Sharing of process incidents in India

I really lament the lack of sharing of information and investigations of process incidents in India. The US Chemical Safety Board is doing excellent work by posting videos of incidents for the whole world to see! I can get more information about the BP Texas incident from the internet than I can get about the reasons for the Jaipur Oil depot fire! I was browsing around for details about incident reporting system in India and I chanced upon this website www.cairs.nic.in
I hope the site is kept updated and the information shared.
I am in the process of collecting incidents from friends and colleagues to share with all, without mentioning the organization's name. Unless we learn from past mistakes, the same incident will keep repeating. If any one of you feel like sharing some process incidents without mentioning the name of your organization, please send the details to me. I will put it up on the blog.

Off site chemical disaster management in India

My opinion about off site disaster management in India for chemical disasters is that a lot needs to be done. When I worked in Saudi Arabia, I volunteered to be part of the on site emergency team.The training I underwent for 5 years for just being a member of the on site emergency team was stupendous! We had not only to undergo 4 hours of practical training every month, but weekly refresher trainings also. I was also sent to a 5 day course on advanced emergency response course for hazardous materials and rescue where we learnt to deal with actual emergencies with live fires, gas leaks and personnel rescue techniques from top of distillation columns!!
In India, the off site response to a chemical accident is governed by the Chemical Accidents (emergency planning, preparedness and response) rules 1996.
However, I have seen videos of off site mock drills conducted in India and there is a lot of scope for improvement. I hope the NDMA (National Disaster Management Authority) will soon improve the situation.

MSDS availability and hamonisation

Today in the process safety seminar, a participant asked about the plethora of MSDS available on the net and which one to follow. There is work going on to standardize the MSDS internationally. Please visit this link for further details.

There is also an ISO standard ISO 11014:2009 available for MSDS.
But how many of your personnel know how to interpret the MSDS terms from a view of process safety? My book deals with such practical issues.

Learnings from Process Safety Seminar

Today I attended the Process Safety Seminar conducted by ICC at Chennai, where I had presented a paper on "Management of Change". The learning's from the seminar are as follows:
1. In an incident involving a blast wave, a magnetic hatch on the top of an ethylene tank flew open due to the blast wave as the hatch cover was facing the blast wave and the hinge was on the other side. This allowed ethylene to come out and add to the fire. One of the lessons learnt is - during a HAZOP study look at these issues. It may be a simple issue but an important one.
2. In another incident, a fired heater was supported on fireproofed support legs. During an incident of a coil rupture and a fire, the fire proofed support legs withstood the fire but the vertical metallic stack which was about 20 m in height could not and toppled on other equipment.
3. In a runaway reaction incident where the reactor exploded, the investigator was trying to determine the thermo chemistry of the reaction in a experimental set up. Unfortunately, the reaction temperature increased so rapidly that it destroyed the equipment in the lab! Luckily no one was injured.
4. IS14489:98 (Bureau of Indian Standards - Code of practice on Occupational health and safety audit)- this focuses mainly on OHS issues. However, a committee has updated it with process safety elements also, but the updated code of practice is yet to be released.
5. There was also talk about behaviour based safety, but I am not a fan of BBS. There is a good article from a union's perspective. See the pdf file "the steelworker perspective on behavioral safety"in this link

Hoses and Process Safety

The US Chemical safety board has reported an accident at a DuPont facility at Belle, West Virginia on Saturday. Apparently a braided hose connected to a one tonne phosgene tank ruptured. An operator who was exposed to the gas died the next day. For details see http://www.csb.gov/newsroom/detail.aspx?nid=302.
I am always wary of hoses in a chemical plant. They are silent killers. They may look good on the outside but may have been damaged inside. A facility that wants to ensure process safety must make a list of such hoses, their service and plan a program for replacement. Visual inspection of hoses may offer tell tale signs of hose damage. However, it is best that these hoses are replaced at a certain frequency even if they do not leak. Another option is to consider getting rid of the hoses altogether by replacing with properly designed piping.
I have witnessed a large fire due to a oil hose rupture in a gas compressor which happened in my shift about 25 years ago!The consequences were terrible.The whiplash effect of the ruptured hose sprayed oil over a wide area, contributing to the spread of the fire.

