilizer manufacturing factory urea manufactured in prill tower passes through a grizzly (a stainless steel sieve) and falls on a conveyor. To facilitate repair works to be carried out to a grizzly bar, two metal rods were placed above the grizzly bar and this was covered by a tarpaulin sheet.Right below this arrangement welding of grizzly bar was carried out. When the welding process was being carried out heavy lumps of urea started falling down from the prill tower and fell on the iron plates placed over the grizzly bar. The iron plates along with heavy lumps of urea fell on the workers working right below the covered tarpaulin sheet and they sustained head Injuries and died.
Causes :
The temporary arrangements made above the grizzly bar to facilitate welding work was not of a strong and rigid construction to withstand falling of heavy lumps of urea from prill tower.

Ref:DGFASLI




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How the Apollo 1 Fire Changed Spaceship Design Forever

Interesting article on how designers learn from their mistakes.....after all they are also human.
How the Apollo 1 Fire Changed Spaceship Design Forever


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Accident and emergency | Chemistry World

Accident and emergency | Chemistry World

‘2015 should be remembered as a year when the chemical industry was sharply reminded of its social responsibility’



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Empty drums are deadly drums

Often empty drums are treated with much less safety precautions than filled drums. An empty drum that has not been purged free of residues chemicals is a potential bomb. Read about an incident from HSE UK, with a small film about the incident in this link.


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Management of Change or Change of Management?

In 1999, when I was carrying out a PSM audit, we were auditing a maintenance mechanic. I was asking whether he can explain what is the meaning of management of change. He replied that when his company was recently taken over by another company, that is management of change!
Are you carrying out MOC for change in Management?

 
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Whitepaper on dust explosions

Read a good white paper by Fike about Dust explosions in this link.

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Ammonia leak kills one

News reports coming in of an accident in an ammonia plant in Canada when a contractor employee who was doing weather proofing job on an ammonia storage tank was killed due to an ammonia release. Apparently, a piece of equipment struck a valve on the tank and caused the leak. This accident highlights the dangers of working with highly hazardous chemicals and the need for proper JSA's to be carried out.

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4 die in boiler explosion - TAMIL NADU - The Hindu

4 die in boiler explosion - TAMIL NADU - The Hindu


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OSHA Investigating Explosion at Orla Gas Plant Previously Fined - KWES NewsWest 9 / Midland, Odessa, Big Spring, TX: newswest9.com |

OSHA Investigating Explosion at Orla Gas Plant Previously Fined - KWES NewsWest 9 / Midland, Odessa, Big Spring, TX: newswest9.com |



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Caspian sea oil rig fire

Thanks to S.Sanjeevi for sending news about the Caspian sea oil rig fire. Read about the incident in this link.

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Lessons relearned - TCE - inadequate isolations

Read a TCE article on Lessons relearned - inadequate isolations in this link.

 
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The Ghosts of Bhopal

On the 31st anniversary of the Bhopal Gas Disaster, and with the post Bhopal generation of Chemical Engineers now managing Chemical plants, let us remind ourselves that the Ghosts of Bhopal are still around. We continue to see compromises in process safety management leading to catastrophic accidents.

• For a new generation who have grown up with ISO and PSM systems, remind yourself that systems alone cannot prevent accidents. 
• You must not be deaf and blind to what the systems are telling you. 
• You must also speak up and not be mute when you observe process safety issues. 
• Do not forget the lessons from the past. 
• For people at the highest level in the organization, do not get lulled into a false sense of security just because nothing has happened. 
• Actively seek out bad news...remember the ghosts of Bhopal are still around, waiting to give you a scare....

An example of the Ghosts of Bhopal is the recent CSB incident investigation report of the Caribbean Petroleum Tank terminal explosion and multiple fires released by CSb in October 2015.
CSB finds that systemic failures at CAPECO included: (The highlighted failures are the same failures that happened in Bhopal)

1. A history of poorly maintaining terminal operations;
2. An inherent financial pressure to fill the tanks within the Planning Department’s stipulated time, which was at odds with safety;
3. A failure to learn from previous overfill incidents at the facility;
4. A lack of preventative maintenance for the malfunctioning float and tape device, automatic tank gauge transmitters;
5. An unreliable computer for calculating tank fill times;
6. A lack of overfill prevention safeguards as an independent alarm;
7. A lack of formal procedures for tank-filling operations for operators and managers;
8. An insufficient mechanical integrity program for safety critical equipment;
9. Poor adherence to human factors principles for safety critical equipment.

I also managed to locate a Dec 31, 1984 article on the Bhopal Gas Disaster written in India Today. Read it in this link.

Read an eyewitness account of a IIT professor who was travelling by train at Bhopal station when the disaster occurred in this link 

Remind your employees, including top management that the ghosts of Bhopal are still around by organizing a process safety week from December 2nd every year
 
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Beware of hose worm clamps!

 A chemical cleaning unit of a heat exchanger was rigged up with hoses, fixed with clamps. When the cleaning operation was going on, one of the workers accidentally stepped on the hose which was sending in pressurised chemical cleaning solution. The hose worm clamp gave way and the hose sprayed chemical cleaning solution into the eyes of the worker, causing permanent damage to his vision.

