An EPA study covering a ten-year period (1990 - 2000)reveals that of the 312 accidents at tank farms examined in this period it was found that operator error accounted for 22%. Additionally, 55% were attributable to tank failure, 10% to valve failure, 4% to pump failure and 3% to bolted fitting failure. Human error also accounted for 100% of accidents that resulted in fatalities, 88% involving stock loss and 87% of property damage, with the root cause attributed to overfilling/over-pressurisation.
Storage tanks fail due to a number of reasons including collapse due to vacuum,human error, poor maintenance, vapour ignition, settlement, earthquake,lightening and over-pressurisation.
Make sure your operators are trained in the safe operation of storage tanks.
RISK BASED PSM PROCESS SAFETY MANAGEMENT INDIA CONSULTANT INCIDENT INVESTIGATION HAZOP TRAINING ROOT CAUSE ANALYSIS AND LESSONS FROM INCIDENTS
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March 31, 2010
March 26, 2010
Process safety - learn from these incidents
The Karnataka Department of Factories, Boilers and Industrial safety and health has posted accidents that have occurred in their state.
Four incidents are posted:
1. Confined space incident
2. Incompatible material incident
3. Accident in Urea plant
4. Toxic gas release in bulk drug manufacturing.
The details are available in this link. Please circulate to all your colleagues as the incidents can happen anywhere.
Some more accidents are given in a pdf file (large file) in this link
Four incidents are posted:
1. Confined space incident
2. Incompatible material incident
3. Accident in Urea plant
4. Toxic gas release in bulk drug manufacturing.
The details are available in this link. Please circulate to all your colleagues as the incidents can happen anywhere.
Some more accidents are given in a pdf file (large file) in this link
Process Safety and Emergency Preparedness
I was reading about the two recent incidents of fires in high rise buildings in Bangalore and Kolkata and the high number of fatalities involved. In both cases, emergency escape paths were either blocked or locked. In a chemical plant emergency, things are much worse - domino effects can have catastrophic effects.Events will snowball quickly and unless you are well prepared, it will be difficult to handle a major emergency. All plant personnel should understand that mock drills are conducted when there is no emergency.In an actual emergency, Murphy's law will apply: "Anything that can go wrong will go wrong". A mock drill mentally prepares you for the do's and dont's.
Plant operating and maintenance personnel, especially those on shift duty must always keep themselves familiar about emergency alarm activation, escape paths, emergency breathing air escape packs and self contained breathing apparatus, crash shutdown procedures,emergency communication systems, what to do in total power failure and other possible emergencies.Most of the emergencies uncannily happen in the early morning hours when all shift people are sleepy and the general shift people are sleeping!
In some of the chemical units that I visit, the people assume that emergency preparedness is the job of the safety officer!If you want to survive in an emergency, YOU have to take responsibility and be prepared. Do not think it will not happen to you.You will not have a second chance.
Plant operating and maintenance personnel, especially those on shift duty must always keep themselves familiar about emergency alarm activation, escape paths, emergency breathing air escape packs and self contained breathing apparatus, crash shutdown procedures,emergency communication systems, what to do in total power failure and other possible emergencies.Most of the emergencies uncannily happen in the early morning hours when all shift people are sleepy and the general shift people are sleeping!
In some of the chemical units that I visit, the people assume that emergency preparedness is the job of the safety officer!If you want to survive in an emergency, YOU have to take responsibility and be prepared. Do not think it will not happen to you.You will not have a second chance.
March 23, 2010
Process safety - 5 Years after the BP incident
On March 23rd, 2005, the worst industrial accident in the US for more than a decade occurred at the BP Texas refinery. 5 years after the incident a news article mentions the following:
“Since the disaster, the company has spent more than $1 billion on improvements at the refinery, and continues to invest more. It's spent another $1 billion or so settling about 1,000 civil lawsuits filed by the more than 170 workers injured in the blast and by families of the dead.
“Those systems require constant vigilance. You start to think you've got it fixed, and eventually you start to focus on other things. If you let your focus wander too far, you're system starts to slip without your realizing it.”