Pilot Error and Process Safety Management - The human connection

Today's paper indicates that Pilot's error caused the helicopter carrying Chief Minister Y.S.R to crash.The investigation report indicates "The cockpit voice recorder showed that there was poor crew resource management among them at any given stage of flying". They noticed a snag in transmission pressure on the instrument displays but failed to co-relate it with other indications associated with the snag. Both of them were busy trying to find out the cause of the snag, with the result that they were not aware that they were veering off course. Crew Resource Management (CRM) is a big issue in the cockpit of a plane or a helicopter. In simple terms, it is how jobs are shared during an emergency.
CRM is very relevant in chemical plant control rooms also. I have witnessed incidents due to wrong actions taken by control room personnel as there was no clear direction who would do what. Having said that, it becomes very difficult to compartmentalize actions during an emergency in a chemical plant. The practical solution to this is to have a senior control room operator monitoring the actions of the DCS operators and guiding them. The senior control room operator's job is like a conductor in an orchestra. Control Room Resource Management is one area where plant simulators can be used to train the personnel.
Another point which is in my mind is the provision of a voice recorder similar to that of a cockpit voice recorder and a CCTV camera in the control room monitoring the actions of the personnel during an emergency. Now I know this is going to get a lot of brickbats thrown at me but the purpose is not to spy on them. It is to make improvements in Control Room Resource Management after emergencies.

Emergency response to terror threats

Terrorism has brought about an added dimension to Process Safety Management. Recently an article mentioned that terrorists may target Indian refineries. Is your organization prepared to handle terror threats? The starting point for determining weak links in your security is by conducting a security vulnerability assessment. Do not assume your current security framework can take care of such threats. Also, prepare an emergency response plan in case the worst takes place. How are you maintaining your emergency isolation valves to shut off feed to the plant and to isolate affected sections? How good are your flare and venting systems protected against collapse during a major fire? How quickly can you safely shut off your plant and evacuate personnel? These are some of the questions that need to be answered.

Are you thinking about implementing PSM?

Twelve years ago, when I was a Dy. General Manager (PSM) in a large organization in India implementing PSM, there were hardly a few industries in India that had heard about PSM.Later, when I became a PSM consultant to the Industry in 2001, I had to struggle a lot to create awareness about PSM.Today the awareness about PSM has tremendously increased. But I am afraid that if organizations are not careful, PSM also will go the way of ISO 14001 and OHSAS 18001. In my opinion, the quality of certification audits for ISO 14001 and OHSAS 18001 has drastically reduced. PSM also should not go that way. To begin with, organizations must be careful when they get into PSM, because they need to know what they are getting into. Wherever I implement PSM, I first check whether the organization is ready - both from a cultural perspective and adequacy of technical competency for PSM. If these are lacking, the organization first needs to attack these issues. PSM is a never ending journey - the scope for continual improvement is immense. Technical competency is a big issue in PSM. Today I see some organizations that are operating hazardous plants who do not have the basic knowledge of chemical engineering principles and reaction chemistry! So, if you are thinking about implementing PSM in your organization, know what you are getting into!

Are your back up systems available?

On Thursday 14th January, it was reported that the entire radar systems at the Air Traffic Control (ATC) at the Indira Gandhi International airport at Delhi failed in the evening for about an hour. It was also reported that no takeoffs or landings could take place for more than two hours following the systems crash. The back up system also failed.The ATC system was finally restored at around 2030 hrs after reloading the system, with the entire procedure taking about three hours. The radar system collapse led to massive delays.
The above incident raises the importance of keeping back up systems always ready. A back up system is just that – it must back up when needed. Obviously something went wrong with the back up also. The only silver lining is that there must have been procedures for manual operation which was obviously put into place as there was no safety of flight issue. How good are your back ups for power supply for the DCS system? How often do you check them? Do not think that it will not happen. I had the personal experience of all 7 DCS screens of a methanol plant operating at full capacity, going blank all of a sudden! Develop procedures and train personnel for handling such situations.

Fire near refinery destroys shanties

It was reported that about 100 shanties were gutted in a fire near the Guwahati refinery on 11.1.2010. Luckily there were no casualties. The cause of the fire is yet to be ascertained. Local residents allege that the effluents released from the refinery in a bypass drain caught fire. The incident raises the question of facility siting and how did the shanties come up near the refinery? The Bhopal disaster was an epitome in facility siting. Shanties were allowed to spring up near the plant leading to greater number of deaths when the gas leaked. In today's scenario, allowing dwellings to come up near hazardous installations poses two risks - one is the exposure of people living in the shanties to the hazards from the installation and the other is from the security and terrorism point of view. The Jaipur oil depot fire also pointed out the hazards of allowing development close to hazardous installations. When will we wake up?

