June 30, 2010

Celanese and Process Safety

I had the privilege working for 8 years in a methanol plant in Saudi Arabia, a joint venture with Celanese,USA, from 1990 to 1998.Their focus on process safety at that time itself was very good.A recent article mentions the following:
"In 2009, Celanese sponsored a process safety symposium in conjunction with the China Petroleum and Chemical Industry Association (CPCIA). The goal was to explain the philosophies of process safety, share how Celanese manages its safety programs, and raise awareness of how to avoid catastrophic injury or loss of facilities.
A key message of the event was that the industry, government and companies were all responsible for process safety and must work together to make process safety improvements. This symposium was such a success that Celanese is again cosponsoring a process safety symposium in September 2010".

Read the full article in this link.
Hope they come to India!

A little hydrogen can do a lot of damage!

A news article reports that an explosion caused by hydrogen gas in a University of Missouri biochemistry research lab on Monday injured four people and destroyed the laboratory.
"The explosion blew out the windows of the third-floor lab and breached the wall between the lab and an adjacent office. When fire fighters arrived on the scene, they found a small fire covering an area of about 5 square feet, Davison says. One sprinkler head was activated, but investigators aren't sure whether it activated from the fire or from the blast of the explosion. The source of the hydrogen gas was a standard 55-inch-tall steel gas cylinder, which did not explode".
Read the full article in this link

June 29, 2010

Gas blowing of pipelines - CSB's recommendations

In my earlier post, I was dead against the blowing of new pipelines with natural gas to clear debris as there is a potential for an explosion or fire to take place where the gas is vented. The CSB, after investigating the explosion in the Kleen energy power plant has made similar recommendations to OSHA and others. I am quoting from their report:
Promulgate regulations that address fuel gas safety for both construction and general industry. At a minimum:
a. Prohibit the release of flammable gas to the atmosphere for the purpose of cleaning fuel gas piping.
b. Prohibit flammable gas venting or purging indoors. Prohibit venting or purging outdoors where fuel gas may form a flammable atmosphere in the vicinity of workers and/or ignition sources.
c. Prohibit any work activity in areas where the concentration of flammable gas exceeds a fixed low percentage of the lower explosive limit (LEL) determined by appropriate combustible gas monitoring.
d. Require that companies develop flammable gas safety procedures and training that involves contractors, workers, and their representatives in decision-making.

Read the full report and recommendations in this link.

June 28, 2010


I am pleased to announce a two day training session on Process Safety Management on August 12th and 13th,2010 at Chennai. The course is a highly practical one and the participants can implement what they have learnt. For further details please see this link
If you want the brochure and booking form to be sent to you, please contact me at bkprism@gmail.com

June 23, 2010

Heed the warnings!

An article in CBS News website indicates that the BP Gulf of Mexico incident was not a one off incident. There was another incident in another BP oil rig in 2003 where a similar incident occurred but the gas did not ignite!
"Shortly after lunch on November 27, 2003, Oberon Houston was in his office beneath the helideck of BP’s Forties Alpha oil platform in the North Sea, off the coast of Scotland. One of a select group (1 percent of BP’s staff) of young engineers and managers targeted by the company for rapid advancement, Houston, 34, was working out maintenance plans for the coming week when he heard what he thought was a deafening explosion.Only it wasn’t an explosion. A gas line had ruptured-allowing thousands of pounds of pressurized gas to escape at supersonic velocity. That caused a thunderous sonic boom. Debris from the burst pipe and its cladding rained down, adding to the impression that “an artillery shell had just hit the platform.” The escaping gas quickly formed a huge and potentially lethal cloud around the rig. Now the threat of an actual explosion was very real. The smallest spark would detonate more than a ton of methane gas.
No one died or was even hurt that day on Forties Alpha, thanks in part to high winds that helped to disperse the gas after about 20 minutes of extreme danger to the platform and its crew of 180 people. But Houston, the number two in command aboard Forties Alpha, knew full well what could have happened. “Unlike a similar incident on the ill-fated Piper Alpha platform,” he observes, referring to an earlier accident in the North Sea, “the gas did not ignite, so what could have been a major disaster for myself and everyone else on board was averted by sheer luck.”
Though Forties Alpha could have produced a similar conflagration, it was nothing more than a near miss which was soon forgotten. BP admitted breaking health and safety laws by failing to guard against corrosion on the ruptured pipe that allowed the gas to escape. It was fined $290,000. The bigger loss came in early 2004. Houston resigned, and BP lost one of its best young engineers."