“The U.S. Chemical Safety and Hazard Investigation Board found in 2007 that the explosion resulted from a lethal combination of cost-cutting, a lack of investment in training and mechanical systems and a lack of vigilance in maintaining safety procedures. The company has implemented sweeping changes in process safety procedures and revamped how it operates refineries. Many of those changes have been adopted by BP's rivals as well.”
“The question that continues to dog BP and the refining industry: Has it done enough?It has rejected, for example, a Chemical Safety board recommendation that it add a process safety expert to its board of directors.”
“It took the explosion,” said Gary Beevers, international vice president for the United Steelworkers union, which represents more than 1,000 workers at the refinery. “As this industry has shown, it takes something terrible for changes to happen.”
My own observation of any big incident like this is that immediately after the incident there are a lot of things done. But the question is the sustainability of these actions. Time and again I have seen that unfortunately history tends to repeat itself unless top leadership are really and continuously committed to process safety.More and more boards of Chemical and refining companies are filled up with non technical persons, with the result that there is no one at the board level to explain to the board the repercussions of cost cutting without a proper assessment.
Read the whole article in this link
“Since the disaster, the company has spent more than $1 billion on improvements at the refinery, and continues to invest more. It's spent another $1 billion or so settling about 1,000 civil lawsuits filed by the more than 170 workers injured in the blast and by families of the dead.
“Those systems require constant vigilance. You start to think you've got it fixed, and eventually you start to focus on other things. If you let your focus wander too far, you're system starts to slip without your realizing it.”
“The U.S. Chemical Safety and Hazard Investigation Board found in 2007 that the explosion resulted from a lethal combination of cost-cutting, a lack of investment in training and mechanical systems and a lack of vigilance in maintaining safety procedures. The company has implemented sweeping changes in process safety procedures and revamped how it operates refineries. Many of those changes have been adopted by BP's rivals as well.”
“The question that continues to dog BP and the refining industry: Has it done enough?It has rejected, for example, a Chemical Safety board recommendation that it add a process safety expert to its board of directors.”
“It took the explosion,” said Gary Beevers, international vice president for the United Steelworkers union, which represents more than 1,000 workers at the refinery. “As this industry has shown, it takes something terrible for changes to happen.”
My own observation of any big incident like this is that immediately after the incident there are a lot of things done. But the question is the sustainability of these actions. Time and again I have seen that unfortunately history tends to repeat itself unless top leadership are really and continuously committed to process safety.More and more boards of Chemical and refining companies are filled up with non technical persons, with the result that there is no one at the board level to explain to the board the repercussions of cost cutting without a proper assessment.
Read the whole article in this link
March 21, 2010
Boiler burst - cause of incident at NFL?
Please see news item from Tribune, Chandigarh:
NFL tragedy
Ropar admn not informed in time
Megha Mann
Tribune News Service
Nangal, March 20
While the boiler at ammonia plant burst at around 11:40 am today, district administration Ropar was informed after 40 to 50 minutes of the incidence.
Confirming this, deputy commissioner Priyank Bharti said that even area SDM Lakhmir Singh was not informed immediately after the incidence.
“As per the protocol, the NFL authorities should have informed us within minutes after the incidence. But it took at least 40 to 50 minutes for the news to reach us. Fortunately, there was no ammonia leakage. Had it been a gas leakage, more damage could have been caused and informing us untimely could have added to chaos,” he observed.
However, official spokesperson NFL Naya Nangal claimed that the SDM and DSP were informed within 15 minutes of tragedy.Sources said that injured Umesh Kumar’s timely action of switching off main gas connection helped in saving many lives. Had the ammonia spread around, more losses of life and property would have happened.
The plant, where tragedy struck, was to be closed on Monday for 25 days maintenance practice. Annual target of NFL for urea production was 4. 78 lac tonnes and NFL had already attained 4.73 lac tonnes production.Daily production of ammonia at the plant is 900 tonnes, while that of urea is 1450 tonnes. NFL spokesperson said that company would meet its target with the help of other units. The unit has been shut down three days before the scheduled time due to accident.