Accidents during transportation of Hazardous Chemicals - learning from NTSB

On12.1.2010, a 55 year old woman died when a chlorine cylinder that was being transported in a mini lorry, reportedly "exploded" at Thirumullaivoyal, near Chennai.
The newspaper photo depicts a mangled mini lorry with remnants of the cylinder that "exploded". I am sure that the investigation will be carried out. But what about the disclosure of the results of the investigation? We must learn from the National Transportation Safety Board of the USA who investigate transportation incidents. They investigate incidents involving aviation, road transport, pipeline and hazardous materials,marine, rail transport etc.Their investigators are on call 24 hours a day, 365 days a year. The results of investigations are posted on their website www.ntsb.gov. Why don't we learn from them? Information shared about the lessons learnt help to prevent another similar incident from happening and lives can be saved.
Another aspect of process safety that has been brought out by the incident is that it was reported that the chlorine was being transported for usage as a disinfectant. Today there are less hazardous alternatives to chlorine for the purpose of disinfection of water. The concept of inherent safety proposed originally by Dr Trevor Kletz propounds exactly this.

Process Safety -Fatigue and training

Between 2007 and 2009, at least 6 commercial aircraft in India landed on the wrong runway. Fatigued crew and lack of training are supposed to be the reasons. Just ponder for a moment - if incidents like these can happen in the aviation industry, can we in the Chemical Industry ignore these issues? Fatigue and training are issues which are relevant to process safety and a lot of work has been done on shift schedules and circadian rhythms.Overtime in a process plant brings about its own problems. My own experience is that a number of incidents happen when the operator is on overtime. We cannot blame the operator. The bigger issue is whether the organisation has a training program that always has manpower in the pipeline - to replace sudden resignations. Just like the software industry, the chemical process industry in India needs to have trained people "on the bench". But this always has its costs. It finally depends on how much risk the organization is prepared to take.

25 Years after the Bhopal Gas Disaster

The bhopal gas disaster on the night of December 2nd/3rd, 1984 led to a number of changes in legislation regarding the management of chemical process safety.
The recent massive blaze at the petroleum storage facility at Jaipur indicates the need for improvement in managing chemical process safety in India.
A comparison of the changes in legislation made in the USA after the Bhopal Gas Disaster with the changes made in India is given below:
Changes made in USA:
1.After the Bhopal Gas Disaster and other accidents in the 1980’s amendments were made to the Clean Air Act (1991). OSHA (Occupational Safety and Health Administration) was authorized to develop its 29 CFR 1910.119 rule of 1992, Process Safety Management. This system is mandatory in the USA since 1992 for chemical industries, storing or processing highly hazardous chemicals, above a threshold quantity. After the implementation of this rule, there was a major incident at the BP Texas refinery in 2005. A thorough investigation about the reasons for the incident and follow up actions are clearly visible to the public. The investigation reports of the incident are made available to the public on the web.
2.The US Environmental Protection Agency also implemented the Risk Management Program in 1996 to prevent an off –site disaster (An off-site disaster is an event that has repercussions outside the boundary walls of the chemical industry in which the incident took place).
3.The US Chemical Safety Board was set up in January 1998 by an amendment of the Clean Air act. It is authorized to investigate chemical accidents in the USA and publish its investigation reports on its website www.csb.gov. The board cannot impose fines or promulgate regulations. It creates public awareness by publishing its investigation reports on the web.
Changes Made in India:
1.After the Bhopal gas disaster, the Factories Act was amended to assign the responsibility of the “occupier”, who is legally responsible for the safety of the workplace and workers, to the highest level of management in an organization. For a public limited company, one of the directors on the board had to be designated as “occupier”. The Environmental legislation also underwent changes, with the Environment Protection Act introduced in 1986. Under this act, a number of new legislations were framed. The Manufacture, Storage and Import of Hazardous Chemical rules, 1989 required safety audits to be carried out in hazardous chemical factories, storing more than a threshold limit of hazardous chemicals.
2.The Chemical Accidents (Emergency Planning, Preparedness and Response) Rules, 1996 was also introduced. Preparation of on-site Emergency Plan by the Industry and Off-site Plan by the District Collector and the constitution of four-tier Crisis Groups at the Centre, State, District and Local level for management of chemical accidents are mandatory under these Rules.
Recommendations to improve chemical process safety management in India:
1.The enforcement of existing legislation regarding chemical process safety by the Indian authorities must be made effective by training the law enforcers in the latest developments in prevention of chemical accidents, inspection and management system audit techniques.
2.While statutory safety audits continue to be performed in the chemical industries, the public should also be informed about the status of implementation of the recommendations of the safety audit.
3.The investigation of Chemical Process Incidents in India should be carried out by an independent body similar to the Chemical Safety Board of USA and their investigation reports must be made public.