Read the full article in this link

June 22, 2010

Bhopal Gas Disaster Verdict 7.6.10 - Will we ever learn?

The Bhopal Gas Disaster Court verdict on 7.6.10 highlights the following:
The following are major contributors to the disaster:
1. Gradual but sustained erosion of good maintenance practices.
2. Declining quality of technical training of plant personnel, especially its supervisory staff.
3. Depleting inventories of vital spares.
4. MIC is a highly dangerous and toxic poison, even then storage of huge quantity in large tanks was undesirable. The capacity and actual production in the Sevin Plant is not required such a huge quantity to be stored.
5. The VGS (vent gas scrubber)and refrigeration plant were not adequate to the need of hour and more so they were out of order at the relevant point of time.
6. The nitrogen pressure was not adequate for long before the incident, so it was not maintained and hardly cared about.
7. The Public Information System was failed, neither the State Govt. nor the UCC or UCIL took any steps to appraise the local public.
8. Other alarming systems were also failed.
Together these factors combined to cause the multiple failures that underlay the calamitous incident, causing a vast destruction of life.
In my various assignments of investigating incidents,some involving fatalities,one or more of the above similar causes keep repeating.Why do we NOT want to learn from mistakes? Its because of a human fallacy - the longer it gets, the more you forget about an incident!

Dangers of Toxic gas cylinders

A newspaper report today indicates that at least 35 people were taken ill when they inhaled chlorine. It appears that the chlorine leaked when someone tried to steal the brass valve! Read more of the article in this report.
In 2009, there was a leak of chlorine form corroded abandoned chlorine gas cylinders.A water purification machinery was abandoned and four chlorine cylinders containing 300 tonnes of chlorine were dumped outside. Over the years, they corroded and finally developed a leak which impacted the villages nearby. Read more of this incident in this link.
Take care of your gas cylinders whether they contain toxic gas or otherwise. They can be potential time bombs!

June 20, 2010

Could another Bhopal occur in India?

I wish I could confidently say NO to the question!Though the big players take precautions,it is the small and medium scale chemical industries that require a lot of improvement.There are approximately 1700 Maximum Accident Hazard (MAH) units in India and they are supposed to carry out mock drills twice a year. Mr Bhardwaj, Member, National Disaster Management Authority is quoted as follows in an article in the Economic Times:
Mr Bhardwaj of the Authority strongly believes that such major accident hazard (MAH) units must adhere to all norms including executing two mock drills in a year. In fact, during the last four years, only 130 mock exercises took place out of which 33 happened to be in chemical industries. “We are emphasising more on prevention of such incidents rather than reacting to those. Yet, we need to prepare for any eventuality. Our mock-drills are big learning lessons as they also involve district administration,” Mr Bhardwaj says.
Read the full article in this link

June 19, 2010

Bhopal and BP - I don't know!