Nangal MLA Rana KP Singh too reached the spot. He held the NFL management responsible for this tragedy and demanded a high level probe. He said that the fire fighting equipments at factory were not up-to-date. SSP L K Yadav asked people not to panic as the accident was result of some technical failure.
NFL tragedy
Ropar admn not informed in time
Megha Mann
Tribune News Service
Nangal, March 20
While the boiler at ammonia plant burst at around 11:40 am today, district administration Ropar was informed after 40 to 50 minutes of the incidence.
Confirming this, deputy commissioner Priyank Bharti said that even area SDM Lakhmir Singh was not informed immediately after the incidence.
“As per the protocol, the NFL authorities should have informed us within minutes after the incidence. But it took at least 40 to 50 minutes for the news to reach us. Fortunately, there was no ammonia leakage. Had it been a gas leakage, more damage could have been caused and informing us untimely could have added to chaos,” he observed.
However, official spokesperson NFL Naya Nangal claimed that the SDM and DSP were informed within 15 minutes of tragedy.Sources said that injured Umesh Kumar’s timely action of switching off main gas connection helped in saving many lives. Had the ammonia spread around, more losses of life and property would have happened.
The plant, where tragedy struck, was to be closed on Monday for 25 days maintenance practice. Annual target of NFL for urea production was 4. 78 lac tonnes and NFL had already attained 4.73 lac tonnes production.Daily production of ammonia at the plant is 900 tonnes, while that of urea is 1450 tonnes. NFL spokesperson said that company would meet its target with the help of other units. The unit has been shut down three days before the scheduled time due to accident.
Nangal MLA Rana KP Singh too reached the spot. He held the NFL management responsible for this tragedy and demanded a high level probe. He said that the fire fighting equipments at factory were not up-to-date. SSP L K Yadav asked people not to panic as the accident was result of some technical failure.
Process Safety - Blast in ammonia plant
On Saturday, a blast was reported in the ammonia plant of the Nangal fertiliser plant.
It is reported that the saturator tower fell down as a result of the blast. Three people lost their lives and my heart goes out to the bereaved families. A news item in the Hindustan Times indicates that the incident took place at 1140 hrs in the shift conversion section. The gas in the shift conversion section in an ammonia plant will primarily consist of hydrogen.
It is reported that the saturator tower fell down as a result of the blast. Three people lost their lives and my heart goes out to the bereaved families. A news item in the Hindustan Times indicates that the incident took place at 1140 hrs in the shift conversion section. The gas in the shift conversion section in an ammonia plant will primarily consist of hydrogen.
March 20, 2010
Process Safety - Phosgene hose leak update
A news article on the EPA investigation of the phosgene hose leak at DuPont's Belle, US facility in January 2010,indicate the following:
1. "This type of hose should be replaced every two months "due to the extremely hazardous nature of phosgene," EPA said. At the time of the Belle plant leak, the hose had been in use for seven months.The hose was 5 months overdue for replacement"
2. "The flexible, braided-steel hose was also the wrong kind of equipment to use in the first place because of the extremely hazardous nature of phosgene"
3."EPA also said that this type of hose should be installed within six months of its fabrication. This particular hose was fabricated in May 2008, but was not installed by DuPont until June 2009".
DuPont is world renowned for their high safety standards and I wonder what went wrong.
Read the full article in this link
1. "This type of hose should be replaced every two months "due to the extremely hazardous nature of phosgene," EPA said. At the time of the Belle plant leak, the hose had been in use for seven months.The hose was 5 months overdue for replacement"
2. "The flexible, braided-steel hose was also the wrong kind of equipment to use in the first place because of the extremely hazardous nature of phosgene"
3."EPA also said that this type of hose should be installed within six months of its fabrication. This particular hose was fabricated in May 2008, but was not installed by DuPont until June 2009".