PS: Regarding Sriram's comment below, there is a requirement in Factories rules Sec 41 C for hazardous operations that "the occupier must appoint persons who possess qualifications and experience in handling hazardous substances and are competent to supervise such handling within factory..."

Vacuum - the frequent killer!

During the last one year I came across 4 cases of tanks/pressure vessels collapsing/buckling due to vacuum developing inside. Why do we forget so easily that tanks/vessels that are not designed for vacuum will fail if vacuum develops inside? Time and again operating personnel make the mistake of either draining the tank/vessel, with the vent valve or vacuum breaker blocked in, or allow the tank/vessel to cool without ensuring the vent valve or vacuum breaker is lined up. The reason for this, I think, is due to human psychology. When we look a a large tank/vessel, we tend to believe it is very strong! If the tank/vessel is not designed for vacuum, this is a dangerous thought! It is a matter of education and all organizations must train their personnel on the hazards of vacuum. Why must be keep repeating the same mistakes?
Watch a beautiful youtube video about a rail tank car implosion due to vacuum at
http://www.youtube.com/watch?v=E_hci9vrvfw

Process Safety Management Vs Experience

There is a school of thought that systems corrupt the people's ability to think. Recently I was in a debate with one of my friends in the Chemical Industry who was arguing that his organization has people with tremendous experience and there is no necessity for him to implement any system.
Trevor Kletz has said it very beautifully "Organizations do not have memory". What happens when these people leave or retire? Having spent my whole career in the chemical industry, I am convinced that the phrase "History repeats itself" can be adpated to "Incidents repeat themselves". I keep investigating incidents of tank ruptures,fires and explosions, runaway reactions that uncannily had happened either to me or my friends decades ago.Having a robust process safety management system that captures organizational memory and integrates it with day to day decision making is what is needed to prevent these incidents from recurring.

Training in the Aviation and Chemical Process Industry - why different approaches?

With the advancement of instrumentation in the chemical industry,today plants are operated by DCS systems. These systems are excellent from a data collection and control point of view. The more I look at it, it appears that plant control rooms are now beginning to look like a plane's cockpit! While a pilot (similar to a control room operator) is put through mandatory rigorous training before he commands a plane, there are no mandatory requirements for the qualification of a control room operator. I was earlier a simulator trainer in a methanol plant in Saudi Arabia and I realized the enormous benefits of the benefits of investing in a chemical plant simulator. We could study and give feedback on the trainees response to various artificially created abnormal scenarios. In India, the concept of simulator training is yet to catch on. With the software experts available in India cannot we provide simulators that are cost effective?
I believe the simulator training is mandatory in the Indian Nuclear Industry but not in the chemical industry. Comments are welcome.

Process Safety and Behaviour Based Safety

There's a lot of buzz to day in behavior based safety. My experience indicates that as far as any safety is concerned, the behavior of top management is what dictates the behavior of the entire workforce.If top management keeps on talking about cost cutting and not talking about safety, that's what they will get - cost cutting measures getting implemented without analyzing the effect of the change on process safety! The BP Texas refinery incident is an example of this. The behavior of top management towards process safety does not involve rocket science. However, presently, a dangerous trend is taking place in the Industry. The board of directors in many of the chemical facilities do not have a technical person. My problem is not with the board of directors but with the information that reaches them. The president and other members of the top management who report to the board sometimes do not clearly communicate the risks involved in the implementation of certain decisions.This is a recipe for disaster.
I'm happy that the Baker Panel report has recommended that a person with adequate process safety experience must be on the board to explain to top management the effects of certain decisions on process safety.

LPG Tanker fire on NH47 - Lessons to be learnt

Yesterday a LPG tanker caught fire after colliding with a car on NH 47 near Kochi. The news article and pictures from the site indicate a total lack of disregard for safety by the public. The picture shows people milling around the tanker which is on fire and there is even a guy with a handycam, taking videos, standing barely 15 feet from the burning tanker. The fire department personnel are also not wearing any protective clothing. The only silver lining is that they were warned about the BLEVE phenomenon and were cooling the tanker. While India claims to be a superpower in software industry, why do we not imbibe the best practices in fire fighting and rescue? Its not that we cannot, but requires a change in mindset!
Lets hope for a safe New Year 2010!