On Thursday, BP's CEO Tony Hayward testified before the US Congress on the spill incident. His answers to the questions put forward by the congressmen reminded me of the answers Union Carbide personnel gave the then Police Chief soon after the gas leak.The police chief had asked what was gas had leaked and what was the antidote. The answers he got was "I don't know". In Thursday's hearing, the CEO of BP also has replied in a similar tone(I am quoting from the article) "I wasn't involved in any of that decision-making," he said.Were bad decisions made about the cement?"I wasn't part of the decision-making process," he said. "I'm not a cement engineer, I'm afraid."
Also, "I am not a drilling engineer" and "I'm not an oceanographic scientist."
What about those reports that BP had been experiencing a variety of problems and delays at the well?"I had no prior knowledge."
At one point a frustrated Rep. Henry Waxman, D-Calif., the chairman of the House Energy and Commerce Committee, interrupted the CEO. "You're kicking the can down the road and acting as if you had nothing to do with this company and nothing to do with the decisions. I find that irresponsible."
Hayward quietly insisted: "I'm not stonewalling. I simply was not involved in the decision-making process."
Rep. Eliot Engel, D-N.Y., voiced the committee's frustrations as the afternoon wore on. "You're really insulting our intelligence," he said. "I am thoroughly disgusted."
Waxman told the BP executive that in his committee's review of 30,000 items, there was "not a single e-mail or document that you paid even the slightest attention to the dangers at this well."

There is a lesson to learn from this - how robust are your risk communication systems so that the bad news reaches the top? Read the full article in this link

June 18, 2010

Emergency response - How ready are you?

An article mentions the following: BP PLC's 582-page regional spill plan for the Gulf, and its 52-page, site-specific plan for the Deepwater Horizon rig vastly understate the dangers posed by an uncontrolled leak and vastly overstate the company's preparedness to deal with one, according to an Associated Press analysis. The lengthy plans were approved by the federal government last year before BP drilled its ill-fated well.Among the glaring errors in the report: A professor is listed in BP's 2009 response plan for a Gulf of Mexico oil spill as a national wildlife expert. He died in 2005.
The plan lists cold-water marine mammals including walruses, sea otters, sea lions and seals as "sensitive biological resources." None of those animals live anywhere near the Gulf.Also, names and phone numbers of several Texas A&M University marine life specialists are wrong. So are the numbers for marine mammal stranding network offices in Louisiana and Florida, which are disconnected.

How ready are you in your emergency preparedness? In some of the plants that I visit,I have noticed the site managements lackadaisical attitude towards the emergency response plan. It would be a good practice if the CEO of the company just activates a drill of the emergency plan without informing anyone about it. The skeletons would then come tumbling out! Read the full article in this link

June 16, 2010

Whistleblower policy for PSM and other systems

Today,organisations get certified to the whole gamut of ISO certifications and the management is lulled into a sense of complacency. I have observed a marked decline in the quality of certification and surveillance audits by certification agencies in India. Except for a few, many of the certification agencies also provide consultancy and training services for helping the organization to obtain certification.Though many organisations have a whistleblower policy, I feel there must be a separate whistleblower policy for any system deviation. This way at least the top management will come to know of what is going wrong in their systems!

Operating Procedures – Can they prevent accidents?

An article on the legal implications of the recent Bhopal Gas verdict quotes from the operating manual of Union Carbide “UCIL’s “Operating Manual Part-I – Methyl Isocyanate Unit” (October 1978), which the prosecution produced as evidence before the trial court, warned as follows: “…[i]t must be foremost in everybody’s mind that there is a probability of injury or accident round the corner. But these can be avoided if all are safety conscious and follow safety procedures strictly. Safety is our prime need. All chemicals like MIC, phosgene, HCl, CO, chlorine, MMA, chloroform and caustic soda, etc., however hazardous they are, can be handled safely by knowing the correct procedure. There is a correct way of handling them and there is ‘No Short Cut’. Any carelessness in operation will endanger you, your colleagues and everybody around you” (page 122).”
Just by having written procedures does not mean they will be followed. It depends on top management commitment to make the procedures work. And this is no easy work – it requires monitoring by top management on a 24 X 7 basis. With top management being busy always, looking at strategy, cost reduction, expansions etc, I feel that the focus sometimes does get lost. Read the full article in this link.

June 12, 2010

Bhopal - Blame it on the system!