DuPont is world renowned for their high safety standards and I wonder what went wrong.
Read the full article in this link
Process safety and societal risks in India
I was going through a risk assessment report prepared for an organization that was planning to increase production capacity using a toxic chemical as a raw material. This chemical is received through pipelines traversing through public areas. I found one thing startlingly out of place. The report used outdated population data in the vicinity of the pipelines. Unauthorized settlements were everywhere near the pipeline and this was not considered in the report. This is a peculiar problem in India. How can we rely on population statistics when the data itself is dynamic on a day to day basis! One other thing that always perturbs me is that I doubt if the user of the report understands the assumptions made and is really able to understand the report.
Just having a colorful report with a lot of drawings indicating toxic end points and red zones does not really mean you have identified the risks involved.While such reports are mandatory from a regulatory perspective, it is better that the organization revisit these reports periodically based on changes in population density.
Lord Tony Newton,independent chair of the Buncefield Investigation Board says "The system should in future consider the total population at risk – societal risk – at each new development application. We should not continue to allow surrounding populations to increase without considering the consequences". I really do not know how we can implement this in India unless there is strong enforcement by the regulatory agencies.
Just having a colorful report with a lot of drawings indicating toxic end points and red zones does not really mean you have identified the risks involved.While such reports are mandatory from a regulatory perspective, it is better that the organization revisit these reports periodically based on changes in population density.
Lord Tony Newton,independent chair of the Buncefield Investigation Board says "The system should in future consider the total population at risk – societal risk – at each new development application. We should not continue to allow surrounding populations to increase without considering the consequences". I really do not know how we can implement this in India unless there is strong enforcement by the regulatory agencies.
March 17, 2010
Process safety and fatigue
It is disturbing to note that fatigue probably played a part in the new US power plant explosion that occurred when lines were being blown with natural gas. It appears that one of the victims who died in the explosion was working 12 hours a day, seven days a week, for six months. If operators are being allowed to work without break even in the US, imagine the plight in India!The pressure of commissioning a plant to meet target deadlines often result in people working overtime. With more and more activities being outsourced, industry must be careful that this problem is tackled to avoid incidents. What is more worrying is that the aviation industry in India is reporting incidents of pilot fatigue due to inadequate rest periods.If it can happen in the aviation industry, it can happen in the chemical industry too!
March 11, 2010
Process safety -Pressure Relief and Flame out devices - Take care of them!
According to a news release dated 8.3.2010, "The U.S. Department of Labor's Occupational Safety and Health Administration has cited BP North American Inc. and BP-Husky Refining LLC's refinery in Oregon, Ohio, with 42 alleged willful violations, including 39 on a per-instance basis, and 20 alleged serious violations for exposing workers to a variety of hazards including failure to provide adequate pressure relief for process units. Proposed penalties total $3,042,000.Forty-two willful citations with proposed penalties totaling $2,940,000 are proposed as follows:
1. Thirty-eight (38) per-instance, willful citations with penalties totaling $2,660,000 allege as follows:
1. Twenty-six instances allege deficient pressure relief, a violation of 29 CFR parts 1910.119(d)(3) and 1910.119(j)(5), with total penalties of $1,820,000;
2. Three instances allege the lack of flame-out protection on heaters and a furnace, a violation of 29 CFR 1910.119(d)(3), with total penalties of $210,000; and
3. Nine instances allege facility-siting hazards, a violation of 29 CFR 1910.119(e)(5), with total penalties of $630,000.
2. Four willful citations with penalties totaling $280,000, allege as follows:
1. Lack of pressure vessel information, a violation of 29 CFR 1910.119(d)(3), with a penalty of $70,000;
2. Cross-connections between fire-emergency water supplies and process systems, a violation of 29 CFR parts 1910.119(d)(3) and 1910.119(e)(5), with a penalty of $70,000;
3. Failure to conduct thickness measurements at designated test sites and as required at the flare header, a violation of 29 CFR 1910.119(j)(4)(ii), with a penalty of $70,000; and
4. Failure to conduct thickness measurements in accordance with RAGAGEP, a violation of 29 CFR 1910.119(j)(4)(iii), with a penalty of $70,000".