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A non profit organisations view about Process Safety in the USA

The Center for Effective Governance in the USA (a non profit organisation) has published a report called "Blowing smoke" where they say that " Voluntary standards don’t work, and existing regulations are not effectively enforced"
Read about the report in this link.
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Report Finds 85 Fatalities in The Chemicals Industry Last Year

Report Finds 85 Fatalities in The Chemicals Industry Last Year



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Quest Integrity: Inspecting fired heaters with plug headers

Quest Integrity: Inspecting fired heaters with plug headers



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Fatality due to inadequate LOTO

 Fatality due to inadequate LOTO

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12 injured in explosion in Tata Steel plant - The Hindu

12 injured in explosion in Tata Steel plant - The Hindu

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Chlorine accidents

Chlorine accidents

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Learn from a Safety Guru | Chemical Processing

Learn from a Safety Guru | Chemical Processing

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Process Engineering | August Process Puzzler: Avoiding a future accident | Chemical Processing

Process Engineering | August Process Puzzler: Avoiding a future accident | Chemical Processing

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Incident due to nomalization of deviation

Operators used to routinely try to clear blockages in an asphalt line by heating the line externally with a propane torch. In this incident, this normalisation of deviation turned into an incident when it caused an explosion in the tank. Read about the incident in this link.

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Key Takeaways from National Chemical Safety Symposium | Powder/Bulk Solids

Key Takeaways from National Chemical Safety Symposium | Powder/Bulk Solids



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Virtual Reality Provides Real Benefits | Chemical Processing

Virtual Reality Provides Real Benefits | Chemical Processing

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When cranes collapse

See a video and photographs of crane accident that happened in Aug 15 in the Netherlands in this link
There are lessons to learn....

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Be careful when dealing with pressurised lines

A man was killed in an accident involving a high-pressure water line at a well site. The victim along with two other men

was trying to heat a frozen high-pressure water line when the line ruptured. The victim was hit by a stream of high pressure water  at a pressure of 3,500 to 4,500 psi.The victim died from the impact of the water.

Read another safety alert from HSE UK http://www.hse.gov.uk/safetybulletins/hydraulic-injection-injury.htm


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Sealant reinjection incident investigation

A paper presented in the Process safety congress at Dordrecht on June 4th, 2015 depicts the detailed incident investigation of the accident at a refinery in Antwerp in 2013 during sealant re injection. Read about it in this link.

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Forty-Eight Case Histories of Intriguing Machinery Problems

Forty-Eight Case Histories of Intriguing Machinery Problems - Nelson Baxter, ABM Technical Services, Mooresville, Indiana


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Readers response to post

Mr M.K.Rao, Executive Director of India Glycols responded to my post "Of Mimic panels and Video walls - back to the past?"
His reply is as follows:

"The subject Blog item is interesting and highly relevant too.

When I entered the DMT control room (IPCL, Baroda) in the year 1981, the scene was similar. The space above the pneumatic controllers had a mimic panel that depicted the complete PFD. In addition, we had a model of the entire plant on a large table in the same control room at a corner. It made learning faster and we used to have a better feel of the process. It was easier to know what was going on at a glance.
 
Going by the best of Past & Present, I feel a combination of

1. DCS work stations
2. Mimic panel representing the complete/ continuous PFD like in the past (Instead of Video panels – which may appear broken)
3. A model (physical) of the plant right in the control room would help"

I agree with his valid suggestions and thank him for responding..
 

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Hydrogen explosion incident

 Read about a hydrogen explosion in a compressor in this link.


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Get To The Root Of Accidents | Chemical Processing

Get To The Root Of Accidents | Chemical Processing


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Dead leg incident

 Read an incident involving a piping dead leg in this link.

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Of Mimic panels and Video walls - back to the past??

 I just returned from a large modern refinery. When I visited the control room, with large video walls, my thoughts went back to 1979 when I was operating an ammonia plant with pneumatic controllers and no DCS. The wall above the controllers had a mimic panel that depicted the complete process flow diagrammatically. This depiction covered the whole control room wall between the controllers and the ceiling, so it was large and easy to see.  The motors and pumps had running lamp indications in the panel. For 300 control loops, we had about 200 hard wired alarms located between the controllers in sets of 20.

See a concocted image of a mimic panel located above pneumatic controllers similar to the one I had used below:

The modern control room I visited looked similar to the one below, with large video walls:

I was recollecting the progress in instrumentation - from pneumatic control systems to electronic to DCS without video walls and now DCS with video walls. - back to the past!!!!
Technology can and will always be an enabler only and as long as human beings exist, human errors will continue...take for instance the modern day DCS. We have so many alarms that inundate the operator during plant upsets, that vendors now sell alarm suppression software! Why do we need that many alarms in the first place???

One important philosophy in Process Safety - KEEP IT SIMPLE AND DON'T FORGET THE PAST!!

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Fire in a laboratory of an industrial gas facility

Reports coming in of a fire in the laboratory of an industrial gas facility in Singapore. Reportedly one person was killed. Read about the incident and see the photos  in this link.

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A temporary change causes a fatality

Temporary changes are dangerous if not managed properly. Read about an incident involving a temporary change that causes a fatality. This incident highlights what Dr trevor Kletz used to say "We do not know what we do not know"
Read the incident in this link.

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Overheated air compressor causes fatality

 Read about an incident involving an overheated air compressor that caused a fatality in this link

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4 workers hurt in explosion at SunEdison's Texas plant : Business

 New coming in about a fire in a polysilicon plant in USA involving Silane. Read about it in this link:
  4 workers hurt in explosion at SunEdison's Texas plant : Business


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