Yesterday in an NDTV program on the Bhopal disaster verdict, the one conclusion that came through is to blame it on the system! Who designs systems? Cannot the government strengthen the systems? It is a travesty of justice for the Bhopal Victims. In 2004, on the 20th anniversary of the Bhopal Disaster, I met (Late) Ms Carolyn Meritt, then Chairperson of the CSB, at IIT Kanpur. She asked me one question, which I could not answer. Why is the PSM system not mandatory in India where Bhopal occurred? I am still looking for answers. See this youtube video on the reaction of Sathinath Sarangi, a bhopal activist.

Crisis Management - don't look at it only when it hits you!

Organisations tend not to invest on Crisis Management as they think it will never happen to them! It is a human fallacy to believe that as nothing bad has happened, nothing ever will happen. I was recently a witness to a major crisis in a chemical manufacturing unit and they were not prepared for handling it.The top management representative at the site had to deal with everything himself. Unless planning for crisis is done and periodically tested, you will not be able to manage it. See this excellent youtube video about the responses of BP CEO Tony Hayward starting from the accident in the Gulf,onwards.

June 11, 2010

Parkinsons Law for Process Safety Management

I have formulated Parkinsons Law for Process Safety Management:
1.If there is an incident in one plant, rest assured that the same incident will reoccur after 5 years!
2. If there is an incident in a plant that belongs to a large group of plants, rest assured that it will not be shared with others in the group.
3. If there is pressure on profits, the first thing to get compromised will be process safety.
4. If the person at the top does not have a perception of process safety risks,process safety will get compromised, no matter whatever systems are implemented!
5. Process near misses will continue to be missed till a major incident occurs.
A OSHA representative has testified before the senate subcommittee on safety in energy industries. The following are quoted from his testimony:
"In the wake of the Texas City explosion, OSHA initiated a national emphasis program with the goal of inspecting the process safety management programs of almost all of the nation's oil refineries. "I am sorry to report that the results of this NEP are deeply troubling. Not only are we finding a significant lack of compliance during our inspections, but time and again, our inspectors are finding the same violations in multiple refineries, including those with common ownership, and sometimes even in different units in the same refinery. This is a clear indication that essential safety lessons are not being communicated within the industry and often not even within a single corporation or facility. The old adage that those who do not learn from the past are doomed to repeat it is as true in the refinery industry as it is elsewhere. So we are particularly disturbed to find even refineries that have already suffered serious incidents or received major OSHA citations making the same mistakes again.
"Consistently throughout the course of the Refinery NEP, we have found that more than 70 percent of the violations we are finding involve failures to comply with the same four essential requirements:
"Process Safety Information: Frequent process safety information violations include failure to document compliance with Recognized and Generally Accepted Good Engineering Practices, (or RAGAGEP, which consists primarily of industry technical guidance on safe engineering, operating or maintenance activities); failure to keep process safety information up to date; and failure to document the design of emergency pressure relief systems.
"Process Hazards Analysis: We are finding many failures to conduct complete process hazards analyses. Often, there are significant shortcomings in attention to human factors and facility siting, and in many cases employers have failed to address process hazard analysis findings and recommendations in a timely manner, or, even to address them at all.
"Operating Procedures: Operating procedures citations are for failure to establish and follow procedures for key operating phases, such as start-ups and emergency shutdowns, and for using inaccurate or out-of-date procedures.
"Mechanical Integrity: This is a particular concern given the aging of refineries in the United States. Violations found by OSHA typically include failure to perform inspections and tests, and failure to correct deficiencies in a timely manner. In the Delek Refinery case mentioned above, for example, OSHA discovered multiple substandard pipes being operated, and the naphtha pipe whose explosion killed two workers and hospitalized three others had already ruptured once within the past few years.
"I have been deeply frustrated by these results.Over a year ago, we sent a letter to every petroleum refinery manager in the country, informing them of these frequently cited hazards. Yet, a year later, our inspectors are still finding the same problems in too many facilities. Clearly, much more work must be done to ensure effective chemical process safety.

Read the whole testimony in this link.