Of particular interest is the twenty six instances of deficient pressure relief and three instances of lack of flame out protection.
1. Thirty-eight (38) per-instance, willful citations with penalties totaling $2,660,000 allege as follows:
1. Twenty-six instances allege deficient pressure relief, a violation of 29 CFR parts 1910.119(d)(3) and 1910.119(j)(5), with total penalties of $1,820,000;
2. Three instances allege the lack of flame-out protection on heaters and a furnace, a violation of 29 CFR 1910.119(d)(3), with total penalties of $210,000; and
3. Nine instances allege facility-siting hazards, a violation of 29 CFR 1910.119(e)(5), with total penalties of $630,000.
2. Four willful citations with penalties totaling $280,000, allege as follows:
1. Lack of pressure vessel information, a violation of 29 CFR 1910.119(d)(3), with a penalty of $70,000;
2. Cross-connections between fire-emergency water supplies and process systems, a violation of 29 CFR parts 1910.119(d)(3) and 1910.119(e)(5), with a penalty of $70,000;
3. Failure to conduct thickness measurements at designated test sites and as required at the flare header, a violation of 29 CFR 1910.119(j)(4)(ii), with a penalty of $70,000; and
4. Failure to conduct thickness measurements in accordance with RAGAGEP, a violation of 29 CFR 1910.119(j)(4)(iii), with a penalty of $70,000".
Of particular interest is the twenty six instances of deficient pressure relief and three instances of lack of flame out protection.
March 8, 2010
Purging of Natural Gas Lines - Adding fuel to the fire?
The CSB had issued urgent recommendations on the natural gas explosion at Con Agra on June 9,2009. The incident occurred when natural gas lines were being purged free of air using natural gas itself.The CSB urgent recommendations include
(a) Purged fuel gases shall be directly vented to a safe location outdoors, away from personnel and ignition sources
(b) If it is not possible to vent purged gases outdoors, purging gas to the inside of a building shall be allowed only upon approval by the authority having jurisdiction of a documented risk evaluation and hazard control plan.The evaluation and plan shall establish that indoor purging is necessary and that adequate safeguards are in place such as:
• Evacuating nonessential personnel from the vicinity of the purging;
• Providing adequate ventilation to maintain the gas concentration at an established safe level, substantially below the lower explosive limit; and
• Controlling or eliminating potential ignition sources
(c) Combustible gas detectors are used to continuously monitor the gas concentration at appropriate locations in the vicinity where purged gases are released
(d) Personnel are trained about the problems of odor fade and odor fatigue and warned against relying on odor alone for detecting releases of fuel gases
It is not safe in the first place to allow purging of an air filled pipeline with natural gas. You can never control or eliminate all potential ignition sources. PERIOD!!
See the CSB recommendations in this link.
See my latest post on this subject
(a) Purged fuel gases shall be directly vented to a safe location outdoors, away from personnel and ignition sources
(b) If it is not possible to vent purged gases outdoors, purging gas to the inside of a building shall be allowed only upon approval by the authority having jurisdiction of a documented risk evaluation and hazard control plan.The evaluation and plan shall establish that indoor purging is necessary and that adequate safeguards are in place such as:
• Evacuating nonessential personnel from the vicinity of the purging;
• Providing adequate ventilation to maintain the gas concentration at an established safe level, substantially below the lower explosive limit; and
• Controlling or eliminating potential ignition sources
(c) Combustible gas detectors are used to continuously monitor the gas concentration at appropriate locations in the vicinity where purged gases are released
(d) Personnel are trained about the problems of odor fade and odor fatigue and warned against relying on odor alone for detecting releases of fuel gases
It is not safe in the first place to allow purging of an air filled pipeline with natural gas. You can never control or eliminate all potential ignition sources. PERIOD!!
See the CSB recommendations in this link.