June 9, 2010

Excellent Hazards of hot work video from CSB

This is a must see for all those involved in hot work, including chemical, oil and gas and food processing industries. What surprises me is that the same mistakes are being repeated again and again. India, with its very young workforce needs to keep educating its workforce and this CSB video is excellent. I myself have witnessed three fatalities due to hot work incidents similar to those described over 25 years ag0.
See the video in this link. Kudos to the CSB!

Bhopal Gas Disaster - Precedence of Profits over People?

As expected the verdict on the Bhopal gas disaster in the Indian court has raised a hue and cry in the media. While definitely agreeing that the verdict is too little,too late, I think we are missing the bigger picture here. What has India done to prevent another Bhopal type of disaster? In the USA, OSHA CFR1910.119 Process Safety Management became mandatory in 1992 for facilities handling, storing and manufacturing highly hazardous chemicals above a certain threshold quantity. There is no such rule in India even today. Why? Even the enforcement of the other existing rules is weak due to rampant corruption. I quote from MJ Akbar's article in the Times of India:
"If there is any explanation for Delhi's fudge-and-fuss approach, it can only lie in the Indian elite's very real indifference to the poor. What, one wonders, would have been the reaction if Carbide had leaked its poison over Lutyens' Delhi rather than five kilometers from the old Bhopal city? Would Anderson have spent 25 years in Tihar rather than a villa in Hampton's?"
Read MJ Akbars article written before the verdict in this link

Decisions and Disasters -2

A friend of mine who is in top management in a large organization sent me this article about the BP oil spill, highlighting the following points:
"With the schedule slipping, Williams says a BP manager ordered a faster pace.Williams says going faster caused the bottom of the well to split open, swallowing tools and that drilling fluid called "mud."
We actually got stuck. And we got stuck so bad we had to send tools down into the drill pipe and sever the pipe,Williams explained.There's always pressure, but yes, the pressure was increased.He discovered chunks of rubber in the drilling fluid. He thought it was important enough to gather this double handful of chunks of rubber and bring them into the driller shack. I recall asking the supervisor if this was out of the ordinary. And he says, 'Oh, it's no big deal.' And I thought, 'How can it be not a big deal? There's chunks of our seal is now missing,'Williams told Pelley.
The BOP is operated from the surface by wires connected to two control pods; one is a back-up. Williams says one pod lost some of its function weeks before. "The communication seemed to break down as to who was ultimately in charge," Williams said. What strikes Bea is Williams' description of the blowout preventer. Williams says in a drilling accident four weeks before the explosion, the critical rubber gasket, called an "annular," was damaged and pieces of it started coming out of the well.
Investigators have also found the BOP had a hydraulic leak and a weak battery".

Read the full article in this link

June 6, 2010

Process Safety Two Day Training at Chennai on 12th and 13th August,2010

I am pleased to announce a two day training session on Process Safety Management on August 12th and 13th,2010 at Chennai. The course is a highly practical one and will benefit the participants. For further details please see this link.
If you want the brochure and booking form to be sent to you, please contact me at bkprism@gmail.com

June 4, 2010

Process Safety and POP's

No, I am not talking about Persistent Organic Pollutants! I'm talking about Pressure On Profits. Time and again, we see accidents happening even in the World's biggest companies who have all systems in place including OHSAS 18001,ISO14001,PSM, behaviour based safety and other programs, conducted HAZOP and LOPA studies etc. A current example is the BP oil spill in the Gulf of Mexico.Why does this happen? While everyone agrees that ultimately it is the human being who is the weakest link in any system, how do we ensure that safety is always looked at all times including times of pressure on profits? On one side OSHA is increasing the monetary penalties for deficiencies. Whether this will spur organizations to invest in process safety – we will have to wait and see. Ultimately decisions linked to spending and investments have a cascading effect on the whole organisation and finally lead to an accident. I was talking to the Head of Safety of a large organisation who had done a HAZOP study for a new facility. He lamented the fact that even though he had presented to the board the fact that the new plant was commissioned with only 50% of the HAZOP study recommendations implemented, there was no reaction from the board! This could be due to two reasons – a lack of perception of process safety risk and the lack of competence required to understand it. It’s a chicken and egg situation. The Baker Panel report on the BP Texas refinery accident in 2005 had suggested that BP appoint a person with process safety knowledge on its board, but as far as I know, BP has not appointed anyone.

June 3, 2010

Process Safety - controlled by Leadership, HR and Finance!

Having investigated numerous process incidents over my 30 year career, I have come to some mundane conclusions which I am sure everybody knows...
1. No amount of management systems can prevent an incident unless the top management (leadership) send the correct signals!
2. Process safety is understood by the operations and maintenance departments but not understood by the Human Resources (HR) department!The HR department should play an important role in understanding competencies, skills and training required for Process Safety. But in many organisations, the HR department does not really understand the requirements of process safety. However, in one organization, I did see a very responsive HR department - its head was an ex-operations man!
3. Last, but not the least, Money makes the World go around! Without allocating adequate resources, audit findings, HAZOP reports recommendations, LOPA recommendations, incident investigation recommendations - all of them are meaningless and remain on paper till a catastrophic incident happens.
The BP oil spill has instilled great fear among Oil and Gas companies who fear that the regulations will be tightened very much and they need to spend a lot of resources.
Meanwhile, new management systems keep on coming, companies keep getting certified and accidents continue to occur......
Stay tuned!
PS: I am not a Pessimist!

Understand the hazards of chemicals!

Two students in the USA were reported to be in critical condition early Wednesday after being burned by a chemical explosion.Investigators with the Atlanta Fire Department confirm the students were mixing chemicals for "recreation" and not as part of a legitimate class project. They describe the explosion was an accident.In your lab, are your personnel aware of the hazards of all the chemicals they use? I heard of an incident where a lab technician in a plant (the Lab was located in the control room building) was taking a bottle of solvent and using the lift (elevator) when he accidentally dropped the bottle. The solvent went down the elevators floor and collected in the well. A spark ignited the solvent and the person had to be rescued from the elevator.
Read the article about the students in this link

Transportation emergencies and GIS

I know in India, that the Andhra Pradesh Government is using the Geographical Information System (GIS) for disaster management. I read a paper on "Assessment on the Consequences of LPG Release Accident in the Road Transportation via GIS Approaches". The authors have suggested integrating the results from consequence analysis to GIS tools, to get an accurate picture for disaster management. The advantage of this method is that the point of accident can be moved to any location using the GIS and a new result will be displayed for the LPG accident at the new location.
Read the full article in this link

June 1, 2010

Emergency Response in the BP oil rig fire - Shades of Piper Alpha?

A detailed article in the Wall Street Journal about the lack of command and control system after the BP oil rig fire eerily brings back memories of the lack of emergency response after Piper Alpha disaster in 1988. In the BP oil rig fire emergency response, the article mentions the following points:
"The chain of command broke down at times during the crisis, according to many crew members. They report that there was disarray on the bridge and pandemonium in the lifeboat area, where some people jumped overboard and others called for boats to be launched only partially filled.
The vessel's written safety procedures appear to have made it difficult to respond swiftly to a disaster that escalated at the speed of the events on April 20. For example, the guidelines require that a rig worker attempting to contain a gas emergency had to call two senior rig officials before deciding what to do. One of them was in the shower during the critical minutes, according to several crew members.
The written procedures required multiple people to jointly make decisions about how to respond to "dangerous" levels of gas—a term that wasn't precisely defined—and some members of the crew were unclear about who had authority to initiate an emergency shutdown of the well".

We seem to not learn from previous disasters like Piper Alpha where similar confusion existed after the fire!
Read the full article in this link.

Fire in Chemical Factory

This youtube video shows a fire in a chemical plant in Andhra Pradesh. The official says that the plant was not in operation since 2006 and did not have permission to operate. But when you see the fire it appears that large quantities of flammable chemicals were stored in vessels that were very close to each other. See the video in this link.