See my latest post on this subject
March 5, 2010
Domino effect and Process Safety
An interesting article on Domino Effects in the developed countries mentions the following "A study of 261 accidents involving domino effect has been carried out. The main features have been analyzed: origin, causes, consequences and most frequent sequences. The analysis has shown that the most frequent causes are external events (31%) and mechanical failure (30%). The storage areas (37%) and process plants (27%) are by far the most common places where domino accidents have occurred. The most common sequence in the event trees resulted to be explosion–fire (21%), followed by release– fire–explosion (15%) and fire–explosion (14%)".
While the study concludes that "The historical analysis has shown that the frequency of domino effect accidents has decreased over the last two decades. Most of these accidents have occurred –as could be expected– in the most industrialized countries (from which, furthermore, more information is available). The most frequent sequences are explosion–fire, release–fire– explosion and fire–explosion. From the analysis of the causes, although the most frequent ones are external events and mechanical failure, a relatively high frequency is found for human error. This would indicate the need to further promote the training of employees, as well as an additional improvement of safety measures, specially in storage areas".
As more and more chemical industries are coming up in India, it becomes very important to study facility siting issues.Incidents like the Jaipur fire clearly indicate the need for a stronger implementation of facility siting rules.
Read the whole article in this link.
While the study concludes that "The historical analysis has shown that the frequency of domino effect accidents has decreased over the last two decades. Most of these accidents have occurred –as could be expected– in the most industrialized countries (from which, furthermore, more information is available). The most frequent sequences are explosion–fire, release–fire– explosion and fire–explosion. From the analysis of the causes, although the most frequent ones are external events and mechanical failure, a relatively high frequency is found for human error. This would indicate the need to further promote the training of employees, as well as an additional improvement of safety measures, specially in storage areas".
As more and more chemical industries are coming up in India, it becomes very important to study facility siting issues.Incidents like the Jaipur fire clearly indicate the need for a stronger implementation of facility siting rules.
Read the whole article in this link.
March 2, 2010
Dangers of melting contents of drums
A chemical manufacturer in India has been asked to pay to pay $8.37 million for a fire that destroyed a Houston-based pesticides maker's warehouse and offices in Pasadena six years ago.
The fire apparently took place when Chloropyrifos drums were placed were placed in a “hot box” in the Houston company's Pasadena warehouse for melting, based on procedures provided by the manufacturer. However, during the melting process, the contaminated chemicals exploded and caught fire.It appears that the drums contained chloropyrifos contaminated with solvent.
It is quite common in pesticide manufacturing to put a drum in a steam bath or a hot box to melt the drum contents. But as this incident shows, you must understand the dangers before doing it.....
See this article for more details.
The fire apparently took place when Chloropyrifos drums were placed were placed in a “hot box” in the Houston company's Pasadena warehouse for melting, based on procedures provided by the manufacturer. However, during the melting process, the contaminated chemicals exploded and caught fire.It appears that the drums contained chloropyrifos contaminated with solvent.
It is quite common in pesticide manufacturing to put a drum in a steam bath or a hot box to melt the drum contents. But as this incident shows, you must understand the dangers before doing it.....
See this article for more details.
March 1, 2010
Process Safety in India -PCPIR's
To promote investment in the chemical sector and make the country an important hub for both domestic and international markets, the government is in the process of setting up Petroleum, Chemicals & Petrochemical Investment Regions (PCPIRs). As per the PCPIR policy ,this is to "attract major investment, both domestic and foreign, by providing a transparent and investment friendly policy and facility regime.These PCPIRs would reap the benefits of co-siting, networking and greater efficiency through the use of common infrastructure and support services. They would have high-class infrastructure, and provide a competitive environment conducive for setting up businesses. They would thus result in a boost to manufacturing, augmentation of exports and generation of employment".
Isn't the setting up of these PCPIR's a good opportunity for the Government to implement mandatory process safety norms in these PCPIR's?
Isn't the setting up of these PCPIR's a good opportunity for the Government to implement mandatory process safety norms in these PCPIR's?